Wednesday 17 August 1994

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

projet de loi 173, Mme Grier

Ontario Community Support Association

David Wartman, president

Dan Stapleton, executive director

Mark Adler, vice-president

St Christopher House

Lucia Furgiuele, director, Older Adult Centre

Dorothy Myles, president, Older Adult Centre

Ontario Physiotherapy Association

Jennifer Cummings, president

Cathy Hecimovich, board member

Ontario Home Respiratory Services Association

Blair Richardson, executive director

Canadian Red Cross Society, Ontario division

Bob Morton, president

Nancy Bell, chairperson, homemaker services

AIDS Action Now

Darien Taylor, member, steering committee

Brent Southin, member, provincial committee

Canadian Association of Retired Persons

Mrs Lillian Morgenthau, president

Federation of Ontario Facility Liaison Groups

Janet Allingham, president

Margaret Gorman, facility representative

Family Association for Mental Health in Etobicoke

Judy Wallace, coordinator

Ontario Nursing Home Association

Pat Morden, vice-president, government relations

Shelly Jamieson, executive director

Ontario College of Family Physicians

Dr Rick Mann, president

Dr David Keast, member


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

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

*Acting Chairs / Présidents suppléants:

McGuinty, Dalton (Ottawa South/-Sud L)

O'Neill, Yvonne (Ottawa-Rideau L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

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

Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Also taking part / Autres participants et participantes:

Ministry of Health:

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

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

Wessenger, Paul, parliamentary assistant to the minister

Substitutions present / Membres remplaçants présents:

Offer, Steven (Mississauga North/-Nord L) for Mr Eddy

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

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

Sullivan, Barbara (Halton Centre L) for Mr Beer

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Clerk / Greffier: Arnott, Doug

Staff / Personnel:

Boucher, Joanne, research officer, Legislative Research Service

Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1004 in room 151.


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


The Acting Chair (Mr Dalton McGuinty): Good morning, ladies and gentlemen. Welcome to the continuing hearings on the matter of Bill 173, An Act respecting Long-Term Care.

Just to go over the ground rules for our presenters and for the benefit of or a reminder to our members sitting on the committee, each presenter is entitled to one half-hour for the presentation, including questions and answers thereto. Keeping that in mind, I'd ask you to begin, please, by first introducing yourselves.

Mr David Wartman: Good morning. My name is David Wartman, and I am president of the Ontario Community Support Association. With me this morning is Dan Stapleton, our executive director, and we will be presenting on behalf of the organization. Also joining us this morning are Mark Adler and Eunice McGowan, who are vice-presidents of the association.

I hope you'll bear with me. I seem to have reached that age where I can neither see with my glasses on or with them off, so I'm going to be stumbling a bit, I expect.

Our presentation will begin with a brief overview of who we are. This will be followed by the areas of the legislation OCSA endorses and our key areas of concern. Given the time constraints, we have submitted in writing a more thorough summary of our concerns for your consideration. Your packages include our presentation notes, our detailed response and our membership listing. The formal presentation will be approximately 20 minutes, followed by, I hope, 10 minutes for discussion and any questions you may have.

What is OCSA? The Ontario Community Support Association is an organization of direct providers of community-based services. Our primary purpose is to support, promote and represent the interests of community-based, not-for-profit health and social service agencies across Ontario.

OCSA was created on April 1, 1992, through an amalgamation of three provincial organizations which recognized that the combined skills, knowledge and experience of their services and resources would better serve all seniors and persons with a disability in the province. These associations, Meals on Wheels of Ontario, the Ontario Association of Visiting Homemaker Services and the Ontario Home Support Association, have long recognized a common interest in supporting community services and have a long tradition of service in the community. In fact, 1993 marked the 30th anniversary of the Meals on Wheels program in Ontario.

OCSA is governed by a board of directors consisting of 25 community leaders from across the province, including representatives from the francophone and native communities. All are volunteers. Their combined experience of service provision at a grass-roots level guides the direction of OCSA.

In over 300 member agencies across the province, our organization provides community support services to the elderly, people with a disability and those convalescing from an illness to enable them to live safely and happily at home. Over 10,000 dedicated staff and an army of over 45,000 active, hands-on volunteers work diligently to provide a wide range of services. Many volunteers are seniors themselves. In 1993, these volunteers donated over 1.2 million hours of service.

The continuum of community support services provided by our member agencies across Ontario include the following: Meals on Wheels; homemaking; home maintenance; friendly visiting; Alzheimer day programs; congregate dining; foot care; client intervention and assistance and community outreach; home help; care giver relief; emergency response; transportation; seniors' day programs; information and referral; intergenerational programs; and telephone reassurance.

You have in your package this brochure. If there's any question about those services, the brochure actually defines the services.

Each year over 600,000 Ontario residents receive help from community support programs. OCSA works with governments, related associations, the general public and the private sector to develop innovative and responsive strategies to expand community support services and support the efforts of seniors and others with special needs to remain independent in their homes.

Our area structure: OCSA is subdivided into 15 areas which form the foundation of the association. It is through this area structure that members are able to have an equal voice in the association while allowing each area the flexibility to respond to needs identified by its own membership. Our area representatives will also be presenting to this committee at the regional hearing centres.

One of the great strengths of a provincial organization like OCSA is the direct, concerted voice provided. OCSA works on behalf of seniors, disabled adults, member agencies and volunteers to ensure that issues which affect community services and seniors are heard and addressed by government policymakers.

OCSA has been an active participant in Redirection of Long-Term Care and Support Services in Ontario. We appreciate the opportunity to share our perspective on the legislation being examined and look forward to the continued partnership with government and other community organizations in the implementation of long-term care reform.

Our areas of endorsement include the following: The membership supports several aspects of Bill 173, An Act respecting Long-Term Care. The association endorses the principles and values enunciated in Bill 173. It has been these principles that have guided our response. We support not-for-profit service delivery where the principles of community-based planning, equity of access and equality of services prevail. We are committed to the development and implementation of standards of care and continual improvement in the level of service quality.


Other specific comments are as follows.

Purposes of the act: The Long-Term Care Act sets out consistent criteria and accountability provisions governing service delivery designed to ensure accountability to the consumer, to government on behalf of consumers and to the general public. OCSA strongly supports the objectives contained in the purposes of the act. It is a key component of this legislation. In our written submission, of which you have been given copies, we have suggested some minor revisions to enhance the purposes outlined.

The bill of rights: We are committed to a service delivery mechanism that is driven by individual consumer needs, which responds to the requirements of natural communities and their cultural diversity and that will support the development of equity of services across the province. OCSA recognizes and endorses the client's bill of rights as outlined in the legislation. The necessity of the client being informed is an essential component to providing client-centred services. We have noted some concerns related to the expectations of agencies in implementing the appeal process in our written material.

Rules governing approved agencies: OCSA supports the alternative MSA models which endorse the principles outlined in the purposes of the act and which are a result of the community planning process. OCSA agrees that the functions of the approved agency will include the following: to provide information and referral regarding long-term care and support services; to offer a range of long-term care and support services; to integrate the functions of assessment and service delivery; to determine the eligibility for services; and to develop a plan of service for eligible persons with a review and revision of the plan when necessary.

Linkages with other social services and health providers are essential. Mutual respect among key stakeholders in the long-term care service delivery system will facilitate and encourage linkages among community service agencies with physicians, pharmacists and other health and social service professionals and community organizations.

The act must ensure that services are planned, delivered and evaluated from an integrated health and social service perspective. We believe in a long-term care system that stresses the importance of maintaining and promoting health, wellness, and early intervention in addressing client needs and that provides flexible service along a continuum of care.

Proposed changes to the Public Vehicles Act: Changes to the Public Vehicles Act will allow a service provider to operate for the purposes of transporting persons determined eligible by an approved agency. OCSA applauds the government for including this provision in Bill 173.

I would like to now turn it over to Dan Stapleton.

Mr Dan Stapleton: I'm going to concentrate on the areas of concern. I should say by way of preface that we conducted a consultation with our membership, and our membership consists of over 350 members, of which over 300 are agencies providing community support services. Based on the input from our member agencies, we'd like to present six key areas of concern with this legislation. The detailed response you've been given includes a number of other concerns, but the six we're presenting were those that were considered by the board and the policy committee of our association as being the most pressing, and they include the following: areas not covered in the legislation; the regulations; volunteerism in the reformed long-term care system; multiservice agencies; categories of services; and definitions. With each area of concern we will present the issues and then suggest recommended strategies for improving the legislation.

First is areas not covered by the legislation.

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

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

Although there are similarities between clients in institutional settings and those in the community, the environments are quite different. Therefore, special consideration is required when transferring staff from facilities to community-based agencies. For example, there are differences in the skill sets and the goals of care or methods of achieving goals. Training resources are required not only for employees who are laid off but also to encourage existing employees to enhance their skill base. A forgotten group of employees who work through brokerage agencies should have their experience recognized in this process.

The community support sector consists of over 10,000 employees who are experienced and trained in the care and delivery of services. These staff have worked for years at low wages and minimal benefits with a strong commitment and loyalty to providing quality services. Unionized employees in the broader socio-health care sector are demanding priority employment in the community sector. Our sector is predominately non-unionized and is thus less able to voice concerns than organized labour bodies.

OCSA strongly believes there needs to be a commitment to fair wages and benefits for employees, and there is also a need to ensure maximum expenditure on direct care service.

There will be significant human resource issues which will require expertise, time and financial resources in order to be addressed successfully.

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

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

Our second concern has to do with the general regulations.

It is our view that Bill 173 has taken an overly prescriptive approach to the provision of community-based services: 42 regulations have yet to be produced. Much is unknown at this point, yet the areas to be covered appear to be quite prescriptive. It is difficult to present a response to the legislation in the absence of the detailed information which will be in the regulations.

Bill 173 allows for the provision of regulations to be retroactive. However, MSAs will be developed over a period of four years. Consequently, it will not be feasible in certain instances to make the regulations retroactive.

The province is moving quickly to put multiservice agencies into practice, yet major components need to be put into place, for example, eligibility criteria, program standards, MSA guidelines and the regulations.

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

Our third concern deals with volunteerism in the reformed long-term care system.

Volunteerism is an essential component in the delivery of community-based services. The volunteer base must be recognized as being deeply rooted in the community and potentially fragile, yet there is only one regulation which requires an MSA to develop and implement a plan for recruiting and using the services of volunteers.

In addition to their valuable work in service provision, a significant amount of money is made available for services as a direct result of the fund-raising efforts of volunteers. If volunteers are not properly maintained, costs will skyrocket. Thus, MSAs will not be cost-efficient and the ability to meet existing consumer needs will be jeopardized.

There is a lack of detailed planning regarding volunteers and long-term care, even though there is a concern about an inadequate number of volunteers currently to support the expansion of programs and services. Historically, volunteers have been the backbone of community support services and they must be recognized and the issue addressed. The relationships presently existing between service agencies and their volunteers must be fostered and nurtured through the transitional process. Volunteers should be kept well informed and actively participate in the change process in the implementation of long-term care reform. Furthermore, sufficient resources to support a volunteer management structure at the natural community level should be provided on an ongoing basis.

OCSA therefore recommends that there be a recognition of the role of volunteers in the body of the legislation.

We also recommend that volunteer management in regulation 11 should be expanded to require MSAs to develop and implement a plan for the recruitment, training, scheduling, supervision, retention, recognition and expense reimbursement of volunteers.


Volunteers are motivated by an array of factors and cannot be shifted organizationally away from their work without risk of loss, and therefore it is absolutely vital to maintain the linkages between volunteer tasks, their communities and the agency staff that sustain them.

Our fourth concern deals with multiservice agencies.

It is essential that there be sufficient flexibility to allow communities to develop an MSA system to meet local needs. It is unclear what the final MSA model will look like in each community until the community planning process is over. Consequently, it is premature to assume that the same model will meet the needs of all residents in Ontario.

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

On the other hand, we must ensure the client does not become discouraged by being continuously referred to various services, as is currently the practice. The act also lacks recognition of the existing multiservice agencies which provide services in addition to long-term care services.

OCSA supports different models for MSAs which endorse the principles outlined in the act and which are a result of the community planning process. We believe that MSAs must not be allowed to develop into large, bureaucratic organizations. They must be small enough to be able to be responsive to local community needs.

We also believe that there must be consistent standards developed, or the unacceptable status quo will be maintained.

Improved coordination and access to available services are highly desirable. Close coordination will be needed if there is more than one point of contact in the community. Communication among providers is key.

Functional integration of information could be achieved through electronic communications systems and/or by combining physical locations for smaller community support agencies to achieve economy of finances and volunteers.

We recommend that if functional integration is pursued, top priority must be given to ensuring that there is an effective computerized information network in place. This must include a financial commitment to design hardware, software, training and support.

Our next concern deals with categories of services.

The separation or distinction between community support services, homemaking, personal support services and professional services reinforces a hierarchy of services ultimately geared to medical needs, rather than fostering a continuum of care. It reinforces a split between health and social services and moves away from wellness, health maintenance and prevention measures. This is inconsistent with the purposes of the act, and it will be confusing to the client and the case manager who will be pressured to approve the need for personal care.

The distinction between personal support services and homemaking services appears to be contrary to the current trend to develop a "generic" worker, which would combine health care aides, homemakers, home support workers, home helpers and attendant care workers. In most agencies, both personal support services and homemaking, as defined in the act, are provided by the same person. These services are provided concurrently, and this worker will be the recipient of a recently developed training program. The inclusion of these two services separately in the legislation we feel is a major step backwards and could interfere with the development of a generic worker.

There are also some concerns about how these two services will be operationalized. This separation will be an administrative nightmare for the service provider or approved agency. For example, how does the service provider manage the client who requires a bath -- that's personal support services -- and laundry, shopping and housecleaning, which is homemaking? Both services are important in terms of maintaining the client's independence in the home. Will the time be prorated?

New terminology is being used and initially this may cause some confusion in the community. Personal support services, for example, was previously known as homemaking. "Homemaking" is being used to describe tasks previously referred to as home help. However, it is recognized that the terminology currently being used varies considerably across the province, and there is a need to have standardized definitions.

We question the use of the four categories: community support services, homemaking, personal support services and professional services. It is more important for each community to have a menu of services which they can tailor to meet their needs. Service priorities must be established through a local planning process and not directed from a top-down approach. This is one of the planning responsibilities of district health councils, which are working in partnership with consumers and service providers. A definition of services to be provided by MSAs must allow for flexibility to encourage the development of innovative programs which can more effectively and efficiently be developed through a community development process.

We recommend that the artificial distinction between homemaking and personal support services be ended by combining them, and we would like to be involved in the development of a new term to describe this service.

There is too high a level of detail in the legislation that we feel will result in rigidity rather than flexibility to meet local needs. Perhaps through standards development and program guidelines these areas can be addressed.

We recommend that community support services, homemaking, personal support services and professional services be combined into one category. Thus, there would be a range of community-based services available. Based on this recommendation, subsection 2(3) would be deleted, subsections (5) and (6) would be combined and listed as one service and all services would be listed in alphabetical order, including services listed in subsections (4) and (7). This proposed change would also affect subsection 1(12). This recommendation minimizes the artificial distinction currently being made between community support services, homemaking and personal support services.

We also feel that the user fee issue should remain separate and not be included in the legislation.

Assuming the legislation is passed and regulations are introduced, a communication plan to educate consumers and service providers on the changes is needed. It will initially be more confusing, especially for the consumer.

Our last concern has to do with definitions.

This legislation is seriously deficient with regard to both its consistent use of some definitions and the absence of other definitions. Definitions, for example, are provided for adult day programs, care giver support services, meal services and transportation services. However, definitions are not provided for other services and terms, such as respite care services, social or recreational services, security checks and reassurance services, friendly visiting, home maintenance and repair, service provider, program supervisor and director. There is extensive detail provided for homemaking and personal support services, yet professional services are merely listed and not defined. "Assistance" under care giver support services is undefined. This is quite open-ended. For example, does this mean that agencies will provide meals, transportation and home maintenance to care givers? Will eligibility criteria for care giver support services be set by the MSA or by the province?

The main issue, we feel, is, what is the most appropriate avenue for service definitions? We believe that OCSA must be involved in the development of definitions of services to be provided, as these services are provided by our members.

I'll just turn the floor back to David for our conclusion.

Mr Wartman: OCSA applauds the leadership demonstrated by the provincial government through the development of Bill 173, which establishes a key building block in the foundation of the new long-term care system. We appreciate the commitment to building partnerships with the community to effectively plan and implement meaningful change. We look forward to working in continued partnership with the government and our community colleagues to bring about the redirection of the long-term care system.


Mr Jim Wilson (Simcoe West): Thank you for your presentation. As you know, yesterday Mr Quirt made it quite clear that your group was primary -- paramount, I should say -- in influencing the government to move towards an MSA model, particularly a model that not only has one-stop shopping, as it were, in terms of how I initially understood the concept, and that was that in geographic areas there'd be one phone number to call, a fairly simplified version of what we see in this legislation, but also that MSAs should deliver the services.

You've mentioned some concerns. The ones that are repeatedly offered to this committee are ones you've touched on, for instance, the role of volunteers, the retainment and recruitment of volunteers and the effect that fund-raising might have. I put to you that no amount of legislation or regulations will ensure that volunteers continue to be attracted to work for these agencies if people believe they're working for an MSA, which, regardless of whether it's a non-profit charitable organization or whatever, I can tell you, because program supervisors and many of the appointments are made by the crown, the public will see as government organizations. Do you have any further comments on how we continue to make sure some of the member agencies retain their identity, because I can tell you, when we amalgamate municipalities and other things the government has been infamous for amalgamating over the years, they do lose their identity after a few years.

Mr Mark Adler: If I could respond, sir, I'd like to say two things. One will have to do with the public perception of who the new service organization is. Looking at the planning process and as a participant at the community level in the planning process, where, for example, in the city of York, where I work, we have two home support and Meals on Wheels agencies participating, Saint Elizabeth nursing, Victorian Order of Nurses, the home care program, public health departments, a community health clinic, as well as a variety of service provider volunteers and consumers on what amounts to a planning consortium which will lay the framework for the new organization, I don't believe, given that high level of public and agency input into the creation of the new organization, that the local community will see these organizations as being government-driven, and in fact there are no government providers at the table, or bureaucrats, in terms of planning and creating these new structures.

Secondly, as a director of an agency that provides a variety of seniors' services, I think I would dispute the contention that people in the community volunteer based upon a knowledge of the history and the philosophy guiding an organization, but rather they are more interested in the direct provision of services. When my agency puts out a call for Meals on Wheels drivers, the community responds, because people see Meals on Wheels as a valuable community support, as a sign of being a good neighbour, and they seek out the opportunity to provide the service for whoever the provider organization may be.

That being said, I think we need to recognize that this is a system that needs resources, and as we stated in our overview, volunteers will not come into the system on their own, they can't be retained by the system on their own, there needs to be resources for effective volunteer human resources management. Volunteers can be cheap, they can be cost-effective and they can provide quality to a system, but there needs to be a system in place to support them.

In the current system now in Metro Toronto, where, for example, there are 80 agencies as opposed to the proposed 20 agencies providing these services, government will be very challenged, and has been, to provide effective resources for those agencies to do volunteer management, recruitment, training, recognition, retention and all those issues. It's our hope that by condensing the system down to manageable size but not excessively sized organizations, those volunteer human resource issues can be dealt with more effectively.

The Acting-Chair: We have time for one more brief question.

Mr Paul Wessenger (Simcoe Centre): Thank you very much for your brief. I'd just like to assure you, with respect to the staffing structure, that will be flexible. We appreciate your comments on that, and although the services may be distinct, there's no reason why one individual can't provide more than one of those types of services.

The question I have to ask is, you indicated you had some concern about the negative impact of employment with respect to the restructuring and in view of the fact that there are increased moneys going into long-term care, increased employment opportunities, approximately 5,000 jobs being created, and the fact that the responsibility for developing fair treatment of employees is at the local level, at the new MSA, in developing a human resources plan that is fair. Certainly I agree with the principles you suggest with respect to how employees should be treated. I'm wondering why you would feel in those circumstances that there would be, or might be, a negative employment impact.

Mr Stapleton: I think our concern is that although dollars have been allocated for long-term care reform, the new structure and the one-stop access will actually create more need because the services will be better known. I think our feeling is that there isn't going to be enough money to provide all the services and that something will have to give and that there will not be enough money to actually manage all those services and keep staff employed.

The other concern is that although there's been talk about new jobs, they're primarily direct service jobs. We have a number of employees who work in administrative functions and it's very unclear whether or not there would be a continued role for them in the new system. Every person who's currently an executive director can't continue in that role, so what we would like to see is guaranteed comparable positions in the new organization and that's something we have currently not felt has been given any assurance to date.


The Acting Chair: Our next presentation will be made by representatives of St Christopher House. Please take a seat, and before beginning, kindly introduce yourselves.

Ms Lucia Furgiuele: My name is Lucia Furgiuele. I'm the director of the Older Adult Centre at St Christopher House.

Ms Dorothy Myles: And I'm Dorothy Myles. I'm president of the members' council of the Older Adult Centre.

Ms Furgiuele: I think we can begin. First of all, I'd like to thank the standing committee on social development for the opportunity to express our response to Bill 173, An Act respecting Long-Term Care. Dorothy and I will be sharing the presentation, and I would just like to say that our presentation is representative of a community-based organization and presents our views as well as our consumers' and care givers', with whom we have conducted a number of consultations.

St Christopher House is a neighbourhood-based multiservice organization located in the west-end communities of Toronto. St Christopher House has at its central purpose the enabling of less advantaged individuals, families and groups in the community to gain greater control of their lives and their community. We work with people of all ages and circumstances: youth, newcomers and immigrants, women, persons with disabilities and the elderly. Our services include after-4 programs for kids, women abuse counselling, literacy and English as a second language, a drop-in for street people and housing-disadvantaged persons, employment training, counselling and placement for youth and young adults and some community economic development programs for unemployed members of our community. At our main House location on Dundas and Ossington, we have an Older Adult Centre serving over 2,000 seniors, families, care givers and persons with disabilities. St Chris is a focal point where community members of all ages, abilities, income levels and cultural backgrounds come to meet.

Ms Myles: I'm new to this game, and as a senior, I'm a little nervous, of course, in the presence of such honoured company. I made a tour just recently with my granddaughter of the Legislature chambers and everything, so I'm not completely unfamiliar with the building.

The Older Adult Centre, of course, is predominantly in a Portuguese and, increasingly now, Vietnamese and Chinese area. We provide a number of community support services, including Meals on Wheels, transportation, home help and client intervention and assistance, which is a counselling and case management program. There's also an Alzheimer day program, an elderly persons' centre, which I am part of, for recreational, wellness and health promotion activities and a newly acquired contract with Home Care for an integrated homemaker program. In addition, we have a strong outreach and community development component to all of our programs.

Our consumers and participants have taken leadership in the planning and directing of activities and committees, and further leadership development has been identified by our members' council as a priority for the coming year.


St Christopher House participation in consultations regarding long-term care is high. Over 200 of our members and consumers were interviewed in their homes or at St Christopher House regarding their concerns and ideas. Members of the Older Adult Centre have joined forces with seniors from across Metro to address health care issues and have named their coalition In the Picture. You may have heard quite a bit about that. They've been in the news and they have so many meetings. They have had meetings with Ruth Grier and the federal Minister of Health.

The Older Adult Centre also helped with three large community forums: one with the Portuguese interagency network, one with the Chinese interagency network and a community health forum for our larger community. Our seniors have also met a few times with Elaine Ziemba to express their concerns about long-term care. All of our community focus groups and forums have been provided in three or four languages and with assistive hearing devices.

In addition, our executive director has participated in the Ministry of Health and district health council's hospital realignment committee and the mental health reform committee.

Ms Furgiuele: Right, and I sit on the district health council's long-term care reform steering committee.

Ms Myles: The Older Adult Centre staff and consumers are also participating on MSA design groups in the downtown and the west-end consortia.

We welcome the opportunity to continue to provide input and feedback from consumers who have traditionally been unable to participate. We support the vision and philosophy of long-term reform.

We have six concerns we wish to discuss today, related primarily to consumer and care giver issues and the eroding of the community sector approach and the philosophy of working with neighbourhoods. I'll just do run a rundown. They are: consumer focus, care-giving issues, community outreach, community development, community voice and the basket of services. Now, many of these are perhaps incorporated in some of the other submissions you will have received. Of course, I'm not cognizant of those, so you may find some repetition.

