Thursday 18 February 1993

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

Chateau Gardens Nursing Homes

Ron Gingrich, executive director

Darlene Fitzgerald, administrator and director of nursing care, Chateau Gardens Queens

Donna Letts, administrator and director of nursing care, Chateau Gardens Parkhill

Saint Luke's Place

Don Attridge, president, tenants' association

John Kauffman, administrator

We Care Homehealth Services

Jeff Hitchcock, owner-operator

Ronald G. Hoppe, representative

Ontario Association of Non-Profit Homes and Services for Seniors

Robert Pettitt, chair, community and government relations committee, region 3

St Joseph's Hospital and Home

Brian Ayer, trustee

Sister Margaret Myatt, president and chief executive officer

David Rudy, vice-president and administrator

Elliott Home for the Aged

Ethel Doughty, board member

Marion Featherstone, resident

David Hicks, administrator

Victorian Order of Nurses, Brant-Norfolk-Haldimand Branch

Cathy Chisholm, executive director

County of Lambton Health and Social Services

Ken Evans, chairman, health and social services committee

Jim Foubister, vice-chairman, health and social services committee

Doug Hutton, director, senior services

Vision Nursing Home

Bernard Bax, chief executive officer and administrator

Chelsea Park Retirement Community

Tony Orvidas, administrator

Victorian Order of Nurses, Sarnia-Lambton Branch

Jack Smith, president, board of directors

Lavinia Dickenson, executive director

Victorian Order of Nurses, Oxford County Branch

Kathryn Bamford, executive director

Southwestern Regional Centre Auxiliary

John Fleming, president

St Joseph's Health Centre of Sarnia

Paul Dusten, assistant executive director

Wendy Miller, director of nursing, continuing care

Victorian Order of Nurses, Middlesex-Elgin Branch

Mary Dryden, executive director

Golden Years Advisory Committee for Schizophrenia

Martha Jean Noble, representative


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

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

*Acting Chair / Président supplement: Fawcett, Joan M. (Northumberland 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

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

Jamison, Norm (Norfolk 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:

Cunningham, Dianne (London North/-Nord PC)

Czukar, Gail, legal counsel, Ministry of Health

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

Wessenger, Paul, parliamentary assistant to the Minister of Health

Clerk / Greffier: Arnott, Douglas

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

The committee met at 0907 in Centennial Hall, London.


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

The Chair (Mr Charles Beer): Good morning, ladies and gentlemen. I think while people thaw out, take their coats off and get a hot cup of coffee, we'll call the meeting to order. This is the morning session of the standing committee on social development in London's Centennial Hall, and we're here to review Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: I'd like to call our first deputation for this morning, the representatives from Chateau Gardens. If they would be good enough to come forward, take a seat, make yourselves comfortable; have a glass of water. We welcome you to the committee. If you would be good enough to introduce yourselves both for the committee members as well as for Hansard and then please go ahead.

Mr Ron Gingrich: Good morning everyone. I'm Ron Gingrich. I'm the executive director of Chateau Gardens Nursing Homes. With me is Darlene Fitzgerald. She's the administrator and the director of care of Chateau Gardens Queens Nursing Home in London, a not-for-profit nursing home, and Donna Letts, the administrator and director of care of Chateau Gardens Parkhill, a for-profit nursing home.

Chateau Gardens finds itself in a unique position in that we operate under the definitions of both for-profit and not-for-profit. In reality today, all our homes are non-profit due to lack of appropriate funding caused by delays in the passage of this bill.

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

I realize time is limited, so I will only give you a brief synopsis of our written submission and then we'll be pleased to address any questions you may have.

While there are many sections in this proposed legislation that are positive, our concerns pertain to the wording of portions of Bill 101 and its omissions. There are many unanswered questions raised by the way the bill is written. We are concerned about a wide range of problems that could be created by the approach taken. While we see an intention to be more equitable, some amendments continue to discriminate against residents of nursing homes. The government must be held accountable to maintain equitable and consistent services in all long-term care facilities throughout Ontario.

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

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

The development of a case-mix index, which scores one facility's care level relative to another, by no means guarantees that funding will be sufficient to ensure that the assessed needs of the residents are met.

This bill holds facilities accountable for providing for all resident needs without ensuring that funding will be provided to make this possible. The legislation clearly states that the care outlined in a resident care plan must be provided.

The problem is, there is no flexibility should the resources not be available to provide the services outlined in the care plan. In fact, this legislation may seriously discourage accurate and detailed plans of care due to lack of resources, and to make matters worse, because there is not enough money in the system to meet all of the residents' assessed needs as identified in their care plans, facilities will automatically be in breach of their contract.

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

There are no details of how the placement coordinator will function. We suggest their duties be outlined in the legislation and that this position be given the responsibility to determine eligibility for placement; to identify a substitute decision-maker for the applicant; to determine the applicant's ability to pay the copayment; to identify a responsible party in the event there is default of the applicant's payment; to take into consideration the applicant's choice with respect to ethnic, linguistic, geographic and religious preferences, or discharge planning and coordination involved when a resident needs to be moved to another location, and to provide service seven days a week, 24 hours a day.

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

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

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

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

We are extremely disappointed to see the reintroduction of the word "inspector." Past experience has shown that the inspector model created an adversarial climate that was not in the best interests of quality care. It failed dismally. All long-term care facilities, regardless of their profit designation, must be reviewed using the same standards and criteria. We strongly support the continuation of the current compliance management program which stresses consultation rather than confrontation.

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

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

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

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

This bill has given far too much power to the government and inspectors without the corresponding accountability. Consumers and facilities, however, have been given very little power, protection or choice. This bill leaves too many issues to be defined by regulations.

In summary, I would like to stress that this bill should provide reasonable and equitable guidelines for all long-term care. Don't reintroduce policing by inspectors. Keep the consultative approach using the compliance management program. There are many talented and dedicated people in both the for-profit and not-for-profit sectors. Bring them together under one act that addresses everyone by the same standards, criteria and funding schedule.

The Chair: Thank you very much for your presentation. I think you are the first witness who has the combination of both non-profit and for-profit, so we thank you very much for coming before the committee. We'll begin our questioning with Mr Wessenger.

Mr Paul Wessenger (Simcoe Centre): Thank you for your presentation. The first question I'd like to ask: You haven't seen the draft program manual? It does contain a draft agreement and there will be a second draft coming out soon.

Mr Gingrich: No, I have not seen it.

Mr Wessenger: The other thing I'd like to ask is, you're familiar with the existing system of inspection under the Nursing Homes Act, which basically tries to work with a compliance model. Does that work well at the moment?

Mr Gingrich: We find it works very well. I think my administrators could probably answer that better since they deal directly with the compliance managers. But we find it works very well.

Mr Wessenger: It certainly is the intention to continue the present model with respect to the nursing homes. I'd like to also assure you that the matter of the language of the quality assurance plan is under review. We have to see if we can have more appropriate language in that regard.

The Chair: Just before moving to Ms Caplan, I believe the committee had copies of that, so it's something I'm sure could be forwarded to you.


Mrs Elinor Caplan (Oriole): The concerns you've raised have been repeated before at this committee and there have been some suggestions about the type of amendment that might at the same time provide accountability and assure quality in a more positive way than the big stick approach of the inspector, or what I refer to as the enforcement model, which just didn't work in the past and isn't going to work in the future. It really is outdated. I'm pleased to hear that you think that the total quality management and continuous improvement approach, combined with compliance management, is working well. I know there were some concerns about it when it first came in.

The question I have for you is around accreditation and whether you believe that, in order to build in appropriate accountability without that policeman coming in, whether a feature in this bill that required the establishment of a quality management program and the requirement or the mandate of meeting of an accreditation perhaps under the association of long-term facilities, which is establishing accreditation programs both for management as well as outcome review, whether you in your facilities would have a comfort with that as an alternative. Because the public must be protected. You want to do this in a positive way, I believe, but we have to find a way that is going to be forward-looking and will result in improved patient care and quality.

Mr Gingrich: We are accredited as, yes, most facilities are.

Mrs Caplan: Not all facilities are right now. That's why I've been asking the question. I did not know if you were or not.

Mr Gingrich: Yes, we are fully accredited, all of our facilities. We feel that there is some overlap between the compliance management program and the accreditation. My administrators would, I think, assure me that they feel it's an overlap.

Mrs Caplan: So you would be comfortable if an accreditation process were in place and you could satisfy the accreditors that you had a quality management program within your facility as part of the accreditation? You could even perhaps lessen some of the bureaucracy that's existing in the compliance management program today?

Mrs Darlene Fitzgerald: I was up for reaccreditation, because we've been accredited since 1980 at our home. They reviewed my total quality management or continuous management improvement then, whatever they're going to end up calling this when they're finished with it. They reviewed it and found it very positive and thought we were doing very well with it.

Mrs Caplan: Because I know that's a field that is changing rapidly and that instils prides in an institution when it achieves that and the big stick is not needed if you have that kind of culture and value within your facility. It's ensuring that the accountability is there. The other proposal was to mandate a residents' council in all long-term care facilities, and that's not a requirement in this legislation. Would you have any problem with that kind of amendment?

Mrs Fitzgerald: We have residents' councils in our facilities and have had for any number of years. Nearly all of our facilities have them.

Mrs Caplan: And you found that a good thing in your facility?

Mrs Fitzgerald: I find it a good thing from that point of view because they audit all our departments in one of the monthly meetings they have. That provides a quality assurance for us.

Mrs Caplan: I just point out that this is not a requirement in the legislation now, but several have suggested that if you were going to move to make the bill a little more progressive and forward-looking, that's the sort of thing you could mandate for all institutions and then look at perhaps accreditation and quality management programs.

The last question --

The Chair: The last question.

Mrs Caplan: Thank you. It was suggested last evening that there be a statement of principles, a preamble or perhaps a statement as it related to the role of the placement coordination service, almost a statement of principles that would give comfort to some of the concerns around consumer choice and flexibility. What was suggested was a statement of principles -- and I'd like to read it into the record -- that encompassed "dignity and integrity of the individual," "reasonable and competent access to information about alternatives in care," "informed consumer choice," "equitable access to services and facilities for clients and their families (within appropriate limits)," "sensitivity to cultural, religious, ethnic and language issues in so far as this is possible," "competent, experienced and academically well prepared staff" and "no vested interest in service outcome." Those would be the principles for ensuring appropriate admission criteria.

My question is, do you feel that it would be important to have that statement of principle in the legislation, and do you believe that facilities should be able to have a right to refuse, subject to appeal, if they don't feel they're able to provide appropriate care for the client?

Mr Gingrich: Yes, I believe I have addressed that. I do feel we need that option. Each facility is slightly different, and in some cases we may not be able to provide the care required by the residents.

Mrs Caplan: Would you have any difficulty with the notion of "appropriate care" being defined in regulation?

The Chair: Excuse me, Ms Caplan. I've got to move on; I'm sorry. Mrs Cunningham.

Mrs Dianne Cunningham (London North): Thank you. Good to see you. Again, I want you know that we have an establishment here that's been very helpful, I think, to all governments, Mr Beer. We certainly visit Chateau Gardens; I think all the members do from time to time. We're very happy to get firsthand visitations and good advice on what should happen. Thanks for coming today.

My questions are going to be rather simplistic because I haven't followed the intricacies of the bill; my two colleagues have been doing that on behalf of our party. But I am interested in the whole issue of quality assurance. Do you think there's enough of a mechanism in our facilities now for quality assurance? Do you think the quality is assured?

Mrs Fitzgerald: Yes, I do, with the mechanism we use where we are evaluating the quality assurance and then all of the risk management things that go for quality assurance for us. We also do utilization review as well. There are any number of areas that you improve upon, particularly when you're dealing with any occupational health and safety issue. They fall under risk, and the quality assurance program, or TQM, helps us to find a solution for those particular problems. Then they're worked out logically and methodically. It's been a very helpful system.

Mrs Cunningham: With regard to consultation, I know that you're talking about the reports we've done with regard to the consultative approach. In your view, is that happening now. I know you said you approve of it, but why would anybody be raising a different issue here, from the government's point of view? Is there something happening out there where we've had to move towards inspectors and another way of doing things? Is there something that we don't know about? Why would the government be putting this kind of thing in legislation?

Ms Donna Letts: I believe that it's kind of backward thinking. We have a concern. We really don't know why the inspector model has been raised again. The compliance program has been working well.

Mrs Cunningham: It's something that we tried to avoid in our school systems in the late 1950s, and I'm happy that you pointed it out.

My other question has to do with the contractual model at the very beginning here, where you're talking about how "there will no longer be a universal, accessible approach to health care in these facilities." I suppose this has been an issue at least since I've been elected, for the last five years. Are you saying that if we pass this legislation -- and I'm trying to keep the funding separate, because I don't think you need legislation around funding; I don't think anybody has to come to the government and say, "We need this legislation because we know we need another funding model, because outside of this legislation we knew we needed another funding model." I don't think we need it. It has been, for the last five years, at least as long as I've been doing this work, another ploy in not having to deal with the real issue. Separate from that, why will we now have a two-tiered system, if this bill is passed?

Mr Gingrich: Under the service agreement approach, obviously each facility will have its own agreement with government on its operation. I guess our fear is that there's nothing to guarantee that it'll be renewed. It has to be renewed each year, as I understand, and our apprehension is that it could be broken, for whatever number of reasons. It is of course very important that we have an agreement to operate our facility.


Mrs Cunningham: So you're saying that if in the contract the government demands that you provide certain services, and given the money that you are able to get, either from the client or from the government of both, you can't do it if you don't fit into what it feels you should be doing. Even with less money, they wouldn't perhaps sign the contract.

Mr Gingrich: That's possible.

Mrs Cunningham: So is this the old for-profit/not-for-profit argument? It's not the same argument?

Mrs Fitzgerald: Not necessarily. The extended care portion that we know now is being amended under the Health Insurance Act so that it will no longer be defined and the service contractual agreement will go from year to year. That's really, I think, the problem we are looking at, because they may decide that they just won't renew the contract.

The Chair: I'll have to move on to the last question; I'm sorry. Ms Carter, you have the final question.

Ms Jenny Carter (Peterborough): Thank you for your presentation. Several presenters have said that they don't like the inspection system that's been proposed and you said that you thought the Advocacy Act now makes that unnecessary. I wonder if you could enlarge on that.

Mr Gingrich: Not totally unnecessary. I've called it the compliance management program. I think that's necessary and I think it's doing the job, to date, that it was intended to do, and I don't believe that we have to go back to the inspection type of model. But certainly residents have the opportunity today for an advocate to act on their behalf if they feel they are not being treated fairly. I just think there could be an overlapping by covering it under this act and also having an Advocacy Act to protect the residents.

Ms Carter: Of course each individual will now have a service agreement with the facility, and presumably if there were any discrepancy as to how he was being treated he could appeal to an advocate on that.

Mr Gingrich: Right.

The Chair: I'm sorry; our time is up, but I want to thank you very much for coming before the committee this morning for your presentation and for answering our questions.

Mr Gingrich: Thank you.

Mr Larry O'Connor (Durham-York): Mr Chair, I might just ask for a clarification from our ministry staff on the compliance review versus inspection and if there is a difference, because maybe that might enlighten the committee as we're getting settled.

The Chair: Okay, very briefly.

Mr Geoff Quirt: I'm Geoff Quirt, acting director, long-term care division. I think it's important to point out that the current Nursing Homes Act doesn't contain the words "compliance adviser," nor does it reference the compliance management program. It still uses the word "inspector," which is the kind of language lawyers like to use to define that function specifically. It's clearly our intention to continue with a consultative compliance management approach, the same approach we use now, even though the legislation now says "inspector."

The Chair: Thank you. I'm sorry; we're here to listen to the witnesses. Comments can be made during questions.


The Chair: I will call on the representatives for Saint Luke's Place to come forward. Welcome, lady and gentlemen. If you'd be good enough to introduce yourselves, please proceed.

Mr Don Attridge: Thank you. I'd like to introduce to you, firstly, Ms Elizabeth Lovely, who is the staff representative of Saint Luke's Place and also the chief steward there. Also here are John Kauffman, our administrator, and George Boniface, who is a member of our board. With that introduction, I myself am Don Attridge, a tenant in Saint Luke's Place.

The Chair: Welcome.

Mr Attridge: I'd like to present to you the feelings of the tenants and residents and staff members of Saint Luke's Place this morning. As I said, my name is Don Attridge. I am a tenant and a board member of Saint Luke's Place and I am here to present some serious concerns of the 154 tenants, 146 residents and 143 staff members of Saint Luke's Place.

We live and work in what we believe to be one of the finest seniors' facilities in the province. Established in 1976, Saint Luke's Place is a non-profit charitable facility for seniors from all walks of life, sponsored by the congregation of St Luke's United Church who donated the land for the building and provided the necessary volunteers for the startup of operations.

As the attached pamphlet shows, it is a well planned and constructed facility where the residents' and tenants' interests are always a priority. That's appendix A.

Since its opening in 1976, the board, all volunteers from the community, set high standards, hired competent staff and has built and maintained a very high reputation for continuum of care provided to its seniors. The fact that I am the president of the tenants' association and a member of the board of directors shows that the philosophy of the board is one of listening and making sure resident concerns are quickly and appropriately dealt with. This is also demonstrated by the highest awards of three years' accreditation received in 1985, 1988 and again in 1991 from the Canadian Council on Health Facilities Accreditation.

The working partnership with the ministry officials has, to my knowledge, always been excellent and very cooperative. The board and its staff are accountable to the community and our seniors through its public meetings, especially the annual meeting where the board of directors is elected and the budget or bylaw changes are approved, as shown in the minutes of the last 1991 annual meeting, attached as appendix B.

As you may sense, we are very proud of our seniors' facility, the open manner in which it is operated and the continuum of care it provides. When we moved in as tenants -- and I would like to stop and say "we" here is my wife and I -- we knew we would be able to live in this facility regardless of what care we were going to require, except for acute hospital care. The apartments would allow us to remain independent as long as possible. If temporary care was required, the staff from the home for the aged would be able to provide it and, if permanent care became necessary, we would not have to leave our spouse or friends and move to another facility but could move into the home for the aged or a nursing home attached. The sense of security that comes from knowing this is very important and most comforting.

It is therefore most disturbing to us that the present government has introduced a bill that seriously threatens a number of values we have worked very hard to obtain. The most threatening of these is the suggestion in section 5 of Bill 101, where the minister will designate a placement coordinator who will have the authority to decide when and where we will go and when care requirements force us to move from the apartment into care.

This appears to threaten our previous understanding. It looks very much like we will be entirely dependent upon an outsider making the decision of when we will be eligible to move from the apartment to the care section of Saint Luke's Place or, worse, he or she has the power to force us to accept another locality.

We chose to live at Saint Luke's Place because we share its philosophy, the participation and input at the volunteer board level; the excellent care provided in the care section. Bill 101 appears to remove this security and freedom of choice. This is going backwards many years and must not be allowed to happen. We urge you to please carefully reconsider the language in Bill 101 giving such powers to an appointed individual.

The other consequence of this section of Bill 101 appears to be that the volunteer board of directors may become redundant. They could lose control of effectively governing the facility, since they may have no say as to who will live in the care sections or what level of care can responsibly be provided.


Saint Luke's Place, as its mission statement points out in appendix C, has a volunteer board committed to care for its seniors and staff and are determined to act as advocates for the elderly. They have done so most successfully in the past 16 years, having gained a reputation for being most sensitive to us seniors and accountable to the public for all their actions. It is most disturbing, therefore, to think that the government would appear to be saying that the board should hand over their keys to a government-appointed individual and become subject to inspections by an inspector to see whether the regulations were precisely observed.

The great strength of Saint Luke's Place is its individuality and pride in being different. The input of many hours, expertise and dollars from volunteers who personally take pride in providing the best care stands to be lost if the incentive of being different, independent and free to progress in the interests of us elderly is removed and replaced by a legalistic system of regulations and inspectors.

The operations of Saint Luke's Place have been open to the public. We have been and are accountable to the government and the community. We do not need to waste taxpayers' dollars on a new system of rigid regulations and inspectors whose primary concern is to see that regulations are met.

Regulations denote a minimum standard. As such, they remove the incentive to staff to give their best, for the tendency in a legalistic system is to make sure the law is observed to the letter, leaving less interest or energy to provide above and beyond what is required. Surely, accountability is necessary, but where that exists and evidence shows that the residents are very content and happy, why introduce a system that encourages sameness? Why make a home that is operating beyond the minimum standards without additional costs conform to a lower standard? We will all lose.

We think Saint Luke's Place is different where we, as seniors, are allowed to be different, where we can be ourselves, where we can arrange our rooms the way we like with our own furnishings, except for the mattress and drapes because they have to be fire-retardant -- we understand that. Don't make us put all our beds in the same way with a dresser and bedside table that matches. Leave us our dignity and self-respect to make choices and decisions as much as we are able. Strict legislation has a tendency to remove this and makes us into robots. Surely that is not what redirection of long-term care is about. This, in our opinion, would be misdirection.

I have taken considerable time of this committee and I appreciate this, yet there is one more point I wish to make.

In the last two years the facility has had to lay off staff because of lack of funding. The result is a decrease of some services to our residents. Under the proposed funding system there is nothing to indicate an increase of funding, yet some residents will be required to pay more -- rumours are, up to $300 or so per month -- yet seniors who stay in their homes will receive the services required for free, whether they are able to pay for them or not. Are we, as seniors in facilities, being asked to subsidize those staying in their homes? This brings a question to mind: Is our quality of care being underfunded to allow for free home care? It would certainly appear like this.

We don't know yet the exact amounts people are going to have to pay in facilities for care, but whatever it is, why should people in their own homes also not pay if they're able?

In summary, we make the following recommendations:

(1) That the role of the placement coordinator be one of assisting in coordinating placement in cooperation with the administration of the home who retains ultimate liability for the care given.

(2) We urge that the coordinator be legislated to respect the seniors' choices.

(3) The legislation must allow the facility to retain its distinctive mission and difference, be it an ethnic, religious, cultural or geographic distinction, with the ability of residents to progress in a continuum of care in the same facility.

(4) Do not allow the legislation to destroy most valuable volunteer input and enthusiasm by overlegislation and an inspection system that will create legalistic institutions where the seniors individuality and freedom of choice becomes secondary.

(5) Let the funding system be fair to everyone, whether they are in a facility or their own home and where government funding is required. Let it be adequate for the quality of life we require.

In closing, please do not ever allow us to go back to the old stigma that was attached to senior facilities not so many years ago. I thank you for allowing me this time for a presentation on behalf of the residents, tenants and staff of Saint Luke's Place.

The Chair: Thank you very much. I think we've just had a few presentations by tenants' associations and we really appreciate your coming and sharing your thoughts with us. We'll start the questions. If I could just remind members of our tight schedule today and perhaps impose the Speaker's rule from back home: one question, one supplementary. If you're subtle and skilful, who knows what you can work into those two questions, beginning with Mrs Caplan.

Mrs Caplan: A good choice. I hear well your concern about questions. We've heard the same thing. I know you were here for the previous presentations so I won't repeat the questions, although in your answer to my one question and one supplementary I'd appreciate it if you would comment on the discussion from the previous presentation around those areas you've addressed in your remarks as well -- compliance, other approaches and particularly the statement of principles.

My first question really would be to ministry officials or to the parliamentary assistant. I know the parliamentary assistant is a lawyer as well. I would like to ask why the ministry, in response to everyone who has come and said terms like "inspector" are outdated, outmoded and so forth, is not considering more up-to-date modern legal language when everyone is asking you to do that. This new legislation is an opportunity to really change and be forward looking and we know we find new words, new language and new definition all the time in legislation. It seem to me that the government is being stubborn in a way which is not necessary. All the time you have court interpretation dealing with new language in terms such as "total quality management" and "continuous improvement." Words like "compliant management" are now common in our language. I think this might be an opportunity for the government to be a little more progressive and change the language to reflect what we're hearing from people. Are you willing to consider a change in language in this legislation?

Mr Wessenger: As I understand your question, you're not asking us to change the basic concept of insuring accountability, and in the system you're asking a question of just the words that are used rather than the terms that are used. Is that correct?

Mrs Caplan: What you're hearing is that language is very important in the message it sends out in legislation, and so the language becomes important as to the response you're going to get. Everyone agrees there has to be accountability; you've heard that from every presenter, but everyone is also saying find new language we're more comfortable with that is not the adversarial old style. I'm asking you if you would consider finding that language. It has been suggested and recommended. You've heard these people say it and presenters before them.


Mr Wessenger: I certainly am prepared to look at other language. I will ask counsel to indicate, though, whether they think there are any problems in that. As we're all agreed, we have to have the accountability in the legislation and have the powers in there, but it's the question of maybe some terms some people find somewhat offensive.

Ms Gail Czukar: I'm Gail Czukar. I'm counsel with the Ministry of Health. Another term could be used besides the word "inspector" and the same powers and responsibilities and obligations on that person could be retained in the legislation.

Alternatively, or in addition, the section dealing with quality assurance could be changed. I think there's already been a suggestion made that we're certainly looking at alternatives to the term "quality assurance" to encompass what I understand to be a broader concept of quality management or quality improvement. The answer is yes, we could use different language, and my understanding is that we're looking at that.

Mrs Caplan: My supplementary to the presenters is that what I've heard you say is that just the language change may not be enough because you would be also concerned about the approach or the duplication since you're an accredited facility as well. Would you feel that within this concept of quality management approach perhaps a mandate for quality management and a mandate for accreditation might in fact be more accountable than the old style inspector as we see it today?

Mr John Kauffman: If I may answer this, I agree very much with you that it would be more accountable, simply because the inspector approach gives us a feeling of someone coming in to look for violations, which is the key word that is used all the time. It sets up an attitude of a negative feeling and a threatening attitude. The accreditation approach is very positive, it is very cooperative and it strives for going far beyond the standards that are set and. It looks to these.

It also has a far greater emphasis on direct resident care than the inspection approach does. The inspection is legalistic with regard very much to the aspects that surround the residence itself. You find the "inspector" coming in to look at whether particular rules are observed rather than talking to and observing the residents. The accreditation approach very strongly strives for looking at how the residents' care is achieved and the aspects surrounding it.

I would also like to comment that I find your principles, what you call the statement of principles, quite acceptable. I think they would be very easy to work with. Again, it sets up an aspect of cooperation that you've suggested.

The Chair: Mr Attridge, did you want to comment on that?

Mr Attridge: Yes. As far as the word "inspector" is concerned, my only comment is that in Saint Luke's Place I feel quite solidly in saying that we have over 300 inspectors in our building. The board, the staff and the administrator -- having to sit where I sit in the hot seat between both, I know they don't get away with too much.

The Chair: That's inspection.

Mrs Cunningham: Which shows the total disregard of some people who put things in writing around legislation. They haven't been out there in the real world to know how it works.

My question is with regard to your residents' council. It's so refreshing to have a group like you come before the committee today because when you go back into the history of your own establishment, it was a church group that got it started. You're still there and you're still working on behalf of the citizens. Some of us around this table, my colleague Mr Hope and I especially, are very concerned with this legislation because we want to qualify some day to get into some kind of place where people will take care of us. We talked about that last night.

Mr Randy R. Hope (Chatham-Kent): Nobody will take me.

Mrs Cunningham: With too many rules, Mr Hope and I just would not qualify. We know that, so we're here to make sure.

Mrs Caplan: You would qualify.

Mrs Cunningham: I don't know. Some days I'm not sure. The people of London don't always believe that.

Mr Hope: It's going to be a long time before I'm there, though.

Mrs Cunningham: Oh, I don't know, Randy. You keep going the way you are and I don't know.


Mrs Cunningham: But residents' councils aren't mentioned in the legislation, are not referred to in any way. I'm just wondering what you think about that.

Mr Kauffman: Maybe the president could speak first.

Mr Attridge: On which?

Mr Kauffman: With regard to the residents' councils.

Mrs Cunningham: Yes. You're not mentioned. This is a form of housing, let's face it. Tenants' associations have all kinds of powers, but here you're not even mentioned.

Mr Kauffman: No. From an administrative point of view, I would very much support the idea of having the residents' council or whatever organization you have of residents and tenants and the participants who live there as a part of the facility and its management. We use the tenants and the residents very much in our management decisions.

Mrs Cunningham: Could you advise the committee as to this quality control issue, that this would be one of the groups that would have some say or interest?

Mr Attridge: They definitely have a lot to say in our place. The residents' council meets far more regularly than the tenants' association does. They come up with positive suggestions and the administrator's invited to sit in when there is a controversial item so that he hears it firsthand and then it's taken care of from there by the proper committee.

Mrs Cunningham: We'll be looking for this kind of amendment from government members because this is a group of people -- tenants -- it's always been very concerned about. We'll look for that amendment. Thank you very much.

Mr O'Connor: I want to thank you for coming here today. It's always a pleasure to hear from people who reside in there so that we can hear their concerns directly. Just taking a look at your brochure, I could see where there are little subcommittees of the residents' council meeting. Whether it be over a game of cards or maybe by the pool table, I'm sure there are ideas that are discussed right there that end up being brought up when the residents' council does get together.

A question I've got and that I'd like to ask staff here -- maybe I'm putting them a little bit on the spot here -- is that it seems that these people have talked about the fine facility they've got. They're high-ranking in the accreditation process. They've scored in the top three times, which I guess is a tribute to not only the people who help maintain it but of course the residents and pointing out problems before they do become serious.

I guess the question I've got is that, in taking a look at the accreditation process, are there facilities that may be approved through an accreditation process that may actually have a problem? I think what we're hearing is that the accreditation process will work if we stick to that. When we look at the legislation, we have to find out why we wouldn't just go to that, or are there problems with that?

Mr Quirt: Yes, we highly recommend facilities to go through the accreditation process , but from our point of view there are some limitations to that. For example, virtually every nursing home in the province of Ontario is accredited. To me, that doesn't mean that the government doesn't have a responsibility to monitor care in those facilities and it certainly doesn't mean that we can stop inspecting, period, because every one of them virtually is accredited.

Secondly, the accreditation process, as has been demonstrated here, happens on a fairly infrequent schedule. If you do very well, the inspectors or the accreditors don't come back to see you for a period of three years. Certainly with a nursing home, or a home for the aged for that matter, a great deal can change in three years. A nursing home might have three different owners in three years.

Thirdly, as has been pointed out by some presenters, the accreditation process is a process that reviews the facility from the point of view of having the appropriate administrative policies and procedures and having the right committees in place. As I mentioned earlier, it's a very valuable process to go through. Many facilities say that going through the process of becoming accredited is the real value as opposed to the certificate that says you are accredited. As I mentioned earlier, we support it and pay a premium to those facilities that are accredited. However, we do note that it's quite possible for accredited facilities to be problematic from a compliance management point of view. This is in no way a reflection on the accreditation process, but we do often have many complaints from accredited facilities.

From my perspective and, I think, the perspective of my staff, while we highly recommend and value the accreditation process, it's not a substitute for a compliance management program that would respond to individual complaints from consumers and deal with the quality of care side of the equation.


Mr O'Connor: In following up with that, we heard even earlier today and before that there's a great deal of nervousness out there about the sanction approach. It seems like there's that heavy-handed approach, that the government's going to go in there and place heavy-handed sanctions, and of course it's going to affect the care. Could you comment on the sanctions. Maybe it's similar to an approach that's in place now, but maybe people who have come today would like to hear that.

Mr Quirt: Okay. First of all, I'd be more comfortable with language in the bill that didn't say "inspector." That's the language we have now in the bill, and as these representatives know and the nursing home industry is aware, our approach is a consultative compliance management approach. Sanctions are something inherent in that which we'd use only as a last resort. Our first job is to respond to a complaint from a consumer or to point out a problem with the operation of a facility, show some ownership over that problem, provide a suggestion on how it might be dealt with and try to be as consultative and collaborative as possible with the facility. Sanctions would only be used when all other efforts didn't produce the desired improvement in resident care.

The Chair: I will just allow anyone a comment.

Mr Attridge: Just as a quick comment, it's not only the word "inspectors" that was referred to by the member of parliament over here; it's the powers attributed to this. You know, a rose by any other name is still a rose, and I would simply like to say that we are concerned over the powers of one individual, and possibly without appeal. This is another thing that's not built into here. We may be told, kind of arbitrarily, what we're going to do, and I don't think there's any place in this day of life for that. Thank you.

The Chair: Thank you. The parliamentary assistant had one point of clarification.

Mr Wessenger: Yes. I note your question on page 6 about saying, is there any difference of treatment between those persons remaining in their home and those living in facilities? I'd just like to point out that people living in the community have their nursing, personal care and quality of life programs paid for. People living in facilities have their nursing, personal care and quality of life programs paid for. People in the community pay their own accommodation, as do people in the facilities.

The Chair: I want to thank you very much for coming before the committee, not only for your brief but also for the various documents you've appended. We appreciate it very much.

Mr Attridge: I made just one error. I forgot to introduce our past president of the board, Bob Pettitt. He was sitting behind me. I couldn't see him, so I forgot him.

The Chair: Welcome, Mr Pettitt, as well. Past presidents of the board are very important.


The Chair: We call our next presenter, We Care HomeHealth Services. If you would be good enough to come forward and make yourselves comfortable and, once settled, be good enough just to introduce yourselves for the committee and for Hansard, then please go ahead.

Mr Jeff Hitchcock: Good morning, everybody. My name is Jeff Hitchcock. I'm one of the owner-operators of We Care HomeHealth Services in Kitchener-Waterloo. We're a private duty nursing home health care company. Mr Ron Hoppe, a friend and colleague of mine, is part of the franchise system that we have across Canada. Nationally, we have a variety of offices. Mr Hoppe has been the spokesperson in regard to the agenda that we have brought forward this morning and he's going to speak to some issues that are of paramount importance to us from our point of view, being a private home health care company.

Mr Ronald G. Hoppe: Good morning, Mr Chairman, committee members, ladies and gentlemen. While Bill 101 does not directly impact upon the provision of home health services with regard to the private sector, I think it's important that we are here this morning in so far as Bill 101 does bring effect to many of the changes in the redirection of long-term care which were stated in the consultation paper that was released some time ago.

