Thursday 18 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, areas 4 and 15

Helen Schultz, director, area 15

Jessica Brennan, director, area 4

St Elizabeth Visiting Nurses' Association, Hamilton-Wentworth; Visiting Homemakers Association of Hamilton-Wentworth; Victorian Order of Nurses, Hamilton-Wentworth branch

Ken Bistrovich, VON board member

Betty Muggah, director, VON home care program

Mike Pennock, VHA board member

Rita Soluk, SEVNA president and chief executive officer

Jacqueline Balfour

St Joseph's Health Care System

Sister Joan O'Sullivan, vice-president

Brian Guest, executive director

Canadian Red Cross Society, Ontario division, west central and central regions

Heather Richardson, director, homemaker program, west central region

Della Crozier, volunteer

Diane Pick, volunteer

Ontario March of Dimes, Niagara regional office and Hamilton regional office

Maureen Lamarre, independent living manager, Hamilton region

Doug Overy, independent living manager, Niagara region

Regional Municipality of Niagara

Roy Adams, chair, community and health services committee

Bev Goodman, manager, community programs, senior citizens' department

Ministry of Health

Paul Wessenger, parliamentary assistant to the minister

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

Gail Czukar, legal counsel, long-term care legislation

Jean McCartney, manager, program design, policy branch

Ontario Dental Hygienists' Association

Elizabeth Craig, executive director

Linda Berry, chairperson, government relations

Victorian Order of Nurses: Guelph-Wellington-Dufferin, Halton, Niagara and Waterloo region branches

Cherry Cross, vice-president, Halton region

Dan Toppari, board member and past president, Niagara region

Cori Phillips, president, Guelph-Wellington-Dufferin region

Coalition of Community Health and Social Service Agencies of Hamilton-Wentworth

Norma Walsh, past chairperson

Nancy Long, representative

St Elizabeth Visiting Nurses' Association

Rita Soluk, president

Wellington-Dufferin-Guelph Health Unit

Dr Douglas Kittle, medical officer of health and director

Hamilton-Wentworth District Health Council

Barbara Mahaffy, chair, long-term care committee

Respiron-Care Plus

George Farnham, president

St Joseph's Villa

Paul O'Krafka, executive director

Margaret Lambert, director, SJV senior centre

Alzheimer Society for Halton-Wentworth

Gertrude Cetinski, education director

Association of Ontario Physicians and Dentists in Public Service, Hamilton region

Dr John Deadman, past president


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

*Acting Chair / Présidente suppléante: Caplan, Elinor (Oriole L)

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

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

McGuinty, Dalton (Ottawa South/-Sud L)

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

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

Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Caplan, Elinor (Oriole L) for Mr Beer

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

Kwinter, Monte (Wilson Heights L) for Mr McGuinty

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

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Clerk / Greffier: Arnott, Doug

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

The committee met at 0930 in the Ramada Inn, Hamilton.


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

The Acting Chair (Mrs Elinor Caplan): Good morning, everybody. Welcome to the standing committee on social development. We have a very full agenda today and with the agreement of all of the members of the committee, we'll be firm on our time.

There's 20 minutes for each presentation. The presenters will have the option of whether they wish to use their whole 20 minutes for presentation to the committee or whether they would prefer to make a presentation and allow time for questions and answers. Leeway will be given, of course, to the deputants in answering the questions and if we reach the 20 minutes and not all caucuses have the opportunity to question every presenter, they will have the opportunity to either speak to them privately, make other submissions -- but I will ensure that the time is divided fairly among all caucuses.

Just for the information of everyone who's here in the audience, the members of the committee each have a nameplate, I believe, in front of them. The government caucus is on this side of the room, the opposition caucuses are on the other side. The committee members are Mr O'Connor, good morning, Mr Martin, Ms Carter, Mr Malkowski. The members on the opposition caucuses are Mr Jackson, Mr Wilson, Mr Kwinter, Ms O'Neill. The parliamentary assistant, who is with us today, is Mr Wessenger. Welcome everyone.


The Acting Chair: The first presentation is by the Ontario Community Support Association, areas 4 and 15. Is Helen Schultz here, and Jessica Brennan? Please come forward.

Please begin your presentation. You have 20 minutes and we'd appreciate it if you'd leave some time for members to ask you questions, but it's your time and you can use it as you wish. I'll let you know when there's five minutes left for your presentation time.

Ms Helen Schultz: Good morning, everyone. My name is Helen Schultz. I am an Ontario Community Support Association director for area 15, which is Haldimand-Norfolk and Niagara. With me is Jessica Brennan, area 4 director, representing Hamilton-Wentworth and Brantford. We are both employed by community-based community services agencies. Jessica is the manager of international and community services for the Red Cross in Hamilton and I am a community developer with Haldimand-Norfolk Community Senior Support Services in Townsend.

What we would like to do this morning is give a brief overview of what Ontario Community Support is and then list some of our areas of consensus with the legislation and then a few of our concerns. We expect that will take about 10 minutes, leaving 10 minutes for questions.

Ontario Community Support Association is a fairly new provincial association. We were founded in 1992 and we arose out of three former provincial agencies which offered Meals on Wheels, visiting homemaker services and home support services.

We have a volunteer board of 25 representatives and we have divided the province into 15 areas; two of the areas are represented here today. We also have community directors with broad experience in health and social services at the grass-roots level.

The services that Ontario Community Support Association advocates for are the full range of community-based services such as Meals on Wheels; homemaking; home maintenance; friendly visiting; Alzheimer day programs; congregate dining, which is known elsewhere as Diners' Club or Wheels to Meals often; foot care; client intervention and assistance, which we are funded for mainly in Metro Toronto; home help; care giver relief; emergency response; volunteer transportation; senior day programs; information and referral; intergenerational programs; and telephone reassurance.

Those are the core programs. I must emphasize that there are other funded programs which respond to local need, such as in my area in Haldimand-Norfolk. We do not have mental health counselling services, so we have employed a seniors counsellor attached to our home support agency to meet that need. There are also services in Hamilton responding to the need for grocery shopping. So we really feel strongly that as well as meeting the medical needs of seniors and describing the core programs, these other programs are essential as far as responding to local area needs.

Even though we come from the wonderful Golden Horseshoe, there's quite a vast difference in our areas. Hamilton is a large, urban, highly concentrated, densely serviced area, but the rural areas around Hamilton-Wentworth have very few services at this point. Similarly, Brant county has very few service providers for community-based services. The Niagara area has a multitude of single-service agencies, mainly Meals on Wheels suppliers, some of which are not funded by the ministry, yet still offer a valuable service and are of course interested in what happens under redirection. Haldimand-Norfolk is the largest region in the province with the smallest population, so that presents geographic challenges. There are very few service providers in Haldimand-Norfolk because back in 1989 all the home support services were amalgamated under one umbrella agency which now has an administrative office and seven satellites. That's a fairly sophisticated home support system for that area.

I just want to outline briefly some of the areas of endorsement and I'll pass that over to Jessica.

Ms Jessica Brennan: You would have received yesterday a presentation by our provincial association and very much what you're seeing in front of you in the written documentation is what they would have given you yesterday. I understand there are some people here on your committee who were not there yesterday so, of course, please keep the copy. For those of you who have already seen something like this yesterday, between Helen and myself, we've made some minor adjustments based on area 4's and area 15's concerns, but really not very substantial.

What we wanted to do today -- because certainly as you go around the province you're going to be hitting the other 13 areas for OCSA and we know you're going to be hearing very much what you heard yesterday, with some different emphases in those different areas as well.

What OCSA did was to certainly read Bill 173 thoroughly, get a sense of it from the provincial level, and then throw to the different areas a number of different issues that we as a group might endorse or have areas of concern. We then brought our concerns back to the provincial association. They then massaged that again in terms of presenting four or five main areas of endorsement and six or seven areas of concern. You will see in the document, at the end of the package that we've given you, 26 issues in all. So you will see that as you go through the province and you meet our other representatives in other areas there may be other issues that come forward to you as particular areas of concern. I just want to be sure that those of you who might not have yet had enough coffee for the morning are not just seeing something that you saw yesterday as well.

In terms of endorsement, then, certainly the association endorses the principles and the values of Bill 173 and feels very strongly about the bill of rights as an insertion into the bill itself, the rules governing approved agencies and proposed changes to the Public Vehicles Act that will facilitate different pieces of the system that's being suggested.


In terms of the bill of rights, we are committed to a service delivery mechanism that's driven by the individual consumer needs, very focused on the consumer, certainly as a community services association with a large number of members who have traditionally been working 50, 60, 70 years in local communities. We have started from individual consumer needs as our basis in the first place and, of course, we want to recognize and endorse the clients bill of rights as outlined in the legislation.

Certainly, in terms of governing approved agencies and the rules governing that, we agree that the functions of the approved agency should include and will include the following, and that's stated in the legislation, but to show our endorsement: to provide information referral regarding long-term care and support services; to offer a range of long-term care and support services itself; 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.

Certainly, evaluating and revising and assessing -- are we doing the right thing for the right people in the right way? -- would be an important piece that the association will endorse.

Certainly, without large elaboration, the Public Vehicles Act allows the service provider to operate for the purposes of transporting persons, and including that in the bill, of course, is very sensible and we endorse that and thank you very much for considering that.

In terms of areas of concern, Helen will just outline some of those key areas, and then in terms of areas 4 and 15, we'll specify some of our particular concerns.

Ms Schultz: We have six areas of concern with the legislation and they include the following: the first is the areas that are not covered in the legislation; the second is the general regulations; the third is volunteerism; the fourth is MSAs; the fifth is categories of services; and the sixth is definitions. I'm going to touch on the general regulations first, then MSAs and then turn it over to Jessica.

On pages 35 to 41 of the bill are listed the types of regulations that have yet to be developed, and the list boggles my mind. It's everywhere from the duties of directors to listing the mandatory services, to eligibility criteria, waiting list, quality management, recordkeeping and so on.

These are vitally essential parts that are perhaps not appropriate to general legislation but are very critical to the way the service will be delivered and to maintaining the principles and values and retaining the philosophy of the community-based services as they exist now.

Each of those services arose out of a need and has a particular spot in the heart of their community. When I read this list of regulations that have yet to be developed, it seems like quite a heavy burden of rules and criteria that are going to be applied to all service delivering agencies no matter where they are in the province.

Quite frankly, we're not used to operating this way and when we see this list of regulations, not knowing what they will end up as -- first of all our request is that OCSA be allowed to take part in developing those recommendations because we're really concerned that the flexibility and the local planning take precedence over a cookie-cutter approach or having regulations very heavily applied across the province. That part of the act is fascinating to me, yet hard to respond to because it's not there yet and we'd like to be part of that if possible.

The second section I want to reply to is the multiservice agencies. OCSA has been a strong supporter of the development of multiservice agencies over the last few years with the caveat that they be developed through the district health council process following a community development approach and that any MSAs developed be neighbourhood-based and accountable to local needs. We believe in the principles and values stated in the partnership documents and reflected in the legislation and we thank you for carrying those through.

There's been a lot said, reminiscing about one-stop shopping, that sort of thing. To us, MSAs don't have to be an amalgamation of existing agencies. It could be functional integration, whatever works locally according to the desires of the local region. It's all fine as long as it's fine with the people who are planning it locally.