Consumer focus: This government is to be congratulated that it has spent so much time and effort to consult with consumers on various aspects of the long-term care service delivery. We understand that over 70,000 elders, persons with disabilities, care givers and volunteers have participated in a process which strongly emphasizes the importance and commitment to consumer-driven reforms.

St Christopher House also consulted over 1,000 consumers through focus groups with our own members and with Chinese and Portuguese interagency networks.

We are disappointed that in light of this level of citizen participation, Bill 173 fails to position the consumer at the heart of four key aspects of the legislation.

Governance: The legislation does not specify that consumers and care givers must be designated a certain number of seats on MSA governing bodies. Our own participants and Metro-wide seniors' and consumers' coalitions have been strong about their position related to governance. Our organization strongly endorses many consumer groups' recommendations of 50% consumer/care giver designation on MSA boards of directors. This will ensure that their voices will be heard in the planning and development of programs. Local MSA design consortia are strongly in favour of this designation. Our recommendation is that the legislation make specific reference to consumers having a designated number of seats on governing boards. This is an important issue for us.

The appeal panel: While the function and responsibilities of the appeal panel are clearly defined, we recommend that consumer care givers be given a specific designation to the appeal panel. That is to allow more participation with the consumers and care givers with the recommendations from the appeal panel.

Ms Furgiuele: Bill 173 makes a specific reference to ensuring that all persons will be served by MSAs regardless of income, religious affiliation or ethnoracial background. Nowhere in the legislation does specific reference to the Ministry of Health's anti-racism strategies appear in relation to MSA mission and governance or functions. These strategies address the present systemic discriminations and barriers to service that both employees and potential clients experience.

In order to ensure access for persons from ethnocultural and racial backgrounds, policies and guidelines outlining employment equity policies, fair and accessible recruitment and selection of staff, opportunity for advancement, means for organizational evaluations and other organizational systems must be firmly in place. MSAs must recruit staff and volunteers who possess language and cultural sensitivity and a demonstrated commitment to outreach and connection with the communities served.

Much has been documented and voiced about the difficulty of accessing services if you don't speak English or can't read or write. Achieving access must be approached in deliberate and committed ways: policies, governance structures, multilingual program and service capabilities, outreach and community development. These strategies are already mandated by this government and should accordingly be reflected in this legislation.

Ms Myles: The ombudsperson: The consumer safeguards described in the legislation related to a bill of rights and other appeal procedures are important measures. There is no doubt, however, that consumers have and will continue to fall between the cracks and require more than the stated provisions.

When all appeal processes are exhausted, it is recommended that a final process conducted by an impartial, objective and separate third party be available, such as an ombudsperson or advocate.

Now, under the care giver issues, much of the longterm care reform will be shouldered by care givers and volunteers. The documents published by the Ministry of Health pertaining to the guidelines and principles of long-term care reform made specific references to the needs of overburdened care givers.

Bill 173 makes reference to care giver support by describing what services comprise this support, including counselling, training, visiting and providing information and respite and other assistance to care givers to support them in carrying out their care-giving responsibilities. We strongly support any legislation that recognizes the enormous contribution care givers make to the health care system.

Care givers have voiced their need for (1) information on available services, (2) in-home and facility-based respite and (3) alternative financial assistance to help care givers, predominately women, face the financial challenge of looking after a chronically ill person at home.

Primary care givers, usually women, work around the clock to provide care. They need respite in order to maintain their own health and wellbeing. We have heard that some consumer groups have suggested using special hospital wings that have been closed for the respite care programs. Others prefer respite in the home.

The word "respite" threw me at first, until I realized I have my own sister-in-law, who looked after my brother. She got so browned off sometimes I used to go up and just sit and talk with her, and this is what is needed in many cases.

In any of these choices, families should not have to pay for this service. Respite care allows chronically ill persons to avoid institutions and for care givers to avoid burnout and exhaustion.


Ms Furgiuele: Community outreach, or someone has called this "looking under bushes": Someone remarked recently that she found it unbelievable that community agencies would spend so much time on outreach activities. She referred to outreach as "looking under bushes" for clients and expressed disapproval, stating that if eligibility criteria are clear and programs well managed, clients will have no difficulty hearing about or accessing services.

At St Chris, and for most community agencies, looking under bushes has become an important means of ensuring that citizens know about and utilize services. We know that bushes for some people can mean English-language barriers, illiteracy, isolation, frailty or disability, poverty or abuse. These barriers prevent persons from ever knowing about services, let alone accessing them.

The act makes an assumption that a consumer will access services provided by the MSAs simply by meeting eligibility criteria. There is no mention of the need for outreach, development and information that likely will be required for many consumers and care givers within newly established MSA geographic areas. Bill 173 puts the responsibility on the consumer to somehow know about available services, rather than on the MSA to ensure that information is provided in languages and means that are appropriate to neighbourhood demographics. Consumers have stated that they are confused by the present long-term care system and not clear about how to access services. Outreach and information, health promotion activities and health education must be mandated as necessary functions of each MSA.

There has been much activity and cooperation among agencies as communities begin transitional planning for MSAs. The district health council has indicated that these MSA-designed consortia must demonstrate a commitment to including all stakeholders, including consumers, persons from ethnoracial communities, care givers and other special-interest groups.

The planning of MSAs is no doubt an important place for community development strategies to be utilized. But community assessment and community development must be stated as important, ongoing, essential functions of the MSA. This will be the only way to ensure ongoing organizational flexibility, community responsiveness and appropriateness of programs. It is not mentioned now and usually only interpreted as something that ought to be done in formulation stages only. Without community development being stated as a legitimate and imperative MSA organizational approach, it will be resisted and misunderstood. The last thing we want to create are more institutions that have no connection and understanding of their geographic neighbourhoods, their consumers or needs.

The community sector must be given equal visibility and voice in the reforming of the long-term care system. The legislation makes reference to health and social service sectors playing important roles in the development of MSA and service delivery, but the community sector, which has been able to respond quickly and innovatively to neighbourhood needs, is left out of the discussion.

An example of the discrepancy is the fact that there is no legislation to protect community sector workers, as there has been for health sector workers.

St Christopher House, like many existing multiservice organizations, reflects the vision of the health goals for Ontario, and efforts need to be taken now and in the future to sustain and strengthen this model. We are truly integrated in serving the vast range of ages, stages, backgrounds and needs in a community in a way that meets health needs in the broadest sense. Seniors, like most of us, do not want to be ghettoized and compartmentalized. Access points in storefronts, using existing neighbourhood organizations, building on the strength of the system is what is required.

Community models have developed integrated approaches, innovative and sensitive outreach strategies, participatory program planning and delivery and responsiveness to community needs. We fear this philosophy of working will be eroded. We fear that the basket of services that are designated community support services will risk being cut in favour of more medically oriented ones. Already there is a proposed hierarchy of services, that is, some that are designated free and some that will cost, yet homemaking or Meals on Wheels may be just as vital as a visit from a social worker or a physiotherapist. We need to work at preventing the development of another bureaucracy with rigid eligibility criteria and anonymous workers who know little about their catchment area and the needs of their consumers.

We are especially worried about consumers who have been marginalized and who we have helped access services: people who do not speak English, people who are isolated, people who can't read or write or who are frail. These are consumers and care givers who will not be able to telephone an MSA directly, because they likely won't even know that one exists.

Ms Myles: Now I'll take over again. Client intervention and assistance, which we place under "Basket of Services": Client intervention and assistance is not mentioned in any document related to long-term care, nor is it mentioned in the legislation. Client intervention and assistance is a counselling and case management function developed by community sector agencies. It includes intake, assessment, supportive counselling, information and referral, advocacy, housing and placement coordination and crisis intervention. Client intervention and assistance workers are typically multilingual, sensitive to the needs of ethnoracial communities and skilled in outreach and community development.

It is recommended that CIA, client intervention and assistance, be specifically included in the list of the basket of services.

Elder abuse: Elder abuse occurs in many ways. It can be physical, emotional or financial. Though not easily talked about, many seniors experience violence or abuse in their home and community. Programs and legislation which will address the incidence, identification and prevention of abuse must be developed, and it is recommended that such programs be established as a mandatory service of each MSA.

Fee for service: We are concerned that some services will be free and others not. No one should be denied service because of inability to pay, and the legislation should make this a philosophical underpinning of each MSA.

Ms Furgiuele: That concludes our presentation.

Mrs Yvonne O'Neill (Ottawa-Rideau): I want to first of all congratulate you for the level of input you've had to this point in this whole process in every possible way you could, and particularly the way you've involved the people you serve in that consultation.

I find that you've brought forward something that many have brought forward, in particular in your last statements, on the client intervention and assistance. I do think that will have to be included in the act in some shape and form.

I'm going to ask a question springing from some of your remarks to the parliamentary assistant, and it has to do with the eligibility criteria. I think you've brought forward that the onus is on the consumer, and you find that difficult, as do many other of the presenters and I myself. I'd like to know from the parliamentary assistant, who is going to determine the eligibility criteria? Is it the ministry or the regional offices or whatever way you're going to deal with that or the individual MSA, and how is the knowledge of the eligibility criteria proposed to be given to the community?

These are fundamental questions, almost every presenter brings them, and I would like to have an answer, and I really think that some of the answers yesterday were less than clear and in some cases almost flippant. I think we must deal with that.

Mr Wessenger: I will ask Mr Quirt to deal with those questions.

Mr Geoff Quirt: There will be eligibility criteria that will apply across the province in each MSA for the services listed in the bill. Those eligibility criteria have existed with the home care program. We're looking at those and modifying those to try to make them more sensitive to consumer needs and we're being helped in that regard by a number of advisory committees looking at --

Ms Myles: I can't hear.

Ms Furgiuele: We can't hear.

Mr Jim Wilson: Mr Quirt, the witnesses indicate that they can't hear you.

Mr Quirt: I'm sorry, I thought I was speaking directly enough into the microphone. Let me start again and repeat what I said earlier.

There will be eligibility criteria that will be developed that will apply to services delivered by MSAs, in the same way that there are eligibility criteria now for the home care program and other services. We want to develop those eligibility criteria with the help of service providers and consumers, and as a result we have program design activities under way getting input from people about how to best measure eligibility. We talked yesterday a bit about how best to assess people and there's an ongoing discussion whether a consistent assessment approach or a consistent assessment form might be advisable. There's a lively debate on that that we hope will result in a good conclusion.


As was suggested by a couple of the committee members yesterday, we'd be pleased to make a presentation to the committee of the work to date on eligibility criteria for the various services, get your input on that, and at the same time run through a legal presentation on the bill itself and its structure.

We would welcome input from the presenters on the eligibility criteria. I'm not sure if you were involved in our program design activities, but I know other adult centres have been consulted in that regard so there will be consistent eligibility criteria across the province. There will no doubt be some variability in the application of those criteria, sensitive to consumer needs at the local MSA level.

Mr Jim Wilson: Thank you very much for your presentation. I very quickly wanted to ask you about one of the terms that's used. I understand your points about outreach and the need to continually be looking under the bushes, as you mentioned in your written submission, and I understand community assessment. Can you tell me what you mean on page 9 by community development? You do recommend that it should be an important, ongoing function of the MSA.

Ms Furgiuele: I'd like to answer that. One of our more serious concerns is around the size and function of the MSAs. We're a small, neighbourhood-based organization. We are mandated to represent the communities that we serve. So who the communities are is what St Christopher House is about. Through the years, with different waves of immigration and different neighbourhoods forming and settling in the west end of Toronto, we've been able to respond to those needs by policies and recruitment of staff and developing programs that are sensitive to the needs of those communities.

We think that the larger the organization, the more chance there is of losing that commitment and that connection with your communities, and community development to us means involvement of consumers and participants in all aspects of the organization. It's an empowerment model, it's an information model, it's an informed model that really allows for participatory involvement in all aspects of the organization.

Ms Jenny Carter (Peterborough): I'd like to congratulate you on your presentation, and I think it's very clear that your concerns are the same as ours. In other words, what we are trying to achieve with this bill is what you are wanting us to achieve, and the question is, are there any gaps there that we can make good?

There certainly is a consumer focus. That is what we're trying to do, and I think maybe there are a few more factors that should come into this picture.

For example, we do have the Advocacy Act, which is coming into force quite soon. You have a problem with people getting access to services, and I think it's going to be about as simple as it possibly could be. That is to say there is going to be one number to call for the multiservice agency and, for crisis, there's going to be one number to call for advocacy, so the question is to get those numbers into people's consciousness. Certainly the advocacy number will be displayed and a third person can call if they feel that somebody else is in jeopardy, and they can even remain anonymous. So I think we have looked after that.

Also, of course, we do have employment equity kicking in this fall, which means that all employers have to make sure their employees reflect the community, so I think that has been taken care of in that way.

You also mention respite care, and the institutional side of that I think was looked at in our Bill 101. Institutions do have to keep a certain number of rooms available for short-stay occupancy so that they will be able to accommodate people for respite care.

One thing you have emphasized is the question of consumers being represented, and I think there is some commitment to having at least a third of consumers on, for example, the long-term care subcommittees, but I think where we may be a little lacking is in our definition of consumers. For example, somebody who maybe is a retired care provider might come in under that category and perhaps not have the point of view that you feel is needed. So I wondered if you could elaborate on that.

Ms Furgiuele: On the part about consumer participation?

Ms Carter: Who should count as a consumer and what the definition might be for representation.

Ms Furgiuele: When we were doing our consultations with our members, it was a daunting challenge because most of our participants do not speak English, can't read or write, as I stated earlier, and many of them are home-bound seniors. We try to devise means of actually getting their voices involved in the consultation and it meant one-on-one interviews in appropriate languages, utilizing family members and so on.

So for us, consumers can be the actual recipient of the program. It can be a care giver. It can be someone who has used services in the past and so on. We support that general definition of consumer.

The Acting Chair: I'm sorry, our time has expired. I want to thank you both for taking the time and making the effort to come down here and speak to us and share with us some of your experience as people on the front lines.


The Acting Chair: Our next presenters: representatives of the Ontario Physiotherapy Association. I understand that members of the committee were provided with a copy of the written brief yesterday. In the event that you do not have that brief with you, the clerk is now handing out another copy. I'd ask you to kindly identify yourselves and then begin with your presentation.

Ms Jennifer Cummings: Good morning. Thank you, Mr Chairman, and thanks to the committee for the opportunity to appear before you this morning. My name is Jennifer Cummings and I'm the president of the Ontario Physiotherapy Association. I'm also a physiotherapist working for the Grey-Bruce home care program. With me is Cathy Hecimovich. Cathy is also a licensed physiotherapist practising in home care.

The Ontario Physiotherapy Association has appeared before this committee several times over the past year on a range of issues. I suspect, therefore, that you know who we are and what we do and don't require a detailed background on our profession.

Just briefly, however, there are 5,000 licensed physiotherapists in Ontario. We are regulated by the college of physiotherapy under the Regulated Health Professions Act and the Physiotherapy Act of 1991.

The Ontario Physiotherapy Association represents over 3,000 of these physiotherapists. One can find physiotherapists and access physiotherapy care in a range of venues, in hospitals and hospital outpatient clinics, in OHIP-funded clinics, in private clinics, in private industry, in sports and fitness clinics and rehabilitation centres, in nursing homes and seniors' residences and, of course, at home through any one of the 38 home care programs provided and operated by the province.

I want to emphasize that we have the statutory authority and the expertise to assess physical dysfunction and to treat, rehabilitate and prevent physical dysfunction, injury or pain. When we encounter the need for treatment beyond our expertise or scope of practice, we refer the patient to the appropriate profession. Neither we nor long-term care require that a physician or any other health care profession supervise our activities or position themselves as gatekeepers into the system or to the physiotherapy services that it provides.

I'm now going to turn our presentation over to Cathy Hecimovich, who will speak to the current issues facing physiotherapists working in home care today.

Ms Cathy Hecimovich: Hello. I've worked in home care now for 10 years. Home care, which is the subset of long-term care, is like nothing else in the health care delivery system. Home care practitioners treat a patient base that is culturally, socially, economically and medically unique in its diversity. We see the undisguised patient, the patient in his or her own environment, who often presents very differently than does the same patient in a hospital context.

In home care, we see their real isolation. We see how well or how poorly their support system works. We see their lack of financial resources. We see cases of neglect and abuse as the family support system breaks down with the stress of continued care for a disabled person. We are often the only outside people who see these people and visit them regularly in their homes.


Physiotherapists working in community-based care treat patients in homes, schools, seniors' residences and nursing homes.

The types of patients we see range from people on ventilators, palliative clients with AIDS or cancer, to people with long-term neurological conditions such as stroke, Parkinson's, MS or patients with orthopaedic conditions such as arthritis, joint replacements, and other frail elderly who are at risk from falls, pneumonia or other debilities of aging.

Of the approximately 1,400 physiotherapists working with long-term care clients in one setting or another, approximately 550 work through existing home care programs. These physiotherapists provide just over half of all home care therapy services, which include speech, dietetics, social work and occupational therapy.

We work alone. Our car is our mobile office, clinic and storage area.

We travel everywhere, in foul weather or fair, in daytime or at night, in rural or urban areas, in unsavoury neighbourhoods. Health and safety regulations that protect the employee in workplaces are often unenforced in residences that we visit. We face unhygienic, unsafe and potentially abusive situations, and pets are not always friendly.

We are incorporating more complex and difficult cases into our case load. Keeping people out of hospitals is a major part of home care programs, and for those patients admitted to hospitals, fiscal restraints are forcing their release faster than ever. So, on the patient side we face enormous challenges.

We also face challenges on the program side due to the current configuration of home care programs. Currently, the 38 home care programs provide access to physiotherapists' services through several avenues: acute home care, chronic home care, school care.

We are pleased that Bill 173 consolidates all those programs under one delivery mechanism, the multiservice agency.

Currently, eligibility for treatment by a physiotherapist hinges on eligibility criteria for admission to the home care program itself and includes such things as a medical referral from a doctor, minimum service levels, inability to access outpatient care in the hospital and adequate family or care giver support.

The eligibility criteria for acute and chronic home care differ on paper, but more important are the differences in interpretation of eligibility criteria by the various programs, which lead to wide variations in services available from region to region.

This is the maze the long-term care patient must navigate to access services. We are very happy that Bill 173 introduces a seamless approach that eliminates the inequities created by variable applications of criteria for eligibility and provides more streamlined and cost-effective access to services.

Currently in home care, not all physiotherapists are directly employed by the various programs. Many work for independent agencies we contract with to smooth out blips in demand and the regional and seasonal variations.

This out-sourcing has been essential to preserve the quality and integrity of physiotherapy treatments in the home care context, and studies commissioned by the Ministry of Health itself have shown that there is no significant difference in the cost of out-sourcing services from internal services.

In home care we have to be able to be flexible and responsive. The public has to be able to access resources as needed without having to go back to the ministry each time for permission. If we don't, or if we can't, the patient suffers.

Ms Cummings: Our submission was provided to the committee a few days ago, so I intend only to summarize the concerns, issues and recommendations that we discussed in some detail in the submission.

We have four major issue areas and an additional four more minor concerns.

First, while we are pleased as a profession to be listed in subsection 2(7) as a "professional service," we are concerned that Bill 173 does not limit the delivery of physiotherapy service to licensed physiotherapists.

There are many people out there, regulated and unregulated, who hold themselves out as providing some form of physiotherapy or physical therapy, but none has the training, the expertise or the experience to deliver true and effective physiotherapy except licensed physiotherapists. None has the regulatory control and accountability that go with being an RHPA-regulated physiotherapist.

We are very concerned that Bill 173 may expose home care patients to ineffective or even harmful or abusive treatment at the hands of unqualified and unregulated practitioners. This concern is especially germane in the context of long-term care, given that these patients are, in the main, precisely those who are the most vulnerable and the least able or least likely to complain.

However, we do support the ability of physical therapists working under Bill 173 to delegate aspects of treatment to support personnel. There are many times when such delegation not only increases efficiency but also decreases costs. However, in order to have the care that they deliver covered by the regulatory umbrella of the RHPA, it is licensed physical therapists who must have the final decision on what, when and to whom to delegate.

We recommend, therefore, that physiotherapy services, as listed under Bill 173, be delivered only by regulated physiotherapists, or by order by or delegation from those physiotherapists, as is provided for in the RHPA.

Second, we worry that Bill 173 has created a legislative straitjacket in terms of the cap of 20% on out-sourcing of services. We recognize the ministry's concerns about funding and open-ended funding commitments. We applaud the ministry's intent to allow the structure of MSAs to reflect the needs of different communities.

Having said that, we know from experience how much long-term care needs differ from community to community. We think each community should be authorized and encouraged to structure its long-term care programs and services around the individual circumstances, requirements and resources of each community. We know that there has to be sufficient flexibility to respond to a host of variables. We also know that out-sourcing is cost-effective.

We recognize and support that Bill 173 gives the ministry the discretionary powers to approve services and programs in addition to those enumerated in Bill 173, as requested by the community. However, while recognizing the safety valves that are built into the bill, we fear the 20% cap will not allow MSAs to configure their services and programs to particular community needs, will in some cases result in duplication of resources already available in the community and in other cases lead to long waiting lists.

Third, while we very much support a bill of rights for long-term care patients, we have one reservation and one addition. We think that in today's fiscal environment the bill of rights should be circumscribed by reasonableness and resource limitations. I think we all know what happens to the interpretation of bills of rights. They are often interpreted much more widely or liberally than was originally intended; hence, our proposal for some realistic and reasonable statutory boundaries.

We also think there should be a mirror bill of rights for practitioners. Bear in mind the environments Cathy described for you in which long-term care is often provided: alone, at night, in remote areas, in residences with no telephones and in situations that are potentially abusive and physically dangerous.

We think Bill 173 should include measures that allow MSAs and practitioners to assure the physical safety and security of personnel providing long-term care.

Fourth, we think case management is a service that should be added to the list of professional services. Case management isn't always necessary, but it is critical when a patient's treatment plan is complex and requires different kinds of services and coordination of the many different care givers. Case management identifies to the client, who may be confused by the vast array of people coming into his or her home, the one person to contact about concerns, questions, additional information and so on. Case management, whether done by separately employed case managers or by the service providers themselves, is a time-consuming service that needs to be recognized and accounted for separate from the hands-on professional services to that client.

I must emphasize, however, that the case manager is not and should not be allowed to be the gatekeeper of the long-term care system. The case manager could be any professional delivering care to the patient under Bill 173.

Finally, our four minor issues are listed on pages 12 and 13 of our submission. They are, in brief, that reports under section 20 be delivered in a format comprehensible to the patient, that subsection 37(2) be expanded to include any RHPA-regulated professional and there be provisions to exclude anyone with a conflict of interest, that section 32 expand representation on the Health Services Appeal Board to reflect the range of professions delivering services under Bill 173, and that notices under section 45 be sent by registered mail.

That concludes the summary of our position on Bill 173. Once again, thank you for the opportunity to appear before the committee. We are happy to respond to whatever questions you may have.


Mrs Barbara Sullivan (Halton Centre): I think your presentation is quite interesting. Many of the points you've raised I'm not sure can be answered with amendments to the act, although one might: The case management issue may well be considered as an amendment. Some of them may well be incorporated in the regulations, however,

I too am concerned about those people who are apparently providing physiotherapy services who don't have the qualifications. I think that concern extends not only to the home care situation, but also to other services that are provided. Some of those may well include physician-operated clinics, which are problematic. I've certainly spoken with the minister about that issue on other occasions.

I don't know how the government intends to ensure that it is professionals who are delivering services that under the RHPA are in fact professional services for which there is a scope of practice and rules and for which there's a discipline. We might want to pursue that.

I appreciate your point about the 20% out-sourcing. It strikes me as affecting the needs that would be identified in a community. By example, in northern Ontario, where work history and clinical needs are quite different than they are in southern Ontario, largely because of the type of injury that occurs there, I'm certain that would be projected in quite a different long-term care need as people age and move into the community. Indeed, physiotherapy services may well be required at a greater level intermittently than would be included in the MSA normal structure. I think that's an important point and in fact we are working up an amendment with respect to that 20% issue.

The work protection issue is one that a number of groups have raised to us. I think only one, if any, has come before the hearings with that particular issue. I think there is possibly something that can be done, either in the legislation or in the regulations or through policy in terms of worker protection. It's a very difficult area because you don't know what you're going to face. As people are in less secure facilities when they're in their own home, the professional abuse becomes more and more of a problem.

I think your brief is a good one. I don't have any questions on it, I guess, other than to ask the ministry or the parliamentary assistant what steps the ministry is taking to ensure that those services which are professional services are in fact delivered by professionals.