To that end, I would like to share a few comments and observations and raise a few points with the committee this morning which we believe to be relevant and related to the overall larger picture with regard to the redirection of long-term care in the province of Ontario.

As Jeff said, We Care HomeHealth Services is a proprietary provider of nursing, home care and family support services in individuals' homes. While the name of We Care may not be that well known in Ontario, as our organization is newer in this province, we have been in business for almost 10 years and are well established in western Canada. In fact, we are by far the largest provider of these types of services in the western provinces.

The issue we would like to focus in on and speak to most specifically this morning is the government's stated preference to utilize only a not-for-profit service delivery model in the provision of home health care services. I think it's also important to say that our company, in appearing here this morning, is not doing so only based on self-interest. It is worth noting, I believe, that at the present time our organization is not involved in contracting with the province of Ontario in any manner whatsoever. Therefore, this proposed change in policy would not result in us losing any business or any revenue whatsoever. Nevertheless, we feel it is very important that we speak to this issue.

At the same time, I would like to preface our comments by saying that we are not here advocating the abolition of not-for-profit service providers. In fact, in many provinces where we operate, we work in conjunction with and side by side with not-for-profit service providers. We support the contributions made by some of these not-for-profit service providers and believe strongly that both commercial and not-for-profit service providers have an important role to play in the delivery of services.

As I said, Bill 101, while not directly impacting upon the delivery of these services, is related to the larger issue which is the redirection of long-term care in the province of Ontario. In undertaking this redirection, the government set forth a series of eight goals which it was hoping to achieve in this process.

Those goals -- I'll recount them quickly -- are as follows: the integration of long-term care, health and social services, improved access to quality services, creation of community alternatives to institutions, greater consumer participation and control over the services they receive, promotion of racial equity and cultural sensitivity, realization of funding equity across the province, enhanced protection for the rights and security of service workers and a continued preference for the not-for-profit service delivery system.

Again, while we generally support these goals, it is the proposed methods of achieving these goals that cause some concern. Again, specifically, the concern we wish to speak to this morning is that the government's preference for not-for-profit service delivery model appears to us to be based only on political philosophy and that no rational, empirical or logical reasons have been brought forward to support this position.

If I may indulge the committee for a few moments I'll review some of the reasoning which has been brought forward to support this position. I will admit that these reasons are few; nevertheless, they are all the reasons we've been able to uncover.

Firstly, in June 1992, the Minister of Health indicated to the standing committee on estimates that commercial operators were capturing a disproportionate share of the homemaking services market and that this was taking place primarily in the larger urban centres. Not-for-profit service providers had expressed their concerns that they were then being left to service only the more remote and rural areas where delivery costs were higher.

One question this raises that hasn't been discussed to the best of our knowledge is: Why were the commercial operators capturing a larger portion of the homemaking services in these urban centres? Was it perhaps that they were able to provide these in a more responsive manner? Was it perhaps that the consumer preferred to utilize the services provided by a commercial operator? I think that is a very, very key question that needs to be answered, especially as it relates to the goal of giving the consumer greater participation and control over the services they receive.

With regard to the not-for-profit sector's concern about an inequitable distribution of the workload between urban, rural and remote settings, perhaps a fairly simple solution to that would be to have any future tender specifications require that commercial operators be able to serve all geographical areas. I'm very confident that commercial operators would respond to this challenge and provide services to rural and remote areas effectively and efficiently.


Another issue that was raised to justify the government's position and concern over the utilization of commercial service providers was concerns relating to the Canada Health Care Accessibility Act, those concerns being that the utilization of commercial for-profit providers in fact may be contrary to this act. This act guarantees public administration of universally accessible health care. If this were a valid complaint, what about doctors? They operate on a for-profit basis. What about hospitals that today are contracting out everything from management services to laundry? What about other provinces that contract out a portion of their home care services? While I'm not appearing here this morning purporting to be any expert on the Canada health act, I do know that the issue is not contracting out, the issue is public administration, and no one has suggested doing away with that.

At the same time, during the estimates process in June 1992, the then Minister of Health also had indicated for the public record that, "decisions haven't been taken that will have an immediate impact on the commercial sector." While these comments were being made, at virtually the same time the minister was issuing directives to home care administrators across the province of Ontario absolutely, positively prohibiting them from further utilizing the services of commercial or for-profit operators. In issuing this directive, there was only one slight problem: The Minister of Health forgot to communicate this to some very important people. This is a point to which I'd like to return in a few moments.

Has any other rationale or supporting data been provided by government to support its position on this issue? Unbelievably, none that we were able to find. I note that a legislative research assistant is here this morning and I'd simply like to add to that comment that if this information does exist, it certainly isn't being shared in the public arena.

With regard to the potential impact this decision to support not-for-profit providers only will have on the provision of home health care services, I think this bears a few moments of discussion as well. Certainly, one of the results will be that more responsible taxpaying private businesses will close and with regard to the potential financial implications of this decision, again, government has not provided any analysis in this area. May I suggest that even a cursory review of the day care scenario will foretell the result.

What happened in day care? Private operators were forced out; private sector jobs were lost; huge additional expense to the taxpayer; no additional day care spaces. The same fate, I suggest, looms in the area of home care if the not-for-profit service model is pursued. What will happen? Private operators will be forced out; private sector jobs will be lost; huge additional expense to the taxpayer; no additional home care services for the citizens of Ontario. In fact, the day care situation was and is such a disaster that one of the government's staunchest supporters -- and I'm referring to the 8,400-plus CAW union members -- has listed this as one of six reasons it was considering withdrawing its support for the current government.

Earlier, I touched upon the minister not communicating her position very well to some important stakeholders. While it is one thing for the general public not to be fully informed, here are some comments of two of the minister's fellow NDP MPPs on this issue, remarks made within the last two weeks, some as recently as five days ago. Said one NDP member, "The government, in suggesting that for-profit agencies will be eliminated, is a little premature, it's not going to happen." Said another NDP member -- this five days ago -- "The government should never have announced this preference for not-for-profit when they have nothing in place to support such comments."

Mrs Cunningham: I bet they're not ministers.

Mr Cameron Jackson (Burlington South): And they won't be.

The Chair: Order, please.

Mr Hoppe: The elimination of commercial service providers will not contribute to the achieving of the stated goals of the redirection of long-term care; in particular, improving the access to quality services. In fact, many quality services today that are available will be eliminated. The elimination of commercial service providers will not achieve the goal of community alternatives to institutions. The community is only an alternative to institutions if it's also economically viable. Certainly, this will not achieve the goal of greater consumer participation and control of the services that citizens receive.

There is one further goal on which I would like to particularly comment. That is on the goal of enhancing the protection of the rights and the security of service workers. While this agenda might be consistent with the general NDP plan, there are a few unique points to consider relative to home care services. The nature of the work is such that there is some fluctuation in the workload. If you are assigned to a client who is receiving 20 hours of service a week and, unfortunately, that client becomes hospitalized or services are discontinued for some other reason, that work will not be available to you in the short term.

To guarantee service providers 40 hours, or whatever the number of hours of work per week, regardless of the client's need, I would suggest, simply might not be realistic. The rights of all employees, whether they're in the home care sector, in manufacturing, in retail -- whatever sector they happen to be in, we suggest that their rights in Ontario are already sufficiently protected through existing labour legislation.

In the Redirection document on this topic, the government also expresses its need to provide more training, thereby being able to justify higher rates of pay and increased job security. We respectfully suggest that there's a workforce with the necessary skills and that the issue at the moment might not be one of providing more training to people with lesser skills. Rather, it's an issue of matching the employee's skills with the client's needs. Training qualified individuals currently working as homemakers to be nurses' aides, for example, when there is currently an abundant supply of nurses' aides, somehow seems to be counterproductive.

In conclusion, let me clearly and directly state our opposition to the government's stated preference to use only not-for-profit service delivery agencies. While Minister of Health, Frances Lankin strongly promoted this preference and issued directives to preclude further private sector participation in the provision of home care services. From our perspective it is utterly hypocritical, but sadly indicative of a political philosophy gone mad, that on Tuesday as Minister of Health, Ms Lankin strongly supported a position which would severely harm private home care companies and their employees, and then the next day, on Wednesday, now as the new economic superminister, stand up to the microphone and proclaim that: "improving the NDP's relationship with the private sector and job creation are among (my) top priorities. If we want to create jobs in this province, the private sector has to be a part of that. We have an economy that needs to be pushed."


With regard to the impact of the government's position and directives on our organization, as I said, we are not currently within the system, so at the moment we don't stand to lose any existing opportunities. However, to comment fully on this topic would provide enough material for a further 30-minute presentation. However, it is sufficient to say that in a province that prides itself on providing equal rights for all, extra special rights for groups claiming to be disadvantaged and extremely extra special rights for politically expedient socialist causes, it is inconceivable to us that a legitimate, qualified, taxpaying corporate citizen such as our organization would be precluded by a whim of government from competing for contracts when other similar private companies are entitled to preferential treatment for no other reason than that they happen to be there first. Thank you.

The Chair: Thank you very much for your submission and for coming before the committee. I just remind members that we are tight for time -- one question, one supplementary, hopefully tight. I also remind the members that we're here to listen to the deputations. There will be plenty of place for vivid discussion among ourselves in the Legislature. We'll begin with Mr Jackson.

Mr Jackson: Jeff, Ron, thank you very much for your presentations. It was a bit of a breath of fresh air as you discussed the realities of health care in this province, which are that if our focus is to make our system as accessible as possible with choice, then we have to have an arrangement under regulation that accommodates the private sector, because there is not a study existing anywhere in this country which shows that government can do something less expensively than the private sector.

Having said that, I just want to reinforce my political party's support and my colleague's and mine with respect to -- we assisted in building the system in this province. We believe the partnership with the private sector achieves two things: increased access points and a responsible use of taxpayer dollars because of the balance and the blend between private and public services.

Your analogy is so absolutely appropriate. We have seen several handicapped organizations come before us asking why the government broke its election promise of creating pilot projects which empower handicapped individuals to purchase their own services yet this government has plowed $200 million down the toilet, frankly, to expand day care facilities when day care centres are closing as fast as the government can build and reopen them. As you noted, there are fewer day care spaces today in Ontario than there were a year ago.

Mr Hoppe: It is sad to say.

Mr Jackson: We just don't want their made-in-Havana day care policy to become their made-in-Moscow home care policy. I commend you for your presentation and appreciate the clarity with which you presented.

Mr Drummond White (Durham Centre): I'll try to avoid responding to my friend --

Mr Jackson: You'll get no argument that way.

Mr White: -- because his idea of health care is of course made on Wall Street. But regardless, the issues that you bring up I think are very valid. I have some friends who run some services like your own.

Mrs Caplan: Are they still your friends?

The Chair: Order, please.

Mr White: Yes, they are very much still my friends. Those issues have not been dealt with adequately. I certainly am aware of the public statements that you referred to. However, that's in reference really to your sector. In reference to the private nursing homes versus the not-for-profit homes for the aged, my understanding is that the Ontario Nursing Home Association is very much in support of this legislation because it brings nursing homes up to the same level of funding and footing for their ongoing expenses as the not-for-profit sector. This is a totally different situation in regard to the institutions than it is for those services in the community. While I agree with your concern as being valid in your arena, in this arena it's quite the opposite. Here we have this made-in-Havana policy which is actually bringing for-profit centres on board. Mr Jackson's language may well apply in your area, sir, but not in regard to the homes for the aged and the non-profit sector. In fact, it's the not-for-profit sector, the homes for the aged, that were so regularly saying, "Why are you doing this to us?"

Mr Hoppe: With all respect, I will grant you those views. I started out my presentation by indicating that I was not here this morning to comment specifically on Bill 101, realizing that this is primarily what it's dealing with. Rather, I was wanting to comment on the specific area of home health care services as they are a part of the larger redirection and Bill 101 is facilitating many of the things that are encompassed in that self-same policy of redirection.

Mr White: In the minister's statement she very clearly indicated that there'll be no attempt to change the balances we presently have. In fact, it brings things up to standard.

Mrs Caplan: The action doesn't fit with the words.

The Chair: Order, Mrs Caplan.

Mrs Caplan: She said one thing and did another.

The Chair: Order.

Mr White: I hope we will hear more from you, sir, when we move on to long-term care direction. This is only the first phase of it and I hope you'll remain an active participant in the process.

Mr Hoppe: I appreciate that invitation and I can assure everyone present here that you will hearing more from us. As the time is short, and with respect to the time, perhaps we could pose one question to members of this committee. It's a question that we are certainly most anxious to receive some sort of answer to, and that is the question I raised in my closing remarks. That is, time and time again we hear that government hasn't taken a decision, that a final decision hasn't been made, that it's the status quo, that the commercial sector isn't being adversely affected. Here we are. We're looking to expand in Ontario. We're looking to create jobs. We're looking to rent office space. We're looking to do all kinds of things that business activity generates. The question of qualification doesn't arise.

We're equally qualified, as or more qualified than any existing service provider, yet it is this self-same government's directive -- apparently it's not a policy; perhaps the difference needs to be explained to me -- that despite our qualification, despite our abilities and despite the fact that no decisions have been taken, we are to be arbitrarily precluded simply because we weren't here last year, we weren't here the year before.

Again, in this day and age of equal rights for all and extraspecial rights for some, we aren't appearing this morning requesting your sympathy or your support. We aren't here requesting favouritism. We aren't here requesting extraspecial treatment. We are here simply pointing out that we are experiencing some frustration at being treated less than equally.

Now, could someone provide us with some reasonable explanation as to why this is the case? Morally and ethically, it's an issue. Perhaps it's even an issue legally. We're not going to start getting into big legal hassles with the province of Ontario. The market for our services is huge and we can pursue that elsewhere. Nevertheless, it is important. We are frustrated and it appears to us to be highly, highly unfair.

The Chair: Thank you. Ms O'Neill, last question.


Mrs Yvonne O'Neill (Ottawa-Rideau): I am very pleased that you have highlighted the contradictions surrounding this whole matter. There's a great deal of uncertainty. Business plans are totally in jeopardy. That was brought to our attention here last night. The only solid evidence we have in writing is that there was a press release in December that stated there would be a preference for non-profits. Other than that, everything has been verbal.

We are members of the Legislature. We have very accurate knowledge. I presume you belong to the Ontario Home Health Care Providers' Association. Certainly we meet with these people and have every right to and want to be very well informed of their needs. They have attempted to meet with the minister and that's not been possible, even though it's an umbrella organization representing literally thousands of people in this province. That's very, very distressing when we know that there are things going on, when we know that there are movements within the Ministry of Health indeed to look at solely not-for-profit providers.

I'd like to ask you two things, because we've had people who are in agreement with the government come before us and some of the accusations they make are that your staff are not well trained and do not do a good job. I would like to know what profit or, as I would consider, small business people do to train their staff, to have that on the record. I'd like to ask you, have you seen -- and I'm not sure of the municipalities that you are in across the province -- any change in the relationships you are having to municipalities as well as the one you already mentioned?

Mr Hoppe: With respect to your first question and these complaints that for-profit staff are not well trained and are not doing a good job, I think such a broad comment is utterly unfair.

Mrs O'Neill: I agree.

Mr Hoppe: Within the for-profit sector there may have been some bad staff from time to time, as there has been in the not-for-profit sector. This is, again, a discussion that could go on for the whole day.

What steps are being taken from our side in our sector to ensure that staff are appropriately trained, that staff are doing a good job? First of all, it's our perspective that a high priority in providing safe, effective care is the appropriate matching of the skill level to the client or the patient's need, ensuring that quality assurance programs are in place and are being followed. I know from firsthand experience that the private sector is now in possession of very advanced technology which enables the cost-effective, safe provision of care services in the most efficient manner ever possible.

With regard to the second question, if you could perhaps just --

Mrs O'Neill: Have you noticed any change in your relationships with municipalities since this uncertainty has developed around your --

Mr Hoppe: Again, I would simply say that being a new organization and trying to become established with some of the municipalities, the only effect that we have noticed is one of tremendous confusion in talking to the municipalities, receiving absolutely contradictory responses to our questions from people across the hall from each other in the same department, receiving absolutely contradictory answers from a superior to one of the workers, and that's only in the situations we are able to get any information at all.

The Chair: Thank you very much. I regret that our schedule means that we have to close off.

Mr Hoppe: We respect that and we look forward to a future opportunity.

The Chair: I think you have put a number of questions before the committee. We will be considering those. Thank you again for coming.

Mrs Caplan: I would like to correct the record.

The Chair: Just one moment, please. I just want to call the next witness and then we'll deal with that. Would the representatives from the community and government relations committee for Region 3, Ontario Association of Non-Profit Homes and Services for Seniors, be good enough to come forward.

Ms Caplan, you wish to correct the record, very briefly.

Mrs Caplan: Yes, thank you. A couple of days ago, Mr Chairman, I referred to a meeting that took place between the Ontario Home Health Care Providers' Association and the government. Inadvertently, I suggested that that was a meeting with the minister. I want to clarify that it was not a meeting with the minister because the minister had refused to meet with this organization. In fact, she refused to meet with them even after being directed by the Premier to meet with them.

The meeting was held with a policy adviser from the minister's office and a policy adviser from the Premier's office. The statement I made was that the message from the government to the association at that time was that there was no place for the delivery of home health care services, or in fact health services, by the private sector was the policy of the government. Further, at that meeting the negative message to the private sector was that by directive they had already begun to move to instruct municipalities not to use the services of the private sector. I wanted to clarify that for the record.

The Chair: Thank you for that clarification.


The Chair: Gentlemen, welcome to the committee. If you would be good enough to identify yourselves for Hansard and then please proceed with your presentation.

Mr Robert Pettitt: My name is Robert Pettitt and I'm the chair of the community and government relations committee for region 3. With me are David Rudy, representing St Joseph's Home in Guelph, John Kauffman from Saint Luke's Place in Cambridge and Brian Ayer, a board member from St Joseph's Home in Guelph.

As indicated earlier by a previous presenter, I am also the past chairman and a member of the board of directors of Saint Luke's Place in Cambridge.

The Chair: You're welcome in both capacities.

Mr Pettitt: Thank you, sir. I want to emphasize that I'm here on behalf of the volunteer boards of directors of 23 non-profit homes which form our constituency, so we represent elected and volunteer board members as opposed to staff and residents. Not that our interests are any different, but we do represent that constituency.

As we've indicated in our presentation, our committee is comprised of elected and volunteer board members of homes for the aged in region 3 of the Ontario Association of Non-Profit Homes and Services for Seniors. Region 3 encompasses the geographical regions of Halton and Waterloo and the counties of Bruce, Dufferin, Grey, Huron, Perth and Wellington.

You will notice that we've listed the number of volunteer directors associated with the board of each particular home on the first page. Region 3 includes 23 non-profit operating homes for the aged with 3,032 beds, seniors housing programs and other services which assist seniors who live in the community. Collectively, these facilities would average over 50 years of service for each home.

As we age, our lifestyle choices are increasingly limited. They can be physical, financial, cognitive or a combination of limitations. With the present emphasis on maintaining the elderly in a community setting and utilizing scarce community services, choices are becoming even more limited. It appears that the choice to become a resident in a long-term care facility may not be available. Concerns such as loneliness and various psychosocial disabilities ought to be accepted as legitimate admission criteria for an approved long-term care facility.

The new proposed standards for facility admission tend to dehumanize seniors in need of care and support because they appear to remove the element of choice to determine when, where, how and with whom to live, socialize, spend their time, their money and to be able to exercise their right to die with dignity. In the proposed system, the placement coordination service will have the final word in determining what a senior's needs are and where they can best be met.

Even though the proposal gives lipservice to the importance of input from the senior, as long as the agency has been given the final authority of when, how and where to live, the senior will be left to the mercy of the system without recourse or an equitable and expeditious appeal process. The proposal leaves the senior open to abuse by either having to remain in his or her own home against any expressed wishes, or being placed in a facility which may not be of his or her choice. The legislation must respect the right of choice of the senior in making the final decision.

While the proposed standards indicate a PCS structure as having final authority in determining the placement of an applicant, it must be recognized that the admitting facility requires the authority to determine if the care needs of an applicant can be safely met, since that facility has that legal liability.

For several years, government documents have encouraged residential alternatives. A number of facilities have responded by providing a wide range of services for seniors in facilities on the same site. Proposed legislation does not recognize the right of residents to move to other levels of care located on that site which are also part of the continuum available to them in that supportive community.

Saint Luke's Place is a specific example of continuum of care where we have apartments, residential care and extended care. The facility allows people to move from one section to the other as their care requirements increase.


With respect to funding, there are a number of concerns centreing around the funding issues which are as follows: The new funding ignores the principle of funding care based on demonstrated need. The proposed funding system simply redistributes the currently available funds, with a small increase in resident contributions in a different way. It is a reallocation of underfunding and not of funding enhancement. It will reward those who have provided limited services and penalize those who have developed a wider range of services.

Many municipalities and charitable corporations will be required to continue their current levels of contribution. In many cases, non-profit providers will have to increase their share of funding as the province freezes its contribution. Municipalities currently contribute about $90 million and charitable organizations raise about $20 million annually just to cover the operating costs of their homes, because provincial grants and resident fees are not sufficient to cover their costs.

Government statements indicate that resident contributions will increase by about $150 million, but in reality they will simply replace withdrawn provincial funds.

If assets are not included in the residents' maintenance payment calculation, or are not available for recovery from their estates, then general tax revenues will be required, even though the resident might well be able to meet that additional cost.

The province is contemplating a completely changed approach to capital funding. It must be recognized that if long-term care facilities are not able to develop any surplus in their operational budgets, there will need to be funds generated, either through an adequate depreciation factor or through grants which are sufficient to meet equipment and building capital costs.

In its Redirection of Long-Term Care paper of October 1991, the present government stated, "Funding to nursing homes and homes for the aged will be increased to improve services for residents and to ensure that increasing care requirements can be met effectively." If funding of anything less than the 1992 average cost per resident day is implemented, there will be the following effect.

Facilities with operating per diems of under the average will be able to provide enhanced programs that many other facilities cannot afford.

In homes with operating per diems of over the average, services will not be enhanced, but will be reduced and staff layoffs will occur.

The average extended care per diem cost in homes for the aged in the province of Ontario for 1992 is $102.73.

As such, our recommendations are as follows: Placement coordination services, along with facilities, must be given joint decisions, making responsibility for placements according to need and ability to meet the need. Facilities, especially those operating under the Charitable Institutions Act, must be able to continue to maintain their distinctiveness and their long-established mission. Seniors must be able to access facilities for personal reasons, such as cultural, emotional and social reasons. Recognition of the continuum of care and the right of choice for residents to relocate on the same site is imperative. Facilities must be given authority to maintain maximum capacity.

The option must be provided for residents to request and receive services above those which are regulated by government, if they are able and willing to pay the costs for those enhanced services. The allowable per diem for funding purposes must be increased to at least $110 to recognize the reality of current operating costs. We must provide an economic adjustment factor for the red-circled portion of funding to homes in order to allow them to shift the emphasis on the services they now provide. We must provide one-time grants to charitable organizations, allowing them to eliminate accumulated deficits and start with a clear slate. We must allow a sufficient depreciation factor to provide for the replacement of capital equipment and building replacement.

We must commence within the first quarter of 1993 a recognized workload measurement study to determine accurately the care costs to be used in setting funding levels, allowing the government to meet its stated mandate of 1991. Lastly, assets and income should be used in calculating the residents' contributions toward their maintenance fees. Thank you, Mr Chair.

The Chair: Thank you very much for your submission and also for listing at the front the various homes within your group. We'll begin the questioning with Mr Wessenger.

Mr Wessenger: Thank you very much for your presentation. My first question is with respect to -- as you are aware, there are differing care levels in different institutions throughout the province of Ontario. Do you think it's fair that people with similar care requirements receive different-type services throughout the province?

Mr Pettitt: Do we think it's fair that they receive different --

Mr Wessenger: Different services, as is presently the case. Do you think people with similar care requirements should receive the same level of services?

Mr Pettitt: I think generally that would be the case; they should receive the same services.

Mr Wessenger: The next question I would like to ask you -- as you may be aware, some institutions provide exceptionally good care in the province, but it's been estimated, for instance, to bring up the level of care to that provided in Metropolitan Toronto at the average home for the aged would cost approximately $800 million, which would be a substantial amount of increase in taxes to provide that increase. I ask you to just consider the aspect that the only practical way of trying to deal with this is to try to bring up those at a lower level on a gradual basis to meet the level of those at the higher level, I would suggest, otherwise you are looking at a substantial infusion of money into the whole system.

Mr Pettitt: I guess the alternative to that is to reduce everybody else to the lowest common denominator and that's what we're trying to avoid as well.

Mr Wessenger: We do not want to see the individual -- that's why there's no reduction in funding for the high level of homes.

Mrs Caplan: I don't like to repeat a lot of the points I've made before with other deputations, but you have mentioned a number of things that have been mentioned before. I want to know if you would support an amendment that would permit long-term care facilities to refuse an admission that was required by placement coordination on the grounds that it was an inappropriate placement and care could not be provided, provided there would be the right of the client to appeal that, or the right of the placement coordination service to then appeal, so that you would give the choice to both the provider, the institution, as well as to the client who was looking for an appropriate placement. I think what sometimes happens is that somebody may want to come to you and you don't believe you can really provide that care for them. Do you think that would be a better approach than what exists in the legislation today?

Mr Pettitt: I think it's a step in the right direction, yes.

Mrs Caplan: Did you hear the statement of principles?

Mr Pettitt: Yes.

Mrs Caplan: Would you comment on that?

Mr Pettitt: We would take some comfort in the addition of a statement of principles, because it does address the element of choice.

Mrs Caplan: Would you like to see it in the legislation, as opposed to in regulation?

Mr Pettitt: I prefer it in the legislation itself. I think part of the difficulty in dealing with Bill 101 is that there are so many sections of the act that refer to "in accordance with the regulations." We haven't seen the regulations and we have no idea what the regulations are going to include. I always have a great fear of government or legislation by regulation.

Mrs Caplan: I agree with you that excellence cannot be legislated. I don't think behaviour can be legislated. I think generally enforcement models don't work. If you want accountability you have to find the kind of environment which will encourage people to take pride in what they do and then stand accountable through either a process of accreditation or a process which requires a quality management program to be in place, and that only if there is an inability to meet these standards set by the accrediting agency, or if there is a complaint which is then founded, should the government be able to take action. I wonder if you would support that kind of an approach, rather than the big stick enforcement approach this legislation seems to be imposing.

Mr Pettitt: We'd certainly be in favour of that approach.

Mrs Caplan: Is that what you have in place now?

Mr Pettitt: Pardon me?

Mrs Caplan: I'd like you to compare that with what you have in place now, or how you've changed in the last little while.


Mr Pettitt: Our experience as non-profit homes operating with the Ministry of Community and Social Service in the past has been one of cooperation and partnership. I think that's the type of atmosphere we would like to encourage and see carried on as opposed to one of enforcement or an adversarial type of situation. Our fear is that we may be moving towards the latter.

Mr Jackson: I appreciate the clarity of your recommendations and the way they're set out. On recommendation 3, earlier you were present and you heard the reference to day care. I want to talk about this issue because it's of concern to me. The leading indicators of stress for seniors have to do with the wellness of a spouse, a move or the passing of a spouse. These are the three most significant issues around stress for senior citizens. The notion is that in many of your facilities there is a continuum of access to the various stages of care, comfort and accommodation. This legislation doesn't provide for the protection that you'll be able to maintain your relationship with your spouse in the same location.

If I use the day care analogy -- this is why your response earlier about how these kinds of protections have to be entrenched in legislation is imperative -- are you aware that under day care rules this government has brought into place as of very recently any subsidized day care space requires that the child has to go to a non-profit centre? You have cases where in a family of two or maybe three children the policies of the government specifically divide families and force a child to go to one centre and the brother or the sister to go to another centre.

Given that this government has already brought into place policies that divide families, we are having difficulty taking its word that it's going to protect senior citizens in a similar fashion. I'd like you to comment about the need for entrenching in legislation, with proper language, protection for spousal relationships and continuum of care and placement to ensure that their needs are met, because certainly this was a major decision for a government in North America, to specifically have a policy that divided families and separated them. Since we've had a precedent from this government, we don't want it repeated now with senior citizens at the other end of the spectrum.

Mr Pettitt: When St Luke's Place was built in 1976, it was encouraged to establish a continuum of care. Originally, the facility had apartments and residential care only. We found that as our residents aged we required extended care and we then moved into extended care. We have had a number of situations where spouses have come into the apartments and one of them, for whatever reason, may have required more care and then has gone into residential or the extended care wing of the home. It allows the spouses to maintain a relationship because they're still in the same physical location or building. It's extremely important that we maintain that choice for them. Residents come into our home expecting that this is going to be their situation, knowing that if one of them requires more care he or she is not going to be separated from his or her spouse or moved to another facility unless it means he or she has to go to the hospital, which he or she knows is unavoidable. My response would be yes, continuum of care has to be entrenched. That's why it's one of our specific recommendations.

Mr Jackson: I appreciate that, because there's medical evidence that the health of the healthier spouse diminishes rapidly when there is this forced separation, when they were anticipating being close and accessible. Many of the facilities in my community have this continuum program, and the notion that when you're finally moved you're in place.

My final question has to do with recommendation 12, and that has to do with assets and income. We're not getting much commentary before this committee on this, but you have, and I appreciate that. Some have cynically suggested that the government is moving strictly to an income test, because it is anticipating doing a brand-new tax on seniors' assets for survivor benefits -- and this is a huge tax that's coming -- and by calculating assets at or near a time when the Treasurer is looking at taxing them for another purpose is at cross-purposes with the government's desire to grab more revenue. That's what's cynically been suggested here, but I appreciate the fact that you've noted that assets and income should be calculated as opposed to the government simply saying, "We'll look only at income and not at assets when determining fees." You may want to expand on that based on your experiences with your charitable homes.

Mr Pettitt: I think our approach is that we're looking for a system of fairness and equity. Fairness and equity mean that assets as well as income must be taken into the calculation, otherwise it's conceivable that somebody could have considerable assets that are earning no income that could in fact be used to pay for his or her care and not be a burden on the other taxpayers in the province.

The Chair: Thank you very much for being with us this morning and for your presentation.

Mr Pettitt: Thank you for the opportunity.


The Chair: I would now like to call the representative from St Joseph's home for the aged. While they are coming to the table, I would like to note for the members that we have received a brief from the Dufferin Oaks Home for Senior Citizens. I believe they are here today. They're not on the schedule of witnesses but they have brought a brief. I've asked the clerk to circulate that to all the members so that their written comments will be part of our record.

We want to welcome the representatives from St Jospeh's to the committee. We have received a copy of your presentation. If you'd be good enough to introduce yourselves to the committee and for Hansard, then please go ahead.

Mr Brian Ayer: Thank you, Mr Chairman, and good morning. Good morning to the MPPs and ladies and gentlemen. With me are the president and chief executive officer of St Joseph's Hospital and Home in Guelph, Sister Margaret Myatt, and the vice-president and administrator of our home, St Joseph's in Guelph, Mr David Rudy. My name is Brian Ayer and I'm a trustee of St Joseph's Hospital and Home in Guelph.

The board of trustees of St Joseph's Hospital and Home wishes to express its support to this government, as well as prior governments, in initiating long-term care reform to replace a number of programs with one act of legislation. More importantly, we are supportive of the concept of providing services to the disabled and older persons who are able to maintain residence in their own homes.

The Sisters of St Joseph's of Hamilton established a home in 1861 in Guelph. Since that time, St Joseph's has met health care needs of the community in an acute and chronic care hospital and, for older people specifically, in a home for the aged. That service has been available to anyone, regardless of race, colour, religious persuasion or ability to pay.

Along with other non-profit homes for the aged in Ontario, St Joseph's has been able to work with the government on a partnership basis and has developed programs and facilities which support the changing needs and desires of the older population of our community. During the past 10 years St Joseph's has assisted people living in their own homes through its outreach programs. The Out'N'About day care centre assists many frail elderly people who are still living in the community, some alone and others with children. The therapeutic program provides stimulation for the body through exercise activities, various craft programs and mental stimulation through educational and recreational programs. A nutritious noon meal is also provided.

The Alzheimer's day care centre provides support to the person who has been diagnosed with an Alzeihmer's type of dementia or other cognitive impairment. The goal is to maintain an optimum level of physical, mental and social functioning for each participant. The program offers support and relief to the care giver and assists in delaying institutionalization. Family members can bring the participant early in the morning and pick him or her up late in the afternoon, enabling care givers to be gainfully employed, if necessary. This innovative program is designed to meet the needs of the participant rather than requiring the participant to fit into the parameters of the program. Will a legislative solution to long-term care allow the excellent and innovative leadership that has been in place? We wonder and doubt it.


St Joseph's Home is an accredited facility through the Canadian Council on Health Facilities Accreditation and has recently received a three-year award for a survey held in November 1992.

With the proposed implementation of long-term care legislation through Bill 101, we are very concerned with the authority which is given to the placement coordination services without apparent accountability. PCS agencies will have the final word in determining the senior's needs and how they can best be met. The goal is to keep seniors in the community. Even though the proposal addresses the importance of input from the seniors, the PCS agency has still been given the final authority over them. We will be left to the mercy of the system by removing the element of choice. These choices are made from a holistic perspective. This proposed legislation deprives the individual of the right of choice based on his or her physical, psychological, spiritual and social needs.

Placement coordination service, as it is proposed, will be able to admit persons to a long-term care facility and the facility cannot refuse to admit that applicant without any consideration in terms of the facility's ability to provide the staffing to adequately meet the care needs of the individual. The facility will only be able to have staffing levels to the point where revenue levels meet operating costs. Will the placement coordination service share in the legal liability which a facility assumes in caring for its residents? Who will be accountable for the residents placed in the facility?

For the past five years the increase in funding has not kept pace with increased operating costs, most of which are not within the control of the home; namely, arbitrated awards, pay equity, increased Workers' Compensation Board assessments and other legislative impositions. Wages account for over 75% of operating costs. The proposed funding level does not allow adequate staffing levels to meet the care needs of applicants to the home, most of whom present with cognitive impairments as well as physical disabilities.