We also strongly agree that a board of health or a regional municipality should be considered after other community-based agencies. I think back to my own region of Haldimand-Norfolk, where we've just lost our medical officer of health, in part because of the difficulties he faces having to represent the Ministry of Health in that area, yet being, in essence, a regional employee. He's always caught in the middle. The director of home care reports to him. It's almost an impossible situation for anyone. So I see first hand every day the difficulty that would arise were a region to administer an MSA.

We do have one concern: There's one clause that the minister could designate the geographic area of an MSA. This raises little red flags for me because, again, I hark back to local planning. If local planning has assessed the natural community, then it seems rather arbitrary for the minister to then impose and say, "There will be this many MSAs," or, "This is the geographic area." That should arise out of local planning. Again, it's very important that that happen, because then the MSAs will stay responsive to local needs. That's what we're here for.

Ms Brennan: Just to emphasize Helen's point related to Hamilton-Wentworth, certainly we have in our area those people in Flamborough who may in fact have easier access to services in Burlington, but because of the way we divide things up, if there was an MSA only for Hamilton-Wentworth, then somehow Flamborough people have to come all the way out from their underserved area into the service area of the core. That also reflects some of the issues around geography and government distinctions for territories, when in fact natural territories already exist and we've been perhaps breaking the rules for some time anyway in that regard.

Ms Schultz: Just one final point that I have to make: No matter what form a multiservice agency would take, it is essential that a free flow of communication take place along the continuum of service delivery. We make an appeal to you for the dollars to fund a computerized information system, with all that it entails: training, hardware, software, the whole thing. It has to be standardized and it has to work well.

Ms Brennan: The only other comment to make is that certainly you have the document in front of you. Issues around definitions, issues around categories of services, particularly looking at the way we call personal support services and such; It's in the document for you to read and I'd ask you to do that.

Certainly, the issue about protection of non-unionized workers, just in and of itself, is an issue for the association. But from this particular area, it's more the issue of keeping the linkages from the client to the person who's been serving them and that, as we develop the system, we don't dismantle the relationships that already exist between clients and people who have been serving them for years. That's one issue.

The final point, and the one I wanted to spend a few seconds on, is really the issue about volunteerism. The bill makes mention of it, but not as thoroughly as we perhaps would want because, certainly, in my organization we have two paid coordinators and probably about 300 volunteers providing the service of transportation and assistance to people in the community. If we do not think about the fact that the manpower, if you will -- pardon me, personpower -- of that 300 is vital to actually providing the service and if we forget that, then when we create the system looking for those people to provide the service and we've not involved them in the discussion, if we also think their loyalty to the organization from which they serve is transferrable to something that they may see as a government agency, then we have some difficulty.

The Ontario Community Support Association is very concerned about the lack of a full volunteer management system taking into account aspects concerning recruitment, placement, evaluation of the volunteer service, recognition of their service etc, the kinds of things that traditionally exist in our community services anyway. That's an area of concern we just want to underline very clearly.

Thank you, and I think we have two minutes for questions.


The Acting Chair: Thank you very much for a very thorough and clear presentation. We have actually just a few minutes for questions.

Ms Jenny Carter (Peterborough): I'd just like to carry on with the issue of volunteerism and, of course, we are very much aware that volunteers make a tremendous contribution in this field and we want them to continue to do so. We have tried to continue this by giving a community-based board for each multiservice agency. The planning process is led by the district health councils, not civil servants, and there is a joint working group with the Association of District Health Councils of Ontario and the United Way, so we really want this whole thing to be community-driven and responsible to the community.

Could you give us some ideas as to what more we could do to keep this tradition of volunteerism going?

Ms Brennan: I think the issue is that the bill only makes mention of recruiting the services of volunteers. It doesn't talk about a volunteer management system. Certainly, what you've described in terms of activity -- I believe firmly that the local entities will plan to include volunteers in an integral way. I believe that intuitively.

The bill somehow, though, doesn't really lay it out as strongly as I would like to see in terms of a management system that also includes the funds to manage that piece of the system. With such a thin statement inside the bill it's just not firm enough to convince me that there will be a real system to help volunteers make the transition and also to continue to do the service that you're describing.

The Acting Chair: Thank you very much for your presentation. Our time is up. If you have any additional information, please feel free to communicate with the committee in writing. All of the information that you send in to the committee will become part of the official record of the committee.


The Acting Chair: I'd like to call the next presentation, St Elizabeth Visiting Nurses' Association, Hamilton-Wentworth; Visiting Homemakers Association of Hamilton-Wentworth; and Victorian Order of Nurses, Hamilton-Wentworth. Please come forward. If there are not enough chairs, just pull one up. As many people who would like to come and sit at the table and participate are welcome. I'd ask that you begin your presentation by introducing yourselves to the committee.

Mr Ken Bistrovich: Good morning, Madam Chair and committee members. My name is Ken Bistrovich, board member for the Victorian Order of Nurses, Hamilton-Wentworth. It is indeed my pleasure on behalf of the St Elizabeth Visiting Nurses' Association, Hamilton-Wentworth, the Visiting Homemakers Association of Hamilton-Wentworth, and the Victorian Order of Nurses, Hamilton-Wentworth, to have the opportunity to present our joint submission regarding Bill 173 to the standing committee on social development.

I am pleased at this time to introduce to you some other members of the joint committee who are seated at the table today: Mr Mike Pennock, Visiting Homemakers Association of Hamilton-Wentworth, board member; Ms Bernice King, St Elizabeth Visiting Nurses' Association, Hamilton-Wentworth, board member; Mrs Betty Muggah, director, Hamilton-Wentworth home care program; and Mrs Rita Soluk, president, St Elizabeth Visiting Nurses' Association, Hamilton-Wentworth.

My remarks to you today are a synopsis of our written submission which you will find in the folder that you have received. For your information, I intend to touch on who we are, the purpose of our presentation, our approach to reform, and our response to Bill 173. I expect our presentation will take about 10 minutes and will leave us approximately 10 minutes for questions and answers.

There are two accompanying background documents in the folder. These have been jointly prepared by our three agencies and in essence outline our proposed model for the provision of integrated community-based services and the progress that we have made to date in moving towards the integration of our operations. Those documents are dated May 1994 and July 1994.

At this point I would like to give you a brief background of who we are and the purpose of our presentation. Collectively, St Elizabeth Visiting Nurses' Association, Victorian Order of Nurses and the Visiting Homemakers Association are the major not-for-profit providers of visiting nursing, homemaking, case management and therapies in Hamilton-Wentworth. The Hamilton-Wentworth home care program and the placement coordination service are administered by the Victorian Order of Nurses.

Our combined services in the fiscal year 1993-94 represent approximately 90% of the total provincial expenditure in Hamilton-Wentworth for community-based health and personal care services.

In addition, our agencies provide a wide range of community support services, including Meals on Wheels, care giver support, a day program and volunteer visiting, which collectively involve over 1,100 volunteer service providers.

The purpose of our submission today is to urge you to reconsider the wisdom of full amalgamation of agencies to achieve the government's goals and to amend the proposed legislation, Bill 173.

Our approach to reform: In January 1994, the boards of directors of our three agencies formed an interagency task force with the following objectives: (1) to identify opportunities for integration of the current operations of our three organizations which are consistent with the provincial guidelines for the establishment of multiservice agencies; and (2) to prepare a model for the provision of integrated community-based services for submission to the district health council long-term care committee.

At the same time as we have formalized the relationship among our three boards, we have been collaborating with the coalition of the other community agencies in Hamilton-Wentworth which provide a range of community support services. Together, we are working towards the development of an integrated service system in Hamilton-Wentworth. Our work together has been undertaken in the spirit of a long-standing approach to interagency collaboration in planning and service delivery in Hamilton-Wentworth over many years.

In May 1994, the boards of directors of St Elizabeth Visiting Nurses of Hamilton-Wentworth, the Visiting Homemakers Association of Hamilton-Wentworth and the VON Hamilton-Wentworth developed and submitted a joint proposal to the Hamilton-Wentworth District Health Council outlining our shared vision of an integrated community-based service system in Hamilton-Wentworth. As well, we have committed ourselves to achieve greater integration of our operations.

In light of the expectations for change and in an effort to build on our strengths, St Elizabeth Visiting Nurses' Association, Visiting Homemakers Association and the Victorian Order of Nurses believe that the citizens of Hamilton-Wentworth would be well served by a region-wide integrated system for the delivery of health and personal care services, a system which:

(1) Provides integrated region-wide intake and screening of individuals through direct client access to a single regional telephone number or local access through identified intake points which are electronically linked to the region-wide system.

(2) Employs a common assessment tool for all service providers and a streamlined assessment process in relation to the client's priority needs.

(3) Provides region-wide integrated delivery of case management, nursing, homemaking and therapy services organized in multiple interdisciplinary teams which may be located in satellite or neighbourhood offices throughout the region and linked with locally administered home support services.

(4) Maintains a dedicated case management service in each of the area's hospitals to support early access and transition from hospital to home.

(5) Maintains the availability and identity of locally initiated community-specific services which are linked with the region-wide services.

(6) Maintains the level of volunteer commitment which has sustained community agencies in both governance and service delivery.

I want to now turn your attention to focus specifically on our response to Bill 173. At the outset, we want to stress that we are committed to the principles and ultimate goals of the government's long-term care policy. We strongly support the need to improve and simplify access for the consumer to a full range of health and community support services in the community. We also endorse the determination to enhance consumer participation in decision-making and to ensure accountability of the provider for excellent care and service within the community.


We are committed to taking leadership in constructive change. However, we have very real concerns regarding both the pace of the change and the determination of the government to implement a new structure whose efficacy and cost-effectiveness have not been demonstrated in Ontario or elsewhere in Canada.

We believe from our experience in working together to develop an integrated multidisciplinary client team that it is possible to achieve the outcome which the government is committed to through a federated model of organization rather than the amalgamation of agencies, as the government's Bill 173 requires.

From the client's perspective, the urgent need is for integration at the level of service delivery and simplified access to needed services. Whether the actual service providers come from one agency or multiple agencies is irrelevant to the client as long as they work together as a team with shared values, common assessment and shared protocols and standards of service. Our challenge, as service providers who have demonstrated our commitment to working together to provide high-quality, responsive service, is to develop the necessary governance and organizational structure to make that happen.

With respect to the organizational and governance structures, there has been no clear demonstration or evidence to show that amalgamation or consolidation of service providers in a single agency will result in improvement in services. On the contrary, there is evidence that the administrative costs associated with amalgamation may further erode the resources available for direct service to the client and may negatively impact on quality and the volunteer base of many of the services.

It is for these reasons that we must express the deep concern of our three organizations about the proposed direction of long-term care reform, specifically, the creation of the multiservice agency as defined in the legislation. We are opposed to the government requirement for a full amalgamation of long-term care services. We ask that the standing committee on social development support our request for flexibility by amending Bill 173 to allow for the evolution of locally determined community models for long-term care services.

In closing, on behalf of the three boards and my colleagues here today, I want to thank you for the opportunity to speak with you. We welcome your questions and comments in response to our remarks or any of the other documents that we have submitted to you today.

Mr Jim Wilson (Simcoe West): Thank you very much for your presentation. I note on page 16 of one of the background papers called A Model for the Provision of Integrated Community-Based Services in Hamilton-Wentworth, of May 1994, there's a schematic on that page that I think best represents to me and perhaps most of the public what the original intent and vision of an MSA and one-stop shopping was. I think you've got it right. It's the first time I've seen it and I appreciate the schematic.