Mr Wessenger: One thing that should be made clear is certainly this act does not in any way override the Regulated Health Professions Act. That would still apply and that would be the guideline with respect to who may provide services, whether within or outside of the long-term care system. There's no override of the Regulated Health Professions Act.

Mrs Sullivan: But I think the concern is -- and I think that probably in physiotherapy the issue has been raised more frequently than in other areas of professional services, where manipulation is done by people who do not have the qualifications. It occurs now. What steps would be taken to ensure that the professional services are in fact delivered by the professionals and not by a person who is self-described as a physical therapist or uses another title and does the same kind of manipulation or assessment, apparently, that a physiotherapist does and indeed may cause physical damage?.

Mr Wessenger: Yes, I'm quite aware of some of the situations with respect to the clinics you referred to, but I'll ask Mr Quirt perhaps to add something.

Mr Quirt: I think the presenters and Ms Sullivan have brought up an important point. Certainly when we designated physiotherapy as a required service, we were referring to the services of an RHPA-regulated physiotherapist. We do, however, see the involvement of other community service workers in the provision of those services. We would hope that RHPA-regulated physiotherapists would assess client need, develop an appropriate physiotherapy program, instruct other workers in its application to work with the client, monitor that program and make adjustments to it as necessary. Clearly, in prescribing physiotherapy as a mandatory service, we were not trying to prescribe something other than RHPA-regulated physiotherapy services.

Mr Jim Wilson: Thank you very much for your presentation and, Madam President, I also want to thank you for the physiotherapy association T-shirt.

Ms Cummings: You're welcome.

Mr Jim Wilson: It's great. As I wear it in Wasaga Beach these days, people think I'm a physiotherapist, and I go to great length to explain to them that I'm really not that professional and not covered under the RHPA.

You make an excellent case about the 20% cap on services; in fact, one of the best cases I've seen presented to date. You call the 20% rule imprudent. You talk about, and I think it's again a very good point, the fact that it may -- and I'll just quote: "It will force MSAs to incur capital and operating commitments that, in individual communities, may unnecessarily duplicate existing health care resources. In other communities, hard and fast application of the 20% rule will inevitably lead to long waiting lists which are not in the patient's best interests and, in effect, introduce a two-tiered health care delivery system between those who must rely on an MSA and those who can source faster treatment elsewhere."

You go on to make some other very good points about it in terms of it may also affect the recruitment of requisite personnel, professionals, to cover services. I just want you to know that we will be introducing an amendment to just delete all reference to the 80-20 split. It is an arbitrary figure. It's one that in no way can be backed up by this government by any study or documentation. It's simply an ideological attempt by the NDP once again to drive the private sector out of the delivery of health care services in this province. The policy for decades in this province has been to simply allow a balance in the system between the private sector and the non-profit sector, but the government is hell-bent on this approach. Some relief has occurred, though. It was a 10% rule last year and the year before. They've now found the arbitrary figure of 20% to be more suitable.

Would you agree with our amendment? We're going to need support from the public at large to try to convince the government to just scrap any reference to what clearly is an arbitrary rule that has no backing whatsoever in fact.

Ms Cummings: We support that individual MSAs should be able to select the services and the way the services are staffed according to the resources and the needs of the community. Taking away the 80-20 rule will allow the MSA to do what fits the community best.

Mr Jim Wilson: It also seems to be even more ridiculous when you consider that the government pays the same rate for your services whether you come from a private-sector agency or a non-profit agency. When we had one of the unions in here the other day, we simply asked them, "If the government pays the same rate and that's the only source of revenue" -- these community-based services that a private-sector agency is providing -- "then how is it that you feel they're making a profit in health care?" They simply could not answer that. They said, "Well, the profit has to come from somewhere."

Logic tells you if there's one revenue stream and it's coming from the same base as the non-profit agencies, I mean the same fee, one comes to the conclusion that having the private sector involved in the delivery of health care services -- it's been the policy, as I said, for decades in this province -- introduces a degree of competition and helps keep costs down across the board. In fact, thank goodness many of the non-profit agencies and associations such as yourselves have come forward and said it's just a ridiculous rule.


I want to know also, because it's been brought forward as a contentious issue -- there are a lot of rumours flying around that currently unionized employees, whether they be physiotherapists or -- I don't know whether you have any physiotherapists in a unionized environment but I assume you do in many cases -- will get preferential treatment because the unions are cooking a backroom deal with the government that their people will get jobs in the new bureaucracies and the new MSAs, but that those workers, and it's a significant bloc if not the majority of workers, who are not covered by collective agreements will simply be shut out of this process. Do you have any thoughts on that because we're looking towards putting some job security amendments in this legislation.

Ms Cummings: I hadn't heard that. I think physiotherapists, still being a resource that is finite and perhaps not as plentiful as some other professions, will make that kind of approach quite difficult.

Mr Larry O'Connor (Durham-York): Thank you for coming before us and making a presentation. There are a number of areas you touched on where I think you've raised some concerns, some fears maybe that you have that aren't real. I know we could listen to my colleagues and sometimes the rhetoric overtakes us here. They're concerned about job security. The reality is that since 1991, 5,000 jobs have been created in this sector. There's been an increase from $550 million, from 1991, to this year, $850 million. So the reality is job creation. The proof is in the pudding because the money's on the table and it's out there in the field and it's providing the services.

The assessment mechanism and case management -- there has been a working group and, unfortunately, not all the members even know all the work that's gone into the legislation because we haven't had a technical briefing for all my colleagues at this point, but we're going to have that. Hopefully, we can get agreement and we can do that maybe tomorrow.

There's been a working group and on that working group and taking a look at assessment has been the Ontario Home Care Case Managers Association. Correct me, but I think that is the avenue on which physiotherapy is now directed to the needs of the client, the consumer in this case. What is the referral process that would allow a physiotherapist's service to be provided in a home setting today?

Ms Cummings: Currently?

Mr O'Connor: Yes.

Ms Cummings: It's on a physician referral basis and if the physician makes the referral for physiotherapy, the case manager then receives that referral and contacts the physiotherapist or physiotherapy service and arranges for that to happen.

Mr O'Connor: Okay. In the working group that is trying to take a look at making sure we can develop a consistent, right-across assessment process so that everyone is going to have access to the services that you provide, the needed service that you provide, one respecting the clinical discipline that you represent -- there's been a broad range of people who have been included in that, which has included some physician representation there.

The concern that you have I think is real; it does need to be included in that process. I think it's being met, though. There is a group meeting to try to define that a little bit better and if there are any suggestions you might have to improve what we've got in there, I'd appreciate any thoughts you might have. We do have a lot of work going on there and I guess not all my colleagues know of that work because they haven't had the briefing that they could --

Ms Cummings: We don't necessarily support that case management be done by a separate group of practitioners called case managers. I would wonder if there are professions other than already-established case managers in your working group.

Mr O'Connor: There are. There are a number of different home nursing programs. I'll go through the group, okay? I'll give you a list: the Alzheimer Association, the francophone one, the Ontario Home Care Case Managers Association, the Ontario Federation of Labour, the Association of Placement Coordination Services of Ontario, the Integrated Living Association of Ontario, the Advocacy Centre for the Elderly, the Red Cross, Ontario division, the OHA, the Ontario Community Support Association, the Community Occupational Therapists and Associates, the Multicultural Alliance for Seniors and Aging, Riverdale Immigrant Women's Centre, the Victorian Order of Nurses, the Ontario Medical Association and some consumer groups, and I don't have a list of who all those consumer groups would be, but it's a fairly broad-ranging group.

I guess the difficulty is you could create a group that's going to be so large that it's hard to get them to focus on what the important thing is, the assessment of the consumer, that the needs the consumer has are going to continue to be met in a more effective way than has been in the past, because in the past we had the 38 home care agencies out there directing it and not everybody has been covered as well as they could have been.

Ms Cummings: The OPA recognizes that you're addressing the assessment needs. However, case management for physiotherapists working in home care, actually, we see the focus being more of coordination, advocacy, ensuring good communication between all the service providers in the home rather than assessment and screening and gatekeeping and that kind of thing.

Mr O'Connor: Yes, I think --

The Acting Chair: Thank you.

Mr O'Connor: -- that was actually presented quite well. The only other point that I'd like to make --

The Acting Chair: Mr O'Connor, I'm sorry.

Mr O'Connor: -- is that the 20% doesn't necessarily affect physiotherapists, because it's my belief that most of them are individuals, in which case you're purchasing a service and there's an exemption for a purchase of service within the bill.

Mrs Sullivan: Could we have a clarification of that from the ministry officials? It might be quite misleading.

Mrs O'Neill: I think that would be very interesting.

The Acting Chair: Can you make that response briefly, Mr Quirt?

Mr Quirt: I'll do it as briefly as I can. There are some -- I wouldn't say the majority, but some -- physiotherapists and occupational therapists who work as private practitioners. The bill's provision that limits purchasing to 20% excludes the purchase of services from an individual. So, for example, if an MSA had already used up its 20% of purchasing professional services in buying nursing services and it wished to contract extra services with an individual physiotherapist, it could do that without worrying about going over its 20% limit.

Mrs Sullivan: It's in the interests of physiotherapists to go out on their own.

Mr Wessenger: Mr Chair, a point of order: Mr Wilson made an allegation with respect to there being some special backroom deal with respect to getting special preference to union members and I'd like to be clear that there's no basis for that statement and if he has any evidence of it I wish he'd put it forward.

The Acting Chair: Thank you.


The Acting Chair: Our next presenters are representatives of the Ontario Home Respiratory Services Association. Welcome to the committee. Please introduce yourself before beginning.

Mr Blair Richardson: My name is Blair Richardson and I'm the executive director for the Ontario Home Respiratory Services Association. I'm pleased to be here this morning and to present our submission to the standing committee.

I want to spend a little bit of time this morning talking about the services we provide and the system within which we work, because it's our experience within that system that leads us then to provide some observations on Bill 173, the long-term care reform, and also some recommendations.

Our association represents the private-sector providers of home respiratory services. Our association dates back to 1985. We provide services to approximately 20,000 people per year, all in a home setting. The largest source of revenue for our industry is the Ministry of Health's home oxygen program. In the current fiscal year, it has a budget of $70 million. The home oxygen program is funded under the Ontario drug benefit program and it is administered by the assistive devices branch, which is also responsible for the assistive devices program. OHRSA members in fact provide services to over 95% of the HOP case load.


Our association's goal is a private sector home respiratory services industry that is viable and that has an opportunity for future growth, and in order to achieve that goal we recognize that a number of things must be happening. First of all, there has to be widespread recognition that the services we provide are both efficient and cost-effective; that we have a reasonable reimbursement for these services; that there's fair competition among service providers approved by the Ministry of Health and, lastly, that the association works on an active and progressive basis for change in the health care system.

Pioneering work was undertaken by our association some years ago in collaboration with the Canadian Council on Health Facilities Accreditation and partly funded by a grant from the Ministry of Health. This pioneering work led to the establishment of a national accreditation program for home respiratory services and it's the first national accreditation program for any home care service. We're very proud of this accomplishment and we feel that it does in fact demonstrate our strong desire for continuous improvement in the quality of services that our members provide to home oxygen therapy clients.

What basic services do our members provide? Well, the basic service we provide is home oxygen therapy which also includes respiratory care. It's provided to individuals with lung disease or cancer when their lung function has deteriorated to the point where they need supplementary oxygen. There's no cure for lung disease but oxygen therapy has been shown to be effective in reducing mortality based on large multicentre trials conducted in England and North America. I might add, the effectiveness of oxygen as a drug is perhaps not shared by all the other drugs that are listed under the Ontario drug benefit program.

In addition to home oxygen therapy, members provide a range of other services, again, all focusing on respiratory disease and the provision of respiratory equipment and professional services, either by respiratory therapists or in some cases by nurses with special respiratory training.

What happens when a person requires oxygen therapy? We've listed here the basic steps in the process in Ontario. First of all, the attending physician writes a prescription, which in turn is based on his work and both home oximetry tests or arterial blood gas test results. Then a service provider is selected by the physician and the client from among those who are under contract to the Ministry of Health. The physician fills out an application form, which is sent to the ministry, showing that the individual has met the eligibility criteria set down by the ministry.

The Ministry of Health admits the person to the home oxygen program and then the service provider makes a visit to the home to install the oxygen therapy equipment, to do a home assessment to make sure the home is a safe environment for the equipment, and then provides teaching on the safe operation of the equipment, the hazards of the equipment, and also answers questions about the disease and any other concerns that the client may have. By contract, the service provider is available 24 hours a day, seven days a week, to respond to client problems.

Following the installation of the equipment, the respiratory therapist makes regular home visits in order to monitor the patient's compliance with the physician's prescription, to observe if there are any changes in the client's condition that will require the physician's intervention, and also to make sure that the equipment is functioning properly.

These services are then reimbursed by the Ministry of Health according to the fee schedule which is in the contract.

The home oxygen program has a number of strengths which we would like to highlight, because we think they're relevant to the current debate about Bill 173. First of all, the physician is free to choose the equipment configuration that best meets the client's needs in discussion with both the client and also the service provider.

The client has a choice of service providers regardless of where they live in the province and usually the client seeks the physician's advice in terms of service providers. But, of course, the ultimate decision is always the client's.

Competition is very keen among the service providers solely on the basis of service levels, because the reimbursement levels for home oxygen therapy are set on a province-wide basis. All the service providers receive the same reimbursement, so then competition to differentiate service providers is purely on the basis of the level of service they provide.

I think the most significant point here is that there's a short feedback loop from the client to the physician. If the client is happy with the service that the client is receiving, then usually this is conveyed to the physician during one or another office visits, and so the physician has a very accurate and up-to-date knowledge as to what level of service is provided by the various providers, and they make excellent use of that information in terms of where they send their future referrals. If a company is providing less satisfactory service than some of their competitors, they usually then find that they're getting a lot fewer referrals from particular referring physicians.

Lastly, there's good coverage for the program in Ontario. In other words, if a person does in fact need the service, they're very likely to be able to get it because both the physicians generally are aware of the existence of the program and government payment for these benefits, and also because there's good geographic coverage provided by service providers.

In terms of program results, I'll just highlight a few points. We think the availability of this program on a home delivery basis has had an impact on the rate of institutionalization. The Ministry of Health has told us in fact that there are only 400 people on oxygen therapy in nursing homes and homes for the aged.

For nearly half the people who are on oxygen therapy, the specialized equipment that they receive enables them to go outside the home on a regular basis. This is very important to them both in terms of the quality of their life, and also their ability to conduct activities of daily living. The close follow-up at the home by the RT or the nurse ensures good compliance with the physician's prescription, which is directly related to mortality rates, and it also allows for the early identification of changes in the client's condition. This helps to prevent acute respiratory problems and the need for hospitalization.

What are OHRSA's concerns about Bill 173? We're concerned about the MSA model. We think that in effect the MSA will become a monopoly for a specific local area and it will also have stringent limits on contract service provision. The home oxygen program experience that I've touched on briefly demonstrates that competition among service providers is the key factor in the quality of service that clients receive.

Secondly, while we do acknowledge the need for changes in the long-term care system, OHRSA's second concern is whether the long-term care clients will be better served in future when this major reform has been fully implemented. Having listened to some of the discussion yesterday afternoon, perhaps some of the people around the table here will feel that we're just another group of service providers who are interested in preserving the status quo and are unwilling to consider that some changes might be for the better, and in fact are unwilling to fairly consider the evidence that these changes might be for the better. It makes me think of tobacco companies denying that there's any link between smoking and lung cancer, but I don't think that's the case here.

The analogy I would like to draw is with computer equipment. Let's suppose for a moment that you're the CEO of a non-profit agency providing home care services. You have a computer installation which is very important to the day-to-day running of your agency and through your front door one morning comes a computer salesman and he says: "I want you to sign this contract to purchase a new computer system. It's going to replace the one that you have now. It's going to be wonderful. It's going to have all of these advantages. We're only in the design process for this new computer but I want to assure you that all of these benefits will in fact occur, and would you please sign here."

I think you would agree that any CEO in that kind of circumstance would probably consider very carefully the claims this computer salesman was making for the equipment, and might be quite sceptical that the promised benefits would in fact be delivered. Certainly, the greater the change promised in terms of the new computer system, the more risk there would be that in fact perhaps those benefits might not be delivered.

Just to belabour my analogy a little more, supposing after the salesman leaves, the CEO then turns around to his chief financial officer and this person says: "I have a lot of experience with computer systems. In fact, I worked for this company some years ago. I know their track record. I'm familiar with some of their research and development people, and I feel quite confident that the promises that are made in terms of this new computer equipment will in fact be delivered."

I think there, again, the CEO's view of the situation might be coloured by the advice that he had received from his chief financial officer.


Even though one of the criticisms that's been levelled at the long-term care system is that it's provider-dominated, I think it still is important for the decision-makers -- you people here -- to consider the input of the service providers in a balanced way, because their knowledge of how the system works and their ability to assess the benefit of various proposed changes I think is pertinent.

In a positive vein, therefore, OHRSA has some recommendations to make. First of all, as we all know, there is a planning effort under way now through the district health councils. We recommend that before any funding flows to local agencies under this Long-Term Care Act, the ministry first take a look at those planning results and, on the basis of that, set out a description of the expenditure that's going to be required to implement the long-term care changes throughout the province; and that, secondly, the ministry provide a description of the savings and the other tangible benefits that will occur, once the new system is in place. This would in fact provide a benchmark against which to measure progress and it will also enable the minister to be held accountable for results.

The second recommendation: Since the implementation of long-term care changes will not occur simultaneously, this provides a good opportunity for an evaluation of the first MSAs that come on stream. We recommend that a proper evaluation be undertaken at a handful of sites. This evaluation should confirm tangible benefits before the long-term care reform in fact goes province-wide. Evaluation results from the early sites should also help later implementation sites avoid some of the implementation problems.

Our third recommendation relates to section 13, which places a cap on contract services. We recommend that section be deleted until such time as it can be demonstrated that the MSA model is less costly or more effective than what's referred to as the brokerage model in Ontario.

That essentially is our presentation. I would like to thank the committee for the opportunity to make these comments. I would be pleased to try to answer any questions which you may have.

Mrs Sullivan: We appreciate the brief you've prepared. I think you've raised some of the issues that are of some concern to members of the committee, not the least of which is, firstly, the cost of the new system and whether those costs have in fact been projected with any kind of accuracy or viability; and, secondly, whether the promises that have been made through raised expectations in association with statements that have been made about long-term care reform will in fact be funded through what we've been told will be a negotiated mechanism for determining how much money will go to an MSA. So I think those are questions which are pertinent and are very much on our minds.

I am wondering -- and I am going to ask the ministry to respond and you to respond -- if there has been any movement at all to bring home oxygen services under the aegis of the MSAs or if that is contemplated in any way and what steps you would see as necessary if that were taken.

Mr Wessenger: I'm going to ask Mr Quirt to reply on that.

Mr Quirt: The short answer is no, we'd expect that oxygen therapy would continue to be prescribed by a physician, that the drug itself would be subsidized by the Ontario drug benefit program for clients eligible for that support and that the assistive devices program would continue to administer that.

MSAs may well, in their information and referral capacity, suggest that a client might speak to his or her physician about a particular therapy, but that would be the extent to which MSAs would be involved in that transaction, I would think.

Mrs Sullivan: I appreciate that response, and I think that probably your association will appreciate it as well.

Mr Norman W. Sterling (Carleton): In terms of the services which you and your members provide to the public of Ontario, what percentage of the total does the private sector provide now and what percentage would hospitals provide, for instance? Have you any idea what the percentages would be?

Mr Richardson: There are three hospitals that provide these services and they would collectively provide probably about 1%.

Mr Sterling: So the private sector is taking care of, let's say, 95% of --

Mr Richardson: Yes.

Mr Sterling: -- the needs of these people in Ontario.

If MSAs are required to have this 80-20 split, your industry's going to come under considerable attack, or the private sector, part of it, is going to come under considerable attack as the squeeze occurs for the MSAs to show the 80-20 split. Is there any movement afoot on the part of some of your private operators to switch over to non-profit and take the profit out, as many non-profit organizations are through high executive salaries and that kind of thing, which has happened in day care and a number of things when governments go through this phoney switch?

Mr Richardson: Members of our association aren't making any of those changes because, as Mr Quirt explained, it is not contemplated that the types of specialized services that our members provide would be rolled up under the MSA.

Mr Sterling: So you're not going to be required to have the 80-20 split for your services?

Mr Richardson: No.

Mr Sterling: You won't be rolled into the total budget of the MSA then?

Mr Richardson: No. It's my understanding that we won't be.

Mr Sterling: Is that in the legislation or is that by exemption?

Mr O'Connor: Section 13.

Mr Sterling: Okay. I have no further questions.

Ms Carter: Obviously you do provide vital services and equipment and part of what I had to ask has already been answered, but I'm just going to push this a little bit further as far as actual information from the ministry goes.

I still wonder whether there are not chronic conditions that might come under the MSA and, if they did, I understand that equipment does not come under the 80-20 limitation. That would come under the assistive devices program, but that still leaves the nurse, or whoever is there, in some circumstances to administer it. How would that work if, in fact, some patients did come under the MSA? Are there patients in that category?

Mr Wessenger: I'll ask Mr Quirt to perhaps explain that and also deal with the issue of equipment in general, which is how it's dealt with under the --

Mr Quirt: Currently, the home care program does provide its clients with equipment necessary for some chronic conditions and to assist in providing their services if they're an acute care client of the home care program. The MSA would continue to do that and the costs associated with that would be, as they are now, covered 100% by the province.

There are some pieces of equipment, however, that individual clients are provided with where the equipment is maintained as the property of the individual client. A wheelchair would be an example and the assistive devices program, in addition to administering the oxygen program that our presenters described, does provide 75% of the cost for a number of those pieces of equipment like walkers and wheelchairs and so on.

The multiservice agency, if they recognized that a client needed that kind of permanent type of support in their home, could make the referral to the assistive devices program and a supplier that contracts with the assistive devices program in each community would provide that service and the client would be reimbursed for 75% of what I understand to be now a fixed amount for each particular type of equipment.


Mr Jim Wilson: It's important that we know what's included in the 20% of accrued budget rule for these community services, and I'd just like a clarification from Mr Quirt.

Would that mean that everything under the ADP, because it's budgeted for --

Interjection: Separately.

Mr Jim Wilson: -- separately in MOH, everything under the ADP would not in any way constitute -- those services or equipment would not constitute part of the 20% accrued budget rule?

Mr Wessenger: Yes, that would be correct. I think there's also an exemption for that equipment that is already provided under the bill. That's excluded also from the 20%. In other words, as you know, some of the agencies now provide such things as, I think, safe wheelchairs and so forth for temporary use for somebody who's --

Mr Jim Wilson: Then what purchases in terms of, say, non-treatment or personnel services -- what purchases of equipment or supplies or whatever, fall under the 20% rule?

Ms Gail Czukar: Equipment and supplies and so on are excluded from the 20% rule for precisely the reason that MSAs shouldn't have to maintain an inventory of equipment or specialized equipment, in particular, and so on. So they are excluded from that rule and they're also excluded from the list of mandatory services that have to be provided.

Mr Jim Wilson: What about in the case of charts that I brought up in the Legislature, where the government clearly has already ruled that computer services contracted out, which are part services, one could argue, certainly fell under the current 10% rule, or contracting out of other similar functions which are essential pieces of equipment, as it were, or essential functions to the operation of an MSA, for instance?

Ms Czukar: The 20% rule applies to services, so it's the services that are included in the four categories. It doesn't apply to administrative services or support services: payroll, administration and that sort of thing. Those can be purchased by the MSA without going into the 20% category.

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

If the members of the committee would stay just for a couple of minutes, we can deal with a couple of procedural matters before breaking for lunch. Firstly, the clerk advises me that you'll be all provided later this afternoon with either tickets -- how are we getting to Hamilton?

Mrs O'Neill: The bus.

The Acting Chair: The bus? For those of you who are driving, there'll be a memorandum with a map telling us where we're going and how to get there; otherwise we'll be boarding a bus at 8 o'clock tomorrow morning.

Ms Carter: Where?

The Acting Chair: At the front door of the main Legislative Building.

Secondly, many committee members have expressed an interest in having a technical briefing. I think we should have that sooner, rather than later. I wonder if we might have agreement to have that briefing tomorrow during our hour and a half lunch period in Hamilton. I think if we set aside one hour during that time, that would be sufficient to allow for a presentation in the order of approximately one half-hour, followed by questions. Is there agreement to that effect? Agreed.

The other thing Mr Quirt is seeking is some direction, some guidance, with respect to the nature of the briefing. Eligibility criteria have been raised. I understand that would consume a great deal of time in and of itself. There's also the original briefing, which has yet to be given, which had been scheduled for the opening date.