Because of an antiquated building and a long distance to the dining room and activity areas, over one half of the residents in St Joseph's Home require wheelchair support. All reserves have been used to meet operating costs and no funds are available for major building renovations or equipment replacement. We have appended some financial data. The current proposal does not relate funding to the level of service which is required.

The government has stated that, "Funding to nursing homes and homes for the aged will be increased to improve services for residents and to ensure that increasing care requirements can be met effectively." It is common knowledge that the average per diem cost in homes for the aged in Ontario is above $102. Is the government committed to ensuring there is funding to meet "increasing care requirements" or will case mix index funding be based on available dollars? If the latter is the case, then we are looking at a program of warehousing the elderly.

When the government of the day decided to license the profit-making nursing homes, it implemented an inspection system to ensure that regulatory standards would be met. The statutes were revised and are viewed as placing the facility in a confrontational position with respect to the ministry responsible for the inspection process. For over 50 years, the non-profit homes for the aged have worked together with government on a partnership basis to develop a program which recognized the primacy of the individual as being paramount with respect to one's dignity, security and self-determination. Operating boards of management, directors or trustees, elected or appointed by their communities, are held accountable for the operation and management of each particular facility. The information is public and the goals are in the best interests of the residents. Part of the trustee's task is ensuring the quality of the program for which they are responsible. At St Joseph's this is accomplished in conjunction with the process of the Canadian Council on Health Facilities Accreditation, where each facet of the facility is measured through a quality assurance-risk management function. Imposing an inspection compliance system does not guarantee quality; it will simply ensure adherence to minimum standards. Excellence cannot be legislated.

Mr Chairman, it is not our intent to be supercritical of the proposed legislation. We do feel, however, there is erosion of the principle of voluntary governance leading to less autonomy and flexibility of governing boards to determine the nature and purpose of their organization as well as its policies and direction. The ability to be creative will be stifled. The proposed legislation appears to be very restrictive rather than enabling, and the concept of governance and authority of the voluntary board will be seriously undermined. The control the government appears to be assuming will not be in the best interests of the elderly who are dependent on the social system of this province.

We respectfully request the following amendments to the regulations under Bill 101 be considered prior to third reading in the House.

(1) Bill 101 must balance the principle of accessibility with the need for a high quality of life. Therefore, the placement coordination model must give due consideration to each person's preference.

(2) Bill 101 must also recognize the right of facilities to make informed choices in the best interests of the applicant and their current resident population. Therefore, appropriate access to an appeal mechanism must be guaranteed.

(3) Utilize a recognized workload methodology to determine accurately the care costs to be used in setting funding levels.

(4) Provide one-time grants to homes for the aged which will operate under the Charitable Institutions Act, allowing them to eliminate accumulated deficits.

(5) Abandon the concept of inspection in all non-profit homes through enhancing the role of ministry program supervisors.

We support the government's commitment to long-term care reform. Very important are regulations which identify resident contribution, plus a methodology of funding which will be adequate to meet the care needs of the residents who live in our facility. It is important that the redirection be done right the first time.

May I ask, then, we go to the final page, which provides a very abbreviated financial statement relating to the prevailing conditions at our home.

If we examine the equity in the home at March 31, 1984, we had $944,883. The estimated equity in the home nine years later -- $524,320. There has been a substantial run-down of our equity base which cannot be allowed to continue. We have created in the past year a substantial cash deficiency which, you will see reported at March 31, 1993, was $170,000.

We believe at St Joseph's we have a responsibility to our residents to operate our home in a fiscally responsible manner, so that their presence, their comfort, their peace of mind can be ensured. We feel we have been invited by government to provide a level of service that government, in fact, has not been prepared to fund.

Perhaps if I could close, Mr Chairman, by inviting all the creative MPPs here -- if they would look back, there are questions on, I believe, pages 3 and 4 -- one which addresses mix index funding. The other concept we are particularly concerned to report back to our board of trustees is the concept of legal liability with respect to placement of residents in our home. Hopefully, the imaginative MPPs here, without going to supplementary, can roll those both into one question.

The Chair: Thank you very much. I think this is the first time where, very skilfully, the witness has turned the questions back on the members, but rightly so, and I noted those as we were going through. Thank you very much for that. We'll move to questions and perhaps answers as well. We'll begin with Ms Fawcett.

Mrs Joan M. Fawcett (Northumberland): Thank you for your presentation. I think that is an excellent question you pose and possibly some of the ministry staff will be able to give you an answer. We wonder and doubt about the very things you wonder and doubt about. There is no doubt about that.

If I could just ask, though, you've gone through the classification system, I would assume, and I'm wondering how you found that. We've had some concerns expressed to us that perhaps the Alberta system doesn't fit Ontario, and I wonder whether you thought it really suited that. Also, whether you feel the funding that will result from that is going to be adequate or whether you have some concerns around that. Are you suffering from hardship because all of this has been later than you expected it to happen? We have been assured that March is the magic month that you possibly will hear about the level of funding, and yet I have also heard that maybe it won't be ready until next September, so those are all concerns.


Mr Ayer: I will ask Mr Rudy to respond to that, but I would say our plans at St Joseph's were based on an expectancy that long-term care funding would be in place January 1.

Mrs Fawcett: Right.

Mr Ayer: It's a matter of grave concern that these financials speak for themselves. It's a matter of grave concern to us that the matter then -- in fact, March, as you have said, Miss Fawcett -- the concern becomes ever greater if in fact that funding is further delayed. It's imperative that the funds -- I suggest microcosmically that the statement we produced is not much different from statements of other charitable homes in the province, and the level of underfunding from our point of view, speaking as a trustee, is absolutely intolerable.

With respect to your question, I'll ask Mr Rudy to deal with it, please.

Mr David Rudy: Thank you. In terms of the classification process, I think if it were done today, you would find the level of care that is evident in the residence is much different than it was last fall when it was done.

I guess this addresses the question in terms of the people referred by PCS, as well the change in people who are there. So there's a great concern, not only that the funding for the classification mix might be adequate, but that the level of care will increase or can increase quite dramatically between the period of time when classification is done. Of course, the staffing patterns will be set, as we said in the brief, on the basis of the funding that's available, so that leaves cause for great concern.

Mrs Fawcett: It concerns me too. Thank you very much.

Mr Jackson: I will leave to the parliamentary assistant and his penchant for getting advice from legal counsel to answer your second question. However, I have no doubts as to where the liability lies and government has an uncanny ability of making sure everybody else has liability and not it.

However, having said that, I want to commend you for raising an issue which is perhaps the most difficult, central issue around long-term care, and that is about the difficulty in making decisions about giving the needed care, or care based on the needs of an individual versus what the government says we will fund, because government has decided that's all the dollars we have. That simple statement speaks to the major tension which exists in long-term care in our province.

I've not said this for the record, but I am going to today, that particularly Catholic or charitable homes for the aged are having a great difficulty with this dilemma. It's perhaps in its very humanitarian or Catholic nature that these homes desire to operate on a model which recognizes these quality-of-life issues, and quality of life means something a little different than what is being thrown out at these public hearings. Quality of life has a much more significant issue in a Catholic hospital, as it does in a Catholic home for the aged.

Now, without overstating that, I'm one of 10 children who were brought into the world by the Sisters of St Joseph's in Hamilton, so my mother can speak at length about that issue. I want to ask you, because I think it's at the root of your first question, about how you are prepared to deal with the issue of a regulatory framework which says these are the limited dollars you have in terms of how you will meet the needs of those residents versus your mission statement and your motivation for service and care, and whether you're going to be able to deal with this contradiction, given the legislative framework as it is before us today. I hope the Sister will have an opportunity to comment.

Mr Ayer: She certainly will.

Mr Jackson: Thank you.

Mr Ayer: We are concerned. We have decided at St Joe's that our mission statement is important and very critical to our responsibility to our patients. Anathema to us would be the concept of warehousing our residents. We would prefer to close down rather than face that as an alternative.

What is so discouraging to us is to provide the level of care specific to each resident. Our concern is to provide that level of care as efficiently, as compassionately as we can without concern about -- we run our hospital, our home, as efficiently as we can. Our concern always is our patient in the context and as described in our mission statement.

We talk about the fund mix specific to the question you address. Our concern is that there is not sufficient planning. We don't see information that satisfies us in Bill 101 that addresses the specialized needs, the specialized extra cost. We don't like to even talk about that in terms of care.

The cost and the level of funding -- and Mr Rudy and Sister can talk about the hours involved depending upon the requirements of each patient. There does not seem to be room to address the increased needs, therefore increased costs. Our concern is to provide the highest level of quality of care to our patients and residents. We're extremely distressed that the process of doing that -- it would seem it's going to be aborted by the shortfall of funding that we understand may in fact prevail when Bill 101 is finally dealt with and passed and brought to parliamentary passage. Sister.

Sister Margaret Myatt: Thank you. In the hospital and the home, which are both on our site, the method of funding is quite different for both, and therefore the ability to control costs in the hospital is different than the home. In the hospital we can close beds, cut services and our expenses go down, the revenue will cover. In the home, of course, the funding is quite different. If we do not have patient days, we do not receive revenue, so that's on a very mercenary level. The two things are quite different.

However, as Mr Ayer has said, our philosophy would not allow us to provide either warehousing, as it's quoted, or inappropriate level of care per patient or resident, and therefore our board has taken a stand, and the Sisters support it, that if the funding is not adequate in the future, the home will indeed be closed.

Over the years, and we've been on the site there over 130 years, we have not restricted access to the institution, either in the hospital or the home, based on ability to pay as one criterion only. In that sense we have, as well as other charitable homes -- I'm not saying other charitable homes don't do the same thing -- run up an increased deficit, for which we are solely responsible.

The Sisters have been very generous in supporting that deficit. We have fund-raising campaigns. We do all those good things to try to offset our deficit. It is becoming increasingly difficult, if not impossible, to do that. We're at the point now where we're at a critical decision, even though in Guelph, as you probably know, the plan for us to rebuild on the site a new long-term care facility is in place. If the funding is inadequate for that new facility, let alone for the current one, I'm not sure what it holds for the delivery of long-term care in Guelph. That's a big unknown at the moment.

Mr Jackson: Thank you very much.

Mr Norm Jamison (Norfolk): Thank you. I notice that many of you are here as part of more than one delegation. That shows the umbrella of the network out there.

I'd like to really address your first recommendation that deals with the placement coordination system and your concerns around that. I'd like to inform you that the placement coordination approach is intended to ensure access to those persons in greatest need. The current system we have does not really ensure this. Many in homes could be served in the community, for example, while people in great need of facility care remain in their home today. The access system itself, I think, through the process of these hearings, will also promote consumer choice -- I think it's important that I say that today -- including responsiveness to cultural and spiritual preferences. Amendments to the legislation are under consideration so that this may be made more clear. The system will also ensure that people will be placed in facilities which can meet their needs. That's the purpose of the facilities' right of refusal. The placement coordinator will also assist the prospective resident by providing a single point of accessing the system and by providing greater information on the choices available.


Finally, it's important to note that the placement coordination system will promote the efficient use of beds by giving priority to those in greatest need. More people in need will be placed and this will reduce the demand for the funding of new beds. This in turn, I think, conserves funds for community service expansion. That deals with the whole funding situation also. I just wanted to say that because I think that by saying that some of your concerns may be addressed in that light.

With regard to the question on funding, we have to realize also that in many cases currently some residents live in nursing homes or homes for the aged with funding levels of approximately $78 whereas others with the same needs live in homes for the aged with funding levels of $135. That's an inequity and has to be seen as that. As to the red-circling, there are going to be infusions of money. Certainly they haven't been announced clearly at this point, but the total levels have. Again, making the system more fair to everyone and as equal as possible is a very important point in dealing with long-term care.

Mr Ayer: That would suggest to me, and perhaps I didn't hear correctly, that each resident's level of need should be treated the same way.

Mr Jamison: No, that's not what I said.

Mrs Caplan: That's what you said.

Mr Jamison: I just clarified it.

Mr Jackson: On a point of information, Mr Chair: Could we get a copy of what Mr Jamison just read? It would be helpful to the committee and maybe even to the deputants if we left copies here so they can hear what the government is saying.

Mr Jamison: Those are my notes.

Mr Jackson: Oh, I can see --

Mr O'Connor: They are recorded in Hansard, of course.

Mr Jackson: Oh, okay.

Mr Ayer: May I ask, did I hear then that amendments that are being brought forward will allow the resident a choice and will also allow the institution a choice? I would like to be clear on that please, Mr Jamison.

Mr Jamison: Through sitting and listening clearly to the whole placement coordination question, those points have been made clear to the committee.

The Chair: I believe the parliamentary assistant had asked to clarify a number of points which included those, so perhaps, in terms of a number of questions that have been asked in pursuit of enlightenment, we will now turn to the parliamentary assistant.

Mr Wessenger: Thank you, Mr Chair. Yes, I'd just like to make a few comments. I certainly do understand your concern about funding. The only thing I can say is that certainly the charitable homes for the aged will be the major benefactors with respect to the increased funding to the institutional sector. I don't know how that will relate to your particular institution, but as a general group they are certainly going to benefit the most as a result of the increased funding.

With respect to the question of the placement coordination, I think it would be helpful if we had some clarification at this time for all members of the committee, as well as yourself, about how the process is likely to work with respect to the more detailed mechanism for resolving disputes when you have a situation where a facility doesn't feel that a patient is suitable, that it can't service that patient, and the placement coordinator feels that the facility should take the patient. I believe this will be set out in the program manual, if I'm correct, but that information isn't available yet. I might ask staff to indicate to the committee and to yourselves how that process is likely to work.

The Chair: If I might, just before Mr Quirt begins, when that's completed, if you wish to ask a question or make a comment, feel free.

Mr Quirt: If I might, I'll address the specific question that you had about an amendment. Yes, an amendment is under consideration to make the intention of the bill more clear. It was always our intention that placement coordinators would recognize, and to the greatest extent possible respond to, client preference, client choice. No one has to go into a long-term care facility if he or she doesn't want to, and the first question that placement coordinators will ask is: "Which facility do you wish to go into? Please indicate your choice so we can put you on the list for the facilities that you wish to be considered for." Client choice is clearly the driving factor in the placement coordination system.

First of all, the placement coordinators would be required to determine if someone's eligible for long-term care placement. In that process they would be required to make sure that consumers were making an informed choice about not only facility options in their community or elsewhere, but also community service options that they might not have been aware of previously. Placement coordinators would then ascertain which facility a client wished to go into. That might be the facility next door or it might be one with a particular ethnic or religious environment half the province away. The placement coordinator who relates to a particular facility would then be responsible for ensuring that every resident who has expressed an interest in getting into that particular facility gets treated fairly in terms of access to that facility. Only those people who have expressed an interest for a facility would be considered for admission there. The placement coordinator would then look at the list of people who have said, "I wish to get into your facility or another facility", and in a fair way determine who needs that service the most.

In the program manual there's a description of people who are in an emergency situation. It talks about people who might be in the hospital vis-à-vis people who might be at home. If you're eligible, a combination of the urgent nature of your need and another factor of how long you've been waiting would be taken into account to determine who fairly got access to the next bed available in that facility.

Clearly, the placement coordinator's job is to determine whether you really need to be in a long-term care facility, to determine whether you and your family understand the options available to you and to determine what preference you have once you understand what the options are in your community. As you're well aware, many seniors would not know the difference between a nursing home and a home for the aged, know where they were or what type of environment they offered. Once that information is provided, the consumer chooses the facility he or she wishes to be considered for and the placement coordinator determines from the list of people who have expressed an interest for each facility what's fair in terms of who should have access first.

There may be situations where the placement coordinator would have to say, "I know that you really want to get into St Joseph's home for the aged, but there's a waiting list of probably three, four or five months there and you might be able to get into your second choice a little sooner," and allow a client to make a choice in that respect.

One other possibility under this new managed system is that someone might go into the facility of his second choice and not lose his place in in line for their facility of his first choice. That's not a possibility now in the system and it's certainly not a possibility across the province. It's possible under the new system for a person who wished to go into a German Lutheran home, for example, in Kingston to know about the fact that there is one in Niagara and to be considered fairly for admission, regardless of where he happens to live in Ontario.

Mr Ayer: Mr Chairman --

The Chair: There is one further point from the parliamentary assistant.

Mr Wessenger: I understand, Mr Quirt, there's a dispute resolution process. I wonder if you might comment on that.


Mr Quirt: At this point in time, if a placement coordinator determines that someone is not eligible for admission to a long-term care facility after the person's health status, functional ability and community living situation are considered, that client who has been deemed ineligible has the right of appeal currently. The other right to appeal that's contained in the act, the right that's related to this, is the right of a facility to refuse to admit someone on particular grounds. Those grounds will be prescribed in regulation and protected in regulation.

There are two examples that members of the committee have used and we have used to illustrate how these regulations might appear. A situation where a facility did not have the structural environment that would allow, for example, for a resident who had a cognitive impairment and tended to wander to be protected in a secure environment would be one example of a reason why it would be quite legitimate for a home to refuse admission. The second example might be that a prospective resident required a particular nursing procedure or treatment and the staff of that facility had yet to acquire the skills, had yet to develop a policy on delivering it safely.

Those are two examples. As we've mentioned many times, we would expect that placement coordinators would not refer clients to the facility unless obviously there had been some dialogue. The placement coordinator wouldn't be doing his or her job properly if he or she were making a lot of referrals that facilities had to refuse to admit.

Mr Ayer: Thank you. That did answer my question.

The Chair: Were there any other comments that you wished to make on any of those --

Mr Ayer: Yes, the liability question was one that's important to address.

Mrs O'Neill: You are not the only one who has asked it, either. I think it would be great if we could get that cleared up. A written statement on that would be better.

Mrs Caplan: And also the question on the clarification amendment on the right of facilities to refuse on the basis of inability to provide appropriate care and then define it more clearly in regulation. Are you considering that as well?

Mr Quirt: At this point it's my understanding that the act allows us to specify the reasons in regulation why a home can refuse. I'm of the opinion at this point in time that such an amendment to the act wouldn't be necessary because we now have the right to define in regulation the reasons why a home would refuse.

Mrs Caplan: But we've heard from so many presenters that they don't feel that's adequate.

Mrs O'Neill: The legal liability.

Mr Ayer: Is there a point of reference in the act that we can refer to that says that?

Mr Quirt: We'll give you that reference in a moment; we're just looking it up. On the question of legal liability, I'll ask our legal counsel to comment further, but it's my understanding that the liability would not be altered under the new system. There's a certain liability held by the home now with respect to the services that it provides to residents in its care. We don't anticipate that liability would be changed dramatically. I'll ask counsel to comment further on that.

Ms Czukar: The reference with respect to homes refusing to admit a person on grounds specified in regulations is in subsection 9.5(6) with reference to the Charitable Institutions Act. I believe that if you're a charitable home for the aged, that's the one that would govern you. It just 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 prescribed by the regulations exists." The grounds that would be prescribed are the ones that Mr Quirt mentioned, subject to changes in wording and so on.

With respect to the legal liability question, I understand from page 4 of your presentation that your question -- you can tell me if I'm wrong here -- relied on an interpretation that your home would be required to have people placed there whom you did not accept or whom you felt you weren't equipped to serve. I think that's been clarified somewhat. In any event, the legal liability would rest with the corporate body that's responsible for providing the care to the resident and not with the placement coordination service if the care is actually being provided by the facility.

Mr Ayer: So we're covered to the extent that we do have a right to refuse, or at least to have that case heard if we felt such a liability were in fact before us.

Mr Jackson: You would have to appeal.

Ms Czukar: In any event, no one can be forced to go to a facility against their will, so if a person didn't wish to be placed, they wouldn't be there in terms of the facility being able to determine whether they could adequately serve the person or not. That is provided for in the section I mentioned, yes.

Mr Ayer: In detail.

Ms Czukar: The detail will be in the regulations.

Mr Jackson: You understand faith very well. You will have to take them on faith.

The Chair: At that point there will perhaps still be a few questions but we've run out of time and we'll have to move on. We want to thank you very much for coming and for your questions.

Mr Ayer: Thank you, Mr Chairman.


The Chair: I now call the last witness for this morning, the representatives from the Elliott Home for the Aged, if they would be good enough to come forward. Please make yourselves comfortable. We have documents that have been circulated to the members of the committee and if you would just first introduce yourselves and then please go ahead.

Mrs Ethel Doughty: Mr Chairman, I would like to introduce people of our delegation: Miss Marion Featherstone, a long-time resident of the Elliott home; Mr David Hicks, the administrator of our home and Mr Murray Maxwell, who is at present the chairman of our board of trustees of the Elliott home.

My name is Ethel Doughty and I am speaking to this committee today from several perspectives, but primarily as a community volunteer board member of the Elliott, a charitable, non-profit home for the aged in Guelph. I am appointed to this board by both Guelph city council and Wellington county council. I now have well over 20 years experience as a community volunteer in the long-term care sector. For three years I sat on the board of the Victorian Order of Nurses, a vital community service agency.

When our regional health council initiated the placement coordination service for Wellington-Dufferin, I was asked to represent homes for the aged on the advisory committee charged with setting up the service and putting it into operation. I chaired that committee for two of the five years I was a member.

Since both my mother-in-law and my father were residents of long-term care facilities, I also see the system from the perspective of a family member. I need not remind anyone here that we are all potential clients of the long-term care program and I should like to think that in our planning we try to relate more to the ever-increasing number of Ontario residents who are today's as well as tomorrow's clients.

I should like to tell you a little bit about our home. The Elliott has been an integral part of the Guelph community for almost a century. It was originally established as a home of the friendless by a bequest from a Mr George Elliott. That home operated from 1903 until 1963 when the present Elliott opened on a seven-acre site adjacent to the Guelph General Hospital. The Elliott is unique in that it is a charitable organization without a supporting charity; it is truly community based.

Many people in Guelph trust that the Elliott will be there for them if or when the need arises. Unfortunately, we were unable for many years to keep up with our waiting list. Now, of course, the placement coordination service keeps all waiting lists.

In an effort to address a demonstrated need for more seniors' housing in our area, the Elliott board, with the enthusiastic support and great personal involvement of the home's administrator, David Hicks, planned and developed a 78-unit life-lease apartment building. The Ellridge opened in 1987. The Ellridge residents live completely independently but can obtain some services such as meals or emergency medical care from the Elliott.

In 1991, in order to provide more supportive seniors' accommodation and possibly shorten our Elliott waiting list, another project was undertaken. This building provides supported independent living and opened in September, 1992. These residents require minimal care and are served the main meal of the day in their dining room. If desired, other meals are also available. Each unit has a kitchenette with a small refrigerator. There are, of course, no stoves, but small appliances may be used. Basic housekeeping is also provided. Once again, we utilize to the fullest the energy and expertise of David Hicks.


We now have a complete continuum of care in a non-profit setting, ranging from independent living to the full range of nursing home type care in the Elliott Home for the Aged.

Our expectation all along has been that residents would be able to move within the complex to the appropriate level of care with a minimum disruption of lifestyle. So far this has been working very well. This continuum of both residential and care options has for many years been advocated by research in long-term care. It has also been encouraged by various Ontario government policies such as the community residential alternative program. This continuum of service choices on the same site does work.

Page 20 of Bill 101 states that a person may be admitted to a home for the aged only if the placement coordinator has determined that the person is eligible and has authorized the admission of that person to the home. Since the placement coordinator is responsible for keeping all waiting lists and juggling priorities, it can be seen that the implications for continuum of care facilities are considerable.

In preparing this presentation, I went back to the Redirection paper released in October, 1991 and on which Bill 101 is based. Two points caught my eye immediately because I had previously identified them as being very important.

The first point is, "Seniors and people with disabilities want meaningful choices in order to live with dignity and respect." The underlining of "choices" is mine.

The second point is, "How do we ensure that a coordinated system of service delivery does not become another layer of bureaucracy?" After reading Bill 101, my first comment is, "Good question."

These two points, among others, cause me great concern, both as a board member and as a member of the community. I refer not only to the immediate community where I live, but to the Ontario community as a whole.

On the subject of choices, in 1968, when it became necessary for my father to seek admission to a home, our family looked around and we chose the Elliott as a place where he would be able to live with dignity and respect. The building had a homelike atmosphere, both outside and inside. We found it to be spotlessly clean. The administrator and staff obviously really cared about the residents.

In the quarter of a century since then, there have been many physical changes at the Elliott. There have been building upgrades and extensive renovations. However, the basic characteristics of the home, the principles on which we base our philosophy of care, have not changed.

Having worked with our local placement service, I have always felt that this service served a useful purpose. Primarily, it can provide information about the long-term care system to people who are becoming involved for the first time. It can help people access appropriate community services.

As our placement coordination service was originally set up, clients were assisted in whatever help was appropriate. However, if a client chose to seek placement in a facility -- and people rarely do this until they feel unable to cope for whatever reason -- the PCS would find the optimal placement for that client, taking into account many relevant factors. Placements were not finalized until the client, the family and the facility were all satisfied that the placement was appropriate.

I think the new system is supposed to work like this, and I am quite reassured from hearing the comments from the gentleman opposite, but in reading the Redirection paper, I find that placement is not really a choice, it's more like a last resort.

Page 39 of the Redirection paper tells us that every other possibility for care must be explored before placement can be considered. It appears that the social and emotional needs of the client are very low on the list of considerations if, in fact, they come into the picture at all. Should not these very personal needs deserve greater priority?

If an applicant is deemed by the placement coordinator to be ineligible for placement, there is a cumbersome and probably lengthy appeal process to the director and even to the minister. Can you imagine putting an 85-year-old or a 90-year-old through this traumatic experience?

There are people who would choose to move to a care facility for reasons of loneliness, anxiety or who find living alone, even with community services, more than they can handle. It concerns and saddens me that based on Bill 101, as I read it, such people could, and probably would, be deemed ineligible for placement and be denied admission to the Elliott or to other similar facilities.

There are other non-profit homes in our area which are as unique in their own way as the Elliott. For example, many Roman Catholic seniors hope to become part of St Joseph's home if and when they require facility care. I understand that approximately 50% of the residents of St Joseph's Home are Catholic. The home reflects this in its care and its programs.

Wellington Terrace in Elora is a municipal home and again unique in that its resident population has a predominantly rural background. I would surmise that each home has a uniqueness which makes it a real home for its residents and they have chosen to live there.

Most homes have auxiliaries -- groups of volunteers from the surrounding community whose makeup reflects the cultural, ethnic, religious or other background of the homes. These volunteer groups are very important. Not only do they raise significant amounts of money, but they provide a link between the residents and the community. They sponsor entertainment, outings, craft programs and provide a special service to the home. Our auxiliary also operates a tuck shop for the convenience of the residents.

The Redirection paper tells us that cultural and ethnic diversity is to be maintained, but I wonder how much diversity can be preserved when the proposed regulations attempt to make every home do everything the same way.

On the subject now of bureaucracy. The Elliott is managed by a board of community volunteers. We have had a whole spectrum of business and professional people on our board: bankers, professors, accountants, physicians, professional engineers, clergy and so on, all with useful expertise and experience. The focus of a board of a non-profit home is on providing the best possible care and quality of life for the residents with the resources available.

I would not cast any aspersions on the for-profit homes, but is it not obvious that a shareholder board must have a somewhat different approach and an added dimension to its focus? In spite of this difference, nearly all the provisions of Bill 101 apply to all facilities, non-profit and for-profit alike. The wording of the bill suggests that the proposed long-term care system will be top heavy with bureaucracy. It attempts to force uniformity on all homes for the aged and nursing homes.

The bill focuses on accountability, documentation, inspections and penalties. I tend to find the tone threatening and suspicious. I wonder, do the creators of this document assume we will all do bad things unless we're threatened with penalties.

Over the years we have worked to make the Elliott a caring home for our residents where each one is acknowledged as an individual, each receiving whatever care is required. Bill 101 looks at each resident as the subject of a plan of care, all aspects of which must be documented. How do you document a hug from a staff member for a resident having a bad day? How do you document emotional support, or is this not a part of care? According to the new funding arrangements such emotional support is not recognized.

The Redirection paper asks, "How do we avoid another layer of bureaucracy?" In institutions receiving government funding, a certain amount of bureaucracy is inevitable. We're accustomed to that, but the new system is piling on an incredible amount of paperwork in an attempt to do what? Impose uniformity at any cost? The term that comes to mind, and you've already heard it several times this morning, is "warehousing."

No one from government has come to our home and asked the board, "Does this home work?" Or, "Do you need help to make it work better?" We should like to ask, "Where is the data indicating that all this documentation, inspection, etc is necessary in our non-profit home?"

Do you know if the residents at the Elliott are happy? As board members, we know they are. Are their families pleased with the care? Yes, they are. Will a compliance officer, who posts a compliance notice in our lobby, make residents happier? Will requiring residents to have the regulation chair or eat the regulation meal make them happier? When will resident happiness, satisfaction and family support be measured? Traditionally in our society satisfaction is measured by complaints that are examined and, if valid, corrected. Do you have such a study of complaints from residents and families to show the degree of required change? May we see these base data? Bill 101 is heavy with inspections, compliance and penalties, but where are the references to government assistance and cooperation or resident happiness?


You may have bureaucratic data on compliance with regulations, but where are there any direct data on the happiness and satisfaction of residents and families? This is the real purpose and value of a community-based, unpaid board of dedicated trustees who have real authority. Bill 101 does not appear to give this authority for such local and informed boards of trustees. If residents and their families are happy and pleased with their care, why not recognize that fact and give authority to such unpaid community boards to set policies that continue such happiness?

As mentioned earlier, Bill 101 is heavy on inspections, especially inspections of documents. This assumes -- inaccurately, I should say -- that if something is not documented, then it was not done. What if it were done, but due to cost constraints staff time was not available to record it thoroughly? We have already experienced the first major example of this inspector style. Last September-October there was a provincial survey of resident care. Government nursing assessors entered every facility and spent several days examining records but never asked residents if they were happy or satisfied.

We can count and record such things as medications, food, staffing levels, inventories, but that does not reflect a home. In your own private home someone could inspect your records to ensure that you paid for the hydro and gas, that you have four chairs at each table, curtains the approved length in each room, but are your children and spouse happy? There is no category on government care level surveys to provide funding for such real issues as 30 minutes with a grieving resident who is distraught over a son's divorce or a best friend's death. This is the difference between a home for the aged and an institutional warehouse for the aged. Please, if changes are required, make them with more heart and less bureaucracy, with more local citizen responsibility and authority, and provide for assistance from government consultants when the local board requires help.

In conclusion, we realize that provincial governments have been trying for many years to improve the long-term care delivery system. We also realize that in today's economic climate any change is extremely difficult.

The present government obviously wants to hear from the citizens; otherwise you people would not be here today. We suggest that you also listen. Listen to the clients -- the frail elderly and the disabled -- who are among the most dependent and vulnerable people in our society. If they choose to live in the larger community, that's wonderful. Then they must be provided with adequate services efficiently delivered. If they choose another lifestyle, then they should have the privilege of doing just that.

Listen to the professional care givers, who have been dealing with the problems of long-term care for many years. Their knowledge and experience can help the system work. We are accustomed to working creatively and productively with government staff. In this regard we wish to express our appreciation for the cooperative support which the Elliott has received from our program supervisor and his colleagues in the Waterloo office of the long-term care division. This cooperative and consultative style works well and should continue. With real cooperation among all the interested parties, all of society will benefit.

I should now like to ask Miss Featherstone, a resident of the Elliott, to share her thoughts with you.

Miss Marion Featherstone: Dear committee members:

You know my name already, Marion Featherstone. I am a resident of the Elliott Home for the Aged. In my earlier years I was a registered nurse. Yesterday, I celebrated my 91st birthday. I am honoured to have this opportunity to speak to you on behalf of the residents of the Elliott.

We, the residents of the Elliott Home for the Aged in Guelph, wish to draw your attention to the fact that the Elliott is a real home for us. We are very happy with the way it operates. The Elliott board of trustees is very caring. We are pleased with the home-like atmosphere,d we know the Elliott is different from other places and we want this to continue. We are very concerned that the government inspectors will want changes. Please, if changes are required, our board and staff are quite capable. We are also concerned that government inspectors are not only unnecessary for a home like ours, but add a totally unnecessary expense to our lovely province that already has too much debt.

The Elliott is a popular choice of Guelph and district senior citizens and there is always a waiting list. We believe that these are the reasons:

The management and staff are efficient and caring. We have 24-hour nursing service. We have comfortable semi-private bedrooms and attractive lounges. We have the freedom to come and go as we wish. We do not feel cut off from our former community activities. We feel safe at the Elliott. We have well-planned and wholesome meals. We have excellent housekeeping and laundry facilities.

The Elliott doctor is available when needed or we may choose to have our own doctor. The activities coordinators supervise and direct a hobby and crafts program and also group exercises, games, music, special events, as well as communion and non-denominational Sunday afternoon service in our lovely chapel. Also, the Elliott auxiliary takes an active part in the welfare of the entertainment of the residents. They operate a tuck shop and tea room for our convenience.

While on the topic of why we freely choose the life at the Elliott, we wish to change a common misunderstanding; namely, that we are more independent when we live in a house or apartment with Meals on Wheels and various home care facilities. This is not true and I would like you all to know that. We feel trapped and lonely. We find ourselves alone many hours during the day and night, often unable to cope with daily problems and worries. We do not want to be a burden on our community. We love it here at the Elliott. Before changes to places like the Elliott are ever considered, why do you not come and ask us if we want them?

The problem seems to be that decisions are made in Toronto by younger government people who never come to talk with us. You may have received a few complaints from other places, but not from the Elliott, as far as I know. If you did receive a few complaints from other places, why not give more places the chance to work out their own problems without government interference? If residents in that place are still unhappy, then make some changes just for those places but not every place.

Since moving into the Elliott, we enjoy the security and independence that comes from knowing that we are free to come and go as we like, without any worries or personal needs. This is how we feel about the Elliott. It is not an impersonal institution. Rather, it is a real home with all the comfort and convenience but without the worry. Please do not allow this to change. You would not want your own home to be the same as every other house and have this enforced by government inspectors. Neither do we want our Elliott to be forced into becoming the same as every other home for the aged and nursing home.