The problem is, the government has taken what was a relatively simple idea of one-stop access -- perhaps that went as far as, certainly, information, perhaps assessment intake, referral to other agencies and certainly one phone number in each area, which was the most important thing that we heard throughout the public consultations -- they've taken that and decided that the agency, the MSA, will have a monopoly also on the delivery of services after -- in many cases I'm sure it'll take the four years to reach the 80% of delivery of services.

I just want to simply ask you, because it sounds like you've already gone 100 miles on your journey towards integrating services here -- and cooperation, it sounds like it's been very good in the region. How problematic is the new MSA going to be for you? What are you going to do to try and preserve the identity of your agencies now, because they're going to take over governance and delivery of services, and I think it's the end of your agencies if this bill is allowed to pass as is?

Mr Bistrovich: Yes, exactly that. That is our point. What we're looking for is to get some flexibility in the system so that we as agencies can explore various opportunities and other options that perhaps may be available to us to deliver the kind of service the citizens and the community of Hamilton-Wentworth expect.

The Acting Chair: Do you have anything further?

Mrs Betty Muggah: Perhaps an additional point or two there. We're not saying, as we go through this journey, that ultimately in a community like Hamilton-Wentworth there may not be some amalgamation and may not need to be some amalgamation, but what we're seeking is some permission to allow that to evolve over time. We have just begun a very active dialogue in our community -- the three agencies that we represent with our sister agencies that are providing a range of community support services across the region -- and we believe that we may be able to come up with some kind of a governance or organizational structure that will provide the kind of accountability the citizens of Hamilton-Wentworth require.

The problem is that the legislation introduces a four-year time limit, it introduces a restriction with respect to a 20% purchase of services, and it seems to imply, as we have worked it through, that ultimately in order to meet the requirements of the legislation we really would have to amalgamate to form this one agency, all of us, that provides this core basket of services.

We're asking for some flexibility so that the organizational arrangements, the governance structures, will allow us to customize the appropriate kind of structure for Hamilton-Wentworth. The legislation doesn't allow us to do that.

Mr Mike Pennock: Just another quick comment: I think the key message we're trying to bring to you today, and it's a Hamilton-Wentworth message and we don't pretend it's a provincial message, is that we have already gone a long way along the road to integration here. As you heard, 90% of the services are already being provided through three agencies, but they are three agencies that have their own stature and history and status in the community, their volunteer base, their donor base. And we can go further on the integration, as we say we're doing, but we think what we have represents the best of both worlds.

You can integrate, you can coordinate at the service end but still maintain and build on the history of strong agencies in the community, and the possibility to continue developing that kind of model is what we're really asking for. We're not saying this is a model for the rest of the province -- what works in Kingston or what works in Kitchener may be quite different -- but we're absolutely convinced, because it's evolved here already, that it is the best model for Hamilton-Wentworth and we're looking for the flexibility to continue evolving it here.

Mrs Barbara Sullivan (Halton Centre): Certainly Hamilton-Wentworth is known to be a model and to reflect the kind of collaborative and cooperative and coordinated efforts between the agencies here. One of the things that will be clear is that, if an MSA comes into place, your agencies will ultimately disappear. There will not be the critical mass for the VON and for the Red Cross -- although not in this presentation -- and will certainly disappear, St Elizabeth and so on.

The volunteer core that supports these organizations is key in two ways: one, in service delivery; and secondly, in fund-raising for the organizations themselves. I understand that about 30% of income from many organizations is a direct result of volunteer activity.

Could you give us an impression of whether you think your volunteers would shift their allegiance to a more bureaucratic single agency that doesn't have the history and the cultural ties of your organizations.


Ms Muggah: We're having a little debate here about who's going to take that. I can speak from a VON perspective. Our VON here in Hamilton-Wentworth has approximately a thousand volunteers. We've been very successful in recruiting, attracting and maintaining those volunteers. They're a critical part of three for sure, three anyway of our key programs, Meal on Wheels, VVP and care giver support.

We are extremely concerned about the need to ensure that the volunteer service sector continues to grow, and I think we'd have to say to you that without clear evidence on the table, we're very, very reluctant to move towards a multiservice agency model that could sabotage or restrict our volunteer growth in the future, and we just haven't seen the evidence. Perhaps a further comment from St Elizabeth's.

Mrs Rita Soluk: Probably just a short comment I would make is that we could illustrate by example here in Hamilton something that happened with the cancer society. They had an office on the mountain which they made a decision they would close. When they announced that decision, the volunteers were quite clear they would not be prepared to provide their volunteer support down the mountain and, in fact, when they closed the mountain, they lost their volunteers. Not only that, it's my understanding that when the Terry Fox run was held that year following the closure, they did not do as well in their fund-raising activities as they had done in previous years, and they felt that was the result of some of the anger they were still experiencing as a result of closing their office.

So if you're looking at the results just within a particular organization with the same mission and same values, and they weren't prepared to move down the hill within the same region, I think that tells you what sort of support we might expect from the volunteers if we pursue this line of action.

The Acting Chair: Thank you very much for your presentation. We appreciate your coming before the committee today and if there's any additional information you'd like to share with us, please feel free to submit it in writing to the clerk.


The Acting Chair: I'd like to call Jacqueline Balfour. Please come forward and introduce yourself to the committee. You have 20 minutes for your presentation.

Ms Jacqueline Balfour: Good morning. My name is Jacqueline Balfour. I'm a registered nurse with 23 years' experience. My work experience includes 17 years of hospital nursing and for the last six years I have been employed by the regional Niagara home care program as a case manager.

I can assure you that I applaud this government's efforts to improve services in the home and reduce reliance on institutional services for the people of Ontario. I have firsthand knowledge that people are happier and do well at home with the right mix of services to meet their needs.

I have seen and am seeing more flexibility even within the current home care program to be more responsive to the deficiencies which will ultimately be addressed by long-term care reform. I have been closely following the process and documents that have been evolving and am pleased to be able to comment today on Bill 173.

I am pleased to see that the bill has captured the essence of what I believe the home care program has been and is continuing to do, and that the following aspects have been recognized as important and have been enshrined in the legislation.

These include page 10, clause 7(1)(b), which will ensure "competence, honesty, integrity and concern for the health, safety and wellbeing of persons receiving the service"; on page 13, subsections 14(1) and (2), which reflect the current practice of providing consumers with information about available services and the referral to other available community services which are not necessarily provided by the agency; page 15, section 20, which refers to the development of service plans based on assessment and eligibility with the review and revision of the plan as requirements change.

I can only hope that case managers will continue to provide these components in the current format of face-to-face encounters with consumers. The old adage that a picture is worth a thousand words is especially true in the assessment process. Eyeballing someone in their own home can show and tell so much.

Often someone who will tell you that they can manage will finally feel comfortable enough, when you've put them at ease and built a rapport, to admit that it takes the better part of the morning to get washed and dressed and as a consequence they have to lie down and haven't the energy to prepare their breakfast. Can this be captured in any way other than a home visit?

You would also be amazed at what people will open up and tell you when they know you are a nurse. Also, it is only on a subsequent home visit a month or three months later that you can be amazed at how much brighter they look once services are in place, or recognize the decline in their walk and suggest a physiotherapy visit to try a cane.

With respect to part III, the bill of rights, on pages 7 and 8, I initially could not understand the necessity of its inclusion in light of the fact that nurses and therapists are regulated health care professionals who are governed by their respective colleges. Protection of the public is the legislated mandate of the colleges and ensures that all this section describes happens. However, upon further deliberation, I realized that this section must seek to ensure that unregulated workers are answerable and accountable. I hope this is the intent, and that it is not the result of a perception that current practice does not respect consumers' rights.

On page 9, subsection 5(1), and page 24, section 40, these sections address the immunity from liability for the director or a program supervisor and the appeal board. I must comment that I can find no similar proviso to acknowledge that all service providers will have any form of protection against acts done "in good faith in the execution or intended execution of any duty, function," and I believe this must be incorporated into the bill.

I believe that the appeals process outlined on page 22, part IX, will be welcomed by service providers as well as consumers, for I have never relished advising anyone that they do not meet eligibility criteria. It is reassuring to know that there will now be an easily accessible mechanism for resolution, or at least a confirmation of what's happened, from the higher authority.

I have grave concerns about the practical application of the order to suspend or cease activity on page 28, section 47. Even though subsection (4) on page 29 attempts to waive the hearing, leaving the authority to suspend or cease activity to the Minister of Health, in my view, sets up a bureaucracy which could take at least days.

This section acknowledges that "the continuation of the activity is an immediate threat to a person's health, safety or wellbeing," yet still leaves the authority to suspend or cease with the Minister of Health. When any worker feels for their safety, there needs to be assurance that service is suspended, period. Also, that service does not restart until an investigation has been concluded and remedies are in place. Even if it is not a crisis situation -- if, for example, a homemaking agency reports a loaded gun in the home -- I believe there is an immediate obligation to suspend service until the matter is investigated and resolved, not to continue service while you seek an order to suspend through ministry channels.

Page 38, paragraph 30, speaks to the service providers having "certain qualifications" or meeting "certain requirements." This seems much too broad and lacking in clear direction in a document which is so specific in so many other areas. It is no secret that we expect to see a proliferation of personal support or generic workers and, as a cost savings, less reliance on professional service-providers, but such a nondescript reference leaves, in my view, too much to chance in ensuring that consumers receive care and service from qualified, trained individuals who are not functioning beyond their scope and without the capacity to recognize reportable or noteworthy observations.


I would be less than honest if I did not admit that I am fearful for my future work, life and job security. I believe that for consumers who made the deficiencies in the current system known to government during the consultative phase, case management bore the brunt of being misunderstood and oft-times blamed for the deficiencies. I see nothing in the bill which verifies earlier documents which indicated that home care staff will form the core staffing of the MSA. I see nothing that ensures the consultation with unions or successor rights with a move to MSAs that was referenced previously.

I can assure you that home care programs have been fiscally responsible and budget-conscious and always cognizant of the most cost-effective means possible in service delivery, but I am fearful that the consumers we have consulted have unrealistic expectations of just what the government will provide under the guise of assisting people to remain in their own homes.

I hope we do not get into the business of cutting grass and shovelling snow with dollars that should be spent for health services. Currently, the integrated homemaker program has a capped budget and we know that the day will come when people are wait-listed. And I note that on page 16, subsection 21(2), the document also speaks of the waiting list for service.

Life experience dictates that it's the squeaky wheel that gets oiled, and it is not the informed, knowledgeable, active senior that I am worried about, but rather the timid soul who has always made do and never asked for help. I wonder whether they will continue to fall through the cracks even in this new revamped system.

Thank you for this opportunity to share my thoughts with respect to Bill 173.

The Acting Chair: Thank you very much.

Mrs Sullivan: Thank you. You've put a lot of work and analysis into the presentation, and I think members of the committee appreciate that. As a consequence, you've covered a lot of areas that I'd like to ask you questions about, but I know the Chair is going to keep me in line.

One of the questions I wanted to ask relates to other interventions that we've had where case managers have suggested case management should be included as a profession in the professional services category. I'd like your comment on that.