Mr Jim Wilson: Mr Chairman, the original briefing started off as more of a defence of the bill than certainly a technical briefing. If the offer is for a true technical briefing, I would agree with your suggestion and also ask that other topics include such things as the regulations, where we are with many of the regulations to date, because it's a whole section of the bill which obviously -- when one reads it, one's unable to really figure out what's going on.

Also, I would like -- and I guess we'll get to it if we go in some sort of numerical order through the clauses or something -- district health councils. We've had no discussion to date in committee about the new legislative mandate and role of district health councils.

Mrs Sullivan: I would prefer something that is technical in terms of issues that are raised in the bill and less of an exposition of the proponents' view of the bill, which I think we were starting to get in a technical session the other day. I think there are numerous questions with respect to the interim period that's identified in the bill: what is an approved agency; how they will be approved; what the criterion are. Most of the unanswered questions relate to what is projected to be included in regulations, and I think that for greater understanding and clarity, we have to know what direction the ministry is going in to ensure that what is covered by the regulations is in fact what we want to see reflected through the legislation.

Mr O'Connor: I agree that we need to have that technical briefing so we can go through the bill and all the clauses and why they're there. I think that's very necessary. The other thing I think would be useful for the committee would be an update then on some of the working groups, because when we talk about eligibility and assessment, some of that hasn't been included because some of the work is yet to go, which will go into the regulations, so maybe an update on the working groups as well that's under way.

The Acting Chair: All right. Mr Quirt, legal counsel, you've heard the needs of the various committee members and I trust you'll take that into consideration. Thank you. The committee stands adjourned until 2 this afternoon.

The committee recessed from 1206 to 1410.


The Acting Chair: Good afternoon, ladies and gentlemen. Welcome to the continuing hearings on the matter of Bill 173, An Act respecting Long-Term Care. I'd ask our first presenters to please come forward and take a seat, representatives of the Canadian Red Cross Society, Ontario division. Welcome. While you're taking your seat, I want to remind all of our presenters and the committee members that we've allotted one half-hour for each presentation. During that time we ask that you make your presentation and, if at all possible, allow time for questions and answers. You'll find that all the committee members have a real interest in the issues that you're dealing with and we'd like to have the opportunity to do a bit of probing.

Mr Bob Morton: My name is Bob Morton. I have the pleasure and honour of being the president of the Ontario division of the Canadian Red Cross Society. Joining me today is Mrs Nancy Bell, chairperson of our homemaker services. One of the ways in which we organize our program is through program committees. We have submitted a brief to you. I would like to begin to present our brief on page 5, to talk a little bit about the Canadian Red Cross Society, and Ontario division in particular.

We have some specific amendments and some specific areas that we would like to talk to the committee about with respect to potential amendments. Nancy will speak to those and then I will conclude with some closing remarks. I believe that will allow some time for questions when we're done. Let me begin.

The Canadian Red Cross Society is a member of the International Red Cross and Red Crescent Movement. One of the fundamental principles of the movement states that there can only be one Red Cross in any country. The society is a non-profit, charitable corporation incorporated under federal law. In each of the provinces there is a division. The divisions are not separately incorporated and are accountable through the secretary general to the board of governors of the society.

The Ontario division of the Canadian Red Cross Society operates 78 local branches, almost all of which run community-based long-term care programs. In accordance with the mission of the society, each of these programs has been developed in response to needs identified by the local community. Particular emphasis is placed on ensuring necessary services are available to the vulnerable members of those communities.

At present Ontario division offers a wide range of programs throughout the local branches, and the statistics are somewhat overwhelming. There are over five million hours of homemaking provided through 52 branches and satellite offices, about half of the homemaking service provided in the province of Ontario; the society operates 16 meal programs -- 12 Meals on Wheels and four Wheels to Meals programs; there are 16 transportation services programs; we have one care giver support services program; there is one adult day care program operated by the society; there are five home maintenance programs, 12 friendly visiting programs, eight security programs, one personal emergency response program, seven telephone assurance/postal alert programs; there are 16 fun and fitness programs operated by society members in the province; and there are 63 branches providing home health care equipment loan services.

In all, these services are provided to more than 130,000 Ontarians through the efforts of over 10,000 volunteers and over 6,000 paid staff members.

Our wide variety of programs and services allows volunteers with diverse backgrounds and interests a variety of opportunities to participate in the society's humanitarian efforts. Working together, volunteers and staff are partners in implementing our mission through the programs we offer.

With those thoughts in mind, we'd like to offer some specific comments about the proposed reform, and in particular Bill 173.

The Ontario division of the Canadian Red Cross Society applauds the government for its effort in proceeding with long-term care reform. We strongly support the principles and goals outlined in Partnerships in Long-Term Care: A New Way to Plan, Manage and Deliver Services and Community Support. These principles and goals were identified through an extensive consultation process with key stakeholders, a process in which the Red Cross was proud to participate. However, there are some sections of the current draft of Bill 173, An Act respecting Long-Term Care, that do not seem to reflect the stated principles and that are of concern to us.

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

We strongly believe that legislation must be enabling rather than prescriptive. Legislation which is enabling will be relevant well into the future. If legislation contains too much detail, it becomes inflexible. Legislation must be flexible if it is to withstand the rapid evolution facing long-term care and allow service providers to meet the changing needs of their diverse communities. Time doesn't permit me to discuss this issue, but perhaps through questioning we can talk about some specific examples of how we feel legislation should be enabling rather than prescriptive.

It's our view that enabling legislation is essential if all partners involved in providing community-based long-term care are to develop new and innovative structures and processes that will lead to genuine collaboration and a seamless continuum of services that is effectively and efficiently provided.

We also recommend that the legislation respect the principles and traditions of the volunteer agencies that provide community-based long-term care services. These agencies are deeply rooted in their communities. Many of the services that they provide have been developed in response to the community's unique needs. These services often have been developed by dedicated and visionary members of the community who chose to volunteer their time and donate their money to ensure that needs were met. We cannot even begin to measure the value of the countless hours of their time donated to meet the needs of their communities and the vulnerable individuals within the communities.

The Canadian Red Cross Society operates in keeping with seven fundamental principles: humanity, impartiality, neutrality, independence, voluntary service, unity and universality. Based on our mission, one of the goals of the Ontario division of the Canadian Red Cross Society is to develop throughout Ontario health and social service initiatives directly related to the needs of the people of the province. Our operating principles require us to make those in need, particularly the vulnerable, our first priority. Where our help is needed, we are required to deliver high-quality, professional services. In responding to our mission, we are often the only provider of services in remote and sparsely populated areas of the province.

Although we support the principles underlying the reform and the purposes as delineated in Bill 173, we are not able to support the creation of multiservice agencies, MSAs, as described in the act. We are concerned that the proposed system will not improve the delivery of services to consumers. We are also concerned that the legislation is trying to fix problems with the service delivery system through the creation of complex and highly prescriptive organizational structures. We suggest that to be effective, any reform must focus on system-wide changes and avoid micro-managing the operation.

The province-wide consultations held over the past several years clearly underline the need for improved access to and coordination of the existing system. The outcome of the consultations did not seem to call for changing the system itself; it called for improving and correcting it.

The existing system has many strengths. We are concerned that with the creation of MSAs as described in these acts, some or many of these strengths will be lost. The province-wide mandate of the Red Cross has enabled us to identify a number of opportunities to initiate systematic changes that would build on the system's existing strengths, increasing efficiency and improving quality.

The mandate of the MSA makes it responsible for delivering an extremely broad range of services. Our experience in the health system has shown that where acute health care services compete with long-term, non-acute or social services, the latter services are usually relegated to second place. Where MSAs are created, their operating plans must ensure an equitable distribution of resources. Also, a significant proportion of the clients of an MSA will be users of hospital services. To meet the needs of these individuals and to maximize the efficiency of the hospitals, there must be a simple and effective interface between each hospital and all of the community-based long-term care services in its catchment and referral areas. The proposed structure for MSAs does not appear to address this important need.


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

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

There cannot be more than one Red Cross in any country. We operate under the bylaws established by the society. These bylaws describe authority and organizational structures and set parameters for our operation. The society has only one board of governors. The board is ultimately responsible for the overall direction and operation of all aspects of the society. No agreement or arrangement may be entered into that will in any way diminish the authority of the society's board or impinge on the society's fundamental principles, particularly:

Independence: The movement is independent. The national societies, while auxiliaries in humanitarian service of their governments and subject to the laws of their respective countries, must always maintain their autonomy so that they may be able at all times to act in accordance with the principles of the movement.

Unity: There can only be one Red Cross in any country. It must be open to all. It must carry on its humanitarian work throughout its territory.

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

We'd now like to make some specific comments. I'll ask Nancy to carry on from there.

Mrs Nancy Bell: When I read the purposes of the act, the purpose that jumped out at me, and the one that we're not doing now, is to simplify and improve access to services. MSAs are designed to provide services and information about services available in their community.

As the daughter of parents who require and are receiving services, information that can lessen the confusion about what's available, how to get it, whom to call, will be greatly appreciated. My parents, Earl and Gladys Bell, have had the following in their home at various times: a Red Cross homemaker, a VON nurse, a speech pathologist, a home care case manager -- in fact, more than one -- someone from assistive devices, a Red Cross manager and the lifeline representative from the local hospital.

When I called my mother to ask her permission to use her as an example, she added two more to the list: a physiotherapist and, recently, someone she doesn't even know who came into her home and went through the whole thing again. Now, mom thinks she's pretty aware and pretty bright, and she is, but she said to me that something has to be changed. She is totally confused about who's who and whom to call.

We, the Red Cross, have three recommendations that we would like to make which we believe will not hurt the purposes of the act but will enhance the delivery of long-term care.

Our first recommendation deals with the part of the bill that divides services into four categories: community support, homemaking, personal support and professional services. In the past we've had community support, homemaking and professional services, but there's now a new category called personal support.

We believe that by putting care into categories the bill does not reflect the present reality or the changes that are going on. Separating personal care and non-personal care will not be practical, and in fact many activities are both. For example, assisting a client to have a bath will be personal support, but cleaning the tub after is homemaking, under the four categories. Over the past few years we have worked very hard to erase the perception, the misconception, that homemakers are nothing but cleaning ladies. Homemakers have begun to achieve recognition as a valued member of the health care team.

Bill 173 also states that no fee will be charged for personal support services or professional services, but it does allow for a fee to be charged for homemaking and community support services. We feel that many of the personal support and homemaking functions are interdependent and it's not appropriate to use these categories for imposing user fees.

Therefore, our first recommendation is that the legislation be reworded to eliminate the specific reference to and the categorization of community services, that the regulations to the act be used to define those services to be provided by an MSA and that the act and regulations respect interrelationships between services.

Our second recommendation refers to the section of the act which says that an MSA can purchase up to only 20% of each of the four categories of services. As you know, at present home care programs purchase most of the services they provide. We know there are problems with the current system, but we believe those problems are from lack of coordination and poor access. Rather than replace the present system, we believe we should build on its strengths.

Under the 20% rule our service would gradually, or perhaps quickly, decline. As a chartered accountant who has seen many businesses of all sizes, I'm worried that this section of the act would limit the purchase of service to 20% to the point where we will not be able to exist. Although the rate, we trust, will always cover the homemaker's salary and the homemaker's benefits, at some point in time the volume will not be big enough to pay for the bookkeeper, the manager, the telephones. The Red Cross is very concerned that people like my mom may face waiting lists, a decline in quality of service and limited or no choice.

Therefore, our second recommendation is that the legislation be reworded to remove limits on the amount of service that an MSA may purchase and that the legislation enable each community to choose the best service delivery model and optimum mix of provider agencies to meet the needs of its residents.

Our third recommendation deals with the section which requires MSAs to comply with the legislation within four years. We believe that this provision reduces flexibility. As MSAs will have no choice about their service in four years, they will not be looking for other, perhaps better, ways to serve their clients.

The government has stated that there will not be a cookie cutter approach, but under the legislation at the end of four years the MSA cookies are going to look essentially the same.

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


Mr Morton: I'd just like to conclude with a few remarks. The Canadian Red Cross Society, Ontario division, genuinely hopes that changes brought about by long-term care reform will not preclude us from continuing our over 75 years of providing service in our communities. Through our comprehensive range of programs, we are fulfilling our mandate to support the frail and vulnerable, enabling them to live with dignity and as independently as possible in their homes.

We are also proud of the Red Cross's contribution to the professionalization of the role of the homemaker. This occupation, primarily filled by women, continues to evolve. Red Cross, employing almost 6,000 homemakers, is the largest employer of homemakers in the province and is committed to continue to provide leadership to the industry. Our comprehensive provincial programs for quality management and risk prevention set standards for other providers. We continue to develop training programs and resource materials to support our homemakers, improving their level of skill and ensuring the best possible quality of service.

We commend the government for proceeding with long-term care reform. We support the principles and goals outlined in Partnerships in Long-Term Care and the purposes of Bill 173. However, we are disappointed that the draft legislation does not demonstrate the vision that we feel is necessary for such an important task. The role of government is to provide the leadership to move the province into the future. In our view, the bill is unduly prescriptive and will not take long-term care into the 21st century.

As we have noted, we have grave concerns with the intent to address systematic problems through creation of new corporate structures. The proclamation of the act, as it is drafted, will force the Red Cross, and most likely many other voluntary organizations with a proven history of services to the people of Ontario, to immediately begin a major review to identify other strategic directions. The Red Cross is committed to meeting the needs of vulnerable individuals in our communities.

Red Cross is ready to play a constructive role in the future of community-based services within Ontario. We have demonstrated our willingness to cooperate with other providers to improve services in our communities. We have identified a number of initiatives that we feel would increase the efficiency and effectiveness of service provision and are willing to provide leadership in implementing these changes.

We're available for questions.

Mrs Sullivan: I'm interested in a number of the points that you've made in your brief and concur that the ideal approach would be to have enabling legislation rather than highly prescriptive legislation that could particularly meet and recognize the diversity of need across the province.

I'm very interested, however, in the issues that you've raised with respect to your incorporation and your particular legal status, in that the bill has such a legal surround that in fact you are precluded from either being an MSA or being a provider of services, including even the 20% of services, it appears, that an MSA can purchase outside of its own aegis.

I wonder if the ministry would comment on the particular situation of the Red Cross, which provides an enormous amount of home care services, including in my community, of long-standing quality and is completely eliminated from the long-term care process.

Mr Wessenger: If I could just comment on that, I'm going to ask legal counsel to respond, but I understand that it's not precluded from purchasing services from the Red Cross. I might ask legal counsel to indicate the status.

Ms Czukar: It's true that the Red Cross would be precluded from being an agency within the definition in the act, because of the requirement of a provincial incorporation, but it's not precluded from being a service provider, and certainly could continue to be a service provider, from which services are purchased within the 20% limit.

Mrs Sullivan: That is not the reading. The "service provider" in the act explicitly includes the minister, an approved agency, a person who provides a service with certain kinds of payments and a person who provides a community service which is purchased by an approved agency. The Red Cross cannot be an approved agency and therefore cannot be a service provider.

Ms Czukar: It can be a service provider because it can be purchased in that last category that you mentioned. If an approved agency or an MSA purchases a service from the Red Cross, then it falls within that definition of "service provider."

Mrs Sullivan: It says "person."

Ms Czukar: "Person" is the corporation. With respect to specific comments on the Red Cross situation, I don't know if Mr Quirt wants to add anything or not, but that's the incorporation status and the definitions in the act that apply.

There is a reason for that, I might add, and that is that with federal corporations the province can't impose requirements regarding consumer participation and so on on boards of federally incorporated bodies. That's why we require provincial incorporation, so that we can ensure that there will be significant consumer participation and that locally based and elected MSAs will not be subject to the decisions of boards of governors over which we have no control.

Mrs Sullivan: I find it absolutely extraordinary that one of the most heavily involved organizations in the entire world, including in our own community, is Red Cross, with the highest number of volunteers of any organization that I can think of, involved in so many aspects of care delivery, and Red Cross is precluded from even putting itself forward for consideration by a district health council as an MSA. In fact, the services that will be purchased, that the Red Cross is so well known for and so highly respected for in our communities, the amount of those services that will now be available for purchase from the Red Cross will be limited to 20%, if the MSA doesn't provide those services. That doesn't provide a critical mass to keep the Red Cross in business. In Ontario we will have the only place in Canada where the Red Cross has no place in long-term care and home care services. This is nuts.

The Acting Chair: I want to allow Mr Wilson time for one short, sharp question.

Mr Jim Wilson: I appreciate that, Mr Chairman. Mr Morton and Ms Bell, thank you very much for coming down again before the social development committee, because I know in the past you've been here on other pieces of legislation. I should tell committee members that Mr Morton is not only president of the Ontario division of the Canadian Red Cross but he's also chair of the district health council in Simcoe county and administrator of one of our homes for the aged. He knows of what he speaks and is a frequent and very valued adviser to the four MPPs in the county. I want to thank you publicly for that, Bob.

I'll make it a two-part question. One is that in your remarks I think you almost begged the question, and that is an opportunity to explain the difference between enabling and prescriptive legislation and perhaps an example of where prescriptive legislation leads to ludicrous situations. I'd like you to share your thoughts on that topic with the committee, because I notice two of your recommendations actually use the word "enable."

Secondly, following along, I guess, what Mrs Sullivan has been talking about, it's very, very important that you have the opportunity right now to respond to comments that were made by Dan Stapleton this morning, for example, of the Ontario Community Support Association, one of the groups that we're told by Mr Quirt was extremely influential in convincing this government that MSAs should not only be one point of access but should also deliver the services, which as you know is the twist the government has put on this that's problematic.

Mr Stapleton said that he does not believe that people volunteer because of the history and unique identity of the organization that they decide to volunteer for. In other words, he dismisses the 75-year history of the Red Cross in terms of people volunteering for it --

Mr O'Connor: You put a lot of words in his mouth, Jim.

Mr Jim Wilson: I wrote it down as he said it.

Mr O'Connor: You're stretching it.

Mr Jim Wilson: -- and the unique identity that it has in people's minds in the community. So if you could comment on both of those, please.


Mr Morton: I'll try and be brief. On the first issue, the issue of enabling, we seem to be creating legislation of late that really puts handcuffs on communities and how they deliver service. I was absolutely struck -- I was talking with the district health council in west Parry Sound yesterday. They were describing to me a situation that arose out of Bill 101, which in and of itself is a prescriptive piece of legislation. The requirement is that each district establish a placement coordination service.

You should know that in west Parry Sound there is one long-term care facility with 103 beds. There are a couple of hospitals, but they're in one community: One of them is a chronic care hospital, the other is an acute hospital. So there are really only two facilities. That jurisdiction was required to establish a new office, a new placement coordination service, hire new staff to place people in the one facility that is there.

Now, granted there may be some benefit in helping people be placed outside of the jurisdiction, but I have to believe that if we had legislation that was more enabling, that gave a little bit more power to the existing players within the system, that improved communication, we could achieve a better result without having -- because we have provincial legislation that says, "Every jurisdiction will have a placement coordination service" -- we wouldn't have the problem that's developed in west Parry Sound. That's the point that I would make, one example, and there are others that I would use to illustrate "enabling" versus "prescriptive." We still need the service. There are better ways or different ways of doing it, ways that are more community-based.

The next question deals with symbols. The red cross and the red crescent are singularly probably the most visible symbols in the world for humanitarian organizations. Why did I volunteer for the Red Cross? I guess I volunteered because I was interested in a particular program stream, but because of what that organization stood for. While there are many people who will volunteer for whatever reason they have, I believe that the opportunity to volunteer for an organization that has a profile and a history, that has a record of service to our communities, that goes through generations, through a couple of wars, is something that we just can't say goodbye to in Ontario. I know Dan and I would take him to task for his suggestion that the symbols are meaningless these days.

The Acting Chair: Thank you very much. I wish we could carry on, but time does not permit.


The Acting Chair: Our next presenters will make a presentation on behalf of AIDS Action Now. Welcome to the committee. Please make yourselves comfortable and please introduce yourselves.

Ms Darien Taylor: On my right is Brent Southin and my name is Darien Taylor. We're both from AIDS Action Now, which is the community-based activist group which fights for equitable access to high-quality treatment and care for people living with HIV and AIDS.

Brent is a member of the provincial committee of AIDS Action Now, a social worker by training and was a counsellor at the AIDS Committee of Ottawa. I am currently a member of the steering committee of AIDS Action Now. I was formerly a co-chair of AIDS Action Now. I'm one of the founders of Voices of Positive Women, which is an organization for women living with HIV and AIDS, and I'm currently a board member of the Community AIDS Treatment Information Exchange.

Like the elderly, people with disabilities and other people with special needs, people living with HIV and AIDS are vitally interested in the current restructuring of the long-term care system in Ontario. We have long supported the overall goals of the long-term care reforms.

The development of a comprehensive network of community-based care and support services has the potential to more efficiently deliver the wide range of services which are needed by people living with HIV and AIDS; to provide more flexible and responsive levels and forms of care than are currently available; to facilitate a higher quality and more independent life for people living with HIV and AIDS in their own homes and their own communities; and, finally, to prevent unnecessary and expensive hospitalization.

To achieve this potential, home-based and community-based support services for people living with HIV and AIDS must be comprehensive, ensuring that the full array of health, psychosocial, domestic, social and other support services are available to meet our diverse and changing needs; flexible, that is, able to quickly respond to changing needs as the health of people living with HIV and AIDS fluctuates; and, finally, well integrated and well planned. At a community level, this means ensuring that services are well coordinated, that service providers are linked up with one another and that the full range of necessary services is equitably available to all who need them. At the individual level, the goal must be to empower people living with HIV and AIDS to be able to plan and manage their own support services.

Will the proposed reforms be able to achieve this potential? There are troubling indications that they may not be able to.

First of all, although there has been extensive and laudable consultation with other providers and consumers, there's been relatively little contact with the community of people living with HIV and AIDS. There also appears to be limited understanding within the government of the ways in which the natural history of HIV and AIDS and the rapidly changing treatments for this disease have significant implications for the kind of long-term care that we need.

Unlike many other consumers of long-term care services, the range of support and the intensity of care required by people living with HIV and AIDS typically fluctuates a great deal over the course of our individual illnesses.

Improved treatments have brought to us greater potential to live longer with higher-quality lives. This in turn has led to increasing numbers of people living with HIV and AIDS needing various levels of health care and assistance with daily living.

An increasing range of medical treatments and monitoring currently provided in hospital settings can effectively be provided in community or home settings.

In fact, it would appear that the only time that people living with HIV and AIDS have been mentioned in the ministry's various policy documents was in the August 1993 draft paper entitled Community-Based Services Provided by Multi-Service Agencies, and only here as people at the terminal stage of our illnesses.

Secondly, we have a number of significant concerns with the legislation's ability to ensure that access to care is equitable; that there is a full continuum of vital services made available; that the planned agencies will be able to respond quickly and effectively to the changing needs of people living with HIV and AIDS; that the restructured service delivery system can be effective while retaining the unique experience and perspectives of community-based groups; and, finally, that planning and resource allocation processes will be responsive and accountable to the communities they serve.

We detail these concerns and proposed changes to the legislation or government policy. Brent will begin with this.

Mr Brent Southin: I'm just going to put some background and people can read the recommendations that we give on their own.

As far as equitable access to care is concerned, we think the fundamental goals of these reforms and of the long-term care system must be equitable access to the full continuum of the services across the province. We are concerned with an apparent slippage in the language used to articulate the guiding principles of the reforms. The government's initial Redirection of Long-Term Care and Support Services in Ontario consultation paper was very clear that equitable access was a fundamental principle. However, by the 1993 Partnerships in Long-Term Care documents and the compendium to Bill 173 the government seemed simply to be talking about the availability of a specified range of services. Section 1(e) mentions promoting equitable access, but only through "consistent eligibility criteria and uniform rules and procedures." More effective administration is fine, but far more important is a serious government commitment to providing the resources and investment needed to ensure adequate levels of services.

A pervasive theme in this, and indeed in all current government reform initiatives, is the drive to cut costs. The compendium extols the advantages of using lower-cost workers rather than professionals for various services. There certainly are tasks for which less specialized personnel are more appropriate, but the restructuring of health care delivery has to be very carefully planned. Any redivision of labour must be done with extensive consultation with the workers involved and the unions that represent them, not by government fiat.