The board and staff are doing a fine job. If this ever changes, we will be the first to know because we live here. We will work with the board and staff, who care for us very much. If this fails, then we, the residents, will let you know, but until that happens, please, no changes. Please, the next time you decide to consider changing the rules about our home, talk to us first and not after you have already gone so far with so much time and expense in preparing a new book of rules that is not needed or necessary.

Thank you for listening to my letter. We hope it has helped you to understand that not all seniors are the same. We cherish our difference. Thank you very much.

The Chair: Thank you very much, Miss Featherstone. I know I express the wish of the committee when, one day late, we all wish you a happy birthday and many more.

Miss Featherstone: Thank you.

The Chair: We'll move to questions. If I could just draw to members' attention that time is tight, we'll begin with Mr Jackson.

Mr Jackson: I won't have a question. I think we have an excellent brief, so I simply wish to say, if I may, to both Ethel and Marion, thank you for your heartfelt comments and thank you for sharing with us the statement which jumps out at me in this brief, "If changes are required, make them with more heart and less bureaucracy." On behalf of the seniors, I thank both of you for giving that message to us very clearly.


Mr White: Thank you very much for your excellent presentation. I'm very impressed that we have a wide group of people: a resident, board member and a director. It's a rare phenomenon when you have a group of people that close and who will work that well together.

The issues that I have concern with are the very things you brought up. You read this legislation and it talks about powers, inspection and this shall happen and that shall happen. What concerns me is that I know that's not what has happened. We've had it clarified time and time again about how this will work, but when you read it, it scares you. For people like you, who are living in a facility like that, when you hear about this sort of thing, it scares you because this is your home.

Miss Featherstone: Thank you. We feel it is.

Mr White: I just want to assure you that from everything I know -- and I have worked for five years in a home for the aged, every day, met with the 95 people who lived there; prior to changing jobs that is. I still go back there regularly and listen to them. I feel assured that this legislation is going to improve people's lot, but that's not how it reads. It reads like powers and things like that. I hope we can improve some of that language so that you can feel that assurance, so that people like yourselves who are in that situation won't be scared and uncertain about your future. Thank you again for your presentation.

Mrs Doughty: Mr White, I read the bill through and it's not what I would call a good read.

Mr O'Connor: Legislation never reads well.

Mrs Doughty: It refers mostly to amendments to already existing regulations and already existing bills, like the Charitable Institutions Act, the health care act and so on. For this reason, we have a little difficulty really being sure of what's intended because of, as you mentioned, the way the bill reads.

Mr White: The language of the original legislation is probably just as bad.

Mrs Doughty: I was afraid of that.

Mr White: There are so many pieces of legislation being worked up here, aren't there? But the intent is to improve services.

Mrs O'Neill: I want to thank Miss Featherstone and Mrs Doughty for their presentation. We've had many of these points brought up before, but I doubt with as much eloquence. The Elliott has brought forward its points with the right people this morning, I think.

I'm very impressed with the way you kept reminding us that there's a real great difficulty with this legislation in its intent to impose uniformity. We certainly feel that way. We hope there will be changes that will be sensitive. We have been given some small indications. You also talk about a threatening tone. Whether it's staff or residents, we've had that expressed often before.

I'm very happy that you brought forward your experience of the fall when the inspection or survey of the homes took place and none of you was questioned about your level of happiness. In my mind, that shows some very great disrespect for people who feel very supportive of the environment in which they live and want to be able to express that.

I don't know whether you've had time to examine the other legislation, the legislation that is now passed but has not been proclaimed, regarding the Advocacy Act and consent to treatment. I don't know whether you've done that in your residents' council, but your suggestion, Miss Featherstone, that complaints be the basis for actions by government in homes would be one that I think would be much more congruent with the Advocacy Act than what is suggested as a method of inspection in Bill 101. I wonder if you've examined that at all or how you feel the complaint system could work, and if you haven't, would you?

Miss Featherstone: We have one board member in particular, a physician, who is extremely concerned about the implications of the Advocacy Act. I'm sure that in some instances it's a very useful piece of legislation, but maybe it should be looked at from the point of view of family members and so on to make it more satisfactory to the general population.

Mrs O'Neill: Do you see it in relation to Bill 101 at all? Have you thought about how the complaint mechanism could work for you rather than the imposing atmosphere of Bill 101?

Miss Featherstone: It's mentioned in the redirection paper, at the bottom of a page, and I think that would have to be looked at very carefully, actually, in order to incorporate it into Bill 101.

Mrs O'Neill: Please keep looking. You're doing good work.

The Chair: The parliamentary assistant has a final comment.

Mr Wessenger: I certainly thank you very much for your thoughts. I certainly know how homes for the aged contribute to such a home-like atmosphere for their residents, and it sounds like yours is one of the best. One thing I'd just like to elaborate on is that I know people say language isn't suitable, it's outdated. One of the problems with the situation is that amending legislation is very difficult, cumbersome and complex, but even more difficult than amending legislation is creating new legislation.

What the government has elected to do here is to amend the legislation so we can get the reform through more quickly than we otherwise could. I can assure you that we are looking at introducing comprehensive new legislation at a future date after the policy statement on long-term care comes in. At that stage, when we bring in this comprehensive legislation, we can try to have more suitable modern language. We'd like to do it, quite frankly, but I'm a lawyer and I know how difficult it is to go through this process. We felt that it was important that we get the reform stated now in order to raise level of care.

I'd just like to ask you one question with regard to the placement coordination service. I assume you're quite happy with the way it works presently in Guelph.

Mrs Doughty: I didn't really say that, because at the moment -- I don't have a lot of experience with that since admissions are handled through the administrator. When we set it up originally, we thought it worked very well and I really don't hear a lot of complaints about it, except that the placement coordinator, under the new legislation, appears to have complete control. We have some questions about that and some concerns.

Mr Wessenger: I'd just like to ask you, do most of your admissions go through the placement coordination or all of them?

Mrs Doughty: They do at the moment, I think. Is that not right?

Mr David Hicks: Up until a few months ago we had been maintaining our waiting list for people who, through experience, had determined that the Elliott is their place of choice. They felt quite informed about the options and so came to us directly. With news of the way the government was moving, we didn't want those people to be left without any further options should the rules totally change. We've had an excellent relationship with the placement coordination service and people who have gone through there have been referred to us as well.

Now, we've shifted our entire waiting list, which was approaching 100, over to placement. It's working smoothly between placement staff and ourselves; the problem is with the community. A person like Mrs Featherstone, when she first came to the Elliott, had known the Elliott from her involvement in the community. They feel that we're not treating them as openly as they'd like to be because we're saying, "You have to go over there and see placement." "Why?" This is an 85-year-old who's confused. "My mother was at the Elliott. My aunt has gone to the Elliott. I've been on the Elliott auxiliary. I only want to go to the Elliott. Why can't I just come and get on your waiting list?" That's where there's a confusion, but we're doing the best we can to work it out.

Mr Wessenger: Fine. Thank you very much.

The Chair: I want to thank you all for coming this morning and for your presentation. It was extremely well done.

To the members of the committee, before adjourning could I remind everyone we have a very tight schedule this afternoon. We must begin at 1:30. The bus will be at the hotel at 6:15. I would ask everybody to make every effort to be back here at 1:30. This meeting stands adjourned.

The committee recessed at 1210.


The committee resumed at 1330.


The Chair: Good afternoon, ladies and gentlemen, as we all scurry in from the cold and grabbing lunch. Let members get their coats and boots off and come back to the table. As they do that, I would just note that it's the standing committee on social development, and we're here to review Bill 101 dealing with long-term care.

Our first witness this afternoon is the Victorian Order of Nurses from Brant-Norfolk-Haldimand, if they would be good enough to come forward, or I should say if she would be good enough to come forward. I'm sure it's quality over quantity.

Welcome to the committee and thank you for coming today. If you would be good enough just to introduce yourself, both for the members and for Hansard, and then please go ahead with your presentation.

Mrs Cathy Chisholm: Thank you, Mr Beer, and good afternoon. It's a pleasure to be here today to make this presentation to the standing committee on social development. I am Cathy Chisholm, the executive director of the Brant-Norfolk-Haldimand branch of the Victorian Order of Nurses.

The Brant-Norfolk-Haldimand branch of the VON began its community service in the city of Brantford with a staff of one nurse in 1907. Demand for services grew and was expanded over the years to include all of Brant county and the counties of Norfolk and Haldimand prior to 1972. Today, the head office of the branch is located at 446 Gray Street in Brantford. There are suboffices in Cayuga, Delhi, Jarvis and Simcoe.

A staff of 130 nurses and 250 homemakers represent a tremendous range of experiential and educational backgrounds. The volunteer board of directors represents a cross-section of the entire branch area, bringing a variety of skills, expertise and community awareness to their governance role, which includes the responsibilities of fiscal management and strategic planning.

Programs currently offered by VON Brant-Norfolk-Haldimand branch include visiting nursing, visiting homemaking, foot care, Alzheimer respite, enterostomal therapy, occupational health, palliative care, early obstetrical discharge, intravenous therapy and placement coordination.

To meet the challenges of the future, the branch is exploring a variety of integrated modes of service delivery. Pilot projects are under development for implementation in the 1993-94 year. In one part of the branch, a team of workers will include registered nurses, registered nursing assistants and levels 1, 2 and 3 home support workers. In another area, the branch is seeking to develop collaborative partnerships with other service provider agencies.

It's from the perspective of a multiservice agency and a major community service provider in the current system that VON Brant-Norfolk-Haldimand branch offers these comments on the proposed legislation, Bill 101. The areas of concern that I will outline include continued fragmentation of the system, limited empowerment of the consumer, inspection and control versus quality management, allocation of resources and placement coordination.

While I certainly acknowledge that Bill 101 was not intended to be the final piece of legislation in connection with long-term care, and there has been some attempt to pull together some facets of the long-term care system, however, there has been a significant piece of this system that has been ignored thus far and that is, in particular, the community sector. The picture presented is not, at this time, one of a redirected, fully integrated system.

Bill 101 is an incremental improvement in that it starts to standardize legislation for long-term care facilities, but does not replace the separate legislation and does not address chronic care beds. VON believes that because the tone of the amendment is incremental, it can be interpreted as less than comprehensive, and it would be most unfortunate if this happened, since the government's vision of system redirection is much broader.

We have a recommendation that the passage of Bill 101 amendments be delayed until the publication of and public debate on the government's long-term care redirection policy framework, and further, that Bill 101 then be rewritten to include the entire spectrum of long-term care.

With respect to limited empowerment for the consumer, we acknowledge that Bill 101 begins the empowerment process in that it allows for direct funding grants to the physically challenged, it ensures consumer access to key information regarding facility services, care, accommodation and consumer knowledge of the care plan and allows for an appeal process regarding eligibility for service.

We offer further recommendations. We support the incremental improvements and recommend that the changes be expanded to include requirements for residents' counsels in all long-term care facilities. VON recommends that consumers have a choice of whether to receive needed services in a facility or community setting within an envelope of available resources. In short, the consumer has the choice of service location.

VON recommends that if the consumers require, and they or their surrogate decision-makers choose facility care, they have the choice of what facility to enter rather than this decision resting solely with a placement coordinator.

Inspection and control versus quality management: History has demonstrated that control through inspection does not always achieve the desired results, but rather increases inappropriate behaviour through the fear and uncertainty created by the inspection process itself. Inspection does nothing to foster creative and truthful relationships which lead to enhanced service provision. Continuation of the inspection system implies a lack of trust in service providers and/or the belief that the achievement of quality improvement standards is not possible.

The necessity for services provided to improve in line with expressed customer needs is a true hallmark of consumer empowerment. VON believes that other processes exist that provide assurance regarding quality of service, and that these processes should be explored prior to the imposition and/or expansion of the inspection system.

Therefore, we recommend that Bill 101 be rewritten to reflect quality management principles to ensure that the highest standards of care be available for the consumer.

Allocation of resources: Bill 101 appears to ensure the continuation of a centralized funding of extended care beds, given the absence of reference to chronic care beds and the separate funding of them. Although funding of long-term care beds is not addressed in the legislation, from government discussions VON understands that level-of-care funding will be introduced in regulations.

At a time when the government is considering the need for flexible funding and service delivery models for the community sector -- for example: capitation, case mix, equity blending with global funding, comprehensive health organizations, multiservice agencies -- consideration could also be given to the possibility of multiple-funding options for long-term care facility beds. However, VON agrees that the current funding model of per diem is a disincentive to caring for residents with complex needs and intensive resource requirements.

The new model should also have fiscal incentives for rehabilitation and discharge, since level of payment based on customer acuity can be seen as an incentive to increasing illness. Is there a danger that the facility need to increase revenue will conflict with the true consumer need for minimal facility service?

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

Prior to expanding facility services, other community-based options should be considered, such as having the funding envelope locally administered to achieve more flexibility. Additionally, utilization of community-based services, such as acute care nursing skills or specialty consultation teams within facilities, should be considered as part of the funding option. As an example, VON nurses trained in infusion therapy could provide such services to long-term care facilities that do not have frequent enough requirements for infusion to make an in-house team cost-effective.

VON would also support a provincial role in long-term care facility planning through the development of provincial standards and requirements for core programs. VON strongly recommends that the government move away from centralized, fragmented funding to district funding authorities -- devolution, in other words -- with a long-term care envelope that includes community-based, in-home and facility service provision. Only then will we see a significant redirection in long-term care from institutional care to community-based services and the development of flexible, cost-effective services reflecting community need and priorities.


Placement coordination: VON supports the concept of expanding placement coordination services province-wide as a key component of long-term care redirection. VON currently administers 10 placement coordination services across the province, so it has a wealth of experience from which to provide feedback and comment.

VON has concerns about the lack of consumer control over location of services in the proposed expanded role of placement coordination, and recommends compelling coordinators to ascertain and provide the consumer's choice of service location. VON has concerns about the continuing lack of clarity and authority between discharge planners in acute care hospitals, admission or placement coordinators currently employed by long-term care facilities and official placement coordination services. The overlap in authority and mandate often results in inequity of access for consumers, and therefore we opt for the recommendation that final authority for decision-making with respect to facility placement rest with the official placement coordination services to ensure equity of access for all consumers.

VON recommends that the devolved long-term care management board would be an ideal place to house the placement coordination service. Since this board would fund all services, it is a logical location for information referral and placement services.

I would like to thank you for this opportunity to come before you today. I would be pleased to respond to any questions that you might have.

The Chair: Thank you very much for your presentation. Certainly, as the committee goes through its hearings, if we didn't know the Victorian Order of Nurses, we certainly know it better as we've made our way around and we're glad that you've come forward.

I just remind members again that we have a very tight schedule this afternoon. I will permit one question from each caucus with one short, sharp supplementary. We will begin the questioning with Mr White.

Mr Hope: No speeches.

Mr White: I'm going to have to work that out -- one and a half questions here -- because there are so many things in your presentation that are very striking. The issue of consumer choice and a number of other things we've already discussed in some detail. The concern I've had from the beginning is that yes, we're taking on the biggest part of long-term care. The facility-based service is the most expensive part and certainly the part that's been, in the past, most in disjunction. But what you're suggesting is that by taking on facility-based, medically oriented facilities and not addressing first what the needs of people are in the community, we're getting the cart before the horse.

Mrs Chisholm: I don't think that's what I mean to imply. Certainly we don't mean to imply that in fact you are neglecting the community side. All we're saying is that they need to proceed in tandem so that the community as a whole is able to understand how the system fits together. At this point in time, it still appears very disjointed. You have the facilities here and the community sector in another place.

Mr White: Would you like to see, with this legislation or with further legislation or programs, the issue about services that are presently available in the community on a broad-based level -- psychological services, social work services, podiatry etc -- some things which are not always generally available at all facilities to be now available under that umbrella organization you were talking about?

Mrs Chisholm: That certainly is one way of providing those services. I think, more basic, in response to your question, would be that the funding base across the province with respect to the facilities needs to be more equitably arranged so that those services can be available. Whether it is through the facility itself that they are available or through some kind of a community agency doesn't really matter as long as those services are available.

Mr White: Onsite.

Mrs Chisholm: Or available to be brought to the site as required.

Mr White: Yes. Thank you very much, Mrs Chisholm.

The Chair: Thank you. The Chair notes a very skilful third question in there.

Mrs Fawcett: Thank you for coming before us today. Certainly, as the Chair mentioned, we have heard from several chapters, but each of you has presented us with maybe a different piece of information. However, one chapter, and I've forgotten which one it was, did mention a problem around the VON going into the community to help a client, and then that client having to go into an institution for a week or two. Certain procedures were being given to the client, and then, once the client went into the institution, there was a problem with the VON going in to continue a service which the institution couldn't do. So there was a slight problem there.

I'm wondering, does that happen often? In your presentation, I noted that you mentioned being able to go into an institution to deliver services, and possibly if we could coordinate this in some way, or if it was part of the regulations, then maybe this would alleviate a lot of problems all around.

Mrs Chisholm: Yes, I certainly think it would. It has not been a problem particularly in my branch, although we have had requests from institutions or facilities to provide instruction for staff in certain procedures. There's no physical reason why a VON could not go into the institution; the block at this point in time appears to be the legislation with respect to payment. If the client or the family were willing to pay independently for a VON visit so that service could be provided in the institution, that is possible, but a lot of people don't have that kind of resource.

Mrs Fawcett: Right. Then, just very briefly, we haven't had much on palliative care, and that is of particular concern now, especially around AIDS patients. I'm just wondering, are there any recommendations that you might have so that we get that part of health care done properly and possibly have less consternation among all people, and get it right the first time when we're writing the legislation or the regulations? The minister did mention it briefly, but there was nothing really to give us anything to hang on to.

Mrs Chisholm: Yes, and the funding that has been announced, I think we would all certainly acknowledge, is not adequate to provide a blanket of palliative care services across the province. It's a beginning. It needs to be expanded over time. But there is the opportunity now, with funding to be available for some part of palliative care services, to probably do a little bit of pilot testing with the various programs that are able to be achieved with the funding available, so that when more dollars are available further down the road, we will then be able to do it right the first time.

Mrs Fawcett: Thank you.

Mr Jim Wilson (Simcoe West): Thank you very much for your presentation. A number of points that you raise, VON has raised. We're very sympathetic, particularly with regard to your concerns with the consumer choice, inspection, the level-of-care funding and the per diem system -- "devolution," as you put it -- and the placement coordination service as envisioned in the bill.

I want to ask you, though, a general question. You had a phrase near the beginning of your presentation where you stated that Bill 101 perhaps perpetuates a "continued fragmentation" of the current system, then went on to talk about the fact that we're doing this in a policy void, that when it comes to it, we don't really know what's going to happen to chronic care in this province because we haven't got the chronic care role study, and yet we're going ahead with this bill. Then you asked the committee to consider a delay of the legislation until there's a public debate.

I want to just give you an opportunity to sort of expand on what you meant by "fragmentation" and why the need for delay.

Mrs Chisholm: When I speak about fragmentation, what I mean is that all we're seeing at this time is one piece. We know there are more pieces to come, but those pieces continually seem to be delayed. I'm referring particularly to the policy framework with respect to long-term care, which will probably give us the overview so that we can see where the pieces all fit. Right now all we have is one piece that appears to deal specifically with the institutional side. There's great need for change across the whole system, so I guess maybe it's a little bit of impatience in that we'd like to see it all and see how it fits together so that then, as we are participating in the planning forums in our community, we will be able to make better decisions, when we can see what the whole picture is to look like.

Mr Jim Wilson: I'd certainly agree with you there. We're trying to press the government to not go ahead with the legislation until it makes a further announcement so we can see what the whole plan is. I appreciate your good efforts in that regard too.

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



The Chair: Could I call our next presenters, the corporation of the county of Lambton, senior services department, if you would be good enough to come forward. I'm reminded as you get settled that the last time I saw you was a very hot August day, not really like today at all. I think I prefer the hot August day. Thank you very much for coming over from the county. Would you be good enough to introduce the members of your group, and then please go ahead with the presentation.

Mr Ken Evans: Mr Chairman and members of the standing committee on social development, let me introduce myself and my colleagues for this presentation. My name is Ken Evans, chairman of the health and social services committee for the county of Lambton, and mayor of Arkona; Mr Jim Foubister, vice-chairman of health and social services for the county of Lambton, ward 1 councillor of Lambton county council and alderman for the city of Sarnia; Mr Doug Hutton, director of senior services for the county of Lambton; Mrs Janice Boomer, administrator of North Lambton Rest Home, Forest, and Lambton Twilight Haven, Petrolia; Miss Victoria Lucas, acting administrator, Marshall Gowland Manor, Sarnia; Miss Virginia Cates, coordinator of outreach; and Miss Marie MacLaughlin, administration coordinator.

Firstly, we'd like to take this opportunity to thank the committee for allowing the county of Lambton to make a presentation and express our concerns with respect to Bill 101. We in Lambton county certainly recognize that reforming the health sector in long-term care is overdue and have very strong feelings on this issue. The care of our elderly is second to none in Ontario. We in Lambton county have recognized that care costs money and have striven to maximize those scarce resources. We have a strong history, as do most counties in Ontario, evolving from the British workhouse to the original house of refuge, which was initiated in Lambton in 1919, with Lambton Twilight Haven opening in 1956, North Lambton Rest Home in 1970 and Marshall Gowland Manor in 1968.

Mr Foubister will be assisting me in presenting the brief. We have additional copies available and would try to answer any questions you might have at the conclusion.

Mr Jim Foubister: Let me begin by applauding the government for recognizing and acting on the need for long-term care reform. We feel it is crucial to retain the inherent good qualities of our non-profit facilities by affirming the county of Lambton's full support for the main principles driving redirection, which are the primacy of the individual and his or her right to a life of dignity, security and self-determination; the promotion of racial equality and respect for cultural and regional diversity; the importance of the family and community; and equal access to seniors' services.

We believe the county of Lambton is the proper body to be responsible for the delivery of both community-based and institutional long-term care services for seniors in our area, in partnership with a local advisory committee and ministry support that provides clear leadership and performance standards.

We have brought with us copies of our presentation for your future reference and we hope to answer any questions that you may have.

We believe it is important that your committee know something of the history of the county of Lambton's long-term care programs and services. In the mid-1980s, a consultant's study was done for the county that recommended the sale of one of our homes for the aged. When the results of that study were made public, council was somewhat surprised at the depth of feeling among county taxpayers that ownership and operation of that home for the aged remain with the county of Lambton. The sale did not take place, and the home in question has subsequently had a $1.6-million addition.

That event may have been the turning point that stimulated this council into being one of the most innovative, interested and capable in Ontario on seniors' issues and seniors' care. Consequently, we will be opening the new 128-bed Lambton Twilight Haven in Petrolia later this spring. This is a joint venture with the province, at an estimated cost of $16.4 million.

As we sit here today, we cannot emphasize too much the importance of the positive relationship between our council and the seniors of the county of Lambton. They have come to depend on us to know their needs related to high-quality programs and services.

Under the topic of governance and accountability, our major concerns with the draft legislation are:

-- That a resident must be accepted on the advice of some person or agency external to the operation of the institution.

-- The mandated requirement that a municipality pay for the operation and maintenance of a home for the aged without the ability to make policy decisions with respect to the institution's management.

-- An assumption that inspections and regulations will bring compliance with generally accepted standards of performance rather than those that are self-directed through programs such as quality assurance and accreditation.

-- Too much stress on regulations that have not been revealed and that are much more easily changed than is the act.

One of the gravest concerns we have is that the direction of the proposed changes is towards greater municipal responsibility to provide care and payment, coupled with a reduced role in decision-making. As you well know, it is only the elected local officials who are accountable to the public they serve.

Along with other groups, the county of Lambton opposes the inspection powers being promoted for the following reasons:

-- They promote a feeling of opposition rather than one of partnership.

-- They tend to ignore the current positive role of the committee of health and social services of the county of Lambton.

-- There is no assurance that the inspector will have skills and abilities that match those of people who are working locally and within the institutions.

-- No funds have been identified to carry out mandated structural improvements or corrections.

-- There may be no provision for learning exactly the nature of future problems or disputes.

-- They will almost certainly create an atmosphere of tension, suspicion and loss of county of Lambton control.

We believe that the proposal to add a mandatory placement function as the "gatekeeper" to the system adds an unnecessary level of bureaucracy to a system that now works, and works well.


We are frankly distressed at a system where such a person or agency assumes none of the responsibility for placement problems. It all resides with the home for the aged, which had nothing to do with the placement in the first place.

With regard to enforcement bureaucracy, we believe that, given the number and extent of legislation now governing the operations of homes for the aged, the proposal to add compliance and enforcement units will result in unnecessary levels of bureaucracy. Furthermore, such units, based at Queen's Park, are bound to introduce an air of concern and worry about their potential for mistrust and unreasonable intervention. The municipal homes for the aged now believe that we operate in a constructive and healthy partner relationship with the province of Ontario, one that is now in danger of being degraded.

The county of Lambton believes that we should be the governing body with an advisory board for community input. We would suggest that you consider a closer link between the government and the accreditation process, providing a constructive and educational system that works effectively now; increased support of internal quality assurance programs; and increased support of risk management programs.

I would now ask our chairman, Ken Evans, to lead you through additional parts of the presentation, and I thank you.

Mr Evans: Consumer choice: Under this topic, the major concerns with the draft legislation are that we would see a centralized bureaucratic control and loss of fundraising capability. There is grave concern that the consumer has no choice in the placement exercise, nor in the purchase of goods and services judged appropriate by himself or herself. No consideration has been given to the importance of choice for the seniors with respect to the rural or urban setting of a home for the aged, or cultural setting alternatives.

While an appeals process has been established but is still largely undefined, the process is likely to appear intimidating and daunting to the average senior. The appeals process will inevitably add considerable time, cost and stress to the overall effort to place a senior and family that may be aggravated by the wait for a decision or, more importantly, that may never be placed because the "window of opportunity" may go past while awaiting an appeals decision.

We are concerned that the present placement coordination service is not capable of knowing the nuances of service delivery and planning that the home's own administration does.

At present, our county homes for the aged effectively work with families to redress social and physical problems of inappropriate placement. The draft legislation does not identify an appeals process that can take their place.

Through the draft legislation, it appears that the residents of the provincial institutions will not be consulted about important and fundamental changes to the way they will be cared for. For example, the implementation of the proposed copayment will probably cause worrisome adjustments for many residents and families, yet there are no plans to prepare them for this change.

Our delegation recommends that the government ensure consumer choice be given a much higher profile through better notification to residents and families of the legislative process through resident councils in the homes for the aged; consultation with families and seniors about options with respect to placement mechanisms; and legislation that gives seniors, their families and advisers a more proactive role in choosing the place of residence and treatment modalities.

Mr Foubister: Thank you, Ken. We applaud the government's pledge of $206 million annually to the support of long-term care facilities. The county of Lambton, as a member organization, supports the Ontario Association of Non-Profit Homes and Services for Seniors' position that inadequate calculations have been made to establish funding requirements for the proposed system.

Under this topic, the major concerns with the draft legislation are:

-- The county of Lambton is firmly opposed to not include a resident's assets.

-- Residents have not been informed or consulted on copayment schemes and the changes that will result;

-- Mandated levels of care, and hence operational costs, are increasing with each passing day, but provincial support is not keeping pace;

-- Educational needs of staff, and hence training costs, are increasing with heavier care levels;

-- Chronic are facilities are better funded than homes for the aged, yet the care level in many instances are exactly the same;

-- Bill 101 identifies capital funding for nursing homes but not homes for the aged;

-- No funding provision has been made for mandatory programs such as modified work, workers' compensation and union contract settlements, which therefore must be subtracted from resident care;

-- The $37-per-day copayment proposal is fundamentally flawed with respect to the estimation of how many of the current residents will be able to make the payment; and the loss of revenue from those now in preferred accommodation.

Historically, budgets have been prepared locally in the home for the aged according to the needs and traditions that are found therein. The county system of government has been very good at serving local need.

This delegation recommends that:

-- Local controls be retained with respect to both copayment schemes and fund-raising;

-- Chronic care be addressed and included in Bill 101 to help reduce the fragmentation of long-term care services;

-- The shift in emphasis be taken from the "funds available" approach to a "consumer needs" approach.

Under the topic of quality of care, the major concerns we have with the draft legislation are:

-- No consultative process with residents' councils in long-term care facilities;

-- A rigid approach that disallows preferred accommodation with its incentives for consumer choice and institutional upgrading;

-- The primacy of the individual has been lost in this draft legislation exercise;

-- The planned constraints of the legislation are so great that quality of life must suffer.

We recommend that the quality of life of each Ontario senior, through a holistic consideration of the individual's needs, be reinstated as the main focus for drafting new legislation.

Finally, we believe, most emphatically, that the county of Lambton is the most appropriate body to govern the delivery of high-quality, long-term care to its seniors. This body has historically provided responsible control over budgeting and operations as a result of its direct responsibility to its local citizens. County councillors, as elected representatives, are ultimately responsible to the taxpayers, and as you all know, we must raise this money by literally putting our hands in the pockets of the home owners of Lambton county. We must therefore have the ability to govern care and service delivery at the local level. Centralizing these controls at Queen's Park, with a larger bureaucracy and its attendant lengthy and complicated appeals process, is wrong.

I assure you that we do not have all the answers, but we have a very long history of a partnership with senior government in providing the seniors of Lambton county with a premium health care service.

We wish to thank you, Mr Chairman, and the members of the committee for your diligent consideration. We're sure that you'll give these important matters, that will have a profound impact on the elderly in the province of Ontario for many years to come, your utmost attention. We wish you very well in your ongoing deliberations. Thank you very much.


The Chair: Thank you very much for a very thorough brief. I may be wrong, but I think it's the first county brief we've had where you've really addressed a lot of those issues, or has there been another?

Mr Jim Wilson: I think this is the second one; I am not sure.

The Chair: Second? Okay. In any event, we thank you for that. We'll begin the questions with Northumberland county and Ms Fawcett.

Mrs Fawcett: Thank you very much, and I do appreciate this perspective from county councillors, because I did spend a little time on county council and I believe in a strong county. Certainly, this brief shows that you have a lot of expertise. As you said, you may not know all the answers, but I think maybe you know more of them than would be known at Queen's Park. You would know what the needs of your community would be certainly better than maybe some of the people at Queen's Park.

However, right at the beginning, I compliment you on many of your suggestions in a lot of the areas that people have continually brought up. I think you really have done an excellent job.

But back on page 2, under "Municipality Responsibility," I was intrigued by what you said there, "That the direction of the proposed changes is towards greater municipal responsibility to provide care and payment coupled with a reduced role in decision-making." I just wonder if you would like to broaden that a little bit, as to how you see that happening under Bill 101 that is different, let's say, than what you have shown us you can provide.

Mr Doug Hutton: I think what we're trying to express is that we, as a municipal government, and the deliverers of services and seniors in institutions are faced with the challenges of Bill 101. We're given certain requirements, they're mandated, then we're expected to pay our fair share. I think there was an expectation that we're either buying into this system or we're not going to be in this system. I think the county has historically been in this system and wants to be part of the system. So if we're going to have a say in the system, if we're going to pay, we want to have a say.

You were adding all these mandated requirements, levels of care, that will be addressed by the inspection process. There's got be a funding arrangement made corresponding to these. We also feel that if we're going to make decisions in respect to the delivery of services -- and we feel that we may put a higher level of care and a higher level of service that maybe is required -- we should ultimately help make the policies on that. We shouldn't stick to just what the base standard is: "It's good enough for everyone else." Maybe in Lambton county, they expect more because they were the folks who made that county.

Mrs Fawcett: Or maybe you are more rural than, let's say, downtown Toronto and so there are very sincere differences.

I would assume that you would want to be the placement coordinator. You would take on that role because you already are doing that, obviously, pretty well for the county, and you see yourselves as being able to carry out that role very well.

Mr Evans: That's right.

Mr Jim Wilson: Thank you very much for your presentation. As Health critic for my party and on behalf of my caucus, I want to tell you that I think you're right on in a number of the points you raised. I also represent an area in Simcoe county, and I'll tell you our county administrators and the good people on our social services committee are very worried about this legislation.

I'm allowed one question but it has three parts. You began by saying that you very much support the four principles behind the Redirection of Long-Term Care. But like many other groups, I gather from the tone of your presentation that you agree that the principles are laudable and, as laudable as they may be, don't appear to be reflected in the actual legislation, because you mention consumer choice, facility choice and the idea that we're to have levels-of-care funding, but you won't be necessarily getting the funding so that you can implement levels-of-care funding. You will be required to admit older and sicker residents, and there's no guarantee that the funding will follow.

I want to ask you two things. One is that I want you to expand, because I think it's an important point to drive home, again how you feel this bill may undermine the authority of your health and social services committee in the county itself. In answering that question, I want you to tell us how much money out of the property tax base the county actually commits to its homes and how many homes you're running.

Secondly, just to touch on what appears to be an adversarial inspection system that's being set up, one point that hasn't been raised that was raised by one of my county homes was that what may appear a simple thing to legislators may be something very wearisome to residents. That is, when you post the results of an inspection, there may be things posted on the bulletin board at home that people will take out of context and that may unnecessarily worry residents; they may not understand some of the things. If there are eight or nine things listed on the board, they may take them out of context and sort of blow them up out of proportion. So with all those comments, I want to give you an opportunity to say a few words about those concerns.

Mr Hutton: With respect to your comment on how many homes we run, we have three homes for the aged in Lambton county, in the various geographical sections of the county, to address all the needs of those residents. They reflect both an urban and a rural setting. Certainly, to address the comments of your colleague, we don't have the problems that they have in the large urban area of Toronto, where you have the ethnic minorities but you have a large workforce that can provide the expertise.

We have no transportation in the county like they have in the large urban centre. We can't draw on those highly skilled technical people who can offer us their professionalism there.

We have a different makeup of whom we have to deal with. This is their home. They've been in the county for a long time and they don't want to get transported off to a large urban centre when they've always been in the country.