I'd also like your comments on whether the work of the MSAs should be accredited in some manner such as might be done through the Canadian Council on Health Facilities Accreditation or some other similar review board or agency, and in particular the paraprofessionals and non-regulated workers -- how their work would be evaluated.

The third thing: You mentioned at the very end the successor rights and union representation. One of the concerns I have particularly is that more than half of our community support workers and home workers are in fact non-union and there is absolutely no guarantee that they will find jobs. In fact, union members, because of the Labour Relations Act, have indeed a greater protection than non-union workers, and clearly there's a bias in the setup of the organization towards a union member.

I know they're larger questions, but you can decide which one you want to tackle before she cuts you off.

Ms Balfour: Okay, I guess really --

The Acting Chair: Just to clarify, I never cut off deputants, I always cut off members.

Ms Balfour: I guess, having had the opportunity to give a pitch for case management, that would be my first choice to respond to of all the concerns you've raised.

Certainly in Niagara, we have the experience of being all registered nurses who are case managers. I feel that we bring tremendous assessment skills as well as our professional judgements, knowing health issues and being able to have a unique perspective to look at whole human beings and a holistic approach.

Certainly it was a real eye-opener to me, when I moved from hospital into the community, that you suddenly saw people as human beings in their own environment. We see ourselves much like quasi-detectives. So much you can see that isn't said; in the fact that maybe the dusting hasn't been done and there's a lot of clutter, even though someone will say, "Oh, I'm managing just fine." You can sense tensions between family members and, again, with getting a rapport, try and pull out the kinds of things that hopefully you can glean about the relationship and how it's impacting on health and the situation.

One of my biggest fears, as we've been moving through this initiative, is in hearing that the government, in its quest for consistency -- which is needed; I'm not against consistency -- is looking very much at an assessment tool. We were told, at a case manager's conference, that the tool was going to be colour coded and people could essentially do their own assessment and send it in. This is, I think, the part that is most frightening because I again fear for these frail people who, seeing a colour-coded, half-inch document would simply be overwhelmed and never proceed.

Mr Gary Malkowski (York East): Thank you for your presentation. Your feedback is most important for us. We're aware of some of the issues that you have already brought. You also mentioned you are concerned that some service providers may not get jobs, but my understanding is that a lot of the service providers who are working now will be absorbed by the MSAs.

You also talked a little bit about case managers being blamed for some of the misconceptions, or at least some of the problems up there, but what's true is some people do make mistakes. That's true. But do you truly believe that the system itself, systemically -- that giving consumer feedback, how we could improve the quality of service among all professionals working with the consumers to make sure that no one feels threatened. How would we go about doing that in long-term care so that consumers feel their rights are protected and that the staff feel they are in a comfortable situation where they can do the best they can, given that people do make mistakes? Based on your experience, how could those kinds of problems be avoided in the future?

Ms Balfour: Actually, I do believe that in having the bill of rights in the document and in building on what is current practice, there's no danger that we won't achieve these ends. Certainly, it's practice now to set up, on that first assessment visit as a case manager with your client, just what mix of services will suit and fit in best.

We can't always give people exactly what they want -- expectation does not always mesh with need -- but we do our best to be creative and I can honestly say in my practice and certainly in viewing the practice of all, if not most, of my colleagues, that we are very cognizant even now in current practice of making the client, the consumer, and his family very much feel a part of the process, and very much we want to be approachable when they're having difficulties, when needs change and when they're in need of reassessment.

The Acting Chair: Thank you very much, Jacqueline. We appreciate your coming before the committee this morning. If you have anything further that you'd like to communicate with us, please feel free to do so in writing.



The Acting Chair: Our next presentation is St Joseph's Health Care System. I invite you to come forward. Welcome. You're not strangers to this committee nor to myself. A personal hello.

Sister Joan O'Sullivan: How do you do?

Thank you very much for the opportunity to respond to Bill 173. My name is Sister Joan O'Sullivan and as the vice-president of St Joseph's Health Care System, I am here on behalf of Sister Teresita McInally, president and chair of St Joseph's Health Care System.

My past experience includes time spent as CEO of two hospitals of various communities within the Hamilton diocese. With me are Mr Brian Guest, executive director of St Joseph's Health Care System, Sister Margaret Myatt, president and CEO of St Joseph's Hospital and Home, Guelph, and Mr Paul O'Krafka, executive director of St Joseph's Villa, Dundas.

My comments will deal mainly with the implications for community-based services provided by our member facilities. Please understand that the development and governance of community-based services are an integral component of the historical and continuing contribution of St Joseph's Health Care System to the communities we are privileged to serve.

St Joseph's Health Care System was incorporated in 1991 and represents a consolidation of the health care ministry of the Sisters of St Joseph of Hamilton which has provided health and social services to the communities in the Hamilton diocese for over 130 years. Our health care ministry is governed through volunteer representation from our communities on local boards of trustees and encompasses programs and services offered by the following member facilities: St Joseph's Hospital, Brantford; St Joseph's Villa, Dundas; St Joseph's Hospital and Home, Guelph; St Joseph's Hospital, Hamilton; St Mary's General Hospital in Kitchener.

As you can see, we are well represented in both the long-term and acute sectors in delivering care. Our mission reflects our Judaeo-Christian values and emphasizes our respect for the dignity of all persons, regardless of age, race, religion or infirmity.

The primary concern that brings me here today is with the proposed scope and governance implications included in Bill 173 with respect to community-based services. My understanding of the proposed multiservice agencies, the MSAs, is that they will, de facto, take over the governance and administration of community-based programs for the elderly in the province.

Specifically, for St Joseph's Health Care System, this would mean the dissolution of such programs as the seniors centre and respite care program at St Joseph's Villa, Dundas, and the Alzheimer day program and the Out and About program at St Joseph's Home, Guelph. I am also unclear as to the government's longer-range plans for other community-based programs, such as the women's detox program administered through St Joseph's Hospital, Hamilton, or the alcohol and substance abuse program through St Mary's General Hospital, Kitchener.

Let me state clearly and unequivocally that we support continuing efforts to coordinate and expedite access for seniors to long-term care programs and services in the community. We also support efforts to standardize funding, the development of critical evaluation and outcome measurement tools and strategic planning.

We have grave concerns, however, that this legislation as it is currently proposed will effectively eliminate the contribution of volunteers and staff who have developed programs and services for seniors in response to identified community needs. We also submit that a shift in governance and administration to a government-controlled bureaucracy, the MSA, will not necessarily be cost-effective nor more responsive to community needs. It is unrealistic to think that one can dismantle a system which has been in place for so many years and reassemble it under a new governance and administrative structure. Health care is not conducive to a cut-and-paste approach to delivery.

There is also the critical element of choice for seniors missing from this proposed structure. For example, if seniors do not feel they are receiving adequate or appropriate care through the MSA, are they at liberty to seek help elsewhere? Will it be available and at what cost? These are real issues which seniors are expressing to us, related to this proposed legislation.

The rationale for our position is as follows:

Tradition of Care: As I have pointed out, we have a long-standing tradition of serving seniors in our community with both residential and community-based programs.

For the last several years, health care facilities have been challenged by the governments of the day to develop community programs as an alternative to institutional care.

We have responded to this challenge and now offer a continuum of care which provides support for both families and seniors. For example, at St Joseph's Villa, Dundas, we provide outpatient care through our seniors' centre, short-term relief for families through our respite care program and, if necessary, facility-based care. This continuum allows seniors and families to plan their future care in cooperation with staff they know and trust.

Last week, during the review by the Canadian Council on Health Facilities Accreditation, at the Villa in Dundas -- that is a third-party review -- the following comment was made: "You are to be congratulated on lobbying efforts with government and insight into providing a continuum of care -- such as estates, day centre, respite and permanent residency at the Villa. Seniors come here experiencing commitment and trust."

We feel it would be a major step backwards to isolate health care facilities such as St Joseph's Villa, Dundas, and St Joseph's Home, Guelph, from providing community-based programs as part of their mission to their communities.

Economics: St Joseph's Health Care System is a major corporation in the health care industry with a combined annual operating budget approaching $300 million. Our community-based programs benefit tremendously from the economies of scale which exist, ranging from purchasing power for supplies to insurance to administrative support.

Simply put, we feel that we operate as responsible stewards for the taxpayers of Ontario, in an effective and efficient manner, and have taken advantage of opportunities for administrative efficiencies.

Volunteerism: The role of volunteers is critical in the delivery of our community-based services, ranging from governance to direct care and support. Our boards of trustees and board committees are all volunteers who are selected from a cross-section of individuals in our communities who are committed to our mission and the care of seniors. Also, the many members of each of our facility volunteer associations respond to our mission and are a key component of all our programs and services, including those that are community based. This tradition of volunteer support is not, in our opinion, easily transferable to a government bureaucracy and would represent a tremendous loss to the seniors in our communities.


Quality of care: Our facility-based community outreach programs are governed and accountable for the highest level of quality care. For example, all of our community-based programs are reviewed regularly by board committees including medical, nursing and community representation and are subject to regular external reviews through the Canadian Council on Health Facilities Accreditation. In our opinion, the quality of care delivered is of the highest standard and would not be enhanced in any way by a change in governance.

In conclusion, we support efforts to coordinate and simplify access to programs and services for seniors, but we do not support a radical change in the governance and administration of those same programs and services which have served our senior population with commitment and excellence.

Without question, we are all striving to find models to deliver the best possible care for seniors in Ontario, but we implore the standing committee to recognize the tradition and mission of existing care givers to this end.

Mr Larry O'Connor (Durham-York): I appreciate your coming before us today. I noted on page 5 of your brief, you mentioned the size of the St Joseph's Health Care System; indeed with a budget of $300 million, it is a major corporation. Yet when we take a look at -- locally, I think the home care budget here is around $30 million. So it's a little bit lower community based when it comes to that.

I was just wondering, we've heard through our hearing process, the consumer appeal process might be too cumbersome and problematic for some of the consumers who may find difficulty in the evaluations that they had. In a corporation the size of the St Joseph's Health Care System, how do you deal with an appeal process to make sure the consumers' needs are met and work with consumers in that area?

Mr Brian Guest: I'll answer that, if I may. All of our boards are represented by community members. About five years ago, we started advertising in all our community newspapers for people who are interested in joining our boards. Actually, we'll now start a system where people will join our board committees and eventually join our boards, so we think we are very well represented and in touch with our community.

In addition, in the long-term care sectors we have residents' councils which regularly provide feedback. We have meetings with relatives, and I think we really go to tremendous lengths to involve consumers through accreditation processes. We're subject to these accreditation processes we talked about. We do regular audits of satisfaction I think of the most formal nature possible. I really believe we have identified exactly what you're talking about as a key component.

You also must remember that all of our communities have their own boards of trustees and they are representative of those specific communities, so it's not a top-down head-office governance model in any sense.

Mr O'Connor: In looking at our --

The Acting Chair: Only one question, Mr O'Connor. Thank you. There are a lot of members who would like to ask questions.

Mrs Yvonne O'Neill (Ottawa-Rideau): I'm really delighted that you came this morning. Your reputation precedes you, not only in your community but beyond. We have the very same concerns you have. I'm going to ask legislative counsel or the director to try to explain to us just how facilities such as yours that not only are evaluated in their communities but beyond that, through the accreditation process, are now going to fit into this whole Bill 173.