Similarly, the primary goal of any restructuring must be delivering the highest-quality and most responsive care, not just cost cutting. The only way this can be assured is to involve consumers in planning, something the government and local DHCs have not yet done. Were consumers to be involved, one factor we would emphasize would be that continuity of care must not be lost in the search for the lowest labour costs. The possibility of having to deal with dozens of different workers because they are cheaper replicates the fragmentation of the current system. We make some recommendations on that.

The system must have a comprehensive continuum of services. We are pleased to see that a continuum of care is one of the guiding principles of Bill 173. The problem here again is that the bill gives no sense of how this principle can be put into practice. A continuum of care means far more than the abstract list of services in the bill; it requires integrated and individualized packages of services which cover all individuals' care needs. How will the continuum of care required by consumers be identified? The only way is through consulting with people living with AIDS and HIV themselves on what they need, and with the front-line HIV service providers.

We have emphasized the broad range of services that people living with AIDS and HIV may need at different times and in different combinations throughout their illness. While the list in Bill 173 is fairly comprehensive, what if a particular service is not on it? Because additional services have to be approved by the minister, the system is cumbersome and slow at best. More ominously, the minister may refuse to recognize specific intensive care needs of people such as those living with HIV and AIDS, especially when they are expensive. If you think such concerns are overstated, remember that this is a government that has refused to put vital HIV-AIDS treatment drugs on the Ontario drug benefit program purely for cost reasons.

There is also a danger that the list of mandated services will come to be seen not as a minimum standard of what must be available but as a ceiling beyond which providers don't have to worry. Subsequent governments may use this power to list mandated services to cut costs or to create a two-tiered system of very basic mandated services, with more extensive services available commercially for those who can afford to purchase them.

The core services listed in Bill 173 are too general. For example, within the category of nursing services there is nothing to say that specialized services such as IV therapy in the home must be available to all people living with AIDS and HIV who need them. Similarly, the overall lists of services identified by the ministry may not be equally relevant in all communities or for all groups of consumers.

Can the MSAs deliver? Multiservice agencies are going to be the key means of delivering services. However, there is nothing in the legislation to indicate exactly how they will work. How will the number of MSAs needed in an area be established? What communities will they serve? Presumably this, and so many other facets of the long-term care reforms, will be worked out by the DHC and ministry planners.

We have a number of immediate concerns.

The government sees the proposed scheme as much more flexible than the current system. The policy framework paper in the Partnerships series notes that the existing maximum number of hours of service will be replaced by a dollar maximum for some services. However, there's no indication of which services or how much the maximum will be. A restrictive maximum could be a disaster for people who need intensive care for a period of time, such as those with AIDS.

The ministry intends to limit the proportion of services that an MSA may purchase, as opposed to directly providing, to 20%. Will this be a limitation on the scope and flexibility of service delivery? For example, MSAs with small HIV-positive populations may need to purchase specialized services. What if their 20% quota has been reached already? Would having to purchase intensive, and possibly expensive, services for people living with AIDS-HIV at advanced stages of illness reduce the availability of outside services for people with other pressing conditions? Or would they simply put such people with AIDS on waiting lists? Intolerable for people whose condition has deteriorated sharply.

The September 1993 Guidelines for the Establishment of Multi-Service Agencies would allow the purchase of 10% of services from commercial agencies. This does not seem to be mentioned in the current compendium. Has this option or restriction disappeared? We support the principle of publicly funded provision of health care and social services and we believe that profit imperatives tend to have adverse effects on the quality of care. None the less, there are areas in which the commercial agencies are excellent and sometimes the only providers of essential services such as palliative care for people living with AIDS and HIV.

The standard response is that commercial provision must be a spur for public providers to improve their services. We hope this will be the case, but in an era of severe cutbacks it is hard to be optimistic. Until it can be demonstrated that the public providers can ensure that the full continuum of care of people with AIDS is flexible and adequately available, then there must still be the option of using commercial agencies. MSAs can of course work to reduce the reliance on commercial providers, but arbitrary restriction must not harm the quality and flexibility of the services they can provide.

The system must be responsive. Eligibility and service planning must be geared to changing functional needs rather than rigid criteria, and amount of care allowed, agency jurisdictions etc must not be allowed to block access to needed programs or restrict the range of services provided. Unfortunately, none of this is clear in the legislation.

The confusion is particularly worrisome for people with AIDS. Over and above the need for chronic support, needs often fluctuate quickly and dramatically. This means that services have to be immediately available when needed and that providers have to be able to quickly restructure the care plan of a person living with AIDS or HIV when their condition changes. There can be no waiting list for vital services such as oxygen, IV therapy, specialized nursing, palliative care etc. If such services are not available as they are needed, it is too late.

Unfortunately, the government seems to accept that waiting lists will continue. But even then the bill gives no sense of how these waiting lists are to be prioritized. A person with end-stage kidney disease waiting for home dialysis or a person living with AIDS or HIV who needs IV drug therapy to prevent blindness are in very different situations from those waiting for friendly visiting. This of course is not to belittle the value of the latter type of service, but there needs to be a prioritization of those waiting in terms of medical urgency of their condition and the consequences to the consumer of delay.

Then we have a number of recommendations that you can read.

Consolidation of services: As in so many areas, how the government plans to consolidate service provision and agencies is not at all clear. How will agencies be consolidated into MSAs? How many? Who will decide?

We see the potential of simplifying access points and procedures and of increasing economies of scale and improved effectiveness, but unfortunately this direction is being driven primarily by cost pressures, not by the goal of improving services and support. How will the MSAs guarantee that they can retain, and indeed improve, the quality of care and responsiveness previously provided by community groups?

If all agencies are to be collapsed into MSAs, does this mean that the services will be subsumed to the lowest common denominator; that is, the types of chronic care services typically needed by the elderly? Will the more complex or unique needs of others suffer as a result?

For example, people living with AIDS-HIV have not generally had access to nursing homes and other long-term care facilities. Has this reflected prejudice or discrimination, insufficient resources or unwillingness on the part of some providers to deal with the needs of the people living with AIDS and HIV? Would there not be a danger of such problems of inability, unwillingness or discrimination also occurring in MSAs, especially in areas with small numbers of people living with AIDS and HIV?

This has been quite clear, as the majority of people with AIDS are still gay men and it was quite clear about the Legislature the hate towards that group of people. Government-legislated agencies, we feel, would not indeed take that into account. There's been a lot of work done with current community-based agencies and the home care program to reduce that discrimination, but we are quite worried that in a new set of circumstances that will have to start all over.

We're also worried about the funding envelopes. There's a recurrent problem with Bill 173: Much of its impact will not be clear until the regulations are drafted. There's no indication of how the funds will be allocated or how priorities will be established by MSAs and DHCs.

What will happen when the envelope runs out? Will this agency no longer be able to provide services? Will certain people be denied? What's going to happen? It's not clear to us.

We want these MSAs to be accountable. We believe that 50% of all the board should be consumers -- a minimum. We're hearing in the committee that one third might be, but it's not in the legislation and we do not trust the government to ensure that.


We have a recommendation that you might want to try: a specialized MSA for people with HIV and AIDS. In an area like Metro Toronto, there's a large number of people with HIV, approximately 8,000 who know at the moment.

The agency must offer a comprehensive array of services, both onsite and coordinated out of the agency. A full continuum of services must be equitably available to all who need them.

We believe that this could work as a way across Metro to ensure that people living with AIDS in Metro have the specialized care they need. We don't believe that -- this isn't out of the paper -- people can be ensured the services in local MSAs throughout Toronto. We don't believe that the funds will be there to have the specialized care needed.

Finally, I just want to conclude with the fact that we have a long history of a lack of health care for people living with AIDS and HIV in this province. We have had some improvements in the past few years, but we believe that if the specific needs of people living with HIV and AIDS are not taken into the MSAs, we will be back to stage 1, where we were 10 years ago when the disease started.

We have a prime example of the type of hatred that people living with AIDS and HIV have had forced on them in the health establishment by a number of health care providers and by the government bureaucracy, and we will not allow this to happen again. I take it that when this goes back for amendments, people will make sure that they have listened to people living with HIV and AIDS.

Mr O'Connor: I appreciate you coming before the committee and bringing your thoughts forward. I think there are times when we forget that the focus here needs to be on the consumer. Quite often, it's easier for us to focus on the service and the providers of the service and not on the needs of the consumer, the person who requires the service, and that they be met.

There are a number of areas that you have pointed to and I just thought maybe I'd like to go through some of them and point out what I think might be misconceptions or misunderstandings.

First of all, overall there has been a huge increase in spending by this government into the community side of long-term care. There's been a 54% increase. This year's amount of funding will be $850 million. Since 1991, when it was $550 million, that's quite an increase -- 54%. There is the intention to continue to meet the need and to put the dollars where that need is. Earlier on in your brief you had mentioned some of the problems you felt there.

Access to services: I think one of the important things that should be looked at is that we're not trying to develop something that prescribes everything that's going to happen as far as the delivery of service in certain locals throughout the province is concerned. We want to leave that planning to the local community so that the needs of the people living in that community -- we're hearing people say that it's a cookie cutter approach. We don't want to get that.

What we want to see happen is that the needs be developed within the community and that they work with the district health council and the envelope funding, and the funding that will needed for the services in the future will be directed from the district health council level so that we can see that those needs are met and that they continue to be met.

The basket of services, for lack of a better word -- and you mentioned on page 4 the whole basket of services -- is not meant to be an exclusive list. I think the problem that we have in legislation is that when we start to try to define every type of service that needs to be met, if we try to be as exclusive as we possibly can, then we end up excluding things. We're not trying to exclude a service that should be provided in any given community. What we're trying to do is create a minimum basket so that the minimum needs of a community are met. Not all communities have all those needs met today. We're trying to give them a basis of where to start from, and then the community will develop and evolve other areas. To do that without naming everything, we're going to have to limit some of what we put in there. The more you put into that list, the possibility of leaving something out becomes greater. I don't know; it's an unfortunate way and I guess that makes it rather difficult.

The Acting Chair: Mr O'Connor, you may want to allow the witnesses time to comment before I move on to Mrs Sullivan, because time is running here.

Mr Southin: The only comment I have about local MSAs, local DHCs deciding what's appropriate for their community is that in a number of areas there's a massive amount of discrimination against people living with AIDS. I believe if it's not in the legislation that certain services have to be provided, people living with AIDS will not receive them.

Mrs Sullivan: You raise a number of quite key and interesting points in your brief, and I think that we're all going to want to refer to it after as well. Two of the things that strike me immediately are, firstly, that the only guarantees in terms of people who will be receiving care that are included in the act are that the care will be provided (a) in as timely a fashion as possible and (b) that the people will be put on a waiting list. Those are the guarantees.

The rights that are included in the rights section of the bill are rights associated more with the method of approach to the patient -- that the patient will be treated with dignity and respect and courtesy, that the patient will have a right to information about service providers and so on.

I think that the issues you've raised with respect to the timeliness of services for AIDS patients are key, particularly where an MSA may not be able to provide those services and may have to cross borders.

Earlier in the week we had a presentation from the Baycrest Centre for Geriatric Care. Our party will be putting forward amendments with respect to satellite offices of MSAs to address cultural, ethnic and religious scenarios.

We are certainly going to want to think about some of the issues that you have raised that affect a disease-specific environment or a specialized care requirement. We will certainly work on amendments to that effect that we would like to present. I hope you will provide us with your advice on doing that. I don't have questions to ask, but I just wanted to provide notice that we'll be coming back to you for further advice.

Ms Taylor: The notion of community is partly where you get at this question. My understanding is that it's very geographically defined here and that by looking at other communities that you've suggested -- cultural, ethnocultural, communities related by disease -- you can begin to get at that.

Mr Jim Wilson: Mr Chairman, I know you don't want me to ask a question, because you're out of time, but if I could just comment, because I think Mrs Sullivan has hit on something that Mr Sterling and I were talking about during the presentation, and that is that you can't afford to be on waiting lists, what about a separate MSA, in this case disease-specific?

Ms Taylor: Disease-specific. We have proposals ready.

Mr Jim Wilson: We could work on amendments to that.

The Acting Chair: Thank you very much for a very interesting presentation.



The Acting Chair: Our next presentation will be made on behalf of the Canadian Association of Retired Persons. Welcome. Please give us your name before beginning with your presentation.

Mrs Lillian Morgenthau: Speaking is always such thirsty business. I think that the clerk was kind enough to do a copy of this brief.

The Acting Chair: Yes, members have been provided with a copy.

Mrs Morgenthau: So everybody can follow along as I carry on.

The Canadian Association of Retired Persons is a non-profit association open to all Canadians aged 50 and over, retired or not. Our membership is coast to coast and numbers close to 180,000 people, 90,000 of whom are in the Ontario part of Canada. In addition to making financial benefits available to members through various benefits, travel, insurance and other options, we act as advocates for mature Canadians before government and non-government bodies.

We have worked diligently to safeguard and promote the health and wellbeing of Canadians over the age of 50. We've been involved in numerous discussions with government and non-government agencies, in the areas of economic security, health care, drug availability, housing and related issues on behalf of our members.

CARP was one of the first to recognize the need to keep seniors in their homes with support services as long as possible. This would allow seniors to maintain their independence in their own homes. If needed, regular assistance in the home is, in our view, far superior to putting them into an institution. The consumer responds better and the cost is far less. If a move to a seniors' establishment becomes necessary, the wishes of the senior as to type, location, cultural resources etc should be paramount. Just as one type of accommodation will not suit every young person, older people in need of care should be allowed the same flexibility to choose where they live, within acceptable cost limits.

We are concerned that the human needs facing us not be subjugated to the preconceived need for efficiency and cost subject to consultation with family and physician. We feel that the consultation of family and the physician are not really spelled out in this particular Bill 173.

If MSAs are established, we ask that their role be specifically limited to the provision of all of the information seniors might need to make their own judgements about their ongoing care.

It is our understanding that this bill originally was to be a bill where information would be given and the consumers would have the choice of where or what or how they would go on in their lives. Since the inception of this bill, it has been broadened to many, many other areas, and we're not in accordance with all the things that are being put into this bill.

Over the past several years a great deal of thought and effort has gone into reforming the organization and delivery of long-term care in Ontario. Bill 173, in its first reading, forms part of this work.

Let's examine some of the underlying assumptions of the reform. An ever-expanding proportion of the population reaches age 65. We have over three million Canadians who are over the age of 65. Planning now has to anticipate the arrival at the battered gates of the system of the parents of the baby-boomers, followed soon thereafter by the boomers themselves. There are 7.1 million people soon to approach the age of 50; over three million are over the age of 50 already. Although far healthier than any generation before them, this age wave carries with it the effects of long-term survival of chronic but carefully managed illnesses and conditions, as well as the emergence of diseases which are not caused by aging but are seen more commonly in the elderly: chronic lung and heart ailments, mobility disorders and many others.

The capacity of families to care for their aging parents is being stretched to the limit, entire cultures and traditions are being tested for respect of the old and the willingness to endure hardships in looking after members of families who are ever more frail and vulnerable, while the care givers themselves are confronting middle age and domestic stress and discord. This group is commonly called the "sandwich" generation, and rightly so.

Unspoken but easily recognized are agendas of institutions, professional pride and turf battles, as well as fundamental beliefs about the proper role of the state in matters of personal choices, autonomy, beneficence, dependence and self-reliance.

The structures proposed here are by nature legalistic, dealing with the awesome powers of the minister, agencies and multiservice agencies. A little power is a dangerous thing; a lot of power becomes more dangerous. Implicit in all of this is a centralized model which strongly believes that all elderly clients, consumers or persons are constantly in danger of being victimized by unscrupulous for-profit service providers unless a benevolent case manager looks out for them. Accordingly, each of these seniors and disabled adults needs a plan of service without which they would go astray in the maze of competing organizations.

"One-stop access" is another buzzword, implying that without it seniors and their hapless care givers would not know what to do. Oddly enough, the same seniors managed to figure out the Income Tax Act, the stock market, even the ins and outs of a mortgage. What one-stop access will create in this scheme is at least one more layer of bureaucracy, of which we have too much already. One out of every four Canadians work for the government. We can't really afford to have more than that. We can't even afford that, and the taxpayers are not willing to pay for it. Our present fiscal position has made it clear that we no longer can afford additional layers of bureaucracy. Our citizens have made it clear that we are no longer prepared to pay for additional layers of bureaucracy.

One aspect of the proposed legislation that is certain to boost costs is the intentional attack on private sector providers. It is doubtful that the average Ontario senior wishes to endorse a monolithic bureaucracy, having witnessed the collapse of such structures in central and eastern Europe in the past five years. Such moves do not reflect any mandate from the electorate.

This organization, CARP, agrees with the principle of dividing services into four categories listed in the act. Some areas tend to overlap, and this is far from being undesirable, but they could present economies for the system. For example, if personal care services were provided in the setting of an adult day program, these resources could be used more efficiently. If a senior attending a day program could get a bath and even toenails trimmed, this would surely be cheaper than sending out someone to the senior's home to do the same thing. Probably you'd have to send two people, because anyone doing toenails won't give them a bath. So here we are with two going when one service could be done at a simple place.

A puzzling part of the divisions created is the separation of the homemaking services from personal hygiene when in fact the independent homemaking program, a highly effective means of offloading home care cases, was based on this premise. The same homemaker who is authorized to change diapers under the heading of caring for children would not be allowed to do so for a senior who has chronic incontinence. Similarly, routine personal activities of living can easily encompass virtually all of the items on the homemaking list, yet it is under personal support services. These designations have major funding implications, as we will later find out.


Conspicuously absent in the entire plan is the family physician who has established a long-term relationship with both the senior and the family. Assessment functions appear to be limited to the person's needs, implying that without proper medical diagnosis and treatment of the multitude of conditions afflicting the old the MSA can determine the true need pattern. For example, an older individual may have a problem with incontinence, without finding out the cause and treating anything from a bladder infection, constipation, a mobility disorder ranging from arthritis to a broken hip, an antihistamine-induced drowsiness or a brain tumour. An MSA delivering adult incontinence products and a nurse to apply them would end up wasting resources by throwing services at a person rather than finding a solution to the problem. Without the medical diagnostic and treatment effort, the same person may even end up in a long-term facility, using even more resources and living in a place not to their liking.

It is this organization's opinion that as currently envisaged MSAs would represent an additional level of administration and bureaucracy. We do not believe that MSAs should be both the administrators of the system and the service providers. This would give MSAs an effective monopoly, which is not in the interests of the citizens who may require services. Our concern is that an unhappy senior citizen will neither be able to change to another service provider nor effectively complain about the services rendered by an MSA. If the MSA is the only service provider, people will require a great deal of courage to complain to them about the quality of their service.

Although the concept of accountability is crucial, the phrase "competence, honesty, integrity and concern for the health, safety and wellbeing of the persons receiving the service" may well create demands on any organization, placing the burden of proof on them, documentation and generation of spurious information adding to the flurry of paper activity and enlarging administrative overheads. If our math doesn't fail us, such costs may well represent up to 20% of the agencies' budget.

We are not certain from reading the act what the difference is between an "agency" and an "approved agency," but judging from wording one suspects that the agenda of eliminating for-profit organizations from the field surfaces yet again, infringing on the availability of choice for consumers. As previously stated, some of the distinctions between chargeable services -- those listed under the community and homemaking heading -- and non-chargeable items -- under personal and professional support services -- may well be artificial and costly. Imaginative matching of needs through multiskilling and multitasking would be inhibited, flexibility of service providers reduced and, in a worst-case scenario, actual turf wars may erupt; eg, one cuts toenails but not fingernails. This is today because the chiropodists are currently instructed that they cannot cut fingernails as well as toenails. I mean, it's unbelievable.

Most importantly, competition must cease to be a dirty word if we want the system to deliver more bang for the loonie.

CARP feels that any person asking for help or information would find the MSAs would respond with literally, "My way or wait in line," and would not give options and alternatives in the private sector. This is unsatisfactory in every way. All options must be presented and the choice made by the senior, his doctor or his family.

This organization strongly supports the concept of aging in place, delivering services to seniors instead of warehousing them for the convenience of the system. The flip side of the coin needs to be kept in mind as well: There must be sufficient room in the long-term facilities, with appropriate staffing and funding, so that they are available before an untenable care-giving situation victimizes the women currently looking after the frail elderly to the point that daughters are forced to choose between marital breakdown or admitting their ailing relative to a facility.

We all know about the people who are caught in that. I don't think there is one person in this room who doesn't know of a family that has been caught in that particular situation. It can be devastating to a young family and to an older family. I think this is one thing we should really look at very seriously. These reforms are long on regulations and policies but, so far, short on caring and compassion.

A major corollary to aging in place is a future planning and funding implication that by keeping the elderly in a community longer their care needs and requirements will be higher when and if they finally enter long-term care facilities. Their medical state will also be more precarious and therefore they will need more monitoring from the attendant physician looking after them in the nursing homes and homes for the aged.

Current funding levels are becoming woefully inadequate, and the level of stress experienced by health care professionals does not bode well for our preparedness to properly look after the frail elderly.

No government in Canada would wish to be blamed for causing suffering to helpless thousands and even for the untimely demise of those so far cared for so well. The effective downfunding of long-term care facilities under the phony slogan of equity must end.

In order to guarantee appropriate assessments of seniors asking for service, heightened emphasis needs to be placed on geriatric medical consultations with the express goal of identifying treatable causes of disability, followed by interventions to maximize seniors' function through rehabilitation. This concept is missing from all foundation documents, yet the greatest efficiencies could only result from achieving and maintaining the general health of the current and future generations of seniors.

CARP proposes a system that is less bureaucratic and monolithic, allowing seniors and their families to obtain advice but without losing the right to choose how they wish to live, whom they wish to entrust with their care and freedom to determine their own future. There is a need for a much smaller endeavour that assists those who can't advocate for themselves, those the act designates as "apparently incapable persons." However, in those circumstances the concept of autonomy must be balanced by that of compassion, a goal unfortunately not achieved in the Substitute Decisions Act of 1992.


The elimination of many service providers, such as the Victorian Order of Nurses, Meals on Wheels and the Red Cross -- those are the kinds of organizations that we have to look at -- and many others will result in a loss of service of many of the volunteers who make these services possible. We would like the assurance that the existing volunteer base be preserved, for without it service will not be delivered. The expertise in delivery of service built up over many years, the intimate cultural knowledge of providers must not be lost in a restructuring of the system.

We do not understand why this government, which has insisted on giving disabled people the opportunity to choose from a variety of services for their care, should insist that older people may not choose from the options available for their care.

We have heard horror stories about elderly people being sent home from hospital without adequate care. We are fearful that there may be dangerous gaps in service in any changeover from one system to another.

We urge you to welcome the "inside" information and suggestions offered by those who now or will before too long be consumers of the services under discussion or who have been dealing with the problems as they exist today.

I thank you for the opportunity to appear before these hearings. We would be happy to continue the dialogue established at this forum and will be available for future and further consultation.

The Acting Chair: Thank you very much. We have about 10 minutes for questions. Each of the parties wishes to place a question. We'll start with Mrs Carter.

Mr Jim Wilson: Mr Chairman, wouldn't it be my turn? I didn't really get a question last time.

The Acting Chair: No, I'll stay with Mrs Carter.

Mrs Morgenthau: You're in tough shape.

Ms Carter: Well, we missed one round. Thank you. I certainly agree strongly with you that the objective is to keep people at home so that they can age in place. That is one of the objectives of the act. Certainly, it is an objective of the act too that the person's needs and preferences are of the greatest importance. In other words, nothing is going to be forced on to a consumer.

But I have to say that I think on page 4 of your presentation there are quite a few misapprehensions. You say that the structures proposed here are "legalistic," "a centralized model," and that somehow people are going to be taken over by administration. I think that's very far from what we're actually proposing here. The organization is going to be localized and it's going to be community-driven. It is not a bureaucracy. We're not imposing bureaucracy here. If anything, we're doing away with it. For example, in Metro at the moment there's only one big organization that deals with home care. Under the proposed multiservice agencies, there would be 15 to 20, so we're not making it more massive, we're breaking it down.

Mrs Morgenthau: That is probably the concept that we're fantasizing. In reality and in practicality, that will not occur. Let's take the MSAs; I think there are about 12 of them proposed for Toronto alone. At this point in time, when there is a chronic care patient, say, at a hospital and they want to get a chronic bed outside the hospital because the hospital is not prepared, really, to take care of chronic care patients, there is usually one person whose duty it is to find a bed. When you have one central area to which you now have to go, from hospital, from home, from anywhere else and find a bed for a patient -- we do not have that kind of facility.

Our feeling is that the cart has been put before the horse, that we're not ready for this kind of Bill 173 and that we should be doing more to get ready before the MSAs. If you phone the MSAs and say you need a bed, they'll say, "Fine, where do you want it?" and they will try. But at this point, if there isn't a bed available, they will not say: "You have other options. There are not-for-profit organizations. Would you like to try some other area?" It's either that or get in line, and it's going to be a long line.