Last year we capitalized, through the funding process that we normally run, approximately $1.5 million for the 1993 operating budget, with the county committed to this. But over the last two years we have committed over $9 million in the homes for the aged through a new building process which is a 50-50 partnership, as well as the additions, and we're looking forward to renovating the other home for the aged to bring it up to standard.

With respect to the posting and the inspection panels, yes, I worked in the for-profit sector of the nursing homes section and we did enjoy that privilege, I guess, of having the inspectors come into our home. It was threatening to the residents. "What, are they going to close the kitchen down if you don't fix it in three days?" Certainly they would leave us with, "It's on the wall and these are the problems."

Through the system we currently have, we work within a partnership with the province through the local area offices, and it has been a cooperative relationship. We have problems at the level of care, of nurses. We work together to meet those needs. It wasn't, "Thou shall put four nurses on." In the for-profit sector -- certainly they have been underfunded in the past, and we don't dispute that at all, but the homes for the aged have historically said that we're fat cats. I think we're not fat cats. What we've done is that our community has recognized that we want to have better than the standard, and we funded it to be like that. So the inspection process is very intimidating. It's intimidating for the residents too because they don't know what's happening. It's very confrontational.

With the funding mechanism we currently have in place, county councillors and county council recognize the needs. They can prioritize those needs and they can talk together and identify needs: "Yes, we're having heavier care. Heavier care costs money. Yes, we need more nurses. Yes, we need more staff. Yes, we need this and we can work together to improve that." County council then makes a commitment of dollars to increase the system. Certainly, the ministry provides us with X number of dollars on the operational side of it, but then we can add those additional dollars to bring in the in-house pastor to look after the spiritual needs of the resident. Maybe under another system, we'd have to hope for the volunteer sector to come in.

Mr Jim Wilson: Very good points. Thank you very much.

Mr Wessenger: Thank you very much for your presentation. I note your interest in wanting to govern the care and service delivery at the local level. If you might elaborate on that, does that mean you want to manage both the institutional long-term care and the community long-term care? Would that be your intent?

Mr Hutton: No, not totally.

Mr Hope: Well, why not?

Mr Hutton: If you're open to that suggestion, I think what they're suggesting and they're suggesting very strongly is that an elected, accountable politician goes to the ballot box and is elected to perform, to look after the taxpayers' dollars. Certainly we recognize that there are other advisory groups out there, but they can't work in isolation of what the taxpayers want, with their own agendas. We're suggesting that there should be advisory groups out there, but accountable to a locally elected body. The one best suited is the local county council, which is elected by the will of the majority. It also represents the various geographical areas of the county. It also reflects what the residents of that county would like to see, and if they don't like it, they can put them out. And a special-interest group are just appointed.


Mr Wessenger: Could I just follow that up? Do you have any for-profit nursing homes in your area?

Mr Hutton: Yes.

Mr Wessenger: So if you took over the placement coordination function, you'd be making adequate --

Mr Hutton: I don't think we're suggesting that we take over the placement. We're looking at, when the envelopes of dollars come into the area, having that body, the county council, then distribute those to the needy. But there would still be a placement coordination; there would be all those other things.

Mr Wessenger: Okay, could I just follow up? What you would like to see with the envelope of funding that comes into your area? You'd like to make the decisions on the allocation of that funding envelope?

Mr Hutton: Yes.

Mr Wessenger: You would. I will just follow up with one other question which I don't think you answered for Mr Wilson, although he asked it. I wanted to ask the same question. You indicated that there are decisions you now make that you're afraid you will lose the ability to make in the future. Could you sort of indicate specifically what those decisions are that you now make which you are fearful of losing in the future?

Mr Hutton: Level of care, for one. We're the catchment area for the whole county for Alzheimer's, so if someone is affected with Alzheimer's, our new unit is specifically addressing the issue of the Alzheimer's resident on a staged program method so you don't have them all thrown into one area. We have day programs, and we feel that this is one of our top priorities. We feel we might lose that.

Mr Wessenger: Fine. Thank you very much.

The Chair: Did anyone have any other comment they wished to make in answer to that? No? Thank you very much for coming, and we wish you all the best with the new home in Petrolia.

Mrs Caplan: Thanks a lot.

Mr Foubister: Thank you, Mr Chair and members of the committee.


The Chair: I would ask our next presenter, from Vision Nursing Home, Sarnia, to come forward, please. Welcome to the committee. Have some London water -- it's cold -- and once you're settled, if you would be kind enough to introduce yourself for the committee members and for Hansard and then please go ahead.

Mr Bernard Bax: Thank you, Mr Chairman and members of the committee. I appreciate the opportunity to address the committee. I might as well admit right off, I'm scared to death.

Mrs Caplan: The only person who bites here is the parliamentary assistant.

Mr Bax: All right. Well, I won't look at him.

Mr Hope: Oh, we have differences of opinion about this one.

Mr Wessenger: That's right. The Chair and I are both that way.

Mrs Cunningham: We just bite each other.

Mr Bax: Well, I do appreciate the opportunity to come and talk to you. My comments will be rather pragmatic, I suggest, but after long thinking about it, I feel it is important to let you know at least my particular views on Bill 101.

I am aware of and have read the official response of the Ontario Nursing Home Association to Bill 101, and I want you to know I basically support their response. I would, however, like to reiterate some points and to add my own perspective to some of the points raised in their brief. I think you all have that brief.

The first thing is timing. I'm delighted the government is moving ahead with long-term care reform. From my perspective, it's long overdue. I am extremely disappointed, though, that the target implementation date of January 1, 1993, has not been met. From my perspective, it only means that the inequities will continue longer and, from my perspective, become worse, as it appears for the private nursing home sector that there will be no economic increase, which has usually been given January 1. We now understand that will not happen until long-term care reform is implemented, and hence my encouragement to make it timely, because for us the cost increases don't stop.

A 1989 lawsuit was initiated by the ONHA, and the subsequent judge's comment that the present system is illogical and unfair is, I think, true. I think we all agree that it's true. This was in 1990, and I'm encouraging the government to not delay the implementation of long-term care any longer. In my opinion, it would only make a bad situation worse by not providing economic adjustment.

As to some specific concerns that I have regarding the legislation, first of all, I'd like to address the appeal process. I think fundamental to our system of justice is the right to appeal. I cannot imagine removal of the right to appeal in the criminal justice system. For obvious reasons, mistakes of one sort or another are made and there is a need to prevent potential abuse of power by a person. The inclusion of the right to appeal within Bill 101 is critical from two perspectives -- and I believe in the right of consumers to appeal but also the right of facilities to appeal. Neither is there right now in Bill 101.

First, the right of consumers to appeal: Applicants' choice relative to ethnic, linguistic, geographic and religious preferences must be preserved. Arbitrary decisions that are potentially possible by placement coordinators must be open to appeal and, I feel, quick appeal equally. The reasons are obvious, I think, if you place yourself in the shoes of a person who requires placement. If a person is of a particular ethnic background and there are a number of choices in your area, you would certainly want the right for that person to choose where his culture and his history can be preserved and where he can enjoy that particular aspect of his life. If a placement coordinator decides to not respect that, certainly that person should have a right to appeal to someone regarding that decision.

The right of facilities to appeal: In a number of areas, we are anticipating moving from an insurance to a contractual model in long-term care. Because it is contractual, negotiation is equally part of the process. Facilities may be treated differently depending on the person that a particular facility negotiates with. This would, for me, not make the standard of care equal throughout and could provide disparity in particular areas. I think that needs to be addressed.

The other area is that governments change policy, governments put in new programming, and it could be the case equally where that is not recognized in contract negotiation. That must be there. I guess, in brief, there must be government accountability in that if policies or legislation are passed, they must follow through with the appropriate resources to implement that particular aspect. It's my feeling that if we go to the contractual model, discrepancies could begin to appear.

I think facilities must equally be able to appeal possible placement recommendations. For obvious reasons, there are differences in facilities. If they can't provide the care needs -- and it could also be the practical thing that we have wards and we have semi-private rooms and, as in all of life, we are not all compatible. It is equally that reality in nursing homes, that two people don't get along, that one is cognitive and noisy and another placement may come in who appreciates the quiet. It's very disruptive, and if you have visited a nursing home yourself, you should be well aware of that. That can happen, and the legislation must allow for the homes to be able to appeal to make sure the best possible placement is made.

The third area where homes must be able to appeal is that Bill 101 has sanctions listed, and this gives, in my viewpoint, enormous power to government. I feel sanctions should only be used as a last resort. Above all, facilities must have the right to appeal bill sanctions.

In summary, on the appeal part of Bill 101, I think in all cases, though, that the appeal process must be very accessible. It must be timely and it must be efficient and if it's not -- again, I ask you to place yourself placing one of your parents and he or she is inappropriately placed. It's really not much good to argue about that three months later or to appeal if your mother has been placed inappropriately and she's unhappy. It could be done at the local level with some kind of an appeal further down, but it must be timely and it must be efficient and it must be highly accessible. Bill 101, I feel, has an obligation to provide for that.


The second area that I would like to just touch on is the resident care needs. The bill is being introduced, from my perspective, in almost a total vacuum. I really don't know a lot at this particular point, and for me as an administrator of a nursing home that's scary. I've written here that there's no commitment that funding is equal to level plus the adequate services. To me, it's extremely important that when that bill is introduced, we know there is a balance between dollars and what is being legislated. If not, I think we could be headed for trouble.

All long-term care institutions in Ontario were reviewed last fall. All our residents were assessed -- called the case mix index. We were promised the results of it in December, in January and now it's February and we still don't know what the case mix index is.

The scary part for me is that the case mix index is being delayed and that we're only going to distribute dollars, not really listen to what the case mix index is saying. All we're going to do is distribute the dollars from facility A to facility B, but the total dollars are not going to be there. In other words, it's not truly an assessment based on need, to provide for the needs that are really there.

The third area I'd like to just touch on is the placement coordination service. The details of how the placement coordinators function are entirely missing. It's my feeling that the existing resources in the placement coordination facilities should be used. They're doing a good job.

The item that probably bothers me a little bit is that their main responsibility is to determine eligibility. Again, from my perspective, eligibility must be the same basis as that used for the case mix index. Then homes will know exactly the type of placement they are receiving. Not doing it that way is really not knowing what the needs are of that particular resident who is coming into the home.

I think it's important that you compare apples to apples. If you're going to determine eligibility, we should all talk the same language, and that part of it should be part of the placement coordinations job that we know, and they can fax or they can tell us about the person we're going to receive. It's not doing any good to tell us after the placement is made, because it could again lead to inappropriate placement.

Placement coordination, I think, must also determine if there is the necessity for substitute decision-makers. It becomes extremely important that this be done at the time they enter the system, if there's a responsible party required for them to act on their behalf, as it's now under the Nursing Homes Act -- that this be addressed -- and from my perspective, also establish the applicant's ability to pay the new copayment. I believe it should be equally part of their function and part of their work to determine their ability to pay and put into necessary paperwork. I understand it will increase substantially, but there's still not a defined or communicative process of how exactly that's going to work if the elderly can't afford their particular resident copayment. It doesn't do any good, I feel, to do that after people have been placed; it should be done ahead of time. I believe Bill 101 in the legislation should also address that.

Compliance consultation is the next area I'd just like to briefly comment on. Maintain the existing compliance program. The enforced approach: Type X theory went out long ago. It doesn't work. Cooperative effort, cooperative work together really makes more sense, and in my viewpoint, the present system works. It has a complaint appeal system whereby residents and families can appeal directly to the Minister of Health or to local offices, and investigations are conducted expediently and everything else. I believe that the enforced approach, as I envision it out of Bill 101, will just lead to coming together -- I can even visualize lawsuits or whatever else may occur where discrepancies occur in interpretation. We've gone to a lot of effort to put the present compliance system into place in the last two or three years. Continue to use it.

Comments about quality assurance and risk management: I think "quality assurance" is probably the wrong terminology to use within BIll 101. I think we have to, as we're doing totally in health care, look at total quality management, continuous quality improvement terminology. To take a look at a cooperative effort again, how we're doing things, I think is extremely important. I would equally caution that I'm seeing that there are too many dollars chasing paper. It does nothing for the care. I'm increasingly concerned that we're so concerned about all these documentary requirements, which I envision more under your possibilities under the new compliance review, that we virtually document and have the people document whether people dress and whether they go to the washroom and whether they have a bath or whatever. It's all costs, but it doesn't really provide a lot of direct, hands-on care. I think you should really think about that aspect.

In conclusion, I would also strongly recommend that the committee, before it recommends changes to Bill 101, should also be fully briefed on the four funding envelopes. As difficult as it is for me to come today to speak to you about Bill 101, I don't know what the rest of the package is going to be. I think for you to protect the residents and people in Ontario and yourselves, it's extremely important that you know what the funding envelopes are going to be for nursing, quality of life, accommodation; and the fourth possible envelope, which is the other, whatever that's going to be; and equally, that the government should really discuss these four envelopes with both the Ontario Nursing Home Association executives and the Ontario Association of Non-Profit Homes and Service for Seniors before these are released to all the long-term care facilities. The changes we are making, which are good, are wide and far-reaching, and my concern is that if they're not done properly, they're going to lead to a lot more difficulties and a lot of heartache for the residents of Ontario, and I just think they're a good thing to do.

I think the essence of what I'm really trying to say today too is, don't leave too many issues to be defined by the regulations; I think it's dangerous. I think the time to deal with some of these important concepts is in the legislation, not in the regulations, in order to prevent, again, the drafting of regulations that really are difficult to change once they are there and miss the intent of the legislation that's there.

Finally, the bill holds the facilities accountable for providing for all residents' needs without ensuring that funding will be provided to make this possible. If anything, I'm most uncomfortable, as a citizen of Ontario, and that we stop this, that we not say what we're going to do and not provide the means to do it. To me, it's worse to do that than the other way, to pretend we're going to do something and not provide the funds.


Maybe Bill 101 is a good place for the government to start to take that seriously. If I read my news and if I listen to what we're saying about government deficits in general, I think it's equally important that the regulations truly provide what they say and that we provide the resources to do it.

Bill 101 with its amendments must be introduced, I believe, as soon as possible.

I thank you for the opportunity to share my views with you today, and I'll only allow half a question.

The Chair: Well put. Certainly the points you've raised throughout your presentation are important ones. We're glad you came and we hope whatever trepidation you may have had has waxed. Now we'll have perhaps three or four half-questions, and we'll begin with Mr Wilson.

Mr Jim Wilson: Thank you, Mr Bax. I just want to reiterate what the Chair has said, that there's really no need to be nervous, unless you consider that this government's going to try and drive private operators out of business.

There are three indications that lead us to believe that. One is that the government did do a study, which it won't release, on what the cost would be to buy out your nursing homes. It spent $200 million in day care not to create any new spaces or new subsidies, where the problem is, but simply to drive out the private day care operators. We know, from indications from the Ministry of Health, that they want to buy out private ambulance operators. They just haven't figured out where the hell to get the money from. So there's good reason out there to worry. I just wonder if some of your trepidation isn't that they've got you in a classic catch-22.

You need the bill to go forward because you need the economic adjustment, but at the same time, it may threaten the long-term viability of the commercial sector. I'll give you an opportunity to comment on that.

Mr Bax: Sure, it's of concern, but I hope that the government will be practical enough to simply say what the private sector is doing and how good a job it's doing. I'm sorry; we don't get any type of handout from our municipality for running it -- and I would challenge all of you to come and visit -- and the care that we're providing to do it. I trust that will be the overriding factor in that; I really do.

The Chair: Where is your --

Mr Bax: In Sarnia, Ontario.

The Chair: In Sarnia. Ms Cunningham puts a supplementary.

Mrs Cunningham: I am interested in one of your comments because it's of great concern to me within most public institutions, and that is growing size of bureaucracy. You mentioned that, in your view, there are too many dollars put into paperwork and not enough into what I would call the front-line workers.

Mr Bax: Yes.

Mrs Cunningham: There's an opportunity for at least four of the government members to listen to this in your response. If we had to do this all over again, where do you see the big dollars? Are they within the nursing homes themselves, are they within the levels of government, are they within the municipality or is it a combination? Just tell us how you feel about it.

Mr Bax: Oh, I think it's a combination. I think if we, for example, have the universal accreditation process -- but the need to really document on paper everything from A to Z and to have proof that we do all these things is not really needed in many homes. They serve no purpose except for some kind of person to really come in and check that certain things have been done.

I really wasn't prepared to respond to that in detail. Given the time, I could certainly take a look at a number of areas where in-services -- you know, the resources that are provided for that versus nurses doing it on-care -- our directors and nurses are no longer on-care nurses; they're strictly paper pushers, one way or another, to satisfy a whole host of regulations and government requirements there.

Mrs Cunningham: Can I just have a 30-second comment there?

The Chair: You have 15 seconds.

Mrs Cunningham: Mr Bax, I visited many of the services here in London. It happens to be my riding, and the county of Middlesex too, I should add, only because they're not represented. The point I'm trying to make is that what you're saying is not new. I find it amazing. I know you're disgusted. That's too bad. But I'll tell you right now, it's amazing that governments get away with it, and sooner or later somebody is going to demand accountability, because I've watched it grow in the five years I've been at Queen's Park, and this bill will only make it bigger. It's protecting bureaucracies and not people.

Mr Bax: Yes.

Mrs Cunningham: I feel very strongly about it and I hope the government is listening. It's also a smokescreen to the real issue, and that's the funding. It's not new. I was elected. I found out what was going on in the sector. It took me about three or four weeks. I'm sure these members got the same thing from their own communities. I think we spend far too much time in legislation that's put forth in draft form such as this, with no answers. I'm here today to listen, of course, but I'm also here to tell the government that we spend far too much time on issues that really don't matter. The funding could be dealt with separately, but it's a wonderful time-user-upper.

Thank you very much for being here today. By the way, you should do this more often.

Mr Jim Wilson: And do it more.

Mrs Cunningham: And put those numbers together.

Mr Wessenger: Thank you very much for your presentation. I'm not going to be too difficult because I'm going to make a few comments and then ask you a question.

First of all, I'd like to advise you that no decision has been made with respect to the matter of an economic adjustment for this year, so that's still up for a decision.

The second question is, I note your concern about getting this legislation through as quickly as possible so the level-of-care funding is introduced. I certainly share that desire with you. I can assure you that the government has the same sense of priority in that regard.

What my question has to do with is that you're concerned about being demanded to provide more than you're going to be paid for in the way of service provision. As I understand the way the system is going to work, the level of care is going to be determined for your institution as a whole and sort of as a general level. Then there will be specified funding levels for nursing and personal care, for instance. The money that you will be allotted for that, you'll have to spend on that, of course -- you can't spend it in other areas -- but you'll not be expected to spend more money than the amount that is allotted for that particular concern. So I was just wondering, what is your concern that you'd be required to do more than the funding would be available for? I'd just like some clarification.

Mr Bax: Very easy: Come and visit and watch one registered nurse's aide push two residents down the hall to the dining room. In other words, the present system makes no allowance, really, for what the needs are and the resources that we are provided. What we're scared of is really exactly that. We're just going to chase it around. We've done it to simply say, "Those are the needs," but have you really done a time study to simply say, yes, we expect one of our staff to be able to push one resident down to the dining room comfortably in a wheelchair or geri chair, rather than having two of them? So I'm greatly concerned that if the case mix index hasn't truly taken into account the time studies or whatever it is, the needs that are provided, we're just going to again be allocated a certain amount of money with an arbitrary labour pool to do the services that were there.

Mr Wessenger: But it's going to be based on a level-of-care funding, which it isn't now. You just get a flat per diem, no matter what the care that's required. There are levels from A to G, and I understand there will be 5.3 times as much money for a resident at the G level as there is at the A level.

Mr Bax: I need to see that in the envelope and I need to see -- the only way I can tell is, I know what I have now. Tell me what my case mix index is and tell me what I'm allocated for nursing; tell me what I'm allocated and I'll tell you exactly where it's at. But I can't really do that until you define for us what these case mix indexes are and the amount of dollars that go with them. I have no way of measuring whether I'm going to be better off providing resources to take care of needs or whether in fact I'm going to be even worse off. So despite the fact that you're right, there are going to be these six levels, what does that mean to me?

Mr Wessenger: There's also $200 million more, which will provide another 5,000 jobs in the institutional sector as a result of this additional money going in.

Mr Bax: I guess we could only see that when we know really what these funding envelopes are going to be and what they entail and how they are there.


Mr Wessenger: Fine. Thank you.

Mrs Fawcett: Thank you for coming. You've done very well. You don't have to worry about coming before a committee at all.

Certainly, my questions were in the same area as the parliamentary assistant's. On this whole classification system, the case mix study, I was interested to know whether you thought that study was adequate. But of course you can't answer that because you haven't got any results and you don't know, really, what the results mean when you do get them. As you said, you want to see the whole picture. It's like we've got the title of the picture, but we don't have anything but the very little bit on the canvas.

Maybe if I could just go a little bit further, a year is a long time too, if you're doing this yearly, to the next patient classification. Do you foresee this as a problem in that the patient may go up two or three levels of care in that year and yet you're only funded for what it was before? Do you see that as a potential problem, being that you do have a nursing home with patients and clients who may not be that well?

Mr Bax: I am not sure whether it will be or not. I'm not overly concerned with that particular aspect because if I take a look at the turnover of residents -- but my point is that when placement coordination does the eligibility criteria, then it becomes extremely important. If I'm losing a classification 6 person, it would be nice if I could simply ask them, "The resident that you are proposing to place, could you tell me the classification that they are in?"

Equally, what could happen if that's not done is that if one facility has a particularly high turnover and they've got all 2s or 3s, they could very well be overloaded and that could really affect them. So there should be some kind of element in the placement as we do this together to try and bring that balance and to keep each home relatively at a constant level of average care that's required. I'm much happier with what we're doing now, but I need to really see it work for a little bit to see how ultimately it is going to be.

Mrs Fawcett: Thank you. I think those points are very good brought forward.

The Chair: Thank you very much. One point: I'm just informed that the case mix index study is supposed to be available in March. Now, March is 31 days, but I'm told as soon as possible in March. So I leave that with you.

Mrs Caplan: And are we going to have the chronic care role study in March? March is going to be a big month.

The Chair: March is the cruellest month. No, that's wrong. April is the cruellest month.

Mrs Caplan: What happened to the Ides of March?

The Chair: We're just practising our poetic references. Again, I want to thank you very much for coming before the committee. We are glad that you came over.

Mrs Caplan: An excellent presentation.

The Chair: I would now like to call the representative from Chelsey Park Retirement Community. While that person comes forward, could I just ask if the following might identify themselves to the clerk if they are here in the audience: Victorian Order of Nurses, Sarnia-Lambton; Victorian Order of Nurses, Oxford County; Southwest Regional Centre Auxiliary. If there is anybody from any of those three groups, could they identify themselves to the clerk. We know that the representatives from St Joseph's Health Centre are here. Thank you.


The Chair: Thank you very much for coming before the committee. Would you be good enough to identify yourself for the committee members and Hansard, and then please go ahead with your presentation. We have 15 minutes.

Mr Tony Orvidas: Thank you very much for allowing me to come today. My name is Tony Orvidas. I am the administrator of Chelsey Park Retirement Community, which is a for-profit long-term care facility which includes a nursing home, retirement home and seniors' apartments. I'm employed by Diversicare Management Services, which is a company that operates nursing homes and retirement facilities in Canada and the United States.

As the newly elected chairperson of the Ontario Nursing Home Association, region 7 professional advisory committee, I also represent approximately 57 nursing homes with 5,000 extended care beds in southwestern Ontario. I also have experience managing municipal homes for the aged. Much, if not all, of what I have to say you probably already have heard or will be hearing. I'll therefore try to keep my remarks relatively brief.

I'd like to preface my remarks, by the way, by asking you to keep in mind two very important points, the first being client self-determination and consumer choice, as I think it's a very credible issue, and the second being equality of treatment, that basically being an end to the discriminatory funding practices of the province for the last number of years. I believe you're well acquainted with that.

You will no doubt be hearing from other groups and individuals who are trying to either delay or maybe even derail long-term care reform, but neither I nor the nursing home association is one of them. Our concerns basically pertain to the wording of portions of this particular bill, Bill 101, and its omissions. We want to see the bill passed and, after it is amended, a new funding model implemented as soon as possible, if not sooner. Since 1990, we have been waiting for an illogical and unfair funding and regulatory system to be corrected, and we're still waiting, as you well know.

While we are very pleased that the government of Ontario has attempted to develop the same set of rules in a more equitable treatment for all long-term care facilities, we are nevertheless concerned that there will no longer be a universal, accessible approach to health care in nursing homes and homes for the aged. We're concerned that there appears to be no government accountability to maintain equitable and consistent services to meet residents' needs across all of Ontario. We're also concerned with the role of the placement coordinator, the lack of choice for applicants, and the lack of appeal for applicants for placement. That's where this client self-determination is particularly important.

Also, we are wondering whether placement will be available 24 hours a day, seven days a week, as is expected of us. We believe facilities should have an appeal mechanism to challenge placement recommendations when a facility believes that it cannot meet the care needs of the applicant both safely and properly.

We are also concerned that the bill sets up a more adversarial approach than the current Nursing Homes Act regarding inspections and the general relationship between government and facilities. The power of inspectors should not be increased, and the use of the existing compliance management program, which barely got off the ground before it was shelved, should be continued. Also, we believe the role of the advocate should be clearly determined and we need to identify where that fits in terms of the role of the inspector and the self-determination of the client.

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

We believe we must all go forward with the bill as soon as possible, since our residents, the residents in nursing homes, have been waiting too long already for discrimination to end. The nursing home association professional advisory committee, region 7, is prepared to work with government and others in partnership to make this long-awaited process of reform both successful and timely.

In closing, I'd like to thank you for your time and for your attention.

The Chair: Thanks very much, and congratulations on your election to your position. We'll begin the questioning with Mr O'Connor.

Mr O'Connor: I want to thank you, of course, for coming today. We certainly do, when we travel the province in a legislative committee like this with a piece of legislation, hear a wide range and varied number of views around the legislation. Of course, everyone would like to have seen things happen yesterday, and unfortunately that isn't the case.

You've spelled out some concerns that you have around the placement coordination, and that's where I'd like to pick up from. Are you currently serviced through a placement coordination service now?

Mr Orvidas: Yes, we are, at Chelsey Park.

Mr O'Connor: Who provides that placement coordinator --

Mr Orvidas: The Thames Valley placement coordination service.

Mr O'Connor: Do you have problems with that placement coordination?

Mr Orvidas: Currently, any problems we do have are really quite minimal in that they are not only flexible but I think quite accommodating in taking into consideration the levels of service we believe we can provide, in terms of understanding when we have to deny admission to Chelsey Park by clients we feel we cannot serve appropriately, whose needs we cannot meet, also in terms of being quite flexible when it comes to someone from one the residential suites in our retirement home wishing to move into the nursing home when he or she is ready and requiring extended care services.


Mr O'Connor: That's good. I'm glad to hear that. I know we've heard concerns around that from a lot of people. I know the right for consumer choice, and the consultation paper that went out last year certainly pointed out some very strong principles, and of course when you take a look at legislation, not being lawyer, it's sometimes hard to see where they put the principles in. Maybe we're going to have to try to work on them to bring out some of the principles and maybe a statement of principles or something.

The placement coordination does seem to be a bit of a problem. But in areas that do have the placement coordination we've heard from a lot of people who say that it does work, that they usually take into consideration the wishes not only of the clients but the ability to serve that clients in the facility they would place them in. It seems to be the case that it's working well here. Perhaps then we should take what we've learned here and make sure that does get applied if we have to go into areas without placement coordination.

I thank you for coming to the committee and bringing those views forward.

Mr Orvidas: I believe it does work well within current legislation and within the current limits to what they are permitted to do. I have a concern with the new legislation and the lack of accountability that seems to be evident.

Mr O'Connor: Do you think the placement coordinators need more accountability, and in what areas would you see that?

Mr Orvidas: I would request that there be greater information provided regarding appeal processes and the opportunity for clients to have more choice.

Mr O'Connor: I think that as we go along further into the process, that will become available. I know that in the draft manual that was circulated around the province -- and of course that was only a draft -- looking for comment to try to improve it, I believe OANHSS, from the non-profit sector, did hold consultations with people from their organization to try to get feedback directly from them, because of course everyone's concerned about how it will all come together.

The Chair: Thank you. Ms Caplan.

Mrs Caplan: Thanks for an excellent presentation. I have a number of very short questions. Do I have to roll them all into one or can I ask them sequentially?

The Chair: The Chairman will pretend they're all wrapped into one, as long as they are short.

Mrs Caplan: They will be short.

We've discussed an amendment that would allow all long-term care facilities the right to refuse on the basis that they couldn't provide appropriate care. Would you support that?

Mr Orvidas: Yes.

Mrs Caplan: As well as the right to appeal that right to refuse?

Mr Orvidas: Correct.

Mrs Caplan: Do you think there should be a statement of principles embedded in the legislation around consumer choice that the placement coordination services would have to consider -- I read them into the record this morning -- all of those things: multicultural sensitivity, geography, dignity? There are a number of them. Would you prefer to see that in legislation or in regulations?

Mr Orvidas: A statement of principles or a motherhood statement of that nature I think is always good, not only in legislation but in any guidelines or standards.

Mrs Caplan: The suggestion that we could change by amendment the proposed enforcement model of accountability to one which would mandate a program of quality management, be it total quality management or continuous improvement, plus a mandated requirement for accreditation and then, upon complaint, you would kick into a compliance mode of cooperative problem-solving rather than having that enforcement model which requires all of that paperwork and reporting: Would you support that instead?

Mr Orvidas: That sounds very interesting, and I think moving towards more of the type of the model we'd like to see.

Mrs Caplan: The other concern I have, and you mentioned it, is the amount of paperwork that the enforcement model breeds. We know that the whole concept of our total quality management approach looks at processes to eliminate excessive reporting at the same time as keeping good records so that you can monitor your outcomes. That's a progressive and modern way to do it. How prevalent is that, do you believe, in the nursing home sector? We've heard about it from so many people who have come forward, and I know that's got to be relatively new in the last two to three years. Do you think most nursing homes have those programs in place now?

Mr Orvidas: The vast majority of nursing homes are currently accredited, and one of the integral components of the accreditation process is the requirement for not only quality but risk management, TQI or CQI, total or continuous quality improvement or whatever you might like to call it.

The Chair: Final question.

Mrs Caplan: They're monitoring their programs as well as their management on the basis of result, outcome?

Mr Orvidas: It would appear to me that they're doing both.

Mrs Caplan: Thank you.

Mr Jim Wilson: Thank you very much. I too would like to add my congratulations and I wish you all the best as the chair of the nursing home association.

Mr Orvidas: Just the region.

Mr Jim Wilson: For the southwest region?

Mr Orvidas: Region 7.

Mr Jim Wilson: It will be an onerous task, I'm sure, given all the changes that are happening in the sector.

I want to just comment that although there have been problems from time to time in the past, you're currently under a fairly onerous and time-consuming inspection system. You mentioned in your comments that you felt there were some increased powers of inspectors that this bill provides for which may be problematic. I just want you to sort of enlighten us on what those increased powers may be and some examples of how they may be problematic for your sector.

Mr Orvidas: The current compliance management program compared to the old style, if I may, of inspection process I think has not only worked towards improving resident care but improved or significantly improved relationships between the Ministry of Health and the individual nursing home operators and managers. It's a consultative, cooperative approach to doing the best we can within the resources we have available, rather than being beaten over the head because a set of curtains is two inches too high or a door opening needs an extra five inches worth of opening, or something to that effect.

Having had experience in homes for the aged, the process of working with program supervisors I thought was always a very positive one. However, from that perspective, I always found that there was not enough accountability, while with nursing homes the other side presented itself: extreme and excessive accountability.

Mr Jim Wilson: Thank you. I think Mrs Cunningham has a short comment.

Mrs Cunningham: Just one statement to you, Mr Chairman. This again is one of the great administrators of one of the good facilities here in London, and I wanted to draw it to the attention of the committee, but mainly because he was probably the first one, within a few days of my getting elected, who made certain that I got out there and found out how his facility operated. I just want all of you to know that and I'm not surprised to hear --

Mrs Caplan: That's probably why they elected him chairman.

Mrs Cunningham: Chairperson.

Mrs Caplan: Right.

The Chair: We're delighted that somebody got the honourable member out there --

Mrs Cunningham: Yes, I'm not surprised. He does everything.

The Chair: -- and doing something, because that would make us terrific.

Mrs Cunningham: Mr Wessenger, you should phone this man and get some better advice than what you're getting, and you wouldn't have this written the way it is.

Mrs Caplan: It's not that he's getting bad advice --

The Chair: Mr Orvidas, you have obviously been placed, now, on a certain pinnacle.

Mr Orvidas: Yes.

The Chair: We thank you very much for coming.


The Chair: If I could then call for the representatives of the Victorian Order of Nurses, Sarnia-Lambton branch, and after they present, I believe the representative of the VON for Oxford county is also here and she will be next up.

Thank you very much for coming to the committee today. We very much appreciate it. If you'd be good enough to introduce yourselves for members of the committee and for Hansard, then please go ahead with your presentation.

Mr Jack Smith: First of all, it's a pleasure to be here today to make this presentation to the standing committee. My name is Jack Smith, and I'm the president of the board of directors of the Sarnia-Lambton Victorian Order of Nurses. Accompanying me today is Lavinia Dickenson. She is the executive director of the branch in Sarnia.

The Chair: Welcome.

Mr Smith: We have a handout here. Do you want it before we give the presentation?

The Chair: Yes. The clerk will get that and distribute it. Thank you. We've just been discussing paper, so I think it's appropriate that we should distribute some. Please go ahead.

Mr Smith: VON Sarnia-Lambton is one of 33 branches in Ontario and administers the following programs.

The visiting nursing program: Registered nurses and registered nursing assistants will make approximately 65,000 visits this year to a high percentage of clients requiring acute care, such as intravenous treatment therapies and palliative pain control. Foot care clinics are offered throughout the county, along with an active shift nursing program.