You have already gone through Bill 101. Now how do we put Bill 101 and Bill 173 in a situation such as yours? Your services cannot be lost. Maybe someone will be able to help us.

The Acting Chair: Are you requesting a reply from the ministry?

Mrs O'Neill: The parliamentary assistant, yes.

Mr Paul Wessenger (Simcoe Centre): I'll ask Mr Quirt to respond to that.

Mr Geoff Quirt: Thank you. In specific answer to the question, the programs and institutional services offered at the hospital level and at the homes for the aged level would not be directly affected by Bill 173. In other words, the corporations that are now responsible for governing the -- St Joseph's Villa, for example, would continue with that responsibility. We are now working with St Joseph's Villa to determine the extent to which it should be involved in the respite care business, providing respite care services to the community at the facility level, and that funding would be flowed directly to the facility and would not be affected by Bill 173.

The extent to which the organizations are involved in the delivery of other community-based services, like Meals on Wheels or transportation, those services would certainly form part of the services to be discussed locally at the district health council planning subcommittee: how best to bring together those programs and services under the MSA umbrella. Of particular concern to St Joseph's Villa, and I'm speculating here, might be the future of its in-house day program.

We have heard from other facility-based operators who have had similar concerns that the day program forms an integral part of their long-term care facility operation. Obviously, St Joseph's Villa and other facilities like it are heavily involved in the community and the bill, as it currently stands, would allow for the continued operation of that program at a facility level within the 10% or 20% purchase limits the MSA might have. It's conceivable that we would consider an exemption of those facility-based day care programs if in fact the committee hears similar concerns raised as we go across the province.

I suspect that may be a position put forward. The government has already indicated that programs independent of facilities that offer social-recreational activities, elderly persons' centres, could remain separate from the MSA if in fact the local planning process were to come to the conclusion that this is the best thing for that community.

Mrs O'Neill: Thank you.

The Acting Chair: Thank you for your presentation. You'll be on first questioner with the next deputation, if that's all right, Mr Jackson, or if you're --

Mr Cameron Jackson (Burlington South): Can I call them back to answer it then?

The Acting Chair: There's about one minute. All right?


The Acting Chair: I'd like to call the next delegation from the Canadian Red Cross Society. Welcome. Please begin your presentation by introducing yourselves to the committee.

Ms Heather Richardson: Good morning. We're pleased to have this opportunity to speak to Bill 173. I'm especially delighted to introduce you to two volunteers.

At this point, I would like to share with you that I am Heather Richardson and I am the regional director for the Red Cross homemaker program in west central Ontario. West central encompasses Hamilton, Wellington, Niagara, Brantford, Waterloo and Halton. I also want to indicate that I have been part of the Red Cross management team for almost five years and I truly believe in the work of the Red Cross and in the work of the homemaker and home support programs. I am proud of the staff and volunteer work in assisting vulnerable people in west central Ontario.

The two people at my side, Della Crozier and Diane Pick, are valued volunteers and they're going to share a little bit about themselves. First of all, we're going to begin with Della.

Mrs Della Crozier: Good morning, Madam Chairman and panel members. I've always considered myself a community person, interested in and caring about what is happening to my neighbours, my friends and my community. Since moving from rural Middlesex county to the rural Milton community seven years ago, I have become involved in my new community. I am a member of the Halton long-term care committee, one of seven that represent the "other" category.

I am also on the Halton Placement Coordination Service board of directors and for the past four years I have been a Red Cross volunteer, the homemaker chairperson at the Milton Red Cross branch.


Ms Richardson: I'd now like you to hear a few words from Diane about her portfolio and then the two volunteers will jointly give the presentation.

Ms Diane Pick: As an illustration of how well the Red Cross utilizes its volunteers, I presently perform four functions with them. I'm the vice-president of the branch, I'm the west central homemaker area representative, I'm the home support representative on the regional council and I sit as a member of the homemaker services committee in Brantford.

The reason I'm willing to give all of these hours to the Red Cross is because I also believe they provide critical services to vulnerable populations. Their seven stated fundamental principles of humanity, impartiality, neutrality, independence, voluntary service, unity and universality are principles that are demonstrated by their staff and volunteers on a regular basis. It's an honour and a privilege to be able to volunteer with the Red Cross.

Mrs Crozier: The Red Cross is a symbol in our communities of people helping people. We all know of the Red Cross international work throughout the world. However, I have come to appreciate how unique, caring and committed the Red Cross organization is in our own community.

The Red Cross depends on staff and many, many volunteers who give generously of their time to provide a wide range of programs and services, such as transportation, equipment loans, first aid, seniors' programs, Meals on Wheels, blood clinics, homemaking, fund-raising for local projects, as well as international famine relief aid to war-torn countries and other disaster aid. The volunteers also give many hours in committee work to this organization.

Homemaking is the core program of the Red Cross community support services. It is a staff-employed service with volunteers involved at a board level. The homemaker service provides personal care, family relief and home management to all ages. This includes individuals and families in time of illness, convalescence, disability and family crisis.

Homemakers help the frail, elderly and disabled with a variety of services during each visit to the home. For example, homemakers might do a morning bath, get the individual dressed, prepare, serve and clean up breakfast, then clean up the bathroom area and tidy up the bedroom and laundry. Their days are busy.

As the homemaker carries out these tasks, there is an opportunity for interaction with the individuals which meets the needs of their companionship. This helps the individuals maintain their independence and self-esteem and keeps them in their own homes as long as possible. It also prevents loneliness, isolation and neglect that can often occur as the individuals grow more frail and less able to do for themselves.

The Red Cross organization has 75 years of experience in providing home support services in our communities. Over the past two years, Red Cross volunteers and staff at both the local and provincial levels have been participating in the process to reform the long-term care system.

The Red Cross, as part of the team delivering services, supports the need for change to the present long-term care system. A consumer-friendly system with simple access and coordinated services will make it easier for the consumer, the care givers and the families to find and receive the care and service.

This all sounds so simple. However, my experience this past year on the Halton long-term care committee has shown just how complex and difficult the task is to reform the present long-term care system. This has been quite an experience and it's hard work. I have some points that I would like to emphasize with you.

Flexibility: The legislation and the regulations need to be flexible for the individual communities to design a system that fits and responds to the needs of the community and builds on its strengths and resources. The list of services should be flexible so as not to be exclusive of the service needs in the future, and the communities need the flexibility to allow them to create a design that best suits their needs.

Consumer representation: The legislation needs to ensure consumer and volunteer representation on the boards of the organizations that the community creates. Otherwise, it will be easy for representation of the health and social service professionals to outnumber consumers and volunteers. In my work on the long-term care committee, the consumer and volunteer perspective has proven invaluable, adding another dimension to the discussions.

Volunteers: Our volunteers give many, many hours of service. They are committed to their clients, to the service they provide as well as to the organization they work with. We need this caring culture, and the committed caring culture we have now, to move into the new organizations that our communities will create. The loss of volunteer involvement will have a direct impact on the services delivered and on the funding available.

I am also concerned about the effects of the transition and the anxiety it creates for our volunteers and our staff. They both must be treated fairly. The human resource issues for volunteers and non-union staff are of critical importance and cannot be ignored. To date, we do not think we have had a satisfactory answer to our concern.

In summary, we need to ensure that the legislation and the regulations allow flexibility for our communities to design a system that responds to the community needs and builds on its present strengths and resources. All of us must work together in a cooperative and collaborative manner to make the changes necessary.

We thank you for the opportunity to present a Red Cross position on this important issue. Now I'd ask Diane to summarize the position of the Red Cross.

The Acting Chair: Did you want to make further presentation?

Ms Pick: If I could, please, I'd like to give an overview of the full Red Cross position. I believe the position's been distributed. I'll just be doing a summary of that for you.

The Acting Chair: By all means.

Ms Pick: To understand the Red Cross position, you need to understand a little bit about our structure. 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 society in any one country.

The society is a non-profit, charitable organization incorporated under federal law. Each province has a Red Cross division, but 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 Red Cross operates 78 branches, almost all of which run community-based long-term care programs.


Our programs have been developed in response to needs identified by the local communities. Particular emphasis is placed on ensuring necessary services are available to the vulnerable members of those communities. We often are the only service provider in sparsely populated and remote areas of the province.

Through our programs, we provide services to over 130,000 people. Our services include over five million hours of homemaking, almost half the homemaking service provided in the province. We also provide over 100 other community-based programs. Almost 10,000 volunteers and 6,000 staff, mostly women, together provide these services.

The Red Cross is supportive of the principles that have been developed for the reform of long-term care. However, there are some sections of the current draft of Bill 173, an Act respecting Long-Term Care, that are a concern to us.

Later in my presentation, I will make three suggestions for amendments to the legislation. We feel that any legislation must be flexible enough to allow service providers to meet the changing needs of their diverse communities. Legislation must allow us to work with other agencies in our communities to find new and more effective ways to provide the services and to make sure that the services we provide remain relevant.

We are particularly concerned that the legislation respect the history and traditions of volunteer agencies like the Red Cross. These agencies are part of their communities. Their services were created to meet needs in their communities, and often it's the volunteers who make the programs a reality.

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 as described in the act. We acknowledge the need for improved access to and coordination of the existing system, but we also see many good parts to the system we now have.

This proposed system will create a completely new organizational structure that is untested. The Red Cross operates services across the province. This big picture allows us to identify some simple changes to the system that would increase efficiency and improve quality. We're very concerned that the system must not fail the vulnerable people who depend on these services.

The legislation, as it is currently drafted, precludes the Red Cross from becoming an MSA or providing services as part of an MSA. I earlier described the structure of the Ontario division of the Canadian Red Cross Society. The legislation's requirements that an MSA must be incorporated under Ontario legislation and that each MSA must have its own board of governors are incompatible with the fundamental principles and corporate structure of the Canadian Red Cross Society.

The Red Cross has three specific recommendations for amendments to the legislation. We believe that these amendments would respect the purposes of the legislation but make the legislation more flexible and allow us to use the strengths of the existing system.

The first is part II, subsections 2(3) to (7) inclusive. This section designates the community services which are to be provided by MSAs. The bill describes four categories for these services and outlines the specific services that fall under each category. We are most concerned about the division between "homemaking services" and "personal support services." We believe that this is inconsistent with the current practice and emerging future trends.

It has taken concentrated effort over the past few years to erase the belief that homemakers are not simply Molly Maids. The women, and I refer to them as women because the vast majority of our over 5,000 homemakers are female, have worked hard to have them become accepted as valued members of the health care team. Through formal educational programs, on-the-job training and adherence to a high standard of practice the homemaker has, for the most part, left behind the rather subservient role she played on the health care team. Homemakers are taking on increasing responsibilities that allow us to better use the limited funds allocated to community-based health care. Not long ago, the nurse was the only health care professional who could bathe a client. Now, a trained homemaker can perform this task.

The separation of the personal care versus non-personal care services is ambiguous and inconsistent with the way services are usually delivered in the client's home. Many functions routinely provided by homemakers cross the boundaries between what legislation classifies as "homemaking" and those called "personal support." One example: Training or assisting a client to plan nutritious meals, shop, store the food and prepare the meal is homemaking, while training or assisting the client in activities of daily living is personal support. The Red Cross feels that the high level of interdependent activities in the personal support category and those routinely provided by the homemaker must be acknowledged.