The Acting Chair: Thank you. We'll move on to Mrs Sullivan, please.

Mrs Sullivan: Thank you very much. With respect to your brief --

Mrs Morgenthau: Why don't you let Mr Wilson handle it? The poor guy's been trying for hours to get in.

Mrs Sullivan: I'm not going to let him on.

Mr Jim Wilson: I'm looking for a sympathy vote.

Mrs Morgenthau: Are you bowing to the lady?

Mrs Sullivan: I have the right of the Chair to speak.

First of all, we concur that a clinical assessment of the medical and other physical needs of the person who's involved in long-term care is absolutely required. Certainly the evidence that's before the committee has been that about 90% of individuals who seek some long-term care services have an acute or a chronic trace with respect to the need for those services. So the medical intervention that you've talked about, the medical assessment, we see as very much a part of that. Whether that's coordinated through the MSA or whether there is a working relationship with the family doctor, we feel it is very much a part.

You have mentioned, as have a couple of other groups, the difficulties with the separation of those services for which there will be fees and those services for which there won't be fees.

One of the other groups indicated to the committee that it felt that the individual who was receiving the services was going to have an additional burden of accounting for the kinds of services that were offered because they may well be offered by the same individual. One person, for instance, may provide personal care such as bathing and assistance with dressing but may also be doing other things with the individual who's receiving the care, with the client.

How do you think that those fees are going to be tracked, and is it kind of a nimble myth anyhow that the chargebacks will be accurate? Because there are chargebacks for basically non-health-related services that are accounted for in this bill.

Mrs Morgenthau: How are they done now, Barbara?

Mrs Sullivan: Well, you see, they're delivered by quite separate vehicles.

Mrs Morgenthau: Perhaps we need those vehicles. If we continue with this and the MSAs are going to take on and absorb, say, Meals on Wheels and everything else that is already in place and well done, very well done, taken over by an administration that has really got to learn how to do this kind of thing, we're going to find that many, many seniors are going to be left at the gate.

The thing that bothers us very much is that, especially with seniors, they know certain organizations and certain community groupings, such as the Red Cross, the VON, the Meals on Wheels, have a lot of things in place already that they know about. If they get absorbed with the MSA, they won't know how to get there.

The MSAs as well, as far as we were concerned, were supposed to be an area of information, telling people how to get what they want, where it's available and to help them get it, but not to be the centralized area that they're talking about now where actually you're going to be at the mercy of whether or not they have a person there who can accommodate you.

My fear, and I think our fear, is that the boomers are coming up, that there are so many aged people who are going to need services. If we don't have the services out there to accommodate them, then it's going to be chaos and the money is not going to do it. We don't have enough money to accommodate them. We need to have services in place that are still there and the MSAs should have the information for it.

There is no way that an MSA is going to place a person who is in a home and has Alzheimer's and all of a sudden is in desperate need of a bed. They're not going to place someone from a hospital or some other spot as quickly or even think about it. They're going to be forced to put that person into a protective environment, whether it's a protective environment that's suitable or that isn't suitable. They can put someone from North Bay into Barrie, away from all their facilities, because there happens to be a bed there.

This is practicality and this is reality. We can have the most wonderful intentions as far as legislation is concerned, but putting it into practical ways and means is another story.

Ms Carter: But we're spending money --

Mrs Morgenthau: No, the money isn't going to do it. It's not enough; it will never be enough.


The Acting Chair: Mr Wilson's been very patient. I want to give him the opportunity to round up this session of questions or to begin the next one.


Mrs Morgenthau: No, it'll spend more.

Ms Carter: You'll see.

Mrs Morgenthau: A difference of opinion, but our research says you're going to find the costs are going to skyrocket.

Mr Jim Wilson: Exactly on that point, Mrs Morgenthau, I want to thank you for your presentation because it's full of an abundance of common sense. I suspect that when the government tells people, retired persons such as yourselves and your organization --

Mrs Morgenthau: I'm not retired; I'm working harder now than ever.

Mr Jim Wilson: Sorry, I'm just looking at the name of your association, the Canadian Association of Retired Persons. I am reading the right brief here, am I?

Mrs Morgenthau: Yes, but that retired person is a falsity.

Mr Jim Wilson: Busier than ever.

Mrs Morgenthau: It's a falsity, let me tell you.

Mr Jim Wilson: We realize that because often in political campaigns we like to call upon retired persons and we do find out that once they retire they're busier than they ever were. They're very busy volunteering for all kinds of things.

Mrs Morgenthau: That's why we mustn't throw them out the window.

Mr Jim Wilson: Exactly, and I think we should listen to them. I think that when the government accuses you of having misapprehensions --

Mrs Morgenthau: Do you think they hired me? No, they didn't. Let me say one thing.

Mr Jim Wilson: Sure.

Mrs Morgenthau: Then you can continue.

Mr Jim Wilson: I think I'll probably -- it's your presentation, Mrs Morgenthau.

Mrs Morgenthau: Look, CARP does not take any funding from the government. The views that are being expressed are very neutral and are the views of our members. We get approximately 100 letters a day. Out of these letters come the views and the opinions of people all across Canada, not only Ontario. What I'm bringing to you is not the way I think; it's the way they think.

The Acting Chair: Thank you very much. We appreciate that. A very candid presentation.

Mrs Morgenthau: I'm sorry, Mr Wilson, I cut you off. Did you want me --

The Acting Chair: Our time has elapsed, I'm sorry.

Mr Jim Wilson: A very eloquent summary, and we'll just leave it at that.

Mrs Morgenthau: My number at the office is 363-8748. You can get me any time. Anybody who's over 50 should be a member of CARP. It was a pleasure. Thank you very much for having me.

The Acting Chair: The pleasure was all ours. Thank you.


The Acting Chair: If I could call upon the representatives for the Federation of Ontario Facility Liaison Groups, welcome to the committee. Please make yourselves comfortable.

Ms Janet Allingham: It will just take a second to pour a glass of water.

The Acting Chair: By all means. Before beginning, I ask that you please provide us with your names.

Ms Allingham: Janet Allingham.

Ms Margaret Gorman: Margaret Gorman.

Ms Allingham: Are we all set?

The Acting Chair: Yes, we're all set. Please begin.

Ms Allingham: Ladies and gentlemen, Margaret and I represent the Federation of Ontario Facility Liaison Groups, which is an umbrella organization of representatives of parent organizations for provincial schedule I and II facilities for developmentally disabled persons.

We appreciate the opportunity to appear before this committee. Long-term care is often considered a need for the elderly. Actually, our developmentally disabled persons spend a much longer period of their lives in long-term care.

Bill 173, in part, states the intent to provide government services for people in their homes, in the community and other community settings as alternatives to institutional care. This is an area in which we have great interest. The basic options presently for our developmentally disabled people are family homes which are foster homes. This, to us, is totally unacceptable. It gives our people very little chance to have association with peer groups and is virtually impossible to monitor.

The other common option is a group home in a community setting, three to five people in a particular house in a residential area. Again, developmentally handicapped people, like the rest of us, do not necessarily choose their friends from the people with whom they are billeted. They need to be part of a larger group where they can have a true choice. Like other members of society, they need to have a choice of living opportunities.

When clients go through the trauma of leaving a provincial centre which has been their home for many years, the result should be improved living conditions, not a change of address and certainly not lesser conditions. Our people are extremely handicapped. A few statistics:

From Huronia Regional Centre, which is my home centre, 43.5% of our people have a profound degree of mental disability. Medical term? Mental retardation. Also, 35% have a severe degree. Those remaining have a similar condition to a lesser degree. Along with this are the complicating disorders that these people have: 54%, seizures; 40%, visual impairments; hearing impairments, 31%; physical disabilities, 21%; 17% have dual diagnoses. A substantial number have to be fed, some by gastrostomy.

At Rideau Regional Centre at Smiths Falls: 64.7%, profound mental retardation; 21%, severe. Thus in Rideau Regional Centre a total of 85.8% of the residents have either severe or profound mental retardation. The other complicating factors are similar to those in Orillia. These figures reflect conditions found in most other provincial centres.

When planning for the care of the developmentally disabled, we must consider the wide range of disabilities. If we were caring for people with broken bones, society would have no problem understanding that different care is required for a broken arm than for a broken back.

Our people are very vulnerable. We do hope that plans made on their behalf do give their wellbeing top priority. Parents have often been told that buildings on provincial centre lands are too expensive to operate and to modernize. A few observations:

Parents at Bluewater Centre in Goderich were very upset to learn that after it was taken over by corrections, it had to be fitted with air-conditioning before the young offenders could move in. This was not done for the developmentally handicapped.

At Oxford Regional Centre at Woodstock, this past year I received notice that there would be one of the cottages closing a little earlier than had been anticipated, the reason being there were jobs for the staff in other sectors of society. Some of the clients would be inconvenienced. Now, I do not blame the administration at Oxford centre for this, but I do question a system that would require such a decision to have to be made.

Huronia Regional Centre at Orillia: The Attorney General's office has decided to take over one of the oldest buildings 18 months earlier than was planned. This building will be gutted and refitted for the Attorney General's office. Apparently, these buildings are useful after all.

In the case of Orillia I'll have to be fair. Some of these areas have been refitted for very nice apartments for six to eight clients: special kitchens, special bathrooms, the whole bit. They're very attractive. Parents are very anxious to get their person into these new apartments.

The federation is quite aware that over the past years there have indeed been improvements made for the severely developmentally handicapped. However, unfortunately, there are those placements that have been unsuccessful when both clients and parents have suffered much grief through inadequate placement policies. We believe it is time to review what has happened, what has been successful, what has not. Plans have been under way for 20 years. The world has changed a lot in 20 years. It's now time to rethink some of our plans.


Our federation has long been concerned that major plans for the severely developmentally handicapped were made without the benefit of reliable research data and test projects. I will briefly mention three such sources of information that we happen to be aware of.

In England, a research section was done at Kent University on cost-benefits and successes and failures of moving clients from institutions, or hospitals as they call them, to the community. It was initially determined in England that 10% of the clients in these hospitals could not go to the community; they couldn't cope with it. After the process was under way, they found that another 5% had to be returned to congregate care.

Next, Dr Bruce McCreary at Queen's University has done considerable research on quality of life for the developmentally handicapped. We have yet to see adequate acknowledgement of this work by the Ministry of Community and Social Services and its application to our clients.

Next, Dr Ben Goldberg, University of Western Ontario, has done an extensive study of community health issues in southwestern Ontario. Dr Goldberg's findings so adequately and clearly reflect our concerns that I have included a copy of Dr Goldberg's report at the end of this brief.

Time does not permit me to do justice to Dr Goldberg's report, but a few points: Physicians require more training in care of the developmentally handicapped; difficulties in getting records; sexual issues; medication issues; concerns that clients cannot just assume decision-making rights without concomitant responsibility; in many areas mental health clinics do not welcome the dual-diagnosis clients -- these clinics feel that the clients are being dumped on them; a need for more residential resources.

Recommendations: We feel that the policy of total deinstitutionalization should be reviewed. Any policy, no matter how good, if taken to extreme, can lose its value and in fact even become harmful. In the great push for deinstitutionalization, families in the community with aging parents have been denied placements because these placements in the community were given to clients from the centres. This has caused much grief and resentment in community parents, and institutional parents are often worried as to when their person will be put out. Services in the centre should not be lessened while there are clients there and overcrowding in the centres is unacceptable for any reason.

Next, we feel that congregate care should very seriously be considered in this bill. At the end of this brief I have some comments by a therapist, David Hingsburger, who has some very interesting and informative comments on this subject.

The advantages of congregate care for these people: They could live in campus-like cottages or apartments of four to six, those who are mobile could move about freely and safely and not always have to depend on transportation, they could have central services of needed professionals -- medical, nutritional -- they could choose from activities either in their own community or the general community and they could be, to some extent, protected from the stresses of the community. After all, some of these people came to the institution because they could not cope with the stresses of the general community.

Such an idea would be a bonus to the taxpayer: More economical use of specialized professionals, less transportation costs and, ladies and gentlemen, consider the cost of buying a house in the general community to house three to five persons. Then, after you've bought it, you refit it for the developmentally disabled: special kitchens, special bathrooms with lifts, ramps and, if it's got more than one storey, elevators, and individual maintenance.

Individual communities are becoming very popular. In recent years developers have been very busy providing these for seniors. They provide residential, recreational and sometimes extended health facilities. Why should this lifestyle be denied to the developmentally disabled?

Next, developmentally disabled persons often live long lives. There should definitely be geriatric and nursing home plans made for them, the same as for the general population.

Some conclusions: Our federation requests that developmentally disabled persons be protected under Bill 173 and other government long-term care initiatives. We agree that services have to be available in the community, but we also request that these services include some congregate care. Let us allow the developmentally disabled to have communities that are truly theirs, where they can live in dignity, enjoy the pleasures they like, with the opportunity to move safely and freely about as well as benefit from professional services.

Our people are very vulnerable. They need recognition from all levels of government, especially the ministries of Citizenship, Health and MCSS.

The federation has also compiled a task force report on the study of future placements of residents moving from Rideau Regional Centre to Ottawa-Carleton. This report was compiled in cooperation with the federation, the Ottawa MCSS and Rideau Regional Centre. It offers a possible congregate care model. It was submitted to MCSS for consideration in December 1993. We would like to have discussion on this report. Although we have repeatedly asked for a meeting for this discussion, it is with surprise and deep disappointment I have to report to you that we are still waiting for this meeting. Hopefully it will soon be granted.

Once again, I thank this committee for the opportunity to appear here and I ask for your support for our severely developmentally disabled persons. There are some inclusions to this brief that I believe are informative and hopefully will be helpful.

Mr Gary Malkowski (York East): Thank you for your presentation. I'm sure that the information in there will help us understand the issues of the developmentally disabled, and you're right that we do need to recognize the range of residential placements right from institutions to community.

I'd just like to ask you something for clarification. The MSAs in the community, would you like to see institutional or congregate living included as one of the options under an MSA?

Ms Allingham: Yes, definitely. It is an option. People should have a choice. As Mr Hingsburger on the last of this report said, this issue is not about segregation, but about choice.

Mr Malkowski: Could you tell me the percentage of the severely developmentally disabled who are being looked after by their aging parents?

Ms Allingham: I'm sorry, I do not have that. I could get that for you, if you would like.

Mr Malkowski: Do you have any idea of what the statistics would be in Ontario of severe and profound?

Ms Allingham: The last figures that I heard on how many were, there was supposed to be approximately a waiting list of 2,500 to 3,000 people, developmentally handicapped, in their own homes in Metro.


Mrs O'Neill: Thank you so much for coming. I think you continue to be a wonderful advocate on behalf of those who cannot always speak for themselves.

Ms Allingham: Thank you.

Mrs O'Neill: I particularly want to take note of the document that you mentioned, the task force document. I have read that. It is an excellent document. I think it should be tabled.

As you likely know, the lead minister in this issue, Bill 173, is the Minister of Health. I am very sorry that you have to report that Mr Silipo has not met with you, but I think you should send this to Ms Grier because I think that anybody who is dealing with Bill 173 should read that task force report, because it is community based, it certainly has to tie in with Bill 173.

Ms Allingham: Mrs O'Neill, I have sent it Mrs Grier.

Mrs O'Neill: Good.

Ms Allingham: And to Citizenship, Education and to Mr Charlton's office.

Mrs O'Neill: I hope you will get responses, and I hope you will follow up with Ms Grier, in particular because of its relevance to Bill 173.

Although it's such a sad tale, I'm glad you have brought to the Legislature the story of the three disabled people in my riding in Nepean. I feel that was a tragedy that should have been somehow discovered. There seemed to be some people involved in it; whether an MSA under Bill 173 can do that, or would even think of doing that, or be equipped to do it, I don't know.

I wonder if you could tell me how you feel Bill 173 could be helpful to you. I think we've heard from several, and you're one of them, that choice is one of the things that seems to be in jeopardy here.

Ms Allingham: Yes.

Mrs O'Neill: If you had one or two things you could tell us about Bill 173 and how it affects those you speak for that you would put in this bill, we'd like to hear that.

Ms Allingham: I guess my first choice, and major choice, is that the bill include some form of congregate care for our developmentally disabled persons. We are not interested only in maintaining these people, but these people do socialize among themselves, and they should be able to compete. If you can't compete at your own level and you can't experience some success, life is not very pleasant. I think there has been an assumption that they want to be out in the "community." What about a community for them? Does that clarify what you are asking, Ms O'Neill?

Mrs O'Neill: Yes, and I think that what you're saying is that in the communities where the MSAs are going to be established, these congregate groups have to be considered as part of the care pattern.

Ms Allingham: Thank you very much.

The Acting Chair: We have a bit of time remaining, if Mr Sterling has a question.

Mr Sterling: I want to tell you, I'm a tremendous supporter of Marg Paproski and her group --

Ms Allingham:: There's a section in Ottawa, I think.

Mr Sterling: Yes, her group and the Rideau Regional Centre. I think it's a shame what my government did, what the Liberal government did and what this government did in the deinstitutionalization of many, many of our mentally handicapped, developmentally disadvantaged people. We have put people on the streets, washed our hands of them as a government and walked away from them. I think it's a shame that in this whole thrust towards deinstitutionalization, we have lost sight of many, many disadvantaged people like the three in Nepean, who have just fallen between the cracks. There are people from Rideau Regional Centre who have just fallen off the face of the earth. Nobody knows where they are. They can't trace them. Presumably they have either died or somebody is taking advantage of those individuals.

What I'd like to see put forward, and perhaps maybe the Ministry of Health can put this under the MSAs, I don't know if it's possible, whether this bill is structured as such, is that every time an individual is deinstitutionalized, that the MSA becomes responsible for that individual, has the legal responsibility for that individual and that it becomes retroactive for every individual who has been deinstitutionalized from any institution in this province. Because then and only then, will we see proper care for these people, either in the community or in some cases, perhaps it will bring some sanity back to this equation and some of them will be readmitted to some of these very, very fine residences. I don't call them institutions.

Ms Allingham: Not any more.

Mr Sterling: I call them homes and residences. I want to tell you, you've got a great ally in myself --

Ms Allingham: We know.

Mr Sterling: -- in terms of your stance on this issue and I only wish that more of my colleagues would pay attention to both sides of the debate in this issue.

Ms Gorman: I wish so too.

Ms Allingham: May I add one thing here? When I was president of the Huronia Regional parents' groupShe was president of Huronia Helpers, a parent group at Huronia Regional Hospital. I asked to be able to track where some of our people went. You know, I want to go and see. I am told: "Oh, we can't tell you. That's confidential information."

Mrs O'Neill: I get the same answer.

Ms Allingham: But I have frequented the streets -- without giving the wrong impression -- the malls and the restaurants in Barrie and Orillia, and if you listen to what's on the street, I'll tell you, you'll get a lot of stories of what's happening to these people, and, as Mr Sterling said, it's sad.


The Acting Chair: Our next presenters are representatives of the Family Association for Mental Health in Etobicoke. Welcome to the committee. I understand that you don't have a written brief for committee members but that we'll be making copies for distribution later?

Ms Judy Wallace: Yes, I will.

The Acting Chair: All right, thank you.

Ms Wallace: I apologize for that. This unfortunately caught me at the last minute.

The Acting Chair: That's no problem. Please give us your name before beginning.

Ms Wallace: My name is Judy Wallace. I'm the coordinator of FAME, which is the Family Association for Mental Health in Etobicoke. I recognize some faces from other legislative committees. Our role in Etobicoke is to work with families in which someone experiences a serious mental illness. I would like to say thank you, first of all, for the opportunity to speak about this piece of legislation; it is very important.

As you are all aware, the care and maintenance of the elderly in our society is a growing need, especially as we all get older. However, I'd like to address my remarks to an aspect of long-term care that I feel has been left out of your consideration, that of the elderly providing care either for another senior or for adult children. I would ask if you have considered the community services and supports that would assist those senior and handicapped care givers to provide that care over as long a term as possible. Have you considered improving the quality of services so that senior and handicapped care givers' health concerns are also a factor? Are the needs and preferences of care givers regarding management and delivery of community services taken into account when planning services?

Much of this legislation is designed to delay the time that an individual will require institutional care. Maintaining the health of the care giver is one of the most important means of ensuring that longer-term community care is available. You want to encourage local community involvement in planning, coordinating, integrating, managing and delivering community services, but how and by whom? Will those needing care and those providing care in the community be partners at those planning tables?

I would hope that all sectors of the community are invited and mandated to participate, as has begun in mental health. Those who are health care professionals, paraprofessionals, elderly requiring care, families who are providing care, elderly who are providing care and other senior support services should be around any planning table.

The bill of rights in part III outlines a comprehensive set of entrenched rights for those receiving care. I would ask how those seniors and handicapped who are also providing care would be covered under this section. It's equally important that the care giver be treated with respect and courtesy, that his or her privacy be respected and his or her culture respected. Care givers also need to know who is coming into their home to perform what tasks to whom and to whom these people are accountable.

Many care givers are providing 24-hour care for a spouse or adult child. In many instances, the shifted role to care giver changes the marriage relationship. It puts the care-giver spouse in a parental role. Respect must be given to that spouse for his or her grieving over the death of that marriage.

Community support services must be sensitive to which activities the spouses wish to keep between themselves and which need the intervention of a professional. For instance, one family affiliated with FAME was facing the problems of advanced arthritis and late-onset schizophrenia in the wife. The couple had maintained a traditional marriage relationship for their ages, they were in their mid-70s, and culture, they were from southern Europe. When the wife had difficulty feeding herself, the husband, as care giver, felt it was his role to cook for and feed his wife. However, when the wife became unable to look after her personal care, neither one was comfortable having the husband provide that kind of care. Mrs C stated that in 52 years of marriage her husband had never seen her naked, and even though she was sick and crazy, he wasn't going to see her now.


Unfortunately, because Mr and Mrs C only wanted one service, no agency was prepared to provide it. Mr C was required to find someone privately to bathe, groom and dress his wife. That left him at the mercies of the marketplace with no protection from bad service. Because of the additional strain of trying to find, keep and pay for a series of personal care attendants, Mr C collapsed from nervous exhaustion and was himself hospitalized. At that juncture, Mrs C had to be placed in institutional care, a situation both husband and wife had wanted to avoid.

What would've helped? Recognition that when two seniors are involved in a care giving and receiving situation that greater flexibility and sensitivity is required. Services need to recognize the relationship between the two people and support their mutual needs.

In another instance an elderly mother, Mrs W, is providing care for her 45-year-old daughter who suffers from a serious mental illness. Because mother's handicap is visible while daughter's is not, only mother is eligible to travel on Wheel-Trans, so that the two of them are not able to go out together. A symptom of the daughter's illness is isolation so she will not go out of the house alone and her mother's unable to go with her.

So the two women are alone in a house together 24 hours a day, seven days a week. What will happen to daughter when mother is no longer able to provide care? Will all her years of devoted care produce an instant street person because she has become either institutionalized or has died?

Mrs Y has expressed concerns that there doesn't seem to be any help for her situation. At 79, she's providing care for twin daughters who have dual diagnosis of developmental delay and mental illness. She says that 40 years on her knees as a cleaning lady has given her severe arthritis. She also has difficulty with her vision and breathing. She's worried about her own health and the long-term needs of her daughters, but can't find a workable solution. What should she do?

I could go on and on with examples of care givers whose needs as elderly, disabled and ill are ignored, but I hope this makes my point.

You speak about multiservice agencies. There is an organization in south Etobicoke that is designated as a multiservice agency, LAMP. That organization has been around for nearly 20 years and is well known by the minister. There's another in the city of York, YCS. It's also been around for nearly 20 years. These two organizations were set up as pilots to see if the concept of multiservice was viable. I don't believe that any other multiservice agencies have been funded since. Has this concept been revived or is there another definition of which I'm not clear? Is there funding to create new multiservice agencies where there are currently none?

I note that municipal health units can operate as multiservice units. I believe this is an attempt to address rural and northern service needs. This proposal does create some problems. For instance, the agency that is to provide community care also has an enforcement mandate. I believe that these two roles are incompatible. They may also prevent those in need of community support from asking for it out of fear for the enforcement component.

The board component of these designated agencies is comprehensive and laudable. However, if existing organizations are to become designated, then time must be allowed for an existing board to meet the rigorous criteria outlined in the bill. And will the same criteria apply to health departments in municipalities? Will an advisory or steering committee have to meet the same standards as a voluntary board?