We have a volunteer services program and 200 dedicated volunteers provide transportation, friendly visiting services and palliative support. Volunteers are also involved in office administration, along with fund-raising and educational events. We also administer the home care program. We are one of the four branches in the VON that do this. Along with this we administer the placement coordination service, which assists families and hospitals in determining the appropriate level-of-care service for those needing long-term care placement.

In keeping with consumer rights, we at VON believe that individuals have a right to access comprehensive, compassionate family and community-centred health and support services. Health care providers and consumers then collaborate to develop, implement and evaluate services.

I'd like to make a few comments under a few headings. The first one is funding and cost containment. We believe that the health care system as a whole is adequately funded, but management of the system needs attention.

A provincial strategic plan should be developed, with funding allocation based on strategic priorities. The government should take a look at where the growth is and stage its funding allocation accordingly. This year in Ontario, for example, there has been a significant increase in the Ontario drug benefit, 3%, in physician costs, 4%, while hospital increases are being contained and there is a possible 0% increase for community-based services.

Funding community-based, long-term care as an alternative to inappropriate use of acute care resources and institutionalization is certainly a step in the right direction. But the government should ensure that there is a viable funding base in the community to sustain the proposed shift. This can be achieved by financing the increase in long-term care by staged reallocation of the existing health care budget. We recommend that the government give serious consideration to building in accountability for consumers and providers for appropriate use of our limited health care dollars.

To support community-based care, certain core programs should be in place. We are certainly pleased to be a community that will be receiving the integrated homemaker program. Other program initiatives might include respite for care givers, in-home palliative care and foot care. However, new programs should be designed to include outcome measurements in the evaluation process.

VON Sarnia-Lambton is interested in moving towards the provision of homemaking services which will provide integrated services for clients who require multilevels of care. The Sarnia-Lambton branch would be interested in and pleased to participate in a pilot project of a comprehensive multiservice agency model.

Under planning, VON supports the government's direction to be as inclusive as possible when discussing the needs of the disabled, and recommends that the needs of the physically challenged, children and adults with chronic disease and high-risk elderly be given equal consideration.

Planning responsibilities should be clearly defined, with the recognition that the further away decisions are made, the more things get lost. The real authority should be closer to the people. Planning provincially, regionally and locally with clearly defined responsibilities will improve efficiency. For example, provincial responsibilities should include the definition of core programs and the formation of a quality management framework, including standards, outcomes and reporting requirements. Regional responsibilities should include specialized service planning, ie, geriatric assessment and specialized rehabilitation resources, while local planning should include the continuum of care from health promotion through rehabilitation at all levels of service delivery.

The lead role for local planning shoud be assigned to the expanded district health council with enhanced social service representation.

Under the allocation of resources, at this point in time the government has been considering the question of devolution of the responsibility for health and social services to local agencies. This is in follow-up to the recommendations of the Premier's Council that recognized the need to have a more flexible and responsive health and social service system in Ontario.

VON would support a government initiative to pilot the devolution concept with long-term care. The envelopes devolved to the local authorities should be inclusive of the long-term care budget, ie, include in-home services, community-based and facility services. This will allow for the flow of funds between the community and the institution, as it is in the best interests of the local community. It may also allow for rationalization of the service delivery.

Under coordination of long-term care, while there may be several agencies providing service to a client, this system can be managed to ensure that the service delivered is seamless. Long-term care services should be available 24 hours a day. Traditionally, clients needing care after normal working hours have access to care through hospital emergency departments. It is consistent with the devolved authority model and quality management practices to empower front-line staff in the provision of appropriate customer-focused service.

We would make these following recommendations pertaining to Bill 101:

-- VON recommends that consumers have a choice of whether to receive needed services in a facility or a community setting within an envelope of available resources. In short, the consumer has a choice of service location.

-- VON also recommends that if the consumers require and they or their surrogate decision-maker choose facility care, they have the choice of what facility to enter, rather than this being the decision solely of the placement coordinator.

-- While supporting the incremental changes proposed to protect and increase the involvement of the consumer in their care, VON recommends that the tone of the amendments be empowering rather than paternalistic.

-- VON recommends enhancement of health promotion and community care options rather than moving ahead on Bill 101, which sends a message that the government is still more interested in institutional care.

-- Therefore, VON recommends that the Bill 101 amendments be delayed until the publication and public debate on the government's long-term care redirection policy framework has occurred.

The Chair: Thank you very much for your presentation and for your recommendations. We'll begin the questioning with Ms Caplan.

Mrs Caplan: Thank you for an excellent presentation. We've heard from a number of VON organizations with the same recommendation for delay.

What we have heard from the parliamentary assistant is a best efforts commitment to the month of March, giving the framework for long-term care, the month of March producing the chronic care role study and now we've heard about the month of March having the classification information available as well.

What I would like to know from you at this point, since we've heard from so many people how important it is -- it's been two and a half years' wait from when this originally had hoped to be implemented -- would you reconsider your recommendation for delay if some of the amendments that had been proposed -- I know you've been here for a little while hearing about some of the amendments that would deal with the paternalistic enforcement, the outdated ideology that's in the legislation -- if some of those changes were made and with the commitment that the rest of the package is going to be available in March?


The Legislature, we don't think, is coming back before April or early May. It is likely that this legislation, even though it is entirely institutional in its focus, with the exception of the support for disabled persons -- I think that's a very important part we've heard; nobody wants delay in that -- likely this legislation will not be dealt with until the spring session. May or June would be my guess. Would you reconsider your recommendation for delay in light of all of the evidence that says we should get on with this?

Ms Lavinia Dickenson: My sense, having worked in the community as long as I have, is that I'm not convinced that the changes will be forthcoming, in that we have been waiting at least three and a half years or more. I think it's imperative in order for local planning to occur. The health council has just recently received this role and certainly isn't necessarily in a position to take on this role in view of the fact that the chronic care role study isn't a piece of any of this. They have a big impact on the system, and certainly if they weren't included in Bill 101, then entry into chronic care could be a back door into the long-term care system.

Presently, the acute care is an entyr into the long-term care system in a lot of cases, and I think that's a valid concern. So before I would say yes, I'd go along with that recommendation, I'd really like to see the policy framework as to how those other pieces are addressed.

Mrs Caplan: Can I ask one more?

The Chair: One.

Mrs Caplan: If the policy framework says that the chronic care role, or that facility should become a long-term care facility and be included under this framework, would that solve your concern from the institutional side?

Ms Dickenson: That would solve it. Yes, that would solve my concern on the institutional side because, theoretically, reading Bill 101, there would be very few people who will need a chronic care bed for all intents and purposes.

Mrs Caplan: Similarly, we'd need the framework to see how you would have the support and resources, of course, for the community components of it.

Ms Dickenson: That's right.

Mrs Caplan: But my concern is that if this sits for too long and we have delay after delay, the patchwork, inequitable, awful system -- when I say "awful," it's just so unfair -- that exists today would be allowed to continue for too long. Thank you.

Mr Smith: I guess our concern, though, is that we would not like to see any of this come in in a piecemeal style.

Mrs Caplan: I understand.

Mr Smith: That's our concern.

Mr Wessenger: Thank you very much for your presentation. I can see by your brief that you're well on the way to being a multiservice agency at present. I'm just wondering what changes would be required in order to make you a complete multiservice agency.

Ms Dickenson: We want to be able to provide a homemaking service not necessarily for every person who's on service but for a certain stream, maybe the palliative care person because his needs are fairly complex and need to be highly coordinated.

We also need to recognize that there have to be enhancements for folks being on call, going out in the middle of the night into strange parts of the city. There are safety features that need to be built in to do these things. While we are providing intravenous therapies and things like that, there needs to be some consideration for the ongoing recertification of staff and trying to keep people interested and working in the community, and it's a changing role as well.

Mr Wessenger: You indicated that you're interested in having a pilot project. Will you sort of be working on that with respect to --

Ms Dickenson: Oh, yes.

Mr Wessenger: Fine. Thank you.

Mr Jim Wilson: Thank you for your presentation. I'm glad the parliamentary assistant asked that question about the pilot project. Your end of the deal would be to keep lobbying for it. What your end of the deal is, Mr Wessenger, are you going to have a pilot project? I might as well ask you that question.

Mr Wessenger: You shouldn't be asking them.

Mr Jim Wilson: Seriously, has the ministry contemplated how it's going to go about the new system, and is there to be a pilot project?

Mr Wessenger: Of course, it's going to work through the long-term care subcommittee of the district health council, but I think I'll probably ask the ministry staff, who can probably give more detail that would be of assistance in this regard.

Mr Quirt: In our December 2 announcement to the Legislature, the then Minister of Health, Frances Lankin, indicated that the intention of the redirection was to bring together service coordination functions with actual service delivery functions.

What that really means is that the resources associated with the home care program and the resources associated with the placement coordination service program -- the people, the skills and the financial resources -- would be brought together with the resources of those agencies delivering services, like Meals on Wheels, transportation, homemaking services and visiting professional services to form a comprehensive, multiservice agency. The minister has asked district health councils, through their long-term care subcommittee, to establish the appropriate planning process so that those options can be considered and that it be done in an orderly way locally.

We expect there will be a variety of different models of comprehensive, multiservice agencies. Some may involve the actual bringing together of agencies under one board. Another model that has worked well, on a county basis, with home support programs is the creation of an umbrella board to which local service providers send representatives, and that could form the multiservice agency. So a small agency that used to just deliver Meals on Wheels could have the capacity, right at that spot, to determine that somebody's eligible for a professional health care visit and arrange for a physiotherapist or a nurse to go out right from that location.

The notion is to equip each portion of the community service system with a mandate to provide a much broader range of services than it can now. As I mentioned earlier, it's a responsibility of the DHC to figure out how many are necessary in their area, where they'd best be located and how they best be configured, but it is not the intention to do it on a pilot basis. The policy decision to move in that direction has been announced.

Mr Jim Wilson: Thank you. I appreciate the explanation as I'm sure the presenters appreciate it.

I do want to ask you -- I gather that part of VON's recommendation to delay the legislation is probably the fear that the community-based services won't be in place. We've had 5,300 hospital beds closing since this government came into office, 2,800 ONA nurses -- that's the only number we have that's solid -- laid off, some VONs laid off around the province and public health nurses laid off. Perhaps, while you have the opportunity, you can give us the lay of the land in Sarnia-Lambton. Are you able to meet the current demand? My theory is that with all these layoffs, the crunch is not too far down the road. Are you going to be able to meet that expected crunch?

Ms Dickenson: I think we've seen the right-sizing of hospitals maybe later than other communities, so we're just beginning to see this now with bed closures.

Our particular VON did not experience any layoffs. The layoffs that were experienced with other VONs were due to the fact that they brought RNAs on stream to diversify the workforce, so that didn't really happen in our area. For the most part, we're able to meet demand except that we're having some difficulties within our fiscal framework in providing on-call services.

For instance, shift nursing right now is being funded through private insurance companies. Certainly folks needing palliative care who do not wish to be admitted to hospital require the services around the clock lots of times. We're trying to fill those needs by fund-raising and filling the gaps, and of course in our economic realities that's not always easily done either.

Mr Jim Wilson: There are a lot of groups competing for the fund-raising dollars out there.

Ms Dickenson: Yes. There are a lot of miracles that are expected by community health agencies, and a lot of fiscal acrobats.

Mr Jim Wilson: Probably because the VON's been traditionally good at performing those miracles.

Ms Dickenson: Thank you.

Mr Smith: I guess the other thing too is that this year we have increased to about 65,000 visits, so it's not that we haven't taken on RNAs as well; we certainly have. We have RNAs as well, but because of the increase in visits, we've been able to take on the RNAs and hold our nursing staff to the same. In fact, we're projecting, probably, for the next year in the neighbourhood of 73,000 to 74,000 visits.

The Chair: Thank you very much. We would wish you continued success with miracles and success with the pilot project, however it may be called.

Mr Smith: We have talked to Bob Huget about it and we will continue to talk to him. Ha, ha.

The Chair: The truth will out.

Thank you again very much for coming before the committee today. We appreciate it.

Ms Dickenson: Thank you.



The Chair: Could I then call the Victorian Order of Nurses, Oxford County branch. If I might, I would just note to committee members that we are right on time, and I appreciate the cooperation of members as we proceed through the afternoon.

Thank you for coming to the committee today. Would you be good enough just to introduce yourself for committee members and Hansard, and then please go ahead with your presentation.

Ms Kathryn Bamford: It's important to know, firstly, that although all the VON branches belong to the provincial --

The Chair: I'm sorry. Could you just introduce yourself first, for Hansard.

Ms Bamford: I'm sorry. I'm Kathryn Bamford. I'm the executive director of VON in Oxford County.

As I was going to say, it's important to note that although all VON branches belong to a provincial and national organization, each branch is incorporated on its own and has unique concerns which reflect the unique community that we serve.

VON in Oxford county recognizes the need for long-term care reform and encourages a collaborative approach to planning and implementation of an enhanced health care system which will continue to provide a quality continuum of care within the limited resources available. I ask your tolerance in listening to some of the repetitious issues that you'll be hearing in my presentation which you've heard with VON Sarnia-Lambton.

Good afternoon, Mr Chairman, standing committee members and interested public. I've been asked to speak to you today on behalf of VON Oxford's volunteer board of directors, who are busy with local community commitments and are not able to be here today. As executive director of the branch, it is my pleasure to do so.

As indicated in my opening remarks, we support the need for improvements in the long-term care system. Rather than reiterating the realized benefits of Bill 101, I shall highlight further enhancements required in the areas of vision, planning, allocation of resources and service delivery which will ensure a comprehensive system reform absolutely necessary within the economic realities of today.

VON Oxford believes consumers requiring long-term care services to promote their health and wellbeing need to have a choice of needed services delivered in their preferred location, by their preferred provider, within available resources.

Bill 101 supports some of the incremental steps towards a consumer- sensitive system. However, if we really believe in consumerism, then we must allow people choices. Firstly, we must be all-inclusive. Bill 101 has not addressed the chronic-care bed population. Secondly, we must create opportunities. Bill 101 needs to include requirements for residents' councils in all long-term care facilities. Thirdly, we must ensure the right to exercise choice. Bill 101 needs to allow individuals the choice of whether to receive needed services in a facility or a community setting within an envelope of available resources.

In recognition of the consumer's right to self-determination, consumers should have the opportunity to participate in the decisions that affect them.

VON Oxford believes more emphasis should be placed on the rights of consumers to be a full partner in the planning of care, including the delivery model and the provider best suited to meet their needs, as well as to be a partner in the evaluation of the service provided.

Bill 101 needs to ensure a preference for not-for-profit service options for individuals due to the return value to the community by way of volunteer contribution of time and resources and community accountability. Bill 101 needs to ensure that consumers' participation is not contrived, controlled, or an act of tokenism.

A provincial strategic plan needs to be developed with funding allocation based on strategic priorities. Certain core programs need to be in place to ensure provincial equity, particularly in a small rural county such as Oxford, which often lacks a critical mass large enough to support some specialized services. We are therefore forced to accept less than the best services available or sometimes to travel 45 kilometres to London, if able. Community-based core programs should include the integrated homemaker program, which we already have; respite for care givers, which we are in the process of acquiring; in-home palliative care, which we presently have; and foot care, which is necessary to keep vulnerable people mobile and independent, which we also have.

District planning requires involvement of the district health council, particularly the long-term care committee. Already our Thames Valley District Health Council long-term care committee has restructured to include 48% consumers and a broad base of community providers. Local health and social planning has begun in Oxford as well, thanks to the insight and inspiration of our local MPP, Kimble Sutherland.

VON Oxford believes the real authority must be closer to the people. As this authority moves away from people it is intended to serve, it becomes less sensitive, and important detail is often lost.

By moving ahead with facility legislation outside of the policy framework and prior to local district health council planning, the government is not fully supporting its own direction for a strategic policy-based approach to the health care system based on consultation.

Funding community-based care as an alternative to inappropriate use of acute care resources and institutionalization is a step in the right direction. However, we in the community require assurance that there is a viable funding base in the community to sustain the proposed shift.

In Oxford county, collaboration between all health and social sectors would be enhanced by the devolution concept, with long-term care including both in-home services, community-based and facility services. We would support being involved in piloting the devolution concept, as with VON Sarnia, given that the agency, having the envelope, reflects community services, consumers, government and a broad-base representation from providers. It is important as well that no one funding model be attached to the terms of reference for devolution. Rather, there needs to be flexibility of payment modes available to allow for the most cost-effective alternative, given the nature of the service.

The legislation promotes fiscal accountability by a control on resource utilization rather than on the measures of resource outcome. Efforts to control the number and types of beds and associated costs continue to be sectoral and need to be expanded to evaluating the benefits of facility versus other types of care from a broader perspective, as well as consumer input. If total quality management is achievable, we must plan a system which ensures accountability rather than one which continues to control and regulate in a sectoral, fragmented fashion.

Seamless service delivery appeals to everyone wanting to correct the fragmentation in the service system. The how-tos of this have created some degree of concern among traditional stakeholders as we local providers attempt to collaborate in spite of the barriers of the present systems. These barriers require further attention in the long-term care legislation in effort to reduce institutional bias.

VON Oxford suggests that the development of comprehensive multiservice organizations funded by capitation may significantly reduce the bed requirements by providing more comprehensive, potentially cost-effective options in the home. VON Oxford is evolving by responding to community needs through seven programs and services. Clients already experience the benefits of comprehensive care, from the least intrusive volunteer services, such as Meals on Wheels and friendly volunteer visiting, to more professional supports and needs, from foot care and RNA nursing care to home IV therapy and palliative care with pain control technology supports. Our network of health and home care social service partners such as Red Cross homemaking, hospice and placement coordination, provides clients with a continuum which particularly benefits those with complex needs in a cost-effective way.

VON have realized the benefits of collaboration in Oxford county in planning and implementation of services. We continue to view health in a broad way, encompassing health and support care in an environment of continuous quality improvement. We are encouraged by the directions set forth by Bill 101; however, we recognize the need for public debate on the government's long-term care redirection policy framework prior to finalizing Bill 101 amendments. This is a necessary conclusion to the consumer public consultation.

On behalf of VON Oxford, I'd like to thank you for allowing me this opportunity.

The Chair: Thank you very much, and thank you also for offering another pilot project. We'll keep a list of --

Ms Bamford: Add it to your list.


The Chair: Who's on line here? We'll begin the questioning with Mr Wilson.

Mr Jim Wilson: Thank you for your presentation. I just want to focus, really, on one point that you mentioned, because I think there's still some considerable debate around the area of cost and providing in-home services, community-based services. Some would argue that when you get into really high levels of care, it's not necessarily cheaper to provide that care in the home because of the machinery required and the capital and all that.

I've never seen a cost-benefit study. We've gone along, and I think all politicians have given a lot of speeches about the move towards community-based care, but we really don't know -- at least I don't -- at what point it makes sense to keep people in their homes and when it makes sense to maintain some institutional care.

Do you have any comments on that? You're out in the field; you have experience. We've not seen the studies. We're kind of doing a lot of this in a vacuum, as you might be aware.

Ms Bamford: I'm not surprised. It's a very complex issue because there are so many variables to consider.

The only thing I can perhaps reference is that we actually were fortunate enough to be involved in a case whereby we were maintaining a medically fragile child at home. The child really had two options: to stay in London in hospital, or to come home with what limited supports we would be able to provide in the community.

We did a little bit of costing on that, and I can't recall the numbers specifically, but I can tell you that within a two-year period, that child was reduced to 11 hours of respite a week, and I could actually provide this committee with that report.

Mr Jim Wilson: That would be very helpful.

Ms Bamford: It was a very interesting study because this child had very complex needs, and the child relied very heavily on the parents providing a great deal of the support. I would say that would be very much one of the factors for anyone who is going home requiring intensive care, in that it's very difficult to provide specialized nursing care 24 hours in the home in a cost-effective way. However, there are many cases where care givers are willing to do and provide a great deal of that support. I think that's where we see in-home services being very cost-effective, with either family and/or volunteer services such as hospice or volunteer visiting services or Meals on Wheels.

Mrs Caplan: There is an improved quality of life as well in that situation.

Ms Bamford: Absolutely.

Mr Jim Wilson: I think we agree with that, and the VON has been very good to sort of train the parents and help them learn some skills that they may need. I guess the problem we run into as legislators with the changing demographics and the changing nature of families is you have to make sure there are people at home willing to help out and able to help out, and that's a problem, too.

Ms Bamford: That will become, I think, very much a part of the assessment. What are the supports, who are the supports, and what are they willing and able to do? That's very critical. That's a very critical factor.

Mr Jim Wilson: Thank you very much.

Mr Wessenger: Thank you very much for your presentation. I'm going to ask a question you won't be able to answer in time, so I'll just ask you to touch on it.

You've raised the whole question of devolution. I'm wondering to what extent you mean devolution. Do you mean planning functions? Do you mean management functions or partial management functions? How do you see the role between local and provincial? Lastly, how do you hold the local role accountable?

Ms Bamford: How I try to look at this is from the individual op, knowing that again, decisions made closest to the individual are the most sensitive to his needs. I'm thinking that locally, in Oxford county, we have our health and social services planning council. We're in a very early stage of developing a model for that, but I see that council as being very much a representation of all health and social service providers in Oxford county. It's broad-based in terms of provider representation and it's broad-based in terms of consumer representation. These people really, given an envelope of funding, would be able to look at how we distribute the dollars locally and they would be accountable to the decisions that are made. If, for instance, they spend too much on in-home services and when they need to get into the hospital there's a six-month waiting list and the public is upset about that, this group would be accountable to answer to that. Now, whether it's elected or appointed, those are all other issues that have to be dealt with. But I think the only way we're going to have devolution is if the funding be at the local level.

I also believe there are some things, just as I indicated in my presentation -- we do not have the economy of scale to have a cancer clinic in Oxford county. We realize that and know there are some things that need to be looked at in a regional way.

We also know there are some things, again, that need to be planned regionally as well as some things, perhaps such as transplants, which would need to be planned and administered provincially.

I'm looking at all of those layers and I'm saying it has to go both ways, though. The planning has to come from the bottom up and from the top down, and they have to be able to look at where the economies of scale are and the efficiencies that can be acquired in that system.

Mr Wessenger: Can I just follow up? How would the district health council relate to this local authority? Are you looking at this local authority being an expanded model of district health councils?

Ms Bamford: I see it as being a tentacle of the district health council, very much a part of it, because of course they have the responsibility to plan and they have the resources and the information that's necessary to plan. I don't think this body would detract at all from the district health council. In fact, I think it would be an enhancement. Already many of the people who are involved in the local planning are also involved either as council members on Thames Valley District Health Council or are acting in an advisory capacity on the committee. So there's already that cross-referencing.

The Chair: Ms Caplan.

Mrs Caplan: I'd like to use the few minutes I have to give you an example of what I'm dealing with on behalf of one constituent right now, which I think tells a story that needs to be told when we're looking at these kinds of reforms. I just have a few minutes.

I had a call from a constituent's wife about a week and a half ago. Her husband is recovering, fortunately, from a stroke. He's in a chronic care hospital. He's recovered to the point that he can go home and he wants to go home. He's upset and distressed about being separated from his family and his home surroundings, and his wife wants him home. He was told, and his wife was told, that he had to remain as an inpatient in order to receive one hour a day of speech therapy. I see by the look on your face that you can understand the frustration of this woman. It was so distressing and upsetting to her that she called me to say: "He's upset. He's depressed. It's costing a fortune to keep this man in an inpatient bed, but they've told us that if I take him home, he won't be able to get the service because he's not an inpatient."

There's no placement coordination service. What I did was to call the administrator of the hospital and say, "Couldn't you give him a day pass so that he could go home, spend the time with his family and come back for the one hour a day of his treatment?" He said, "We'll look into this."

The next thing I heard was that the patient had been transferred to another chronic care hospital where he was now undergoing another assessment, which took three days, to determine what his need was. At the end of the second assessment, it was determined that he needed one hour of speech therapy a day, and he was informed by the second chronic care hospital that he had to receive this as an inpatient and could not be given day passes and so forth to go home because this was contrary to the institutional rules.


Long-term care reform, I think, is about trying to be more responsive to those kinds of individual needs. My question to you is -- and obviously you've dealt with the kind of individual and patient and spouse and family in this kind of situation -- can you see a better way? Will Bill 101 respond to that kind of situation? Because clearly these services -- one-on-one speech therapy, one-on-one physiotheraphy, occupational therapy for a stroke recovery victim -- do not have to be provided on an inpatient basis in a chronic care hospital at an expensive $800 a day, $400 a day. What would it cost -- you would know -- for VON to contract for a speech-language person to go into that patient's home to deliver that service for an hour a day?

Ms Bamford: Actually, I wouldn't know, but I could make a guess and it would be significantly less. I think what that problem illustrates is the way we've fragmented or we've sectorized, if we have these pillars of institutional care and different types of services. There's been a certain tolerance in the system. In fact, it's fostered that because of the way the pockets of money have been separated. Children's services are an example of this, where children have to wear certain labels to access certain pockets of money. It's gone from the sublime to the ridiculous. I think the only way that we're going to eliminate these problems is if we break down those barriers. I don't know whether it means dismantling all these boards and collapsing them into one. Whatever it is, it's making people accountable to the continuum and not just to their own sector.

So then the problems have to belong not to just that sector. The problems have to belong to the continuum. That's why we keep supporting locally the health and social support services together. It's very important, because if we think of health care and disease care and health promotion, one does not stop when one goes into -- Meals on Wheels, being a social support, is very much a health service. It's hard to know where the blurring of those two areas occurs. It's a continuum and it's almost cyclical; it goes around and around. So I think it's important however we structure the new system, however that appears; and as I say, perhaps it's having one board and then having to look eyeball to eyeball, and you have to be as accountable as I do when this woman comes with the concern.

I would say that most people would probably just have gone home and gone without the service, and I'd say the majority probably do that, so you're fortunate to know about this situation. But how do we change the system, I think is a big challenge. I think first of all there has to be a degree of trust among all providers that we're all here for the same purpose, and unfortunately that's not the way it is now.

Mrs Caplan: I'm on the verge of advising this constituent to take him home after the therapy session and then take him back the next day and, if asked, to say she has a pass. It seems so unreasonable for them to force somebody to stay in an institution who doesn't want to be there, who doesn't need to be there, in order to be able to get a service that should be available without being told, "I'm sorry to have to stay here in the institution." Can you think of anything else I can advise her to do in the meantime?

Ms Bamford: I think if it were my parent, I would probably take him or her home and try to make do without the service for a while, and either push for change and ensure that change does take place, or find an alternative way of getting at speech therapy.

Mrs Caplan: But you see, she's frightened because she's been told that if he doesn't have an hour a day for the next few weeks, his aphasia, his recovery from the stroke, may not be as good as it might be if he has this treatment, and the family is being torn. She wants him at home. She wants to take home and she wants what's best for him at the same time.

It's the inflexibility of the institution that is the barrier, how you make that more responsive as part of long-term care reform, I think, and also looking for the shift from institution to community for these kinds of services that we're trying to accomplish. I don't know if Bill 101 does it, because it only deals with how we fund nursing homes and homes for the aged; it's another whole component. But this story has just happened, and I thought if somebody had some advice -- the parliamentary assistant might want to give me some advice on what to do to get this chronic care hospital to say: "It's okay for you to have a day pass everyday. Come visit us for your therapy only."

Ms Bamford: But I'm thinking of the child I referred to earlier in providing the continuum of care very cost-effectively. This parent ran into the same problem with speech therapy and ended up getting tapes from the library and teaching signing to this child herself and being very successful at it. Desperate people can often think of some very creative ways of circumventing problems. I think that's what we continually are amazed at in the community. People are very creative and innovative, as they have to be.

The Chair: Thank you very much for being creative and innovative with us this afternoon. We appreciate your remarks, and I think particularly the sort of context that you've placed them in. It's been very helpful. Thank you.

Mrs Fawcett: I have a suggestion for the ministry that maybe all of the VON chapters and branches that wish to participate in that pilot project should be allowed to do so, because then we'd get an experience from right across the whole province. I imagine with the network that they have, we would then come with the absolute, best model.

Ms Bamford: Thank you.


The Chair: I call our next witness from the Southwestern Regional Centre Auxiliary, if you'd be good enough to come forward. Welcome to the committee. If you'd like some water, feel free.

Mrs Cunningham: Could I have a question of Mr Wessenger, please, while the delegation is getting ready?

The Chair: All right.

Mrs Cunningham: I just wonder how the public can get hold of the draft policy manuals. We've had a couple of requests here and I've just now had another one.

Mrs Caplan: Will they be available in March?

Mr Wessenger: I'll ask staff to indicate --

Mr Quirt: The first draft of the policy manual is out. It was shared with members of this committee and it's been sent to about 40 provincial organizations for comment. The second draft is due out in the next few days, in a week or so. If anyone would like to call, our office is the long-term offices in Queen's Park, long-term care division. It's in the blue pages or in the Queen's Park phone book either under the Ministry of Health or Community and Social Services. We would mail a copy of that document to whoever wished it.

Mrs Cunningham: I can advise you right now that Persons United for Self-Help wants a copy.

Mr Quirt: Why don't we just send it to PUSH. In which location?

Mrs Cunningham: Here in London.

The Chair: Thank you. Welcome to the committee, if you would please identify yourself for Hansard and then please go ahead with your presentation.

Mr John Fleming: I'm John Fleming, president of the Southwestern Regional Centre Auxiliary. If you can't hear me, I'd appreciate you letting me know, because I have one bum ear and the battery has just played out.

The Chair: We hear you very well.

Mr Fleming: Fine. The Southwestern Regional Centre is a large, self-contained institution with large, beautiful grounds, a cottage and a wooded area for a summer camp, a ball diamond, a farm with farm animals, fields of edible crops and a miniature golf course donated recently by a service club. It has its own sewage plant, and water supply drawing water from Lake Erie.

The centre was constructed a little over 25 years ago, and it is the largest employer of labour in the district. As of March 31, there are still 511 residents, 487 of whom I believe could well be considered as unsuitable for community living.


Southwestern is recognized as a leader in innovative programs for residents. People come from all over Canada and the United States to see the programs carried on there and how efficient the staff care is for the residents. There are learning classes, including the use of computers. I might say I have a book here that lays out all the different courses they have, and there are a great many. There is a special swimming pool designed especially for handicapped people which includes a new electric lift to make it easier for residents to get in and out. Many wards are now laid out like apartments, giving a homey atmosphere, with their own kitchen facilities. Dances and other entertainment, as well as church services, are held for the residents. You will be pleasantly surprised at the interest and pleasure many severely retarded still get from music.

The centre has an apartment furnished for the parents who come from a distance to see their children. All medical facilities, including doctors, nurses, an infirmary and a dental office, and even a barber and a beauty shop, are available. There is also a cafeteria and coffee shop.

I am president of the auxiliary and I have a son who has been there as a resident almost since the institution opened. I am there frequently, and I can say nothing but nice things regarding the way the staff treat residents. With everything available in this one institution, and with so many people for the residents to meet every day, it helps keep them happy -- and they are, in general, happy. I would defy anyone to prove that, except for those who are mildly retarded, community living can do as much for residents as life in these institutions, and I certainly will say one thing: They can't furnish the help required for some of these people who have to have it so quickly the way an institution can where all the services are there.

I have always been proud of the institutional system for our mentally disabled that was put together in Ontario, which is second to none. I doubt that any country was using their unfortunate people better. Yet in the last few years, government has brought in plans for closing these institutions which were built at great expense to the people of Ontario, to be replaced by community living, a much more expensive system.

As a matter of fact, according to our administrator a little more than a year ago, he claimed that it cost five times as much to keep one resident in a group home as it did in his institution. If you were to consider that that institution was designed originally for 2,000 residents, and you bring it up from the number of people who are there now to more the size that it should be, you would cut your per diem rate a great deal. The more expensive system can never be used by a great many of these unfortunate people. This takes away the rights of many and favours the few.

I have been unable to obtain a copy of Bill 101. The government person to whom I talked was going to send me a copy, but I never received it. I couldn't get one from the institution, I couldn't get one from the town of Blenheim, and I couldn't get one from our member of Parliament, Pat Hayes. So I had to go by guess and things that I read from different federation members. But I do believe, from what I have read, that in relocating the residents, the wishes of parents or guardians have been ignored, and I consider this to be wrong. I think the parents should be consulted before any change is made.

We have had several meetings with parents in the last three years, and I have been in other institutions when parents were at the meetings. I can assure this panel that those parents wanted their children left in institutions, a system that looks after more people better and for less money. Our next board meeting will have a turnout of parents.

When community living started, many people listened to those who were pushing the new system: an excellent system, I believe, for the mildly retarded, but a system without the backup required for those mentally and physically disabled needing constant medical attention. The euphoria of the time led people to believe that anyone coming from an institution to a group home immediately improved, could learn a trade and immediately become self-supporting and capable of holding a job. Now we know differently.

With little money available for our group homes, there are few new openings, so now there is a pause when the government and members of Parliament have time to reassess the situation. I hope that this will be done and that there will be a change of thought in Ontario.

The Chair: Thank you very much for your presentation and for coming to the committee. I think you're the first one from the centres, from the auxiliaries, who has come before the committee, and we appreciate that. We'll begin the questioning with Mr Hope.

Mr Hope: Well, how are you doing, John? I know you and I have had a number of conversations on this, and I even got myself into trouble on some of the comments I've made.

Mr Fleming: Well, I'll say one thing for you: You're one member who certainly has been through that institution several times.

Mr Hope: I know that during our conversations many a time we've talked about the idea of moving services into the community, moving people into the community. You've been through the experience, with the multi-year plan, of the services supposedly being in the community and not being there, and people falling victim. I know there have been a number of studies, and I'm wondering if you can inform the committee about the transition from institution to community when we're not prepared in the community to deal with it.

Mr Fleming: Many of the residents are subject to seizures, very severe ones. There's just no way, because if they took a quick seizure you'd have to get them into a hospital, and if that hospital has a backlog, who are they going to treat first, those people from an institution for the retarded, or are they going to take what we call "normal" people first? If so, by that time they could be too late. At the present time, if anything happens up in that institution, they are immediately looked after.