We recommend that this section of the legislation be changed to respect the role of the homemaker and that such specific detail be moved to regulations.

Part VI, section 13: This section stipulates that an MSA may not spend more than 20% of its budget to purchase community services. This requirement is not to be administered globally but applies to each budget line for each of the categories of services. This is unlike the present system, whereby home care programs broker most of the services they provide, purchasing them from autonomous service provider agencies.

Presently, many services are provided effectively and efficiently by a number of established agencies with long histories of service to their communities. They are often supported and governed by volunteers who are part of the community. Stable relationships have developed between provider agencies, care givers and the individuals they serve. Rather than replacing the existing system, efforts should be made to improve coordination and enhance efficiencies.

In most communities, services are provided by several provider agencies. Each agency must retain a critical volume of service to remain viable. The volume of service must be adequate to support the operation if the agency is to stay in business. Where MSAs are declared as a move towards assuming 80% of a given service, the critical volume necessary for the alternative service provider to exist will be lost.

We recommend that this section of the legislation be changed to eliminate limits on services that may be purchased.

The Acting Chair: Five minutes remaining.

Ms Pick: Okay. I'm almost done. Part VI, section 15: This section allows the minister to exempt an MSA for up to four years from the provisions of legislation. The principles underlying the reform recognize the uniqueness of each community and support the community's right to determine the best way to provide service. However, if the communities are obligated to have MSAs, as defined by the act, in place within four years, they will be unlikely to pursue alternative ways to address the needs of their residents. The government has repeatedly stated that there is not to be a "cookie-cutter approach." This provision appears to be contrary to that statement.

We recommend that this section of the legislation be changed to eliminate the time limit.

We hope that the changes brought about by the long-term care reform will not preclude the Red Cross from continuing our over 75 years of providing services to our communities. We feel that the proclamation of the act, as it is drafted, will prevent the Red Cross and likely many other voluntary organizations from continuing to provide services that we have developed. We are committed to meeting the needs of the vulnerable members of our communities now and into the future.

Thank you for allowing us to make this presentation.


Mr Jackson: I'd like to thank you for your presentation, because not only do you give three specific recommendations, but you set out very clearly a part of the contribution which the Canadian Red Cross makes in Ontario. I'm absolutely overwhelmed by page 5 of your written brief, which lists the variety of services you provide and tells us you're providing five million hours of homemaking and representing about half the total component of delivery in the province of Ontario. That's absolutely staggering, and yet this legislation would propose to dismember you from those services at some bureaucratic discretion. On the second page, it talks of 130,000 individuals who are provided with service -- 10,000 volunteers and 6,000 staff. That's incredible.

My question is, are your staff aware of the implications of this legislation -- that's a lot of people -- and have they been given any kinds of assurances about how transition might work? And perhaps this is a terrible question for you: Do you have any kind of severance proposal or budgeting proposal for the hundreds and thousands of dollars in severance packages that will be required from staff when you dismantle some of these services? You know what I mean by that. You're not dismantling the whole Red Cross; you're dismantling huge components, and agencies within and services within. Have you budgeted for this, as one person called it, the sabotage of your staffing components?

Ms Richardson: I'm glad you asked the question. Certainly you've hit the nail on the head. The financial impact on the organization would be tremendous, and certainly the whole concern around severance does also relate, as you well noted, to assurances to staff. Of course, as it was made clear in the presentation, the majority of our staff are at this point non-union-based, and certainly it is our hope that all staff would be able to receive from the government some type of assurance that their services, because of their training and their experience, would be maintained through any transition. Certainly, this is something that we would request from the government, that there would be some work done together so that the organization itself would not remain encumbered by that type of responsibility.


The Acting Chair: I'd like to call the next presentation, the Ontario March of Dimes, Niagara region, and also the Ontario March of Dimes, Hamilton region. This is a joint presentation. Please come forward now.

Ms Maureen Lamarre: I'm Maureen Lamarre, from the Ontario March of Dimes that covers the Halton region, Hamilton-Wentworth and Brant county. I'm the independent living manager, which means that I'm responsible for all the programs that relate to attendant services in those three areas.

Mr Doug Overy: I'm Doug Overy, from the Ontario March of Dimes, Niagara region. I too am an independent living manager, supervising independent living programs in Niagara and Haldimand-Norfolk.

Madam Chair, respected committee members, the submission before you today is based on information contained in a written brief that will be or has been presented to the committee which outlines the Ontario March of Dimes stand on Bill 173 at the corporate level.

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

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

Since 1981, the Ontario March of Dimes has provided 24-hour on-site attendant services in support service living units, known as SSLUs, and through outreach attendant services across the province. At present, Ontario March of Dimes operates 19 SSLU sites, 19 outreach attendant services programs and up to eight respite programs that service over 912 disabled persons annually with a combined budget of $12.3 million. Our attendant services programs operate on a non-medical model that promotes consumer autonomy and self-directed care.

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

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

In Hamilton-Wentworth and Halton, the Ontario March of Dimes, in conjunction with other similar service providers, such as Participation House, has facilitated meetings to discuss the multiservice agency model development. As well, in Niagara and Haldimand-Norfolk, a coalition of service providers and consumers has been brought together in each of these regions to educate the attendant services consumers regarding choice for access to attendant services as outlined in Bill 173. In addition, we have met with consumers individually and in groups. The consensus of all is that choice in accessing attendant services is essential. We agree that our outreach attendant services should be outside, but linked to a multiservice agency.

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

Service Provision and Assessment: Prior to the shift of funding from institutions to community-based services, Ontario March of Dimes urges that there be equitable local resources developed across Ontario to ensure that essential services such as homemaking, visiting nursing and attendant services are available in all parts of the province.

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

Ontario March of Dimes supports the broad range of services provided by long-term care. However, the ministries of Health and Community and Social Services have made reference to the fact that personal support and professional services would be "generic" in nature. The concept of generic services should be carefully considered to avoid opting for the least expensive option rather than the best quality and most appropriate service.

Certain groups providing attendant services, such as the Ontario March of Dimes, Participation House and others, have developed specialized skills for servicing client groups while fostering integration. These skills, along with the options they represent, should not be sacrificed in pursuit of a generic service provider. When asked what they like about their attendant services, consumers invariably responded that services are tailored to their needs.

Respite Services: Additional support is required for family care givers. This support should include, but not be limited to, regular relief through easily accessed and flexible respite care services. A range of adult day programs provided without charge and financial compensation for family care givers is needed.

The availability of family care givers should not become a barrier to eligibility for any long-term care services.

Training and networking support to family care givers should also be developed in recognition of the enormous cost savings to government which this represents. The family care giver often provides services at large financial, emotional and psychosocial expense to himself or herself.


Appeal process: There should be a single and expedient process in place for consumers and agencies to appeal decisions of the multiservice agencies. Services must continue while a decision is being appealed. The appeal committee must contain substantial representation of adult disabled groups.

Funding of long-term care:

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

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

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

(2) Support services: We are concerned that the possible transfer of funding for outreach attendant services programs to the multiservice agencies could jeopardize the smaller outreach programs. Many of these programs offer services which are unique and respond to consumer need in innovative ways. We believe the province should continue to directly fund the SSLUs and outreach attendant services programs.

Existing outreach attendant services programs operate with a fixed or capped budget, which limits the number of consumers it can serve. Most of these programs have waiting lists for services. In both Niagara and Haldimand-Norfolk, for instance, the waiting list, or number of requests for services not fulfilled, is equal to the number of consumers receiving attendant services; for example, 65 in Niagara and 18 in Haldimand-Norfolk.

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

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

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

Many rural areas of Ontario, such as Haldimand-Norfolk and parts of Niagara and Halton, have a very limited accessible housing inventory. Haldimand-Norfolk has no supportive housing available. In recent supportive housing allocations, Haldimand-Norfolk was not included in the list of recipients. If equity in service provision is truly the goal of long-term care reform, then demographics such as rural versus urban populations must be factored into the equity formula.

Ontario March of Dimes believes that supportive housing should be encouraged in the widest possible range of housing types and locations. Our 13 years of experience in operating SSLUs demonstrates that the SSLU is a successful model which merits expansion. The need for SSLUs is increasing in our local area. In Halton region, for example, we have processed 80 requests for attendant services and accessible housing for an available 22 units located in Oakville.

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

Conclusion: The Ontario March of Dimes encourages the Ontario government to enact Bill 173 in order to proceed with long-term care reform. However, local consumers have identified their desire to have services designed to meet their individual needs, that respect their right to risk and foster or enhance their independence. We are committed to working with the government to ensure that the reformed long-term care system respects the autonomy of persons with disabilities in choosing services which most appropriately meet their needs.

Summary: The Ontario March of Dimes has supported and continues to support the efforts of the government of Ontario to reform long-term care and community support services in this province. We feel these reforms must be founded on the principles and in the context of Canada's universal health care system and should include: guaranteed access to essential long-term care services; consumer choice in accessing services; a separation of assessment and service provision functions; an appropriate and speedy appeal process; adequate funding utilized in an efficient and equitable manner; expanded supportive housing initiatives.

Finally, we believe that long-term care reform must embrace and promote the notion that adults with physical disabilities and frail, elderly persons are not necessarily sick and in need of treatment, that when assistance with activities of daily living is all that is needed, access to the service should be direct, without delay and by the consumer's choice of service providers.

The Acting Chair: Thank you for your presentation. We have time for one short question.

Mrs O'Neill: Thank you very much for coming. Are you one of the pilot projects for the direct funding of the attendant care? Have you been lucky enough to be one of those?

Mr Overy: The direct funding pilot project is being handled through the Centre for Independent Living in Toronto. They are selecting and handling the candidates' requests. To my knowledge, there will be 80 to 100 individuals directly funded and no announcement has yet been made on who these people are.


The Acting Chair: The last presentation for this morning's session is the regional municipality of Niagara. Can you please come forward. Welcome. Please introduce yourselves to the committee, although you're well known.

Mr Roy Adams: Thank you, Madam Chair and members of the committee. We're pleased to be here.

Ms Bev Goodman: My name is Bev Goodman. I'm the manager of community programs in the senior citizens' department for regional Niagara.

Mr Adams: My name is Roy Adams. I'm former mayor of the city of St Catharines, a regional councillor for the municipality of Niagara for 15 years now, a member of the Niagara District Health Council, completing six years this year, and involved in many other community activities.

Before I present our brief, I'd like to make just a few comments. One is to the effect that we in Niagara have been very fortunate over all the years of our existence to have at the helm of our senior citizens' homes and programs Mr Doug Rapelje, nationally and internationally known and recognized for his innovative and enthusiastic programs that he has provided, which have been copied and perhaps are trying to be copied in the program that we have in Bill 173. I'm very pleased to note that Mr Rapelje has recently been appointed to the National Advisory Council on Aging. I'm sure his expertise there will be most useful and beneficial.

We appreciate this opportunity to make, not comments alone regarding Bill 173, but our concerns.

The regional municipality of Niagara has a long-standing commitment to services for the elderly. Many of the principles of the redirection of long-term care are supported by the model we have developed since 1952.