As you discussed in the development of a plan of service in section 20, when an individual applies for service the agency shall assess the person's requirements, determine the person's eligibility and, if eligible, develop a plan of service.

How will this help any of the families I discussed earlier? Will Mrs C's needs be considered in isolation from those of her husband? Will this help Mrs W whose daughter's needs must be considered as well as her own? Can Mrs Y separate her own needs from those of care giver that she must perform?

It's critical and necessary to negotiate with all the relevant members of a family when providing long-term care services.

Section 22 discusses that services will not be provided without the person's consent. Although I would never want anyone to feel intruded upon with community service, I still maintain that an entire family assessment is needed to determine need. There will also be instances in which the substitute decision-maker under either Consent to Treatment Act or Substitute Decisions Act will change that clause.

In the required services, I see no mention of psychogeriatric assistance. I realize that services prescribed as professional services were intended to cover a range of supports. However, it seems that specific inclusion of psychogeriatric treatment should be included as either provided or procured.

As a small point, under subsection 29(12), surely, if a plan of service is developed respecting the bill of rights, part III, then it would involve the person from the onset, and if the relationship between agency and client is contractual, a copy of the service plan should be provided to that client and family.

A great deal of effort's been expended on ensuring that all possible changes in service delivery have been considered and planned. That is a thorough and responsible approach. I'm also pleased to see the detail outlining the client's right to sue under various conditions.

Sections 52 and 53 seem to run parallel to the Advocacy Act. Will advocates and supervisors be attempting to assist the same individuals? Who will be in charge if both are called?

Paragraph 11 of section 56 mentions the requirements of the agencies to develop and implement a plan for recruiting and using the services of volunteers. What services will volunteers perform? How will they be accountable? What liability will the agencies have for their volunteers? What protection will volunteers have from the agency?

I have commented on a number of items contained in the long-term care bill but my overriding concerns remain on what consideration has been given to the elderly care giver in the development of this legislation. I cannot quote statistics from other fields, but in mental health, 60% of community care is provided by families. Many of those family care givers are mothers of adults, spouses or older siblings taking over from deceased or infirm parents. In one instance, the care giver was a 62-year-old woman whose mother had died, leaving her to care for her grandmother.

The burden of community care often falls on those who feel they have no options. It's important to remember those providing care as it is to support those who need the care. Remember, no matter how many services are needed in a family, it's still less costly than institutional care, which brings me to an ongoing concern. How will these multiservice agencies be funded? Where will the government find the money when millions are being stripped from the health budget to fight the deficit? What will happen if there are not additional resources to implement this bill and communities have no resources to develop the required services?

Thank you again for the opportunity to present family views on this.

Mrs O'Neill: Thank you, Ms Wallace, for coming. You've brought things in a different way or used different words than others, but you've brought some of the very same crucial problems and I'm actually going to ask legal counsel to help me get some of the answers for you.

I do think you are very correct when you say there's nothing about psychogeriatric care in this bill; at least I can't see it. So that's going to be my first question to legal counsel: Am I overlooking something or could it fit into one of the titles that I do not yet recognize? Respite care and case management, which I think you've said in a different way, are also lacking, and others have brought that to our attention. So I ask legal counsel if they can give you any guidance and direct you to parts of the bill that may attend to some of those concerns you've brought.

So if I may, Mr Chairman, ask legal counsel to attend to psychogeriatric services, case management and respite care. They seem to be omitted from the bill. Are we overlooking parts of the bill that could be interpreted to be attending to those issues?

Mr Wessenger: I'll ask legal counsel to clarify the definition.

Ms Czukar: With respect to psychogeriatric services, they're not mentioned specifically in the bill but the multiservice agencies and approved agencies would have the capacity to purchase those kinds of services in particular from specialized service centres that would provide those, and that was the intention, not to require every MSA to provide that kind of highly specialized service but to have it accessible through the MSA on a purchased basis.

Ms Wallace: I would feel more comfortable if that was more clearly stated.

Mrs O'Neill: Every MSA needs it.

Ms Czukar: I guess it's a question of allowing the flexibility on the part of the MSA, together with the family and the consumer, to be able to identify the needs and to access whatever kind of service is needed, so that rather than prescribing particular kinds of services that could be accessed, we'd leave that open so that it allows the greatest kind of flexibility.

Ms Wallace: Could I make a further comment on that? Our experience has been that people with psychiatric disabilities are not first on the list of "please come to our service."

Mrs O'Neill: Exactly.

Ms Wallace: People with psychogeriatric problems are not first on the list of seniors. Most services are happy to have seniors because they're nice, grateful, tidy people. But psychogeriatrics don't tend to fall into that category and don't tend to be real popular, and so services which can avoid this group do so with great energy.


Ms Czukar: I think that Mr Quirt, the acting executive director of long-term care, might wish to add something with respect to the availability of those services and so on. I'll just answer the question with respect to case management and respite care.

The term "case management" is not used in the bill. There is a section 20 with regard to the plan of service that requires approved agencies to assess people's needs and to develop a plan of care with the participation of the person and their substitute decision-maker and anyone else they might wish to involve, and to review those needs and redesign the plan if necessary and to deliver the services that are in the plan. That's seen as a kind of operational, functional definition of case management and certainly ongoing coordination of those services and so on can be done by the MSA as part of their mandate.

With respect to respite care, that's included specifically in the definition of care giver support services, which is, as I understood your presentation, what you're most concerned about and certainly respite is a very major part of that kind of constellation of care giver support services.

Ms Wallace: Respite care is not always an issue that can be easily addressed particularly in dealing with seniors who are care givers looking after someone with mental illness, because it's very difficult to say to somebody in their mid-40s: "You're going to go on a vacation and this is where you're going to go. You're going to go to Kipling Acres for a couple of weeks with the old folks." It's a very, very difficult issue and it puts a lot of people in a very stressful situation because they have no options.

I don't have an answer to that. If I had a magic, golden answer to that I'd sure sell it, but we don't. But we do know that people need very short-term support, and case management can often be too stressful and too assertive a service for a lot of people. What they need is just two or three hours off to go to the bank or go to the hairdresser, go out for a coffee or, heavens, go to the grocery store.

Ms Czukar: So in both those cases in terms of case management and respite -- respite is mentioned as an aspect of care giver support because we know that it can be an outcome of a variety of different kinds of services that can be provided in different ways. So, again, it's to allow for flexibility and case management. Also, that term is not used, because it means many different things to many people and different kinds of things can constitute effective case management for different people, some of whom want something very structured and some of whom don't.

The Acting Chair: Thank you. Mr Wilson.

Mr Jim Wilson: Thank you, Ms Wallace, for your presentation and giving us a family perspective. You ended your presentation by talking about the cost of MSAs and in fact, in essence, raised the question of priorities; that is, if there's not enough money in the system, should the government be spending what is estimated to be a large sum of money in establishing and operating MSAs. The Catholic Health Association of Ontario has indicated to this committee that its estimation to provide nursing services alone through an MSA, administrative costs in Metropolitan Toronto alone -- I think their assumption is there are 15 or 20 MSAs in Metro -- would cost an additional $7 million.

With that in mind -- I think you've been following the reform of long-term care over the last couple of years -- what was your original vision of an MSA? What were your expectations prior to reading this bill?

Ms Wallace: Quite a number of years ago there was a concept developed for one-stop shopping -- by the secretariat for the aging?

Mr Jim Wilson: Seniors affairs, I think it was.

Ms Wallace: It talked about the ability to find all services under one roof so the people weren't, as happens in a lot of services, having to go 40 different places or spend eight days on the phone trying to find something. It was supposed to simplify things and make things much better.

We have a multiservice agency in Etobicoke. We have two other community health centres, which would also probably function in the same way. What can happen in that is that it can become so diversified, in that it's providing services to a community, that the critical services get sort of left behind and the fringe fund services take over. For instance, I would never say that it wasn't important to have a toy library, but I don't think a toy library supersedes psychogeriatric services. So I think there needs to be some clarity on what people can and can't do and where they can and can't expand in providing appropriate services.

I am concerned about the cost. At FAME, we have been sitting on committees for mental health reform and we are aware that mental health reform will go ahead $62 million short of what we thought we had to start with. So cost for those of us in mental health is a rather large factor. If the health budget is losing that much from mental health, what else is going? Where is money going to be found to do things when we're being told there's no money to do anything?

Mr Jim Wilson: When we first started talking about one-stop shopping, and then the term "MSA" came along, did you think the MSAs would be sort of a phone number you could call and get information and referral and perhaps assessment, or what they've become now, which is also they have a monopoly on delivering services? To me, they're two distinct things and yet this legislation binds the two together and mandates the MSAs to perform all functions.

Ms Wallace: I think there are a couple of things that have to be looked at. If you have an information outlet that people can access by phone, that's fine, but you're making some assumptions that people will know the right questions to ask. My experience is that people don't, that they are looking for something, but they don't know how to phrase it because they're not professionals asking another professional for something.

So I think it is important, although expensive, to have staff who can go out into the community, do assessments in homes and that requires more than an information service.

Mr Jim Wilson: Should they also be delivering the service that's recommended then?

Ms Wallace: I'm not sure. There are pluses and minuses to that, and I think if they are delivering the service, that there have to be a lot of safeguards put in and a lot of very careful evaluation mechanisms devised and implemented so that there's clarity that the service that is being provided is a service that's wanted.

Mr Jim Wilson: Because I think with some of the seniors' groups and the retired persons' associations -- CARP -- that appeared earlier, there was mention about some fear being expressed about the fact that the same group that now does the intake assessment and delivery of services is also the same group that you have to register your complaints with. In the mental health field, we've taken great pains or tried over the years to make sure there were separate avenues for complaints so that they wouldn't also --

Ms Wallace: I can tell you, it hasn't been very effective.

Mr Jim Wilson: No, it hasn't, and that's why I wanted to ask you. I'm afraid that with respect to this, although there is an appeal mechanism here to an outside board, I think the fear is that perhaps vulnerable people may not actually want to complain to the same people whom they rely on their services from. Do you have any comment on that?

Ms Wallace: I think that's a very serious problem and it certainly has proved to be a problem in mental health, even though there appear to be other avenues. A group that FAME is affiliated with, Quality of Care Coalition, has just written two papers on that, one about community services and one about institutional services, and our feeling is that there has to be an independent evaluation mechanism that people can access when they need to. They need to be able to make their complaints in such a way that they are not victimized by the complaint process. It needs to be looked at very carefully and developed very carefully so that both sides are protected because one of the things to remember is that people can make complaints in such a way that they look very different than they really are, and staff can be victimized as easily as vulnerable people can be victimized. So there needs to be protection built in both directions on that.

I think, as a whole, the Ministry of Health has got to develop some much better evaluation tools. We've looked. We found some that we think are applicable in a wider range, but we very, very definitely feel that the evaluation has to be provided independently and it has to include interviews with people who are recipients of service, with their families and with people who have left a service because they didn't like it, and then you get a broader picture of what's happening.


The Acting Chair: Thank you. The parliamentary assistant has a question.

Mr Wessenger: Yes, I just have a question. I noted you raise some of the problems with respect to the individual not being able to get services and you mention about the appeal process not being maybe the most effective way in any system of really dealing with a complaint. If you have to go to the appeals process, it means the system probably has not worked very well prior to going to the appeal level.

In your experience in dealing with various organizations, which I assume you have dealt with community-based organizations --

Ms Wallace: Yes.

Mr Wessenger: -- those that have local boards as distinct from those that have larger models, including government models, do you find the process of dealing with a complaint more responsive if you're dealing with a more community-based organization as distinct from one at a provincial level?

Ms Wallace: The question is not an easy one to answer because when you're dealing with the community agencies, you're dealing with probably one or two services in a community. So if you complain long, loud and hard, the answer is, "Fine. Don't use our service," and everyone whom you would want to refer there is then cut off, or if a family does that, then they are out on their ear.

Whereas, for instance, in our area of focus in mental health, if we have a complaint about a hospital, we can be pretty vocal about that hospital because it's going to be really hard pressed to turn people down. I mean, hospitals just aren't supposed to do that. We know they do, but they're not supposed to.

So the community agencies, I think, probably in the long run are harder to complain about, but they are easier to deal with on an informal basis because you can pick up the phone and say, you know: "Hi, Joe/Hi, Jane, there seems to be a problem here. Can we do something about it?" But if it can't be resolved that way, then you're pretty well dead in the water. Whereas, a clearly independent evaluation mechanism would remove that and, I think, provide a much better structure.

The appeals process, I should say as well, for seniors can be a very, very cumbersome thing and very, very frightening. There are a lot of seniors we work with who would like to complain about the kind of care their relatives get and they are terrified. They just can't do it because they've been brought up not to complain about professionals. They've been brought up to believe that if the doctor or the nurse says something, it's clearly next to God and they have to be wrong and they must adjust themselves to what's being said or done.

So a formal process like that is necessary, but it's also not enough because it doesn't address the very reality that a lot of seniors live with, and particularly if you're looking at seniors whose first language isn't English.


The Acting Chair: The next presentation will be made on behalf of the Ontario Nursing Home Association. Welcome to the committee. Please make yourselves comfortable and before you begin your presentation, please give us your names.

Ms Pat Morden: Good afternoon. I'm Pat Morden and I'm the vice-president of government relations at the Ontario Nursing Home Association. I'm also the administrator of Shalom Village, an organization in Hamilton which provides long-term care, sheltered housing, day programs, kosher Meals on Wheels.

Ms Shelly Jamieson: My name is Shelly Jamieson. I'm the executive director of the Ontario Nursing Home Association.

We very much appreciate the opportunity to share with you the experience of our members in addressing the challenges of providing health and social services in the various communities where our members are.

As background, the Ontario Nursing Home Association represents some 296 private sector organizations. They're both profit and not-for-profit organizations and they provide long-term care services under licence from the Ministry of Health to almost 28,000 Ontario citizens and their families. We believe that our collective experience in providing services to adults and young adults requiring ongoing health and supportive services across this province can provide some useful insights to the work of this committee.

Throughout the consultation process on the needs for reform in long-term care, our association has been very active, as many of you know, in initiating and promoting changes that will ease access to information and services for seniors and others in need of similar care. As one of the major publicly identified access points to long-term care services -- and that's what nursing homes are; they've been traditionally seen as that access point -- we recognize the impact that more accurate and timely information about services can have on an individual's ability to remain in their community and to make well-informed choices.

While the ONHA supports the one-stop shopping concept, it's very concerned that the method of delivering services proposed today could create a very bureaucratic and expensive approach.

Our close contact with seniors accessing services, both in the community and within our facilities, and our active involvement in the evolution of change have reinforced our opinion that the intent of the impetus to develop one-stop access was just that, to provide a single entry point for information and for counselling on what services were available and how they could be accessed. At no time did we understand that the thrust of this bill was to support the government to be an exclusive, monopolistic gatekeeper and provider of service.

While consumers do need one point of entry, setting up one agency and eliminating the various network of service providers, including Red Cross, Saint Elizabeth, VON and private sector agencies, will result in a loss of staff available to meet specialized needs and the multitudes of volunteers who provide added service and support. It is highly questionable to us that one agency will be able to meet all of these needs.

It is our understanding that the plurality of service choices and options in Ontario was a strength of our health care system. In our opinion, the proposed structure of the MSA dramatically reduces consumer choice. Rather than the creation of a huge bureaucracy that, at best, only duplicates services already available to consumers, we support the development of a consumer-based information system used by all participants in long-term care: people who are accessing nursing homes, homes for the aged, chronic and acute care hospitals and various home care agencies. Such a system would enhance significantly individuals' access to the system and facilitate appropriate allocation and use of community resources.

The ONHA believes that a balance of public and private sector agencies delivering services best serves the needs of the consumers in this province. Private sector nursing homes, commercial home care agencies, retirement homes and laboratories, all these groups provide services that we feel are of equal or better quality than the public sector when quality is evaluated by comparison to provincially established standards.

The reduction of all non-MSA service providers, as proposed in Bill 173, will not, in our experience, improve quality of care, will not improve accessibility, will not improve service delivery and will not save money. Repeatedly, we have asked for information which supports the fact that in fact this approach would do that and we have yet to see or hear of any. Issues of accessibility, quality service and cost-efficiencies are the elements that matter in creating the reformed long-term care system, not the ownership of the agencies and facilities. It is management, not ownership, that is the key to the delivery of accountable, cost-effective care based on approved standards.

Evidence suggests that the private sector is efficient, offers equal quality, puts much-needed competition into the system, raises its own capital and contributes to society through taxes and employment. One of the many drawbacks of Bill 173's model of service provision that we feel needs emphasis is the creativity and innovation which comes from individuals motivated to demonstrate the "profitability" of their service; that is, wanting to ensure the ongoing viability of their service by being the best they can be, being respected, being chosen as a service that people want and value and by ensuring value for the dollar.


Bill 173 proposes to develop a service which enables the service provider to decide who needs their service, how much they need, how much it will cost, as well as providing the service. This proposed model has no inherent incentives to be efficient or to provide quality. By evaluating its own effectiveness it will, however, provide a mechanism for life in perpetuity with potentially no link to the real needs. Fee-for-service physicians in this province currently practise using this type of model. The incentives for inefficiency produced by this type of service arrangement are well known.

We wonder whether the decision to restrict private and public agencies was based on any economic argument or merely an ideological one. It's hard to imagine that in the 1990s, even a socialist ideology would completely exclude the private sector and completely destroy voluntary agencies.

The Minister of Finance's very marker for economic recovery is reportedly small businesses. The businesses that will be ruined by this bill are the very ones which the Minister of Finance is relying on to pay taxes. MSAs won't pay taxes. We thought entrepreneurship was the mode of business most likely to succeed in the 1990s.

Ms Morden: The MSA concept proposes to create operational efficiencies by being large. We believe the facts show a much different conclusion. This model will create a system which is far more costly to operate and, as Shelly said, we've been looking for the exact dollars but those aren't available, and therefore, what will happen, for equal dollars as today, we'll be providing less service to the community. As this government knows, larger workplaces are now more costly to administer because of the various labour law requirements.

Why would the current system work better? Non-profit providers create efficiencies using volunteers to augment their staff. Volunteers will be lost to the MSA, for reasons I will detail in a moment. Profit-making organizations create efficiencies based on sound business practices with the goal of keeping their businesses afloat, practices which must ensure a quality service or their goal of continued success will not be met. People just won't use their service.

The proposed MSA, or monopoly on services and access, will not benefit from either of these efficiencies. Concurrently, the cost of ending the existing services, terminating staff, starting a new service and hiring staff to do what others are already doing will be very costly, not just in dollars but in individuals.

Bill 173 will be equally devastating to both the volunteer non-profit agencies and commercial agencies, as they both now share the same risk of losing their businesses. Thousands of workers will lose their jobs when non-profit and commercial agencies they work for are eliminated by the creation of the MSA. These workers, with the skills and knowledge to do the job, will also be disadvantaged in applying for MSA jobs because of the social contract obligation to place health workers displaced by hospitals.

I previously mentioned volunteers. As a provider which offers a multicultural service with a strong volunteer base -- the base is not just dollars, it's also the time they give us -- our experience, in relationship to the other long-term care providers and community agencies, is that the volunteer has a clear link to Shalom Village or to the service they volunteer to.

What would be the link to the MSA? I don't think any other large government agency is swamped with volunteers, I just don't see it, and I hesitate to think that the MSA would be any different; thus, the tangible and the many wonderful intangible benefits of volunteers in service provision are going to be lost.

Bill 173 proposes that the MSA will provide all but 20% of the services it needs. Once again, the needs of the cultural and ethnic groups in this province will be missed. Small service groups that provide language-specific, kosher Meals on Wheels, those will all be lost.

The MSA will bring one-stop shopping to health care, literally providing only one place to shop. What it will mean to a person needing in-home care is that if the MSA does not meet his or her needs, whether they're clinical, ethnic, spiritual or linguistic, there's nowhere else to go. The consumer will lose all choices. Under the current system, persons who are unhappy with the service can choose another. Vulnerable, ill people are unlikely to complain about the care they receive. That's difficult for all of us, but most especially with the MSA when your complaint will actually go to the person who decides whether you can have service. People are not going to complain.

Canadians are well known to be private, reserved people. I can't imagine that our seniors want to spend their last years having their lives managed by Big Brother. "I'm from the government, I'm here to help you" is one of the most distrusted phrases around. Many Ontario citizens have struggled their whole lives to have choices, to have some control over their lives, to decide what they need and who can help them.

Many seniors I meet have risked life, limb and family to achieve such rights. In one move, the development of the MSA will deny them these hard-sought ideals. When they asked for easy access to information, they were not asking for someone to take control; rather, a system to facilitate their own decision-making, information counselling, to help them make the right decisions, use the right services.

This monopoly of the MSA will make the decisions as to what is best. This type of thinking smacks of agism, which is racism directed towards the elderly. "They don't know what's good for them, so we'll decide." It's interesting that for the disabled the same government is giving the individuals the control, establishing what dollars are available and allowing the individual to choose how these dollars are to be spent. The disabled are being given the opportunity to choose what is most important for their care and options to meet their needs. What makes the government feel the elderly need a paternalistic system which denies the ability to have choice?

The long-term care sector, which ONHA is very familiar with, has developed an effective model for managing a multitude of service providers. The ministry has established standards for care, guidelines for access, methods of evaluating care and dollars for the health portion of the service. Through a funding mechanism, agencies are encouraged to be efficient in the accommodation envelope, but not permitted to use care dollars for anything other than care. Dollars received in accommodation over and above expenses can then be used to enhance services and structures to ensure the ongoing viability of the particular organization. This is true of both profit and non-profit organizations. A similar arrangement with government establishing core services, dollars available and in consultation standards for care, could combine the concept of ease of access with the clear benefits of encouraging a variety of service providers, which will also maintain efficiencies and volunteers.

ONHA clearly recognizes the need for change in the system, especially the provision of timely and accurate information about long-term care services to the consumer. Bill 173, however, goes way beyond this concept without, we believe, enhancing care or quality of service.

The following recommendations would, we believe, address the identified gaps in our current system while maintaining the choices currently available to the consumer and maintaining the tax contributions that drive the government's ability to initiate change and enhance service:

(1) The development of a consumer-based information system to ease information flow to all users of long-term care services. The piloting of this system in both rural and urban areas would provide useful information.

(2) The government determines the core services to be provided and equitable, measurable standards of service be applied across the province using the current range of service providers.

(3) Maintaining the current balance of service providers to ensure consumer choice and meeting of individual ethnic and spiritual needs.

Ontario's consumers asked for clear access to information so they could make an informed choice. Bill 173 does not meet this need. Bill 173 takes away choice and makes all the decisions about services for the individual. The bill proposes that the government will become the monopolistic provider of home health care services. Tax dollars, consumer choice, jobs, quality service and thousands of volunteers will be lost by the implementation of Bill 173.

We strongly encourage you to re-examine the goal of the Bill 173 process, which we believe was to develop a cost-effective system of consumer information to ensure access to appropriate long-term care services. Using the insights gained through this review process, restructure the bill to ensure it meets the need while preserving the quality choices now available to the citizens of Ontario.

We would be happy to answer any of your questions or to provide further information if it would be helpful.

Mrs Sullivan: Thank you for a coherent criticism of the structure, the model that's been selected by government for long-term care reform.

I'm interested in the point that you make that the issues that are addressed in this particular bill relate more to the structure, the management surround, rather than the content, the quality and the services which are to be provided. I think, for the most part, that's true, other than the issue of the basket of services which is defined at the beginning of the bill, where there's a level of standard that is to be implemented across the province, and of course we have had a problem in the past with an equivalency of servicing in various areas of the province.


We also share, by the way, your concerns about the fact that there haven't been the cost studies and the feasibility studies haven't been done with respect to this model. What kind of incentives do you think should be put into place to ensure that the quality and efficiency that ought to be associated with long-term care reform are in fact included as a part of that reform?

Ms Morden: I think the incentive for efficiency from our perspective is, number one, that there are measurable standards that are in some way evaluated not by the agency providing the service, and the efficiencies can be structured, we believe, within the funding. If the dollars are established and guidelines in terms of those standards are established and how the dollars are to be spent, then again efficiencies -- you want to save money, but efficiencies, if you have a variety of agencies, some may use it for different things. Within my facility, I might use it to develop a new program that I can pay for. Another group might do something else with their efficiencies; you may even want to put guidelines on that.

But I think having standards that are measurable and that people are called accountable for those -- and the core dollars are already established, so you know how much you're going to spend, but those two things could really put some limits on it.