Mr Hope: The other question I'd ask is, in our community, in Essex-Kent, we've seen the disabled living in nursing homes or homes for the aged or rest homes. As a comparator of what they provide in services and what the Southwestern Regional Centre has, I wonder if you can give the committee a synopsis of the difference in services that are there.

Mr Fleming: To begin with, they don't have the money to have the same type of equipment or the same type of skilled help. In some of those institutions it's very grim. There's one right near Blenheim where a lady -- I believe she was a superintendent -- is up on charges of abusing people. That particular home today has a mixture of retarded and psychiatric-type patients. It's pretty grim when you go there. On the other hand, they've got no place else to go. If you went through it, I'm sure you would think, "Thank the Lord I'm not there."

Mr Jamison: Thank you for your presentation. I just have a comment to make. In my area we have the Association for Community Living, in Norfolk and Simcoe. I had the opportunity to visit, with the minister, a number of locations within our community where in fact people had gone from their institutional setting at Le Manoir to live, and it was made clear to us that the expense, at that point, certainly -- we've been well into this in Norfolk for some period of time. This institution is now being phased out as much as possible, and I understand there is some goodly concern about levels of disability and so on.

But the two homes that I visited just recently -- I'll give you one example. There were three people living there. Two of them had part-time jobs, and they were absolutely delighted that they were now contributing, that they were actually paying taxes. Imagine that: someone happy to be paying taxes. So I'm not sure that I agree that we should carry on the way we have been. The community living approach is a different venture and certainly it's something that has to be closely scrutinized, but in my opinion, from what I have seen in my own area, I believe that there are some very good benefits to the people involved there. I've seen it first hand.

Mr Fleming: I believe in that for the mildly retarded, and that sure, they can learn to hold a job.

Mr Jamison: Some of the people I saw were -- well, it depends on what you would classify as being mildly retarded.

Mr Fleming: That's true.

Mr Jamison: Some of the people I saw functioning very well were not just mildly retarded.


Mr Fleming: We also get back to dollars and cents, because if you have three people there and you're going to handle them right, you've got to have staff on 24 hours a day. That's a pretty expensive deal. When they started to open up the community homes, the ideal number was supposed to be 14 residents. Then it kept cutting down and cutting down.

I was over at one in Chatham because one of my son's friends is in that institution. My boy had a birthday on Sunday, so I'm picking the other boy up and my boy and he are going to the show and to a restaurant on Saturday night. In that home, they bought a duplex: three on each side. It means two staffs. If they can knock a hole in the wall, they can cut it down and have one staff, but that's not the way it's done.

Mr Jamison: Just to finish off, the indication I received through the minister and the minister's staff was that it was less expensive in most circumstances to provide the services that way, and it seemed to be more beneficial to the individual.

Mrs Fawcett: I appreciate your coming today. I'm not familiar with this centre, but certainly from what you have said in your remarks it does sound like a very good centre. I think we all agree that the choice of people, the choice of families, is very, very important. Have there been residents from this facility moved out into the public already?

Mr Fleming: Definitely. As I say, I'm going to pick up one of them on Saturday night who is in a group home in Chatham.

Mrs Fawcett: Do you have any reports or can you tell us whether you think it's working?

Mr Fleming: Well, he's not doing badly, but it depends on the degree of retardation. My son's learning power, for example, is caught at age six. I don't care how smart somebody running a group home is; they can't change that. Nobody can change that except the good Lord. My boy is also crippled. If he stands up for any length of time, he wilts right down to the ground within five minutes.

They were going to put him in a group home in Chatham. At the time, they were going to do over the old Holiday Inn and put him and another boy in one unit. What for? He couldn't do anything. Where is he further ahead, to be cooped up in a residence with two or three for the day, or out there where he meets several hundred people?

The boy that he was being put in the place with would have very violent seizures. They never knew when he was going to have them, so they put one of these crash helmets like they use on a motorcycle on him so he wouldn't split his head. But I could just imagine him and my son being together. The boy falls down on the terrazzo floor and splits his head open. By the time my son, who's about one mile an hour, ever got to the telephone, which he couldn't use, or he got hold of somebody to get some help for that boy, that boy would be dead.

Mrs Fawcett: I suppose we would hope that all of that would be taken into consideration when the placement of these people out in the community --

Mr Fleming: It certainly was a consideration to me, because I made sure my boy didn't get out.

Mrs Fawcett: Of course, and I think all of those things have to be taken into consideration. I appreciated your personal experiences being told.

The Chair: Thank you very much for --

Mrs Cunningham: Can I just --

The Chair: Yes. I'm sorry.

Mrs Cunningham: No, it's all right. I just wondered if you were going to let me here.

Mr Fleming, there are so many people who really admire the work you do with regard to Southwestern Regional Centre, not just for your own son but for the other residents.

I too am a mother of a special young man who has seizures and who can't be on his own. We've been fortunate, to this time, to be able to keep him in our home. His injury was the result of a car accident, so we have help that we were able to get through litigation, and that's how I spend my time. I can tell you that anybody who doesn't listen to parents when it comes to the best care for their children is a person who doesn't know very much about the world. So I'm really glad that you came here today. I'm thinking that your message is probably that we need a little bit of everything when it comes to caring for people.

Mr Fleming: Yes. I'm not trying to knock community living for everybody.

Mrs Cunningham: No, but you're saying that if we are going to deinstitutionalize many of our citizens, we have to have good services in place.

Mr Fleming: Right.

Mrs Cunningham: You're also admitting that there are a lot who never will be able to be deinstitutionalized -- they just won't be able to be -- and there are community outreach programs for people who are in institutions, and they do get out of the institutions and they do other things with their lives, but heavily supervised.

Mr Fleming: I refer to my son as my boy, but he's 37.

Mrs Cunningham: They'll always be our boys. I must say, though, that I have other children in my family too, and I refer to them, even more so than to Kevin, as "my boy," because I don't think they're as mature as he is from time to time, but that's in more of a fun way. They certainly keep some of the local establishments busy. Mrs Caplan and I enjoyed their company at a very important place in London last night called Joe Kool's. So everybody has different ways of spending their lives.

I just want to say thanks for the work you do, because there are so many parents who don't have either the energy or maybe the support system we need to do the work we do on behalf of special children. I am glad you came today to let the committee members know. I'm not being political. I don't think enough people know that parents do know what's best.

Mr Fleming: We have several London boys in the Southwestern Regional Centre. As a matter of fact, one of my son's friends who is in a wheelchair and is in the same ward as him is from London, really a great boy, and the boy I am picking up from a group home in Chatham on Saturday is a London resident.

Mrs Cunningham: There are lots. There are many in our sheltered workshop. Unfortunately, that budget has been cut, and so you can imagine how busy I am to reinstate that funding. But again, thank you.

Mr Hope: John, invite them to a Saturday night dance so they get the true feeling of what it's like.

Mr Fleming: Yes, because the roof really comes off the building then. They really enjoy it. The degree of retardation doesn't matter. They wheel them down there in wheelchairs and help them every way they can to get them there. They still have some rhythm in their bodies in some places.

The Acting Chair (Mrs Joan Fawcett): One minute. I'm timing you.

Mrs Caplan: I just want to make the point that as technology is changing, and it has changed so rapidly over the last few years, there are many people, both adults and children, who have been forced to be in institutions because of their disabilities who now have that opportunity to have the choice. I think part of what long-term care reform is about is to make sure they and their families understand that this choice is available. I'll give one example, and that's people on ventilators today being able to be out in the community and not having to be in a home.

We've heard a lot of concern about choice and flexibility with this legislation. It would be my hope that it would remain as flexible as possible so that the choices that become available in the future, as new technologies change, allow those with physical and emotional and mental and psychological disabilities to have as many choices that the new advances will allow, that they are at least considered an option for them, that they are able to participate in the decisions that are going to affect their quality of life and that they also be allowed to take some of the risks that are inherent with some of those choices. That's what dignity is all about. I just wanted to make that point.

The Acting Chair: Thank you, Mrs Caplan. We appreciate that.

We really appreciate your coming today and putting this on the record. It's very important to us.



The Acting Chair: The next group is St Joseph's Health Centre. I believe the representatives are here, if you would come forward. I would appreciate it if you would identify yourselves and then begin your presentation.

Mr Paul Dusten: Thank you, Madam Chair. We appreciate the opportunity to present before this committee today. My name is Paul Dusten. I'm assistant executive director of St Joseph's Health Centre of Sarnia, and I'm joined this afternoon by Wendy Miller, director of nursing, continuing care in St Joseph's Health Centre.

St Joseph's Health Centre of Sarnia is a 317-bed community hospital offering both acute care and chronic care services. We are one of three hospitals located within the catchment area of Lambton county. As part of a mutual agreement reached between the three hospitals and with the support of the district health council, St Joseph's Health Centre is responsible for all chronic care beds operating within the city of Sarnia. This currently represents 160 beds. A new, modern chronic care facility operating as part of St Joseph's Health Centre was constructed and opened in October 1990.

This strategic move to concentrate the provision of chronic care services from one primary centre has allowed us to develop the skills, services and expertise best suited to the specialized needs of those patients requiring chronic care. We support an interdisciplinary approach which includes appropriate medical intervention, skilled nursing and a broad range of rehabilitation and recreation services.

Our approach goes beyond the provision of institutional care. We are a link between the acute care, nursing home, homes for the aged and community-based services which exist in our community. We now operate an active day hospital which supports and fosters independent living and reintroduction of the patient back into the community.

Through our specialized skills in identifying and meeting the unique and individual needs of chronic care patients, we strive to prevent a one-style-fits-all institutional model that creates ghettos of underserviced patients.

To operate effectively, we work in harmony with other long-term care providers in our community. There presently exists a high level of cooperation, ensuring a continuum of care within the county. Also, we operate what we believe to be a unique process by including on our continuing care admission and discharge committee representatives from St Joseph's Health Centre, the medical director of continuing care, nursing, social work, rehabilitation services, Sarnia General Hospital, community physicians, placement coordination services coordinator, Lambton psychogeriatric consultation services -- on request by invitation -- and others as may benefit the work of the committee.

It is with this linkage and continuity in mind that we question the advisability of proceeding with Bill 101. We find that Bill 101 only addresses a small portion of the long-term care issues which challenge us, and most notably does not include any reference to chronic care.

Our belief, quite obviously, is that chronic care is an integral and critical part of any long-term care model, and we would encourage the ministry to await the important directions and discussions which will be generated by the release of the long-term care policy framework and chronic care role study before embarking on Bill 101 in isolation. A piecemeal approach leaves open many questions and creates confusion in areas such as continuity and quality of care, funding and governance.

I speak first re continuous quality improvement. Our hospital was one of the first to adopt CQI, recognizing its benefits over a strict quality assurance and inspection model as proposed in Bill 101. In addition, our hospital, along with hundreds of others, as well as nursing homes and homes for the aged, already participates in a voluntary accreditation process, a process which has been developed and refined with the commitment and dedication of those involved in the provision of long-term care services.

The bill proposes yet another process, and in the absence of the information yet to be outlined in the chronic care role study, one wonders whether long-term care patients may be subjected to as many as three separate standards of care: one for acute care needs, another for chronic care and yet still another for nursing home or home for the aged care.

In governance, we believe that a continuum of care is best served with governing boards based on voluntary involvement, with the accountability and flexibility to work best in harmony with other long-term care providers in their community, presumably through district health councils and not in isolation or tied to service agreements which may be in conflict with actual needs and opportunities which may present themselves.

The bill also proposes changes in funding and payments. At present, chronic care services provided at St Joseph's Health Centre are funded through the hospital's global budget and copayments paid by the patients or their representatives. With the introduction of the copayment system, an important step was taken towards providing uniformity in long-term care funding mechanisms. Prior to this, with the absence of the copayment, patients with limited ability to pay preferred, and were probably directed, toward chronic care designation.

We would welcome any system which would continue to provide uniformity and equality in the funding and/or payment systems. However, in the absence of information pertaining to chronic care, it is difficult to assess the potential impact of Bill 101 in this regard.

I will now have Mrs Miller say a few words.

Mrs Wendy Miller: I'd like to direct you to the role of the hospital in Bill 101, particularly the acute care hospital with the long-term or chronic care beds.

The one consistent agreement among key players is the real support for reform and an eagerness to participate in the reform process. Participants eagerly await a coherent and carefully designed system for long-term care that allows people to live in dignity, both in their community and appropriate institutions.

Chronic care has changed dramatically in the last decade. To be truly comprehensive, chronic care must meet the needs of all ages and must fully serve all who require services. The chronic care patient is no longer identified as a client who requires basic or custodial care, in particular the elderly and people with disabilities. It is important that all stakeholders understand and address the complex needs for quality of life, rehabilitation, appropriate medical interventions, psychogeriatrics, skilled nursing, palliation and social and recreational needs provided by highly skilled interdisciplinary teams of professionals.

There are indeed reservations about the role hospitals are to play in the system. Hospitals maintain high standards of care in both acute and continuing care units and provide advocacy, opportunities for research and education for staff, health care providers, patients, families and the community. Hospitals are recognized for their expertise in a variety of disciplines. Chronic care beds in the acute hospital sector are not merely custodians of the elderly and the disabled.

Access to facility services: A new system must identify the continuum of care and provide a smooth transition for patients to move from one level of care to another. The movement from one level of care to another must be truly integrated, accessible, affordable and fair.

The amendments, parts I, III and VII, identify the importance of a single point of access for facilities, the coordination and management of access to facility services and the acceptance of admissions pre-authorized by a designated placement coordinator.

Two key players in the continuum of care are not identified, the chronic hospital and the acute hospital with chronic beds, neither does the amendment address the fluid movement of placement to a higher level of care and vice versa. There are no considerations for ethnic, linguistic, religious or geographic preferences. This is not a homogeneous population.

Under placement coordination, the ministry will identify placement coordinators, determine eligibility in accordance with set criteria, determine priority for admission and manage waiting lists. This does not describe a system for placement based on communication, health and social service needs, one that is accountable and dynamic. The client requires the right care at the right time and at the right place.

There is no evidence that the prospective client is reviewed by an interdisciplinary team or a committee with consumer-advocacy participation. Who will the placement coordinators be? How will the services be delivered? Whom will they service? There seems to be much prescribed regulation.

Placement coordination services have roots in many communities. What is wrong with the present system? The focus should be to build a system on the strengths of the old with a minimum of bureaucratic procedures. The reform should be based on enhancing services and not creating new layers of bureaucracy.

There need to be mechanisms in place for updated reviews and appeal procedures that are accessible and non-threatening. There needs to be a consistent drive towards open communication and effective partnership in the management of waiting lists. The appeal board must be accessible to the consumer. The power of the appeal board is astounding. An appeal board with a quorum of one does not describe an equitable system.

It is unclear where the patient is located while waiting for placement in the institution designated by the placement coordinator. The informal care giver perhaps is no longer able to provide care and may be encouraged or desperate enough to seek admission of the patient to acute care, thus taxing a system that has already experienced the reduction of beds.


Geriatric assessment units: This is an opportune time for the ministry to identify the implementation of geriatric assessment units in hospitals. Hospitals provide a tremendous concentration of human and technical resources. Objectives for geriatric assessment units are as follows:

(1) To comprehensively assess the health of referred patients both with a traditional disease-oriented model and a functional model.

(2) To provide short-term medical treatment, to include physical, psychosocial and rehabilitation.

(3) To identify service needs required to ameliorate functional and social support problems, and to arrange appropriate referral to community-based resources.

(4) To maintain the patient in the community as long as possible at the highest level of independence appropriate to the individual's ability to function.

(5) To reduce burden of care on the family and significant others.

(6) To assist in the identification of often reversible mental and physical disorders.

The idea of chronic care step-down units: Many long-stay patients in acute care are typically elderly recovering from life-threatening crises or critically ill with chronic problems. Many of the patients occupy beds in ICU or cardiac care units. Their condition does not warrant an ICU bed, yet they are too ill to be released to a unit bed. The establishment of a chronic care step-down unit would alleviate some of these problems. The step-down units should develop a strong geriatric focus that identifies discharge and rehabilitation plans unique to the population they serve.

Eligibility: What designates eligibility? The Alberta assessment classification system is a system that drives chronic care back into custodial care. This is a model to foster dependence. The tool does not identify medical interventions, psychosocial needs, rehabilitation, continence programs, skilled nursing care, special skin care or equipment. There is no evidence of psychogeriatric, patient-family teaching, quality of life or specialized programs. The tool is designed for payment for care only.

The transient family needs have not been identified in the placement of patients. Many families relocate due to company transfers and economic necessities, and wish to relocate their institutionalized family member. Will this be a determination for priority for admission or recognized if the person is out-of-province?

The act addresses suspensions of admissions to a home if the home demonstrates a pattern of returning admissions that would be in violation of the regulations. This is a punitive relationship, not one of collaboration. I am curious as to the location of patients awaiting placement. Waiting time would be extended due to the suspended admissions and lack of available beds. Will this impact once again on acute care beds?

Amendments I, III and VII identify enhanced accountability in long-term care facilities, empowering the province to withhold payments if the home is in breach of the service agreement. This system does not support a high level of public confidence when the language encompasses words such as freeze admissions, suspend or revoke approval to operate, and withhold payments.

Will there be a limit on the number of times admissions will be frozen due to breaches of the act before an institution is closed or ordered to implement corrective action? Will advisory boards, advocacy committees or residents' councils be established to demand or monitor the accountability of this institution?

Again, this punitive action does not foster public confidence or establish mechanisms for ongoing accountability prior to such extreme action. This accountability format will ensure negative attitudes and stress within a community.

The act addresses plan of care. The act addresses accountability for plan of care. It states that the province will be empowered to make rules respecting plans of care. There is no indication of recognition of the interdisciplinary team that would identify a genuine holistic approach to long-term care. There is no evidence of human and technical resources or the network of health and social service providers that would contribute to an integrated plan of care. The act does not identify standards of practice that are already in place, such as the College of Nurses' that identifies the expectation that its members establish a plan of care that identifies and implements the nursing process. As well, the Gerontological Nurses' Association has developed standards of care for geriatric patients.

Available information: The enhanced accountability requires the institution to make available information about finances, staffing and operation of the home. The information does not support the development of an informed opinion. It is difficult to assimilate and make informed opinions when there is no substantiating information on the licence of the institution, the licence of the care giver, educational backgrounds, job descriptions and union contracts.

The desired procedure for complaints regarding operation of the home, conduct of staff and treatment or care should be addressed via a residents' council or a volunteer advisory board with independent, objective advocates to speak for patients and families. To be able to present conflict situations, there should be a mechanism for patients and families to meet with a spokesperson prior to the discussion of their concerns.

Inspectors: Tools for measuring, monitoring and evaluating quality of care address the powers of inspectors. What are the criteria for the inspector? Will they have a geriatric background and broad knowledge of health care programs? Where are the programs for total quality management or continuous quality improvement that involves all levels of staff participation?

The inspection process, again, is so punitive. How do you evaluate care? Would it involve identification of programs that are in place to provide recreation, counselling, education, rehab and dental services, patient and family interventions?

The inspector would have the right to question staff. The wording within the power of the inspector is not reassuring. This is not a collaborative approach. In a small community it would be very risky to complain about your employer or the institution you are inhabiting.

In today's culture, there is a movement towards decentralized decision-making, continuous quality improvement, consumerism, client advocacy and care giver accountability. These thrusts, as well as approaches used by professional bodies and accreditation agencies, encourage adherence to standards of patient care, but through a more consultative, participative approach rather than an inspection mode.

Where are the mechanisms for monitoring the requirements for staff education and participation along with patients and families for the operation of the institution? Will legislation demand accountability for comfort allowances? Who will monitor and ensure that comfort allowances are spent on dental care, clothing or appropriate seating?

In conclusion, Bill 101 sets up a scheme for an adversarial relationship between all the key players. Ontario's diverse population is clearly reflected in client groups that we serve and the people with whom we work. There must be communication and full partnership in the reform process. There must be a comprehensive service continuum that bridges both acute and long-term care. There must be a linkage between levels of care, access to other services, flexibility in planning and innovative creativity that addresses fiscal responsibility. The system must be accountable and must function as an integral part of a continuum of services that encompasses continuous quality improvement, quality of life, and care that is based on ongoing research, education, evaluation and advocacy.

As I stated previously, there is agreement and support for changes in the system. I thank you for this opportunity to address pertinent issues of Bill 101 that I feel have had a negative effect on our patients and the acute care hospital system.

The Chair: Thank you very much for a very full presentation. I think specifically on the chronic care side, as you know, there has been reference to that, and that in March as well, I believe it is, the chronic care role study is to come out.

We'll move to questions. Mr O'Connor.

Mr O'Connor: I listened quite attentively. You presented a lot of issues. As we have travelled across the province, of course, we've heard some of these raised before, because we've had the opportunity to hear them. Sometimes you haven't had an opportunity to hear some of the responses, but we always, of course -- the intent is to go around to listen and to try to improve the legislation. Of course, we've heard that it does sound somewhat bureaucratic and, I guess, in legislation it seems that way because we have our fine bureaucrats and our lawyers who developed this for us to make sure that everything is covered, and sometimes it doesn't sound quite as user-friendly as it could be.

I know that you are somewhat concerned about the plan of care. In the bottom line there, it says that the College of Nurses has identified expectations that its members establish a plan of care that identifies and implements the nursing process, and, as well, that the Gerontological Nurses' Association develops standards for health care of geriatric patients. For your information, the draft document of the manual that had included discussion around a plan of care was circulated throughout the province. Those two associations were involved in that consultation. So I guess somebody in the ministry agreed with you, and they were involved in that discussion. So it's something where sometimes if we can share a little information, we can try to help that comfort level.


I guess in question, again, we're trying to look at things that will be as flexible for the consumer as possible, and we've heard about the appeal board and the question around the quorum. I know that trying to make things as friendly as possible and as accessible as possible -- when you're 85 or 90 years old, you don't want to be having to wait for months --

Mrs Miller: It's difficult.

Mr O'Connor: -- while you manage to get through an appeal process.

A concern I might have is that if we get too bureaucratic and develop a quorum of three or five in trying to draw those people in so that that client, that consumer, has a chance to have that appeal heard, sometimes we make things too bureaucratic. In the legislation we talk about a quorum of one, and I guess that's similar to a lot of judicial-type hearings that take place now. So I just thought maybe I'd like you to expand on your thoughts around the quorum, because we want to try to keep it as friendly as possible and as accessible to the consumers, and I think that if we do get too big with it, we may run into problems as well and not be as accessible. Maybe you can share some of your thoughts around that.

Mrs Miller: Well, I think probably it should be reflected back into how the patient is assessed to get into the institution in the first place. I think that is where it should start. I think you should have an interdisciplinary team, because I think you have to look at all facets of the patient, and this board where the people apply for placement into a home or chronic care, wherever they would like to go, could also be the appeal board. They could go back and say, "I was refused admission, and now I'd like you to explain to me why."

On our own admission discharge committee, we do have that process in place. We have a process where our medical director sends a letter to the physician and says why the person was denied admission to our institution, because obviously they didn't fit our level of care. But there certainly is an appeal, and we would encourage you to reapply and maybe update your information. We try to make it open.

Mr O'Connor: I guess one thing that we have heard from placement coordinators' services that are present right now -- and there is one in --

Mrs Miller: This placement coordination service person sits on our admission and discharge committee, as well as representation from the other hospital.

Mr O'Connor: We heard from someone today, did we not?

Mrs Miller: Yes, you did.

Mr O'Connor: My thoughts are, then, as you say, let's not get too bureaucratic. By dovetailing present systems that we have in place, should we then perhaps eliminate the need for appeals? But in that very extreme case, should there be the need for an appeal, it would be enshrined, because sometimes we have to take a look at that extreme case, that there may be an example.

Mrs Miller: I think there always has to be an opportunity for appeal. You can't be just so cut and dried that: "Yes, you are. No, you're not. This is where you're going." As I stated before, if the process was one, your process of admission was also your process of appeal --

Mr O'Connor: Thank you.

Mr Jim Wilson: Thank you for your presentation. Yes, the appeal process is important, but have you had an opportunity to review the eligibility criteria as outlined in the policy manual?

Mrs Miller: I've not seen the policy manual, unless you're referring to the Alberta assessment tool. No, I've not seen the policy manual.

Mr Jim Wilson: I think we should ensure that these presenters also receive a copy of the draft manual, because it's fine to talk about appeals, but wait till you see the eligibility criteria.

Mrs Miller: Okay. Where would we have got this? How would we have known it was available?

Mr Jim Wilson: The government has been responsive, but I'll tell you that when we started the first week of hearings, I didn't even know this thing existed other than that somebody had given me a few photocopied pages out of it, sort of under a whistle-blowing attempt. Then the minister did authorize that the manual be circulated to all members, so you can now get one. It's not available at the local bookstore, but I think Mr Quirt will ensure that you get one. He's very good about that.

Mrs Miller: Thank you. I appreciate that. That would be great.

Mr Jim Wilson: Really, I don't think any of us on the committee has been involved in continuous quality improvement programs. At least, maybe some have in the health care setting; I don't know. Larry might have been.

Mr O'Connor: Sure.

Mr Jim Wilson: The language of the act speaks to quality assurance programs. Can you tell us the difference, and why it's so important that we perhaps amend the wording of this act to ensure that we have continuous quality improvement programs?

Mr Dusten: I think that CQI is a broader term, perhaps, in that quality assurance is known to us as more of an inspection model, one of determining what is in place and whether or not it's being done consistently. I think CQI is more one of what needs to be in place to meet the needs of the clients or the customers and getting involvement of them in the process, looking at internal processes and procedures to make sure we're constantly improving upon what exists and doing that with stakeholders in mind, as opposed to taking what already may be in place in the facility and ensuring that it's complete or done.

Mrs Miller: I could follow through with that and give you an example. I am now team leader of a demonstration project. what we're looking at is admissions to the hospital. So on our committee we have representation from health records, lab, X-ray, admitting and we have two consumers. What we're reviewing is to see how difficult is it, how much information do you need and do we give you enough information when you come? We want to make it very comfortable for you to come into our hospital and reduce your stress. That's what continuous quality improvement is. All the people involved sit down, and we consider them all our customers. I'm admitting's customer, and vice versa. Everybody is a customer, and we look to see what we can do to make it a much better situation for all the people, all the customers involved.

Mr Jim Wilson: Thank you. That's very helpful.

Could I just ask you one question? It's to do with your comments on the Alberta assessment system. I wonder if I might, through the parliamentary assistant, ask Mr Quirt to respond, because this came up last week or earlier this week. You note on the bottom of page 8 what the Alberta assessment does not do and what it does do. I wonder if we might ask, through the parliamentary assistant, Mr Quirt, to respond to that, and then I'd like to see your thoughts on that.

Mr Quirt: Yes. The Alberta assessment instrument, now the Ontario resident classification instrument, has only one purpose. That purpose is to measure the requirement for nursing and personal care so that we can distribute the resources we have available for nursing and personal care, in as fair a way as possible, to all our nursing homes and homes for the aged.

The instrument takes a snapshot of one day in time in the facility to measure the relative requirement for nursing and personal care. There may be few people away at home or there might be a couple of people in the hospital; that's fine. We simply measure the people who are there that day to determine their relative requirement for nursing and personal care.

It's not intended to measure the need of things like rehabilitation, the services of an occupational therapist, of physiotherapists, the services of a social worker, the requirement of recreation and many other important services we want to see delivered in long-term care facilities and that, for the first time, we've earmarked funding for.

Because we're using the instrument just to measure nursing and personal care does not mean we're not interested in funding and providing all those other quality-of-life programs. The instrument has nothing to do with the development of the plan of care for the resident either. I would applaud your suggestion that plans of care have to be developed in a multidisciplinary way, involving the resident and his or her family, and certainly this instrument has nothing to do with individual care planning.

Mrs Miller: I'm sorry you thought I was -- all I was identifying was that it said the government would set up the plan of care. I wasn't referring back to the Alberta assessment tool.


Mr Quirt: No. We're simply having a requirement of the bill that there be a plan of care. When you recognize that's a requirement of the discipline at this point, we would recommend to our facilities that they take the advice of other organizations such as the ones you've mentioned and how they develop that plan of care.

Mrs Miller: May I ask you a question? When it comes to the Alberta assessment tool, could you identify to me some of the components that identified skilled nursing care versus personal care in it? Can you think of any of the categories from A to G?

Mr Quirt: The instrument measures the services required for nursing and personal care generally. It does not differentiate between the services, necessarily, that would be required from an RN as opposed to an RNA as opposed to a health care aide. What it does is to measure the requirement for the resources of a nursing department on three levels: It measures the resources one might need to consume as a result of needing assistance with the activities of daily living; it looks at the resources from a nursing department that a resident might consume because of the behaviour that may require supervision or support from staff; it also looks at a third key indicator of resource consumption in a nursing department, that being whether a resident is continent or incontinent.

It aggregates those three areas through which clients might consume resources in a nursing department to come up with a rating or a scale from A through to G. Its job is to simply allocate funding for nursing and personal care in a way that makes each facility get its fair share of the available resources, and it replaces the system that now provides $78 a day to a nursing home regardless of whether somebody consumes an hour and a half of care or four or five hours of care.

Mrs Miller: Yes, I realize that. Our facility went through the Alberta assessment tool in October. They were there for five days, and I sort of identified it as a good workload measurement tool.

The Chair: Thank you very much for your very detailed presentation and for coming before the committee today.

Mrs Cunningham: Mr Beer, could I ask a question that will reflect on this brief of Mr Wessenger or the staff?

The Chair: Yes.

Mrs Cunningham: In this particular brief, the presenters -- and I think they're well known in their community as being very good at what they do -- are telling us that governing boards based on voluntary involvement are the best form of government, and they refer there to the district health councils. I'm wondering what the role of the district health councils will be in your view. I was surprised to see them not referred to in the legislation at all, and there hasn't been a lot of talk coming from the government but there have been a lot more questions coming from the public. I'm wondering where you see them fitting in and whether they're going to be part of the regulations. I'm not saying they should or shouldn't be, but what's your intent at the moment?

Mr Quirt: The district health councils were asked on November 26 and again on December 2, by the former Minister of Health, Frances Lankin, to assume the lead role in planning for long-term care services in each community. As you're well aware, the district health councils have a tradition of planning and providing advice to the Ministry of Health on health-related matters. In this new capacity, they'll be requested to plan for long-term care programs and give advice to both the Minister of Health and the Minister of Community and Social Services.

The Minister of Health also asked them to change the configuration of their long-term care subcommittees so that social service perspectives and consumer perspectives would be assured of being adequately represented on their subcommittee, and we are now meeting with representatives of the Association of District Health Councils of Ontario to develop a planning framework within which district health councils would discharge this new responsibility. So they'd be expected to recommend a long-term care plan to both ministers to develop strategies in their community for the creation of comprehensive multiservice agencies, which we mentioned earlier, and give the price to the government on how resources allocated to their particular area should best be spent on long-term care services.

Mrs Cunningham: What will they have to do with service agreements, if anything?

Mr Quirt: They would not have anything to do with the service agreement that's described in Bill 101. That would be a contract between the province of Ontario and the operator of the facility, whether the operator was a church or a local government or a private company. The DHCs have traditionally given advice to the government on the location of long-term care beds in their community and the requirement for them, and they would continue to do that. They would be free now to give advice on long-term care beds, whether they happen to be in a nursing home or a home for the aged. Previously, they were limited to giving advice to the Minister of Health on the nursing home program.

Mrs Cunningham: I think that since a lot of the individuals who came before the committee didn't have that information, it would be important that we get some response to what you've just said. There may be people who don't think that's a good idea, based on experiences, but I don't know; I mean persons who are involved in this whole delivery system.

Mr Dusten, Mrs Miller, if you have any observations on the responses that we got today, I'd be most interested in hearing them. I think you should put them in writing to let us know how you feel. I certainly would have some points of view which I'm willing to get across --

The Chair: Mrs Cunningham, there's perhaps another piece of information we could add to this.

Mrs Cunningham: Anything, so we can respond to it in some way.

Mr Quirt: Sorry, Mrs Cunningham, but I neglected to say that the decision to ask district health councils to take the lead role in planning was a decision taken as a result of the consultation on long-term care services, which involved about 75,000 people in 3,000 meetings across the province. In particular, the consumers' alliance, a group that brought together senior consumers and a number of different consumer organizations, strongly recommended that the district health councils be given the lead role in planning long-term care.

The Chair: Thank you again for coming this afternoon and opening up a number of interesting avenues on long-term care.


The Chair: I would now call the representatives for the Victorian Order of Nurses, Middlesex-Elgin branch.

While they come to the table, if I could just inform members of the committee that there are two documents that have been circulated which are not being presented orally but have been presented, the brief from the Elgin County Homes for Senior Citizens and the submission from the St Joseph's Health Centre here in London. Those are provided for the information of members.

Our next presentation, as I said, is from the VON of Middlesex-Elgin. Welcome to the committee, if you would be good enough to identify yourselves for Hansard and then please go ahead with your presentation.

Ms Mary Dryden: Good afternoon. I am Mary Dryden, executive director of the Victorian Order of Nurses, Middlesex-Elgin branch, and accompanying me is Dr John Haywood-Farmer, president of the board of directors.

The Victorian Order of Nurses of Canada is a national not-for-profit, voluntary health care organization. VON understands the need to put caring first, caring through all stages of life and for the best quality of life, whether it be in the community or an institution.

The Middlesex-Elgin branch of the Victorian Order of Nurses has been in existence since 1906. The branch serves the counties of Middlesex and Elgin, with a main office in London and a satellite office in St Thomas and Strathroy. VON provides health care and home support programs. There are over 200 staff consisting of registered nurses, registered nursing assistants, health care aides, community developers and financial and clerical support staff.

The volunteer board of directors brings expertise, specific skills and commitment to the branch. The directors represent various community groups and serve as board members because of an interest in and a desire to serve the community. The responsibilities of the board are policy development, strategic planning, fund-raising and external relations.