For example, our department provides one point of access to the services of the department to community-based seniors -- since January 1, 1994, permanent and short-stay admissions to our homes for the aged have been coordinated by Niagara Placement Coordination Service -- six homes for the aged, providing 919 beds, including 11 short-stay, night care and intermittent care beds; a wide range of community-based options:

-- Seven-day programs for physically frail, cognitively impaired and/or socially isolated seniors. Younger persons with special needs may also be accommodated. Over 200 persons are currently registered in this program. All programs can accommodate persons with Alzheimer disease or related dementia, and one program operates in a specially designed centre for the cognitively impaired. Transportation to the program is provided in specially equipped vehicles.

-- Seventeen satellite homes (supportive housing program). These are private homes with an operator under contract to the region and, on average, three or four seniors. Many of these residents are developmentally handicapped or have a psychiatric history. This is an extremely cost-effective program. The per diem cost is about one third that of our homes for the aged.

-- Home sharing. Clients are matched to share a home for companionship, financial security or service exchange. For example, a younger person may share the home of a frail elderly person, paying a reduced rent in exchange for doing the yard work, snow removal and heavy housekeeping.

-- Alzheimer respite companion program, with 45 trained workers providing in-home relief for care givers of a person with dementia. Currently, 100 clients are registered and service can be provided seven days a week and overnight.

-- Home help services. Some 7,740 seniors are registered with this program, which referred workers to do home maintenance, housekeeping, yard work and companion sitting.

-- Friendly visiting. Some 93 frail and/or socially isolated seniors are visited regularly by our trained volunteers.

-- Talk-a-bit (telephone reassurance). Trained volunteers contact frail and/or isolated seniors, both as security check and for socialization.

-- Volunteer transportation. Volunteer drivers provide rides to elderly clients, primarily to medical appointments.

-- Information and referral, for persons seeking the services of the department or other community-based services for the frail, elderly or their families.

-- Public education. Our community programs staff organize and implement a number of education programs: Families Who Care -- a six-week education and support program for family care givers is offered three times a year; Information Fair for Seniors and Their Families -- agencies providing services to community-based seniors set up displays, provide staff and information. As well, seminars are held on such topics as the safe and effective use of medications, fire safety, home safety, back care etc.


Concerns: We have carefully reviewed the proposed legislation and would like to raise a number of serious concerns. Our concerns relate to the integration of case management and service delivery functions; the standardized approach to services in communities; increased administrative costs; the bureaucratic nature of the system; consumer fees; the impact on volunteer services; impact on employees.

Integration of case management and service delivery: One of the "four basic principles of an expanded system," according to the minister's press release of June 6, 1994, is "integration of case management and service delivery." This integration is one of the fundamental changes in the government's approach to the community-based long-term care system.

The lengthy consultation process undertaken prior to the drafting of this legislation certainly indicated that clients and families had concerns about access to service and wanted to be able to contact one service to access a coordinated array of services to help them remain independently in their own homes. The primary issue thus was access and a coordinated approach to service. Clients also expressed concern about the lack of availability of certain services. In our community, for example, we had not been funded for the integrated homemaking program at the time of the consultations, and there were many concerns expressed about unmet needs for affordable homemaking and personal support services.

There has been no rationale provided to convince us that the integration of case management and service delivery will necessarily result in improvements to service delivery. While case management and service delivery may be integrated in the organizational model -- in that case managers and service providers will generally be employed by one organization -- it is most likely that the two aspects will be done by different persons or units in the organization. In fact, the client would most likely deal with at least four parts of the organization: intake; assessment/case management; service delivery management/coordination; service delivery. Earlier visions of long-term care reform took the opposite approach, with a complete ban on the delivery of service directly by the new case management service.

In our opinion, each community should identify the solution that is most appropriate, taking into account its present system, geography, history etc to determine the extent to which case management and service delivery should be integrated.

Standardized approach to community systems: In a statement to the media, the Honourable Ruth Grier said: "I believe that change of this nature is best achieved with community involvement. This really is a partnership with the community. There isn't a cookie cutter at Queen's Park cranking out identical MSAs for communities to have in place at a set time. MSAs will be established in time frames that meet the needs of communities."

In fact, the legislation as proposed could be called a cookie-cutter approach. Programs to be provided are clearly listed under the categories: "community support services, homemaking services, personal support services, professional services."

The MSA will be prohibited from spending more than 20% of the amount budgeted for each of the program areas for the purchase of services and thus must provide at least 80% directly.

Many of the services, such as home care, which are major providers of service that would be included in the MSAs, have contracted for service from other agencies while retaining the responsibility for the overall coordination of the service plan to the client.

No evidence has been supplied that service would be enhanced if it were directly provided by the MSA rather than contracted for, and certainly no evidence has been provided that an 80-20 split in direct-indirect provision of service in all communities in the province of Ontario will enhance the service to clients and their families.

Community development of the new long-term care system should stress building on existing strengths and partnerships and on the long histories of many providers, volunteers and donors. These strengths should not be ignored.

In the Niagara region, for example, nursing and homemaking services are purchased from other agencies, most notably from the Victorian Order of Nurses and the Canadian Red Cross, two organizations with outstanding histories of non-profit service to the public.

Communities vary widely in their geography, urban-rural mix, proximity to major referral centres, proportion of elderly and physically disabled adults, current services and relationships. Communities should thus be able to plan the best way for the delivery of the mandated services to their clients, whether directly or indirectly, given a single point of access and coordination.

It may be questioned what role there is for the long-term care advisory committees to play in the development of the long-term care system in their communities with the inflexible approach outlined in Bill 173.

Increased administrative costs. It is claimed that the integration of case management and service delivery will reduce the overall costs of administration of the service system, and these savings can be redirected to service delivery. No evidence has been provided that these savings will actually occur, and examples can be provided of situations where costs would actually increase.

For example, the regional municipality of Niagara offers seven adult day programs, six of which are located in homes for the aged also operated by the region. Costs of the day programs including occupancy costs -- rent, utilities, telephone, janitorial, maintenance etc -- are charged to the program. However, there is an availability of onsite management and shared responsibilities that would not be possible in the proposed model. For example, a registered nurse is assigned to the entire program to do client assessments, referrals, health teaching etc. However, if a client needs medications or first aid administered at the program, this is provided by the home's registered nursing staff at no charge to the program.

The MSA would need to increase the registered nursing staff significantly in order to provide the level of service that's currently being received by the clients, or formalize an agreement with the home to provide the irregular parts of the nursing service, and this could only be done at an increased cost.

There are many other examples in the service system where arrangements and relationships have been developed over time which are beneficial to clients and not a burden administratively.

The Long-Term Care Act seems to have developed on the assumption that the entire system is flawed. In fact, we believe there are serious problems that need to be addressed, but not with a standardized approach to be imposed on each community and requiring communities to discard the parts of their system which have worked so well.

Bureaucracy: The administrative work that would go into the provision of service will be cumbersome, expensive and unsettling to the client. For many services -- for example, Meals on Wheels, friendly visiting, home help services -- there is relatively little paperwork involved. While the new system will have the advantage of one point of access for service, it does mean that to access those services, the full bureaucracy of the MSA will be encountered.

The new system is intended to be consumer-focused, with many safeguards. Unfortunately, in their zeal to protect the consumer, the drafters of the legislation have gone overboard. For example, the approved agency is required to give a written notice with certain content to the consumer who is the subject of the plan; the person, if any, who is lawfully authorized to make personal care decisions on behalf of the consumer; the person, if any, designated by either the consumer or the lawfully authorized personal care decision-maker.

The notice must include a statement of the bill of rights and the obligation of the approved agency and its purchase of service agencies, if any, to respect and promote the rights of the consumer; procedures for consumers to make complaints or suggestions about the approved agency and its service providers, if any; a statement of the right of the person to have access to and an explanation of his or plan of service and personal record; a statement of the right of the person, the lawfully authorized personal care decision-maker and persons, if any, designated by these persons to review the service agreement between the minister and the approved agency; and any other matters that may be prescribed in regulations.


We have attached a case example of the consumer seeking service from the MSA and an example of the resulting notice. In our opinion, the notice would do almost nothing to safeguard the rights of the consumer and would offend, confuse or intimidate many. In addition, the administrative cost of the notice provision would be excessive, with little or no positive outcome. It is vitally important to safeguard the rights of the consumer, but there are more effective ways to accomplish this: through agency policy, staff training, quality improvement programs, professional standards enforcement and public education.

Consumer fees: The bill states that the agency shall not require payment except in accordance with the regulations, which will apparently allow for a charge that incorporates common community living expenses. There will be a serious loss of revenue to existing agencies, for example, to those providing adult day programs, if this is implemented in the manner that is proposed in the draft guidelines for the adult day programs.

These guidelines suggest that charges would be allowed for transportation and food. This would not be based on the agency's costs, but the equivalent of the charge for community services; eg, public parallel transit and Meals on Wheels. These programs do not provide the same-day service that the day program provides. Public parallel transit programs provide only curb-to-curb service, while day program transportation may involve assisting the consumer with outer clothing, locking doors, assisting down the steps. Day programs also generally provide coffee and snacks in addition to the noon meal. These comparator programs, especially parallel public transit programs, are highly subsidized, and similar subsidy would be necessary to make up for the lost revenue from consumer fees.

Similarly, clients of the Alzheimer respite companion program pay approximately $4 an hour towards the cost of the service. Eliminating the fee will result in the need for significantly more funding for the program or reduced services.

Revenue lost for these two programs in the Niagara region alone would likely be over $200,000 a year. Eliminating fees will seriously reduce the chances of expanding much-needed services.

Impact on volunteer services: A fully implemented MSA will have a serious negative impact on many volunteer services. While regional Niagara, a relatively large government organization, has had good success in recruiting and training volunteers as friendly visitors, talk-a-bit volunteers, volunteer office representatives, activity volunteers and volunteer drivers in its community programs, we are aware that many volunteers identify very strongly with a particular local community or with a particular client group or service.

Our current system allows for volunteers to choose the type of organization they wish to be affiliated with. These choices will be seriously reduced if virtually all volunteer work with the services for the frail, elderly and physically disabled adults must be channelled through the MSA. Volunteers play a vital role in the long-term care system and they need and deserve choices. Similarly, the fund-raising ability of the many volunteer boards will be reduced or eliminated.

Security of employment: In our region, there are currently many employers of persons providing community support, homemaking, personal support and professional services to elderly persons and adults with physical disabilities. These employees are currently staff of home care, placement coordination service, regional municipality of Niagara, 11 Meals on Wheels associations and a large number of voluntary agencies, such as the Alzheimer Society, the Victorian Order of Nurses and the Canadian Red Cross.

If an MSA is developed which integrates the intake, assessment case management, service management and service delivery currently provided by all these agencies, there are serious employee and labour relations challenges to be met. These problems are extremely challenging, and solving them will require significant resources and energy. If we are not assured that the new system will result in a better or more cost-effective service, then these resources and this energy could be better expended in the direct delivery of service to consumers.

Conclusion: Our review of Bill 173 has revealed very serious concerns. We believe that the passage of the bill in its present form will very negatively impact on the quality of services to our consumers, on the relationship of consumers and service providers and volunteers, on the ability of the individual communities to find the best solutions for their own communities and on many highly skilled and dedicated staff and volunteers.

Thank you very much, Madam Chair and members of the committee, for the opportunity.

The Acting Chair: Thank you very much for an excellent presentation. We do have a few minutes for questions. The first questioner is Mr Malkowski.