Mr Jim Wilson: Thank you, Ms Jamieson and Ms Morden, for your presentation. I paid attention to every word in it and just want to commend you for an excellent presentation. Again, you've shown courage in often beating back the trend to come and support government legislation and bring us a perspective with some very good ideas.

I'm absolutely intrigued, and it's been mentioned in roundabout and in some direct ways by other groups, the need for an information system. When you think about it, if the government would adopt a proper, smart health card system, that is the basis of a good information system, for also your long-term care system, the drug benefit system and many other systems as governments may seek to add to the information on line. Unfortunately, the government is taking a very expensive, wrong decision to simply slap a photo on a magnetic strip card.

I think you're right because you point out quite correctly that one-stop shopping, one-stop access, was sold to the public for many, many years as a fairly simple concept that we all understood, and you explain that in quite good terms. I don't think the public, to this day, understands what a monopoly is being set up.

I know, and we all know, that the people of Canada and the people of Ontario hate monopolies. They absolutely hate monopolies. Whether it's the phone company or the Beer Store or the liquor store or numerous other entities in our society, they're a constant source of complaint when people start to think about monopolies. In fact, government is charged with the legal responsibility in our society to prevent monopolies, and here we are setting one up in health care and trying to rid the system of what I think is healthy competition and other things.

I don't really have actually a specific question because I agree with what --

Mrs Sullivan: I do.

Mr Jim Wilson: -- you're proposing here. Your final remarks, as I recall, are that the process here needs to lead towards a restructuring of the bill. I think to do what you want to accomplish, we would basically have to rewrite the bill outside of the bill of rights provision and outside of perhaps some of the purpose clauses. My caucus has a great deal of difficulty supporting this bill and at this point won't be supporting the bill on third reading unless we can get some specific amendments in.

I leave you with a semi-question here, and that is: Given that you know that the government has a monopoly on the votes in the House too, certainly a majority of the votes, a monopoly on the way legislation will go, this bill will pass; we can undo some of it when we form the government next year. However, what would you like to --

Mrs Sullivan: Fat chance.

The Acting Chair (Ms Yvonne O'Neill): For a person who hasn't got a question, you have taken quite a bit of time. Are you going to complete this then?

Mr Jim Wilson: I'm not done.


The Acting Chair: Okay. Mr O'Connor.

Mr Jim Wilson: One minute, one minute. I just want to leave it with -- perhaps you could give us some specific amendments that you'd like to see in the actual Bill 173.

Ms Jamieson: We'd be happy to do that. I would just like to add, we had quite a spirited debate at our board about whether to come today or not. We have lots of things to do. We have some of our own fires and, frankly, this is a peripheral one, but we decided that this is something we've been saying for six months at meetings to Karen Goldenberg, to all kinds of people, that we were concerned, we wanted to see pilots, not pushing ahead, we wanted to see cost data and we keep getting, "Thank you very much," and away we go. So we decided that it's not fair to be critical of the process and then not to participate right at the end. On that basis, we made the decision to come today.

Mr Jim Wilson: Thank you.

The Acting Chair: Mr O'Connor.

Mr O'Connor: I appreciate you coming and sharing some of your thoughts with us.

I guess part of the concerns that I have in some of what you say is that what has evolved to bring the MSA forward won't allow the consumer the choice, the opportunity to be involved in the provision of care, the choices of provision of care that can and will evolve out of this.

We had a presentation late yesterday by Victoria County Community Care, and they shared with us what they saw as services that evolved and they came together. Of course, any type of community like that is going to require a great amount of volunteerism, it's necessary, and they've been able to maintain that and it has evolved.

What we're trying not to do here is to establish an agency, a brokerage. I know that the previous government had set that out as a model. In fact, our early consultation papers had said that we would move towards a brokerage model and be the purchaser of services and put that out to a very extensive consultation. It's from those consultations, though, that the idea of a brokerage model purchasing services wasn't recommended back to the government.

I just wondered if maybe you have some thoughts that you could add in how we could -- because it is very important that the consumers -- that's the focus here, the consumers, the people whom we want to provide and continue to provide care for in a better fashion than we have always in the past.

Ms Jamieson: We certainly support that.

Mr O'Connor: And a continuum of care. If you could maybe give us some suggestions how we can approach it from a consumer element.

Ms Jamieson: I think the interesting piece about the consultation is, it's like all new concepts which are somewhat radical. When one-stop access came out people were horrified because it proposed huge change to the system and people felt threatened. What I find interesting is somehow we charged ahead to this bigger model, and I'm not sure the consumers have ever asked for anything different than they were asking for in one-stop access. I think the kind of model that was proposed with one-stop access would be very saleable to consumers and to service providers today, and you might get those kinds of efficiencies you're talking about.

I know Victoria County Community Care services. They're an excellent organization. I can imagine them making business decisions about how they should provide services in their community by amalgamating services. That's something that comes together naturally.

Where I think consumers lose choice in here is not in choice in terms of access to services, it's choice about who delivers the service. I think when someone who's telling you about the range of services also is in any way related to the person who's delivering services, we have an inherent problem in the system relative to accountability and speaking up. I think that's where our concerns have led.

Unfortunately, whenever you bring up the fact that you think that this model isn't good, we get slapped -- a lot of service providers but certainly the ONHA -- with the thing that we're not concerned about what the consumers think. I talk to consumers all the time in my personal life and my professional life. They think they need to go somewhere and make the job easier to get into the system. I agree with them, and we would support anything that we thought did that, but we just don't think this is it.

Mrs Sullivan: I appreciate this opportunity, because yesterday we had a comment from Mr Quirt with respect to the manual which is being developed for the community service agencies. He indicated that there was such a happy and wonderful acceptance of the manual in the long-term care facilities that of course that approach would be taken. So I said, "Well, that hadn't been the experience that I had heard about," and I thought now is a particularly opportune time for you to comment on the specificity of the manuals.

Ms Morden: I can comment on that, because I deal with that manual every day. I think that there is an acceptance of standards. There has been some discussion around particular standards, how they're to be implemented and how people put priority on them. That's always going to go on when you're trying to make professional, ethical decisions about care, but I think that if you talk to any long-term care operator that's looking -- because we've been asking for standards, that there's an even choice for people, that people can have a guarantee when they want to make a choice of a long-term care facility, that they can really be guaranteed that there are certain standards of care that are going to be carried out in that home. Although there are definitely problems with process -- you've got government setting standards and people who are independent wanting to make those decisions, some difficulties in priorities -- I think that there is acceptance of the idea of standards and having standards.

Ms Jamieson: I think perhaps the birthing of that manual has been difficult and perhaps there are more restrictions within the manual than we think are necessary to measure whether you're doing a good job. So, it can be prescriptive in areas where we should be looking at the outcome, not how we got there. At the end of the day, I agree with Pat, the manual is providing an equal playing field and it's going to make us all, homes for the aged and nursing homes, equally accountable, and we don't shy away from that.

The Acting Chair: Thank you both for coming. I'm glad you made that decision.

The committee recessed from 1703 to 1711.


The Acting Chair: We resume the social development committee and we now are going to deal with the presentation from the Ontario College of Family Physicians. I understand that we're going to have an audiovisual presentation. Perhaps you'd like to introduce yourselves as we begin.

Dr Rick Mann: My name is Dr Rick Mann and I'm the president of the Ontario College of Family Physicians. We brought the audiovisual equipment along with us to try to warm up the room for you. Hopefully, the light will allow us to do that. Sitting beside me is Dr David Keast, a family physician from London, and assisting us in the audiovisual department is Ms Cheryl Katz who is the executive director of the Ontario College of Family Physicians.

We want to thank the standing committee on social development for this opportunity to make a submission in respect to Bill 173. Dr Keast and I are appearing on behalf of the Ontario College of Family Physicians, a voluntary, not-for-profit organization of approximately 5,000 family physician members serving in cities, towns and villages across the province. We are the provincial chapter of a national organization whose mandate is to promote high standards of medical care and education in family practice.

As family physicians, we strongly believe in the principles of continuity of care, cost-effective care, community-centred primary care and quality management in meeting the many diverse aspects of health, medical and psychosocial needs.

The Ontario College of Family Physicians is concentrating its submission on those aspects of the legislation which may impact on the principles of quality, familycentred primary care.

The stated objectives of Bill 173 are as follows: to ensure availability of and equitable access to community services rather than institutionalized care; to improve quality of community services and health promotion of service consumers; to simplify and improve access to community services; to promote efficient management of human, financial and other resources involved in the delivery of community services; and to encourage community involvement.

The Ontario College of Family Physicians supports the vision of an integrated single source of community-based service. Realizing this vision presumes appropriate assessment of the nature and frequency of services required.

Dr David Keast: I want to speak to you for a few minutes about input into decision-making. Dr Mann and I are going to pass the ball back and forth here. I'm going to leave what's written here for you to read at your own leisure on the couple of ones that I'm going to address and just simply make some comments about it, sometimes from my own personal experience in providing care to patients in the community.

The first one is on input into decision-making. Really, in the legislation, in my reading of it, anyway, there doesn't appear to be anywhere any involvement for physicians in providing input into the decisions that are made for the eligibility and the appropriateness of the services for the patients. We think that may be a bit of a mistake.

We have a long-term longitudinal knowledge of the patient in their family situation. We often care for their spouses, for their children, for their parents, for other members of the family. We live in their communities, and we often have an exceptional knowledge-base of these particular patients that would be helpful in determining the services that these people would require.

We think that it's really important that the legislation have somewhere in it some way for health professionals such as physicians to have some input into determining the nature and the need for the services. We think if that isn't there, there could be mistakes made, diagnoses missed, services duplicated that may not necessarily be appropriate.

Secondly, I want to talk to you about access to service. This somewhat upset me when I read the bill because I had just gone through an experience with an 85-year-old woman in my practice. She is widowed. She has no family in town and basically, I'm about the sole contact that she has in the city other than her church and some neighbours. She has diabetic polyneuropathy. She is weak. She falls. She fell in her kitchen and she fractured her wrist. She was taken by a neighbour to the emergency department and a cast was placed on her wrist and she was taken back home. At 5:30 on a Friday afternoon she called my office in a panic. She had no support to turn to. She didn't know what she was going to do for the weekend because she didn't know how she was going to feed herself, wash herself, get all the activities of daily living done, and she was frightened and alone. She desperately needed some homemaking service and reassurance and somebody even just to check on her.

According to the bill, I would have to say to this woman, "Well, certainly these services are available, but you call and ask for it, please." We really think that there should be some way in which family physicians can advocate for their patients to obtain services when patients may not be prepared to advocate for themselves.

Often elderly patients don't want to make a fuss. They don't want to disturb people. Consequently, they won't be aggressive in pursuing their needs, and sometimes that's a role that I, as a family physician, take on for my patients. It disturbed me somewhat to see that there was nothing in the bill that permitted other people to access the services on behalf of needy persons.

Dr Mann: I'd like to talk for a moment on community supports upon discharge. The multiservice agency concept may be a cost-effective alternative to institutionalized care in larger population centres. However, in rural and remote centres, it may not be cost-effective to provide specialized professional and support services in the home; for example, occupational therapy, physiotherapy, speech language pathology etc.

In the community where I live -- I live in Bruce county -- there is a vast area to be served in that county. Although it may be very cost-effective where there is a population and patient density, it may not be very cost-effective for service providers to be travelling over 120 miles in one direction on a daily basis to look after individuals. If I think or we think that Bruce county is somewhat remote and isolated, imagine how more difficult that may be providing some of those services in a cost-effective manner in the northeast and northwestern part of the province.

The appropriate level of community services must be readily available in all locations across the province before the patient is discharged into the community. We cannot allow people to fall between the cracks. If these services are not available in the community, then we fear that the burden of care falls on the family care givers, who may be ill-equipped to meet the increased demands.

In the absence of appropriate and timely community support services, deinstitutionalized care may not be preferable for patients or their family care givers. So the infrastructure must be in place before we look at deinstitutionalizing people. We don't want to see the type of thing that happened when the psychiatric hospitals were closed happen again, where people were basically dumped on the street with no support services. That has to be in place in part of this legislation.

Deinstitutionalization must be coordinated with the patient's family physician, who knows the patient, to achieve seamless care. Failure to coordinate community care with the family physician may result in increased reliance on walk-in clinics and hospital emergency departments, at greater cost to the health care system.


Dr Keast: I want to speak to you for a moment about the bill of rights part. We would strongly support a bill of rights for recipients of services, but on the other hand, we wonder where there is a bill of rights, if you would, for the service providers.

Part of my practice also involves working in a long-term care institution and we have a number of elderly, demented patients in that institution who are at times both physically and verbally aggressive and sexually inappropriate. With the extension of increased services in the home and no protection for service providers in the bill, we are somewhat concerned as to what may happen to nurses, occupational therapists, physiotherapists and homemakers at the hands of some of the recipients of the services.

These people often don't mean to behave in this way but they do. If people felt that they were forced to provide the service, regardless of what was going on, we feel that would be a severe mistake. We would support some kind of rights for the service providers as well.

Next, I'd like to talk about equitable access to seamless care. Basically, what seems to be happening at the moment is that we're moving to a regional concept of budgeting and governance in the health care system, the district health councils, if you wish. At the same time, this legislation sets up the MSAs, which are designed in specific geographic areas. For example, it is rumoured that the Toronto region may end up with 15 or more MSAs, and in other areas you may have one MSA for a region.

The worry that we have is that not all services may be available in all MSAs and we'd hate to see that the services become regionalized in one MSA. Let's say, for example, that linguistic services were available in greater Metropolitan Toronto, because you have a large number of ethnic communities here. In a smaller community just to the north of Toronto, there aren't that many people requiring a specific linguistic service, but there might be one recipient in that area. We think it would be a mistake if that person couldn't get that service, just because they were in the wrong geographic area.

We would hope that there would be some interplay between the MSAs so that a neighbouring MSA that did have that service could provide it to an outlying area where there were fewer recipients who needed that. So what we're looking for, I think, in this idea of equitable access is that there's some flexibility in providing these services.

Dr Mann: We have, therefore, three major recommendations that we would like to make to this committee: number one, that the integral role of the family physician be recognized and that provision be made in the bill for medical input into decisions regarding eligibility for and the nature of services; that access to the services by a physician on behalf of their patient be incorporated into the bill; that there be formal communication links between the MSAs and the patient's family physician so that duplication and fragmentation can be avoided.

Secondly, we would like to suggest and recommend that discharge planners in acute and long-term care institutions should also be able to have access to services as part of the discharge planning process.

The third recommendation that we would make is that there should be protection in the legislation for not only the service recipient, but also for the service providers.

In summary, then, the Ontario College of Family Physicians supports the concept of integrated and coordinated access to needs-based and culturally sensitive community care. Bill 173 appears to have developed a process to simplify access to care. However, better access to service is not the same as better service. Long-term care reform must ensure that high-quality, cost-effective services are available universally throughout the province.

Ms Carter: It's good to have your input to this. Obviously, physicians are a very important part of the whole picture. I just have one or two comments, and then something I'd perhaps like the ministry to comment on. I guess one of the objectives of this legislation is to make sure that facilities and all the different kinds of care provision are uniformly spread across the province. I think we know that some districts are very, very well catered to already and others are not, so I kind of feel that your fears that some areas will not be well catered for are really the present situation and what we're trying to do is to fix that.

Of course, we don't have a cookie-cutter model of an agency; this is something that is going to develop in each of the local areas so that where you have a rural area, obviously it will develop in a different way than it would in Toronto, so I hope that's a problem that won't arise. We have mentioned just earlier the Victoria County Community Care, which of course does function in a rural area and already has a lot of similarities to what we see developing under this legislation, and it seems to be doing an excellent job.

Now, you are concerned about the involvement of physicians; you see people getting into touch with the agency and having their needs assessed and you wonder where the physician involvement comes in, but I guess the answer is that there are a lot of things that aren't spelled out in detail in the act because if we spelled everything out, it would be an enormous volume instead of just a comparatively small number of pages. I would have thought that it's self-evident that the physician's opinion has to be a large part of assessing a person and that obviously you will be involved.

Now whether a doctor could access the system on a patient's behalf, as in the situation that you mentioned, the lady with her arm in a cast, I would not have thought that was a problem, but I would perhaps ask for an opinion on how we would be fixed in that kind of situation.

Mr Wessenger: I will ask Mr Quirt to reply to that. I think it's fair to say yes, there's no reason why a physician cannot continue to access the MSA. I think there are also some provisions under regulations perhaps for some procedures to be laid down that may involve more formal involvement of the physician.

Mr Quirt: We really don't foresee a great difference in how clients would access the long-term care system with the advent of the multiservice agency. Clearly, now physicians are a major source of referral to our community-based long-term care system. We expect they'll continue to be that.

There will be some differences in terms of their formal role as gatekeeper and I think, as other physicians before the committee have suggested, that services like placement coordination and the proper assessment on a multidisciplinary basis of the client and family need is an assist to the physician. We certainly don't foresee any change in how referrals would be made from physicians.


As you pointed out, if the bill leaves the impression that you would have to say, "Sorry, I can't phone on your behalf; you're going to have to make your own phone call," then we've created the wrong impression with the bill. You'd certainly be in the same position to make your referral as you are now, and obviously, as is the case now in the system, the client and family are going to have to be in agreement that the long-term care services in the community are appropriate and they're going to have to agree to receive those services, but that certainly is the case now with home care.

It's conceivable that multiservice agencies would be able to provide services like a nursing visitor, a physiotherapy program, without necessarily the doctor prescribing it, as might be the case now with home care, but clearly the physician is one of the important players in a multidisciplinary approach to service, and we'd hope you'd have a better team of colleagues to work with with the advent of the multiservice agency.

Mr Jim Wilson: Thank you, Dr Keast and Dr Mann, for your presentation. I don't think there's any given in the legislation that physicians will necessarily be involved in assessment. I do welcome comment from the government, but it seems to me that these MSAs will have to be hiring people to do assessments. Whether that's going to be registered nurses or other people who have appeared before this committee and told us that they're equally capable of doing the job is something that we simply just don't know at this point, but it would seem to me you'd have to have full-time people available at the MSA to do assessments.

I do want to ask you, though, when you talked about deinstitutionalization, and it was raised earlier today, there's an ongoing concern that people continue to be either discharged or deinstitutionalized in our society without the services in the community and that really nobody seems to have any responsibility for those decisions. As you said, the 85-year-old woman called your office as a last resort, not knowing where else to turn.

Have you given any thought that perhaps the MSAs in this case, as part of this new model, should actually have responsibility for deinstitutionalization, have some sort of legal responsibility for the person's care who is discharged, because right now they could fall between the cracks and there's a complete runaround when you try to figure out what happened and who's to blame.

Dr Mann: Do you want to handle that one?

Dr Keast: Sure. Just to comment about the other comments that were made, the bill, to me, still doesn't specifically spell out that there is physician input into helping in the assessment. And don't get us wrong, we don't want to do the assessments. Family physicians strongly support an interdisciplinary approach to providing health care and primary care to patients, and part of that interdisciplinary approach becomes very important on discharge planning.

The comment that I would make is that, in my experience, the places where the difficulties arise are the nodal points; they're the transition points. I mean, people do okay when they're in an acute care institution, but things go awry when they get transferred from acute care to a chronic care institution, or they go awry when they get transferred from chronic care to home or from acute care to home. What we're really concerned about and what we would hope that the MSAs would address appropriately, is that there would be an interdisciplinary involving of all the appropriate disciplines, including physicians but not restricted to them, to be sure that transitions occur between these various places in a coordinated fashion with appropriate services in place.

The example that I mentioned of my particular patient, hopefully that would not happen now in London because we now have a quick response program and the people in the emergency department would have been able to access the quick response. But at the time this happened, it wasn't there. I was able to get something for her for the weekend and something in place.

What I was trying to say is, we don't want to lose that ability to advocate when it's necessary, but on the other hand, we don't want to be the sole gatekeepers. We just want to be helpful and involved and part of an interdisciplinary process that's involved in making sure that people get their needs met where they want them met, be it in a nursing home if that's where they would rather be, or in the community if that's where they would rather be, and it should be their decision as to where is the appropriate place to receive the service.

Dr Mann: To answer your question a little bit, Mr Wilson, I think that there will probably need to be some accountability, and I would sort of see that if the MSA is going to take the initiative into coordinating the services, that if people are falling through the cracks, they should have some responsibility as to that process.

Mr Jim Wilson: I think the bill of rights attempts to capture some of that, except it's not clear to me what steps the consumer can take to ensure that they don't fall between the cracks and that a body is ultimately responsible. The bill of rights, I suppose -- we've been told you can take court action I suppose against the MSA if something goes awry, but you mention the deinstitutionalization of mentally handicapped individuals that all three parties are guilty of having messed up in this province, and it struck my caucus some time ago that perhaps some body has to have responsibility for all the transferring around that occurs, and that there be a legal recourse, a simple legal recourse for people.

Interjection: I agree.

Mrs Sullivan: You've raised a number of issues we have been quite concerned about and have stressed with some other intervenors before the committee, not the least of which is the inclusion of clinical factors in the assessment of the person who's seeking long-term care. We have learned in front of the committee that about 90% of individuals who are attempting to enter the long-term care system present with some kind of an acute problem, and that whether the services that are required are nursing or medical services, they certainly have to be considered a part of the care package, if you like, or care plan for the person involved and that the assessment doesn't simply end, that there has to be a mechanism through which there is constant revision and updating.

Dr Michael Gordon who appeared -- actually he didn't appear for Baycrest. I was trying to remember what organization he appeared for, but anyhow, he appeared before the committee, and one of the things that he suggested that Baycrest had discussed was some kind of a medical adviser system within the MSA, particularly to assist in complex cases or in situations where the client doesn't have a personal family physician, and we know that situation exists. That's one of the things that we've been kind of interested in.

Our view is that we ought to be making an amendment to the section that says that the agency shall assess the person's requirements to expand the nature of the assessment in terms of the services that should be judged.

The other question of course that we've had is who would do the assessment and who would coordinate related and other professionals associated with that assessment, and we've had very strong interventions from case managers who believe that case management should itself be seen as a professional responsibility that has to be provided by the MSA.

I think that your point about multiple entry points into the long-term care system is an important one. The physician is certainly one place where I think the majority of people in Ontario have a comfort level and a trust with respect to the next step that would be taken. The hospital discharge program may also well have to be integrated in some kind of a more formal way.

There are other people in our communities whom we may want to -- I don't know if you can legislate it, but you may want to acknowledge that a referral, for instance, from a clergy situation may be just as valid as a referral from a professional care giver.

One of the things that we're concerned about is that with the hospital restructuring that's being undertaken everywhere in Ontario, the pressure to reduce hospital stays and to move the patient to an outpatient or ambulatory care basis is in fact adding to the stress on our community services. Certainly in my community and in many other communities, facilities and services are not available in the community to replace the consistency of care that's provided in the hospital scenario and we see that as a problem.

I think your brief is a good one and we'll work up some amendments.

Mr Malkowski: Thank you for your points that you've raised. One thing I'd like to talk about is the community support available when the person leaves hospital. In large communities, such as Toronto, there are quite a few support services available, but, say, in smaller or rural areas, such as Manitoulin Island, there may not be as many support services available. So what would you feel would be a cost-effective way of providing these support services such as the MSA or what would be another cost-effective option for providing support services once people are discharged?

Dr Mann: That's a really difficult question. One of my concerns with the bill is that we may be raising expectations for the public that we are not going to be able to provide the services for, from a financial point of view.

Those are things that we have to look at, certainly, and it may be more appropriate, instead of having individuals at great distances from one another, perhaps having types of care institutions that would be able to provide the care for those people, and, if they're ambulatory, then perhaps coming into a centre to have the services -- physiotherapy or occupational therapy or nursing services, for example -- within a community, not coming down from Manitoulin Island to Toronto, but somewhere having an area, Gore Bay or an area, Little Current, for example, where the services could be provided for people who could come into the institution there.

That may be a more cost-effective way of providing services for those whom we can do it that way for. There may be people whom we're going to have to go out to the community, into their homes or where they live, in order to provide the services and I think we'll have to recognize that there are some things that are going to cost and if we truly believe that we must and should provide these services for these people, then we're going to have to look at finding ways of financing it.

The Acting Chair: Thank you, Dr Mann and Dr Keast. I would like to now mention to the viewers that the social development committee hearings on the long-term care Bill 173 will no longer be televised as we go on the road to Hamilton, to Thunder Bay, to Sault Ste Marie and to London. We hope to be back with the viewers towards the latter part of these hearings, but for the next few days and weeks we will no longer be televised on the subject. I now adjourn the social development committee to Hamilton, tomorrow morning at 9:30.

The committee adjourned at 1745.