Services and programs provided by the branch include, in the area of health care, the visiting nursing program, which offers general and high-tech nursing care, a palliative care speciality team, a maternal/newborn resource team and intravenous therapy; foot care clinics; occupational health nursing; paramedicals and long-term disability rehabilitation assessments; and shift/private duty service.

In the area of home support, the programs include the Thames Valley Placement Coordination Service; the HOMME program, helping others maintain Middlesex elders, which is a seniors home support services program; the palliative care volunteer program in Middlesex county; the Alzheimer community support program in Middlesex county; and as of April 1, special services at home, again for Middlesex county.

The beliefs of the VON are outlined in the philosophy, which states:

-- Individuals have primary responsibility for their own health.

-- The value and dignity of human life are respected.

-- Access to comprehensive, compassionate family and community-centred health care is the right of all individuals regardless of their ability to pay.

-- Volunteers make a valuable contribution by extending and complementing the services provided by health professionals.

-- Community services of assured quality are essential.

The goal of VON services is to promote health and independence and to enable people to live in comfort and with dignity. VON continually develops new programs and services to meet the needs of the residents in Middlesex and Elgin counties.


VON's historical involvement in this community therefore necessitates that we speak to you today regarding the implications that Bill 101 will have on the health care system and the community as a whole. The concerns that we will be addressing include fragmentation of planning, consumer choice, community linkage and the appeal process.

In terms of fragmentation of planning, the legislation is a small part of the entire long-term care system, albeit an important one. The government, in moving ahead on Bill 101, has sent a message that it is still more interested in institutional care rather than developing health promotion and community care options.

Today in Ontario, the resources allocated to institutional care -- ie, chronic beds, extended care beds and residential beds -- far exceed resources allocated to community and in-home services. By proceeding with legislative changes for facilities before developing and publicly debating the policy framework for long-term care redirection, government is reinforcing the status quo institutional bias. By moving ahead with facility legislation outside of the long-term care policy framework and prior to local district health council planning, the government is not supporting its own direction for a strategic, policy-based approach to the health care system based on consultation.

The legislation allows for the government to designate the number of beds and to require certain types and capacity of beds for certain levels of care, service, programs etc, but does not reference these requirements in terms of any planning process provincially, regionally or locally. It would be ideal if the legislation were delayed until the policy framework is released and debated and the district health councils' planning for long-term care can be referenced in the legislation in terms of the designation of number and types of facility beds.

With respect to consumer choice, Bill 101 allows for direct funding grants to the physically challenged. It ensures consumer access to key information regarding facility services, care, accommodation and consumer knowledge of the care plan, and also allows for an appeal process regarding eligibility for service.

While supporting the incremental changes proposed to protect and increase the involvement of the consumer in his or her care, VON believes that the tone of the amendments is incremental and not comprehensive and could be interpreted as paternalistic rather than empowering.

VON recommends that consumers have a choice of whether to receive needed services in a facility or community setting within an envelope of available resources. In short, the consumer has the choice of service location.

Thames Valley placement coordination service has an excellent model, and VON supports the concept of expansion of PCS programs province-wide with the provision that the coordinators will provide the consumer or surrogate decision-maker the choice of service location. A separate brief was presented to you last night by the director of the PCS program.

With respect to community linkage, provision has not been made for consumers to move from community to institution and back to community with ease in order to meet short- or long-term needs. While there may be several agencies providing service to a client, the system can be managed to ensure that the service delivered to the client is seamless. To accomplish this, the service providers would need to look at creative ways in which to work together towards a common goal.

Regional responsibilities should include specialized service planning -- that is, geriatric assessment and specialized rehabilitation resources -- while local planning should include the continuum of care from health promotion through rehabilitation at all locations of service delivery: in-home, community and facility-based.

The use of a comprehensive multiservice coordinating body as proposed by the government should provide direct consumer access as well as encourage creative partnerships within and between existing community agencies. In considering options for service delivery, it should be noted that VON is broadening services to a multiservice model to better support multineed clients at home, within certain financial boundaries.

In order to ensure continuous provision to consumers of long-term care, VON recommends the proposed legislation must include a linkage of community agencies.

With respect to the appeal process, VON supports the concept of the consumer having the ability to access an appeal process for those decisions with which he or she is in disagreement.

In recognition of the consumer's right to self-determination, consumers should have an opportunity to participate in decisions affecting them. VON believes that more emphasis should be placed on the right of consumers to be a full partner in the planning for care, including choosing the delivery model and the provider best suited to meet their needs, and to be a partner in the evaluation of the services provided.

The appeal process as documented in Bill 101 does not clearly define the location or timeliness of the appeal or the financial responsibilities that may be delegated to these vulnerable individuals and their families. VON recommends that the appeal process for the client be simplified, with localized access to the appeal board.

VON recognizes the need for reform and encourages a collaborative approach to planning and implementation of an enhanced health care system which will continue to provide a quality continuum of care within the limited available resources.

Thank you for allowing VON this opportunity to present its position.

The Chair: Thank you very much, and not only for underlining a number of issues that your counterparts have made in other presentations, but I think what's particularly useful is the local setting in which all of this takes place.

I wonder if I could just, being the Chair, go forward with a question. First of all, we've heard a lot, especially in certain places, about how well the placement coordination system functions. Now, from your perspective -- and indeed last night we had an excellent presentation from the director here and we had one in Thunder Bay and I believe in Windsor -- can you just describe how you function within that system with the Thames Valley? Where do you come in? How do you interface with the PCS program, you know, and if you want to use an example just to help us understand how that functions.

Ms Dryden: How it fits into the organization?

The Chair: Yes.

Ms Dryden: VON is a sponsoring agent for the placement coordination service.

The Chair: So this got started in part through people coming together, and you sponsored this. Do you administer this one?

Ms Dryden: Yes, we administer the program. I believe in 1984 and 1985, when the decision was made to set up a placement coordination service in this area -- the Thames Valley service provides service to three counties: Middlesex, Elgin and Oxford -- apparently a tender was put forth to the community. VON was one of the agencies, institutions, that submitted a tender and was successful in securing the sponsorship and administration of the program.

The Chair: How do you determine who participates in that? I mean, in terms of administering it, do you have a board?

Ms Dryden: The VON has a board. We have a board, a group of volunteers who oversee the VON agency. The PCS program has its own advisory committee and it reports to the VON board. One of the VON board members sits on the placement coordination committee as well, but in everyday affairs, so to speak, the PCS operates very much independently and sets its policies and procedures accordingly.

The Chair: If I were a member of a long-term care agency in the community, I wouldn't necessarily be on that committee, but how might I, whether I was a nursing home or a home for the aged, have impact on the policies and approaches? Do they review procedures on an annual basis? How does it function?


Ms Dryden: The committee itself represents the various groups in the community, like the chronic care hospitals and the nursing homes, so there are representatives from all those areas sitting on the committee. The placement coordination staff are very active in terms of being accessible to the individual agencies and also visiting the individual agencies on a regular basis, so there's input. People technically could input through their committee of representation, and also directly on a one-to-one basis when the staff are visiting the facility, or when they're accessing service through the PCS; they could also do it that way. PCS has also circulated a number of its policies and procedures so that the agencies and institutions using PCS are aware of what the procedures are and changes and that sort of thing.

The Chair: I raise it because I think there has been a lot of interest where we have been told of one that works and works well. Other groups have tended to say, "Look, we think this does work well," but at the same time there has been the expression of a great deal of concern about the function of the placement coordinator as set out in the legislation. I think it's useful to sort of get some sense of, where it works well, why it works well. How is it organized? What does that then tell us about how this particular program ought to go forward? Because in my own area I don't think we have that function, or at least not in that way.

Thank you. Mr Wilson.

Mr Jim Wilson: Thank you for your presentation. I just want to ask you about one sentence on the last page. It says, "In order to ensure continuous provision to consumers of long-term care, VON recommends the proposed legislation must include a linkage of community agencies."

I gather under that section, and from other comments we've had from other VON agencies, that the VON really can serve as the multiservice agency. Is that what you're telling us, and you don't want another layer brought in?

Secondly, just before you answer that, can you give us a feel for how big a job it is in your area of the province to bring together all the agencies? Because each area is different. As the Chair -- his area of the province is sort of near mine, and we don't have as many services as they have in Metro, that's for sure. We all kind of know each other, and bringing us together probably isn't as big a chore.

Ms Dryden: In terms of the comprehensive multiservice delivery agencies, certainly the VON is in a position to provide that function in the long-term care reform, but not necessarily just the VON. We don't necessarily feel that it should be a monopoly in that case. There are other agencies similar to the VON that could be comprehensive multiservice agencies as well, because there are advantages and disadvantages to a monopoly type of system. Our feeling is that allowing different agencies to be multiservice agencies in the long-term care reform would then give the clients and their families a choice in what services they wanted to access for whatever reason, whereas with the monopoly, that's it. People essentially would not have a choice in this system.

Mr Jim Wilson: So what you're saying there is that the mandate of a multiservice agency include some sort of wording that would require it to ensure that it is making linkages. I'm just fishing around. I can't see us writing this into this particular bill. Maybe counsel or Mr Quirt would want to comment on this, but I can see it as forming part of the regulations or whatever. Do you know what I mean? It's a good sentence, but I don't know how it goes into legalese and how you get it into the legislation. I think that's the intent of these agencies, but whether it needs to be written in or not, I don't know.

Ms Dryden: I guess the essence of it would be that there be some collaboration rather than duplication as well, so that depending on how long-term care reform rolls out in the end, so to speak, it supports those principles of contracting with agencies that are multiservice and that can service clients from sort of beginning, early needs right through the continuum as their needs change and become more comprehensive. Then agencies that bid for being comprehensive multiservice agencies that would need some kind of enhancement to their current services would maybe look at some partnerships or working with other committee agencies, rather than duplicating those services again and creating another layer of increased costs, that sort of thing. It's easier said than done.

The Chair: Perhaps I could just ask Mr Quirt to comment on that.

Mr Quirt: Yes. Bill 101, as you know, is an act to amend a number of acts that will still be in force following the passage of Bill 101. It'll amend the Homes for the Aged and Rest Homes Act, the Charitable Institutions Act, the Nursing Homes Act and a couple of others, and it's not the vehicle through which we'd like to develop a legislative base for community programs like comprehensive multiservice agencies. So, as has been mentioned previously, it would be our intention to amend our existing acts for a while and then replace them, ideally, with a new, long-term care statute that would not only bring nursing homes and homes for the aged under one piece of legislation, but that would also provide a legislative framework for the changes that are proposed on the community side, including comprehensive multiservice agencies where they will be referenced in that bill.

We can proceed with the development of comprehensive multiservice agencies under our existing funding arrangements and existing home care program and other statutes, but it may have to fund a multiservice agency from a couple of different places for a while. But we can proceed with developing that community body without legislative reform having to precede that kind of community development.

The Chair: Mr O'Connor.

Mr O'Connor: I want to thank you for coming, because any time that we get into a discussion like we do quite often in this committee, we often find out that the information we hope would be provided to people throughout Ontario doesn't always get out there. In noticing, on page 5 of your brief, that you felt we're fragmenting planning and that the government is reinforcing the status quo in an institutional bias, in hearing that, I started looking through my notes to see exactly what the minister did say when she made a statement in the Legislature. Maybe I can just share some of what she said.

I won't read all of her comments, but she had talked about the restructuring of long-term planning capacities to ensure the inclusion of representatives of municipalities, social service planning, delivery sectors and consumers. She went on to say, "My colleagues and I believe that our new system should place the emphasis where it belongs: on community-based services that will be locally planned and delivered.

"By changing the composition of their long-term care subcommittees, district health councils will be able to assume the lead role in planning long-term care in their communities."

"Rather than continue with separate case management programs to determine eligibility and purchase service from community agencies, we will, over time and in an orderly way, integrate the functions of case management and service delivery. We will bring together existing agencies such as home care, placement coordination services and a range of service delivery agencies to create comprehensive multiservice agencies."

This is what she had stated in the Legislature. Sometimes that doesn't always get out. I went a little bit further into it because I know you've talked about that status quo in the institution and you know we're trying to make sure that all the needs are met, the whole broad spectrum within the community, and I noticed in that statement she announced $133.5 million of the redirection budget which would be going to the integrated homemaker services in 17 program areas. I see, of course, that Elgin is one of them, and I know that Durham and York and a number of different areas have received some of that funding.

Just further on in that statement, she also went on to recognize some other needs. "To meet their needs, the government will also provide $4.82 million an annual basis starting in 1993-94 for palliative volunteer visiting programs, for the education of more than 1,000 community-based service providers and for the establishment of 14 pain and symptom control teams." These teams will be located across the province and "will provide consultation and backup to persons delivering palliative care" within the communities. So there are a number of smaller programs, of course, that will all be part of the larger picture.

So while you come to us with your concerns that we're taking a look at -- we're only dealing right now with the institutions, and I'm sure my colleagues have some concerns that way as well -- we all see the need for an overall redirection in long-term care, and that will take place over a period of time.

I guess one problem with taking a look at that old Hansard, of course, I'm sure my colleagues would point out to me, is that she also stated at that time that the chronic care study would come out in the new year. So I guess we're a little bit late; we're into the new year. It'll come out this year. So there are problems when you do quote old Hansards as well and I just want to point that out, but you see where she's tried to state publicly the role of the community and the importance of it.


Ms Dryden: I'm aware of those statements that you have made. I guess those of us who have been working in the community for any length of time and have been involved with the long-term care consultation and reform are anxious to see some of the movement in the community area and some changes that would benefit the clients of families that we're serving. We know it's coming.

Mr O'Connor: I'm glad to see that you're here and you're going to play an active part in that. I'm glad you're getting a little bit of the money to play that active part as well.

Ms Dryden: We hope to.

Mr O'Connor: Thank you for coming.

The Chair: Final question, Mr White.

Mr White: I also wanted to pick up on that issue. I share some of those same concerns. It's a huge elephant that we're moving ahead. I'm wondering, with this particular reform to the institutional care, with the placement coordination services -- you know of so many of them, many of them of course being operated by the VON -- would there not be more of a tendency now to find appropriate services in the community, through the placement coordination services with the VON, through those informing agents and bodies, than would have been the case prior to the PCSs being established?

Ms Dryden: Certainly, and I can speak for this placement coordination service program, that its goal and all of its interactions with its clients and families have been to help it assess the needs and identify the needs and not necessarily meet those needs with an institutional flavour. Certainly, in many cases they've referred clients and families to communities. It has essentially been one of their main goals, if at all possible, to keep them in the community setting.

In many cases they have utilized many of the community services versus maybe the client's and family's thinking that it's time now to move into an institution. With a little bit of education and referral process, they were then able to keep these people at home, where ultimately most people want to be if that's at all possible.

Certainly, in this area we've seen that change, and PCS has also used the services of the home care program. Many people have come to PCS as the first line of help and have been rerouted to the home care system as well. So it has not been just an institutional approach that PCS has had; it has been an approach to keep the client at home, if at all possible and if that's what the client wished to do. So certainly, that has increased home care's involvement and then filtered through the different programs such as VON as well.

Mr White: So although only incremental, the introduction of the PCS in this legislation does effectively move us away from an entirely institutional-based model.

Ms Dryden: That's true. It's not necessarily just institutional care that a PCS would be dealing with. They would hopefully still take the same approach, that they would assess the clients and families and help them to meet their needs appropriately, not necessarily with an institutional base. It's true.

Mr White: Thank you, Mr Chair, for allowing me a second question.

The Chair: Thank you again for coming to the committee this afternoon and making your presentation. We appreciate it.

Ms Dryden: You're welcome. Thank you for having us.


The Chair: If I might then call upon our last presenter for this afternoon, the Golden Years Advisory Committee for Schizophrenia. I believe it is Mrs Noble who is with us this afternoon. Mrs Noble, we thank you for coming. I believe you've come from Owen Sound; is that correct?

Mrs Martha Jean Noble: Yes.

The Chair: I think, if nothing else, that may give you the record for the farthest trip today. I'm not sure what the weather is like up there --

Mrs Noble: It's terrible.

The Chair: -- but I know it can be tricky going back and forth. We have two documents that you have brought along. I think you can present them to us however you would like. As you know, you have half an hour and time both to present your issues and for us to ask some questions. If you would be good enough, just for Hansard, identify yourself and then begin your presentation.

Mrs Noble: Yes. I'm here on behalf of the Golden Years Advisory Committee for Schizophrenia. That is long-term care. Those are the ones who came home from anywhere from -- I guess our oldest member has had her daughter for 32 years. We've had no in-home support. It's been 24 hours day in, day out for us. Those are our golden years.

I'm here on behalf of Harvey and Jean Noble. That's my husband and I. God has given us quite a load to carry. We have one daughter with chronic schizophrenia and we have one daughter with multiple sclerosis. So from all this, we feel we would like to feed back into the system whatever we can to help make life a little easier for the rest.

The Chair: Could I just ask you one question? The Golden Years Advisory Committee for Schizophrenia, is that essentially Grey county or Owen Sound?

Mrs Noble: Yes, Grey county, Bruce -- we have several little families throughout Ontario that we keep in touch with. We're a kind of support for each other and we keep hoping for improvements day to day before we go to meet our Maker. That's why I'm here today, if I can help that movement along at all. It's to help us rehabilitate our siblings suffering from schizophrenia. Our table of contents is, "What is Schizophrenia, Background Information, Purpose and Goals and Objectives."

The Golden Years Advisory Committee was established in February 1991 to address the needs of families supporting the long-term mentally ill at home. Schizophrenia is not a rare disease. As far back in history as 3000 BC, scholars have found descriptions of people with similar symptoms. Schizophrenia is not generally accepted as a product of modern civilization but one which has been with us throughout history.

Schizophrenia is a very destructive illness, most common in young people between the ages of 14 years and 28 years. Recently, research has proven again and again that schizophrenia is a biochemical disorder in the brain. As recently as 30 years ago, the diagnosis of schizophrenia often meant lengthy institutionalization. The discovery of anti-psychotic drugs, also known as neuroleptic drugs, has changed all that. Anti-psychotic drugs have enabled many people to function successfully in the community.

To have a chronically mentally ill loved one is indescribably painful. There is no illness that causes more distress or anguish than this horrible disease. The patient suffers from some or all of the following: hallucinations, delusions, loss of judgement and loss of the ability to plan and function in society. They truly try to make sense of distorted thoughts or internal voices they hear. They truly believe it is all real. People suffering from schizophrenia may have difficulty in knowing where reality ends and fantasy begins. Many people suffering from schizophrenia are highly intelligent, artistic and very sensitive. They are often rejected by friends and family, relatives and society. They do not understand the disease.

On a statistical average, two thirds of all young sons and daughters who become ill with mental disease return home to live with their families. Some 40 million families around the world know what it means to love a relative with schizophrenia. That's 40 million families, not people, and if each family consists of four members, a conservative guess, then there are 160 million people caught up in the biological disaster known as schizophrenia.

This is the background where our problem started. It started from lack of planning on discharge. Our main aim now is that we will be the last generation caught up in this horror. We understand now that there is some discharge planning going on, but it does not involve us. "We're long-term. We're long gone. We're buried. We're at home with Mom and Dad." So this is the start of it.

In the 1970s, some of the institutions for the mentally ill closed. The hospitals turned them away after a brief stay. The people were too sick for group homes. Some wandered the streets half starving, others froze to death and some were badly abused by society and the system. From the universities and colleges came some of our siblings, very ill and frightened, to share with mothers and fathers their desperate needs for survival. Like many parents, we are now senior citizens, and our sons and daughters not only suffer from schizophrenia but are socially handicapped. The need for in-home care and therapy is a very important step in encouraging the social exposure and stimulation that are necessary for the long-term sibling suffering from mental disease.

The relatives of these young victims over the years themselves often become victims of the system by trying to care for their siblings at home. However, the present system has effectively isolated these young people from the mainstream of society and our homes have become small institutions. Respite home care or attendant care, a supportive house and supportive housing should be made available to families that are exhausted from the unrealistic expectations of the present system. We must take note of the abuse and hardship that is now apparent in senior families that have supported and cared for long-term siblings suffering from mental disease for many years. Exhaustion and unrealistic expectations breed the foundation for patient abuse.


After many years of caring for siblings, parents are facing the concern of brain damage in our siblings. Was it caused by the disease or was it caused by the drugs? We know now that two thirds of all mentally ill young people return home to families with little or no discharge planning. I would like to just say that I was at a meeting yesterday and it is now recognized that we do have brain-damaged siblings and we have no services.

It has already been established that drugs alone are not the answer. It is the hope of the Golden Years Advisory Committee that the government will take serious note of the neglect of the long-term mentally ill. They are human beings who live in great anguish, who suffer from the pains of isolation and are rejected by society and the system. Their needs are as simple as yours and mine: the need to have friends, to be involved in the community, to worship in the church of their choice, to have supportive apartment housing; individual assessment, as some require a more structured and supervised living environment and some need to receive training, with the primary objective to return our siblings to as high as level of wellbeing as possible. Our goal is to help them to function at their maximum capacity.

The family structure and bonding is very strong in these special families. They have mourned the loss of the past, the horror of growing old and having no answers. We must be the last generation of parents to suffer the abuse of long-term neglect.

We wish to express our feelings on disability. Be it physical or mental, it should not be a factor, and to make it anything else would surely be discrimination. With the government's request for information, we wish to express our desperate needs for in-home care, in-home respite and supportive apartment housing.

In the new long-term care planning for the future, mental health appears to be preventive medicine. I mean by that that they appear to be educating people on AIDS, smoking, alcohol, and drug abuse. We would like to say at this time that we are mental disease, and there's quite a difference between mental health and mental disease. We sincerely ask that our sick young people become part of the long-term planning.

As our time grows shorter, the need becomes greater for these siblings. When the history of the past 40 years is written, we have no doubt that mental disease will produce some of the worst horror stories of all time.

We did a survey in our group as to what long-term abuse consists of in families that do not have that in-home support. This is some of what we came up with:

Our survey on long-term care giver abuse due to mental illness revealed many stress-related illnesses due to lack of support. We found parents who were burnt out emotionally and physically; high blood pressure; ulcers; anxiety; exhaustion; many sleepless nights; depression; resentment towards the system and society; feeling trapped by fate (it is only by the grace of God that it's not you); guilt because you cannot stop the frustration and neglect.

We need:

-- Respite in the home, if this is what the family needs: hourly, daily or weekly.

-- In-home care to follow mentally ill patients home from the hospital to their homes. I believe they are now recognizing that as a need in some places, but that does not touch on long-term that is at home now. It looks as if we're having a hard time placing these long-term siblings at home and, as I say, we are all senior citizens.

-- In-home care for chronically mentally ill patients to be provided as needed, as the majority of these siblings live with senior citizens.

The purpose of the Golden Years Advisory Committee for Schizophrenia is to establish the needs of siblings suffering from long-term mental disease, the needs being respite care, in-home care, socialization, housing, and inheritance protection. I want to bring that up today; I think I've got a few moments here.

One out of every 100 will at some time or another suffer from schizophrenia. We do know that out of this there will be some who will have one or two attacks and then they will get over it. It will maybe be classed a nervous breakdown, exhaustion or something, and they will go back to work and never have any more problems.

We know there will be another third who will become part of the system and will need support. They will need medication. But that group will probably be able to do some part-time work and earn $160 a month and not have family benefits touched.

Now, our people, because they have brain damage, because they are sicker -- and I want to say this also pertains to handicapped people. If you cannot work, you cannot possibly earn $160 a month. We as parents would like some type of trust set up so that we can give this extra money as a part of an inheritance to our children without touching their family benefits. It seems as if you can work and get it if you're well enough. Why, if you're sicker, should you not be able to inherit that? What difference? It would make life a lot easier for them. That's our inheritance.

To have schizophrenia removed from the mental health, to long-term care -- we know it is a disease. It's a horrible disease, and until we find a home for it, we cannot accomplish too much in looking after our people, to make the government aware of the families that care for siblings suffering from mental disease and to improve the wellbeing and lifestyle of siblings suffering from long-term mental disease.

Would you like me to go on now? I have the objectives here in the back. We have carried out some of those as the Golden Years committee. Would you like me to go on with that now?

The Chair: If you wish, or we can ask questions on your presentation.

Mrs Noble: All right.

The Chair: I think your objectives are quite clear. We can read that, if that's all right.

Mrs Noble: That's fine.

The Chair: First of all, let me just say that we are very glad that you have come to the committee because you obviously have a perspective on this issue that is really very different from the ones we've been hearing. I think the observations that you have, both about parents as well as about those with schizophrenia, are very important to us.

We'll begin the questioning with Mr White.

Mr White: I also want to thank you for coming. This is an important perspective you bring. We're talking about a long-term care issue, really: the care for children, siblings, people who will be with us for a long time and who, as you so well point out, require respite care. Families certainly do. To support you at home really requires a range of services that just hasn't been present for you.

Mrs Noble: That's right.

Mr White: I have worked in this field to some degree in the past. My sister, as a matter of a fact, does some in-home work with families in, I think, the Bruce county area. She works out of the hospital, but she only goes to the hospital one day a week. But she visits with families in the rural areas of Bruce county. I'm wondering if you have a similar program there in Owen Sound.

Mrs Noble: We have found that when they've come home with us, if we move -- and in our case we did move after we had retired and went up there -- you don't fit into the system. We have found too that once you get them at home -- and we do know several of our members have asked for respite -- we don't get it. This is from the Grey-Bruce Regional Health Centre. They just say they don't have any beds. In fact, we have campaigned to try to get respite beds and we haven't had much luck in this. We also went to home care and pursued the thought of respite, and were getting this, "We do not have the budget for long-term care." And when we go to mental health, they say they don't have any money. So then we're told, all right, if our next-door neighbour can take in three or four mentally ill young people and this is called a licensed home, they will get $26, $27 a day plus $3,000 a year respite. And we're saying we don't get any respite.


Mr White: So there's a problem if you move to the area and your son or sibling wasn't discharged from the hospital locally, and there's also a lack of respite care in the hospitals.

Mrs Noble: Oh, there definitely is.

Mr White: Have you been involved in any community planning in regard to the very kinds of services that you are talking about? I know I was, in my area of the province: fairly extensive plans to offer community-based services such as the ones you suggest. Has there been that kind of effort in Owen Sound?

Mrs Noble: We tried, we really did, and finally we just started mailing in letters to the Ministry of Health and to the Prime Minister. It appears that they realize that two thirds go home. That's a lot of people without a budget, you see, and someone is saying, "Well, where does the money come from?" They know it's long-term care. We're finding this. Long-term care is kind of a dead end, but it's not fair to us as families.

Mr White: It's a very sad situation, and I'm sure it has been repeated in a number of areas of our province. I only hope the best for you. Thank you for coming.

Mrs Fawcett: I want to thank you for coming. My goodness, they say the Lord gives you only what you can handle, but you must be a very, very strong person. There have been a lot of years that you have had to provide long-term care, and you -- and your husband, I would assume -- are the sole providers. Certainly it would seem that you're falling in between the cracks of health care, and somehow we have got to make sure that you people are included somewhere. If nothing else, respite care should be available to you, and also help for those suffering. Certainly the Friends of Schizophrenics in my area have solicited my help on numerous occasions, especially around the Advocacy Act, and I'm sure there are certain areas of that that have provided you with a few problems as well, because you can't always, even as a parent, do what you want to do.

So I really take everything that you say here very, very seriously, and we will endeavour to make sure that somehow that you get included in this. Thank you.

Mrs Noble: Thank you.

Mr Jim Wilson: Thank you, Mrs Noble. As you know, I represent the riding next to you in the Collingwood area. I wish you a safe drive back, and certainly appreciate your coming all the way to London to share your views with us.

I think you'll find that there are a lot of politicians at Queen's Park who have either family members or friends who suffer with schizophrenia -- we've noticed that in other committee hearings we've had -- so it isn't for lack of some high degree of understanding among politicians. It seems to be a lack of getting our acts together and getting services in place.

With that in mind, you know that this particular piece of legislation amends the Ministry of Community and Social Services Act to allow direct grant payments to individuals for the purchase of attendant care and other goods and services. It's to be done on a pilot project.

If you don't mind, I'd just like to ask the parliamentary assistant really a two-part question. What is the status of schizophrenia in terms of whether it is recognized by the government as a disability, and secondly, would people with schizophrenia qualify somehow to be included in this pilot project?

Mr Wessenger: With respect to the question of the disability, I will certainly ask staff to indicate that, because I don't know whether it's considered a disability. But with respect to the question of it being involved in the pilot project, no, as I understand it, the pilot project is related purely to physical disabilities. I think I'll just ask staff to comment on it.

Mr Quirt: The term "disability" is not a strict defining terms in terms of the pilot project, Mr Wilson. It would be better to put it that people who need personal care, or assistance with that, and people who had the ability to manage their own care would be candidates for that pilot. "People who are disabled" certainly describes it in a broader way than simply "physically disabled," and that was our intention, to describe it in a broader way than "physically disabled."

Quite frankly, I'm not as familiar with it as I should be to support the committee with respect to the government's position on services -- community health services, for example -- for people with schizophrenia. But I'd be happy to make a request of my colleagues in the ministry to provide you with some information on the state of services for people with schizophrenia with respect to community-based programs, with the community mental health programs and so on, and try to provide you with that early next week.

I'm not sure, quite frankly, at this point in time -- I certainly wouldn't rule out someone with schizophrenia in terms of the direct funding project, but it's intended for people who would accept money from the province and purchase their own supports. I think it would depend less on the diagnosis that someone had and more on their need for personal support services of an attendantlike nature. I certainly wouldn't preclude people who were diagnosed as having schizophrenia from the pilot, but I'd have to find out more about the services that now exist for them. I'll certainly raise that issue with the committee that's now working to design the pilot project.

Mrs Noble: Could I just say at this time the majority of senior citizens are paying for our in-home help? These people, you know, become quite disorientated. There's their laundry, their personal hygiene, and it becomes a real problem for senior citizens. You get to the point where all you can do is look after yourself. The one way we got around it was that we now hire help. In our house we have six hours a week for this girl, which we pay for, so I'll leave that with you too.

Mr Jim Wilson: In your experience, is schizophrenia a very debilitating disease?

Mrs Noble: Yes, it is.

Mr Jim Wilson: I know that from firsthand experience in my own family. All committee members should take note, and I appreciate your comments, Mr Quirt, and I would appreciate the parliamentary assistant getting back to us on the points that have been raised by Mrs Noble, particularly because you'll note number four in the objectives is exactly, "Initiate a pilot project to assess the benefits of in-home care (attendant care)," so actually it would be very nice if Mrs Noble's request could fit in with this legislation. So get back to us; we'd appreciate that.

The Chair: I think Mr Quirt has a comment he wishes to make.

Mr Quirt: Just a further piece of information: Through the long-term care consultation, the need for programs that support family care givers, respite programs, for example, and other ways to help people who are perhaps not the client or the patient in the system but the people around them who are supporting them to live independently, was a proposal in our consultation document and very strongly supported.

We intend to work with representatives from other ministries and from the community to look at ways in which care givers can be better supported, in addition to respite services. Clearly, in that case, regardless of the reason for a family having to support a member to live independently in the community, I would suspect that families having to support family members, for whatever reason, would be included in that planning. I'll also bring it to the attention of the people responsible for that project and, with your permission, provide them with a copy of your presentation here.

Mrs Noble: Thank you.

The Chair: Perhaps we might also indicate that when we have that information, we would make sure you receive a copy of that as well. I think that might be helpful to you in your own community.

Mrs Noble: It would be, yes.

The Chair: Did you have another comment you wish to make?

Mrs Noble: No, I think that's wonderful. Everyone's aware of it. I feel that I'm going home with an awareness and that's what we all started out to do, to make the government aware of the injustice of it. Do you know that when we were married 45 years, we had to put this girl in the hospital for a month in order for us to have a holiday? The standard thing is that one goes away for holiday and one stays at home. It's a very crippling thing in a family. The family cannot function.

I look back on my life and I know that we have been deprived of a lot of good, healthy living because we've always had to put her first. Mind you, she was in her last semester of accounting when she came home, so she is well educated but she's had a lot of brain damage.

We've got a housing project going now and this in-home care and what not is very important. If we can get the in-home care, this means we can do the supportive housing, the little apartments where they can do their own thing, you see, which we think is probably the answer. Thank you.

The Chair: Thank you. I think if there's been awareness raised it's been here on our side. we're very appreciative that you took the time to come. Hopefully, we'll be able to address the kinds of issues you've raised a lot more effectively in the future because of it.

Mrs Noble: Thank you. You know, my daughter with multiple sclerosis is now in palliative care. She's had MS since she was 15. She's 46 now, so in the long-term planning we know we won't have her too long. However, from it all we hope that something good will come. I just sat and I put it down the best I could for you.

We are greatly concerned and saddened that young disabled adults, through no choice of their own, become victims when the time comes that total care is required. I would just like to say it's not just MS. We've got accident victims too. In a farming area there's snowmobiling and there are all kinds of things.

The choice of facilities in Grey and Bruce counties is very limited. Long-term care is now filled with the very old and frail requiring total care. The environment is doom and gloom of the soon to die.

At this time of planning, we would like to suggest that a designated unit centre for young, physically disabled total care people be established at the Grey and Bruce regional centre. I must say that in order to get that unit, we have to go to Kitchener or London. I think there's enough of a population within the area that it would be well received.

The unit would greatly enhance their lifestyle, ensuring them of dignity and fulfilment. At the present time there is adequate space and equipment and there are several internists on staff at the Grey-Bruce Regional Health Centre, making this project very cost-efficient and beneficial to the young, total care adult.

As parents, we sincerely ask that you consider the very real need of these young people to be allowed to die with as much dignity as possible.

The population of Grey and Bruce is 150,000 and, as I said, the Grey-Bruce Regional Health Centre has adequate space and sufficient equipment. With everything being made smaller, we have the space. Several doctors -- and there are internists there -- are already employed. The cost of establishing this unit would be a minimal cost to the taxpayer and a great benefit to total care. Thank you again. I want to thank you all.

The Chair: Thank you for that, and certainly putting that in Hansard will make sure it gets back through the parliamentary assistant to the minister.

The committee now stands adjourned until 9 o'clock Monday morning in Sudbury.

The committee adjourned at 1755.