Mr Malkowski: Thank you for your presentation. There's one thing I'd like to talk about. You were talking about volunteer services. Perhaps there could be some kind of amendment to the legislation that would require an MSA to have a coordinator of volunteer services so that we can keep the volunteers and they can maintain the volunteers in their local areas and stay affiliated with the organizations they've been traditionally involved with. Would you have any feedback on that?

Ms Goodman: Certainly, we've found that volunteers often have a very specific community or a very specific service in mind when they choose their volunteer work. The suggestion that it will require staffing in terms of volunteer coordination and management is correct. It's not a free service. Volunteers don't get paid but the recruitment, the training and so on can be expensive.

We recruit a lot of volunteers to work in our agency, but we also know that there are volunteers who will choose an agency that's much more focused and much more directed to their individual community rather than with our programs.

Mr Jim Wilson: Thank you very much for what is indeed a very excellent presentation to this committee. You've summarized a number of the concerns, and I think the accuracy of your brief is exceptional. The government tends to want to dismiss a number of these concerns and say that perhaps they're exaggerated. I don't think so and a number of other groups that have already appeared before the committee certainly back up your contentions.

I think the one big area -- there are several, but the one I just want to focus on is your comment which I think was again right on with respect to the integration of case management and service delivery by the MSAs. When one starts to examine that, as you have, one could come to the conclusion and does come to the conclusion that what we're doing, I guess, is exchanging different agencies in the community now that are delivering services for a monopolistic multiservice agency with different departments. You make the case more clearly, I think, than anyone else has so far before the committee that people will still have to go through a number of different channels to receive service under an MSA, so is the exchange that's about to take place worth the pain?

Mr Adams: I would agree wholeheartedly. We believe that the system we've had in place has been effective, it's been appreciated and it's accomplished its task. If we're going to take and break that down and try to form new agencies to carry the torch, I think it's disastrous.

Mr Jim Wilson: Do I have time for a supplementary?

The Acting Chair: No, you don't unless the -- there's time for one more question. Mrs Sullivan.

Mrs Sullivan: I think that one of the things you have raised goes back to the fundamental rationale for coming forward with this kind of a bill. You talk about the consultation process that led to long-term care reform and the discussions that occurred, and we hear from government members that many thousands of people were involved in discussions about the whole pace and changes that were required in long-term care.

I think in the beginning of your brief, on page 3, you indicate: "The primary issue...was access and a coordinated approach to service. Clients also expressed concern about the lack of availability of certain services." That is certainly our impression of what that consultation process provided, what the outcome was of that consultation process, and that the process and the people who were consulted never, ever contemplated that there would be a monopoly organization that would be set up to do assessment, to determine who had access to what services and how.

I wonder if you'd like to comment further on that consultative process itself here and whether you concur that the people in this community did not ask for or want a monopoly on services and access.

Mr Adams: I had the responsibility and the pleasure of chairing the consultation committee on redirection of long-term care, and we travelled through the region. I've sort of said that everything we were being told and listening to and even proposed in the programs seemed to be going by the board, and, "This is the way it's going to be," and reinforcing our position: When programs were in place, why take them apart?

We realize there are communities that did not have the overall programs in place. There's where the addressing should be directed. Most importantly, get on with it and leave alone those who are capably running programs that are meeting the needs of and being given high commendations from the public, the citizens we serve, for the programs and the services we provide. I say leave us alone; let us get on with the job.

Mrs Sullivan: So you didn't hear a great outcry for a new organization.

Mr Adams: Absolutely not, ma'am.

The Acting Chair: Thank you very much for an excellent presentation. I know the committee appreciated hearing from you.

The committee stands adjourned. We will be taking a five-minute break and then meet for a working lunch session beginning at 12 noon. We will reconvene probably at 1:30. Thank you all.

The committee recessed from 1152 to 1212.


The Acting Chair: We're going to begin the working session now and ignore the munches. If we're ready to go, there's a slide presentation, I believe. It would be helpful, Geoff, if you could introduce who's going to do what and just bring the committee up to date.

Mr Quirt: Certainly. Thank you, Madam Chair, committee members. We're prepared today to do three presentations for you, as requested. One presentation is a technical presentation of the bill itself, the various sections and what it's intended to achieve. A second, shorter presentation you've requested is a brief update on the program design activities under way in which a number of consumer and provider stakeholders are involved, and a third presentation is a presentation on the work to date, our current thinking on eligibility criteria for services from the new MSA.

I want to make it clear that we're completely at your disposal, so that if you feel you wish to continue the discussion on the legislation, for example, our staff will come back whenever you'd like to continue with those other two presentations. So we wouldn't want you to feel constrained. We will adjust our schedules to yours to make sure you have as much time as you feel is necessary.

I'd like to introduce Gail Czukar, who you all know, who will be doing the legal overview, and also Jean McCartney, who is at the presenters' table, who is our manager of program design in the long-term care policy branch of the long-term care division.

With that, we'll ask Gail to take you through each section of the bill. There are some materials we'll be handing out that you may wish to follow as she's going through her presentation.

Ms Gail Czukar: Thanks, Geoff. There is a package of materials, overheads, that was handed around. I think it says "Highlights" on the top. I was going to use these to make my presentation, as I've been doing briefings for other groups and so on, but given that the committee was pretty clear yesterday about what it wanted, which was to go through the act section by section, that's what I'm going to do. I'm going to try to do it fairly quickly and respond to some of the issues that have arisen so far but not take up the whole hour. So this may be a bit of a challenge.

I'll just start with section 1, the purposes of the act. We've heard some people talk about these already. This, as you know, is a general statement section that sort of provides a context and background for how the act is to be interpreted and used.

Part II, the definitions: I'll just draw your attention to a couple that we've already dealt with; the definition of "agency," which is pretty fundamental to the act because a multiservice agency is an approved agency that has been designated by the minister as an MSA. So the first thing to do to become a multiservice agency is be an agency, and who can be an agency is a non-profit corporation under the Corporations Act or a non-profit cooperative corporation, a municipality, a board of health or a council of a band. The other definition that we've talked about fairly often is the "care giver support services," which includes respite care and other sorts of things.

I might just say that some of the services that are listed in this section farther on in the categories are defined here and others are not, and the reason for that is that some were felt to be fairly clear in terms of ordinary meaning. Of course the principle of statutory interpretation is that if a term is not defined in the act, then it has its ordinary meaning and you can turn to the dictionary and other sources to discover what it means. It's only where the act seeks to have a particular meaning to a term that might have a different ordinary meaning that we would define it in the act. "Care giver support services" had to be defined in order to give some idea of what kinds of things would be encompassed there, and similarly for some of the others that are in the definition section.

I'm not sure that there are other definitions. I guess the other one that has come up is the "service provider." "`Service provider' means," and there are a number of things listed there, "the minister, if the minister is providing a...service...an approved agency...a person who provides a community service" -- that is, who is funded by the ministry to provide a community service, and "community service" is the generic term for all of the services that are listed in the four categories in the next subsection -- and "a person who provides a...service" that is "purchased by an approved agency." As we mentioned yesterday, "person" here includes corporations, so it can include any agency or commercial provider from whom an approved agency purchases a service.

As we'll see, there are different obligations and rules which apply to service providers and to approved agencies. Generally speaking, approved agencies have more obligations than do service providers.

Further on in the definitions section, we have the four categories of services. I don't know that I need to say too much about those: community support services, homemaking, personal support and professional services. There may be some questions about those later.

Part III is "Bill of Rights." This bill of rights was put here in order to have some consistency with the facility sector, because there is a bill of rights, as we know, included in all of the facility statutes. This bill of rights is based on that one with the ones removed that pertain pretty much to people living in a residence. Many of the rights in the bill of rights in the facility statutes have to do with the residential nature of those programs, so these were adapted to be suitable to community services. They're general statements of rights: to be treated with dignity and respect, free from abuse, having services that promote autonomy and so on and so forth.

Again, this is intended as a statement of expectations for both consumers and providers, to make it clear what we expect, and as a backdrop, again, for interpretation of the act; that's what's said in subsection 3(2).

The enforcement mechanism in subsection 3(3) is a deemed contract. This is a case where the obligation is between every service provider, that is, anyone, whether on a contract basis or independently, who provides a service under this act must respect these rights and is deemed to have a contract with the consumer to that effect.

Part IV, "Directors and Program Supervisors": The reason that this is here -- I think this has been misinterpreted somewhat -- is to allow for the appointment of officials -- these would ordinarily, in almost all cases, be ministry employees; they would not be people from outside -- to perform the functions of someone called a director or a program supervisor.


I don't believe that we've ascribed any functions in the act to the director. Under other acts which govern programs that will come under this act, particularly existing statutes that govern the services formerly administered by Comsoc, directors have functions defined in the acts, and we may very well need to define particular functions for a ministry official who would be called a director in the regulations. If we chose to have complaint process obligations or something like that, we might require the director to do certain things. In the facility statutes, for example, the director has the function of issuing licences and that kind of stuff. So that's the reason this is here. These do not refer to directors of multiservice agencies or any service providers outside the structure of government.

Similarly, the appointment of program supervisors: There are of course program supervisors within the structure of the ministry, and they work in the area offices for the area managers. Area managers, by the way, are designated as directors for the purpose of other kinds of administrative delegation within the ministry, and they could very well be the ones who would be designated as directors here, depending on what functions they would take on.

Program supervisors do have a function within the act, and that's dealt with in the section on inspections. So program supervisors have to be appointed by the minister to have the authority to carry out those kinds of things that are set out in that section further on in the act, and this is what circumscribes them.

This also allows the minister to appoint, in unusual cases, someone outside the act as a program supervisor to do something like carry out an independent investigation of a complaint or something like that. That's why it's not restricted to employees of the ministry but allows for the appointment of someone outside the act where that's necessary. That's why subsection 4(3) talks about putting conditions or limitations on an appointment.

The immunity section in section 5 is a fairly standard one in legislation, which says that the director or program supervisor is immune from liability personally for acts done in good faith and so on and so forth, but the crown is liable because it's accountable for the actions of this official who has been appointed by the crown.

Part V, "Funding and Approvals": This is a general funding statute; that is, it sets out that the minister can make agreements with people to provide services under the act, to make payments, provide financial assistance. It's not dependent upon detailed regulations as the facility statutes are, which state that payments can only be made in accordance with the regulations. This is a much more general funding authority and also allows for capital funding and grants and contributions where there are, in some cases, shared funding arrangements between the ministry and other organizations or municipalities. So it's a quite broad funding provision.

The approval section in section 7 has to do with approved agencies. "The minister may approve an agency to provide a community service if the minister is satisfied that...the agency...will be financially capable of providing the service; and" -- and it recognizes that that's with financial assistance from the ministry -- "is or will be operated with competence, honesty, integrity and concern for the health, safety and wellbeing of the persons receiving the service."

The reason that these conditions for approval are important is because later when the minister can revoke an approval or suspend an approval or take over an agency, of course it refers back to these kinds of conditions for approval and also just provides an accountability mechanism for the ministry.

There is the possibility of retroactive approvals for cases where an agency may be up and running, needing to get up and running, and able to provide a service or take on certain functions before the official approval has been processed and so on.

It would be anticipated that existing agencies that are performing functions outlined in the community services would be approved as agencies when the act is proclaimed in order to carry on with the existing system until such time as multiservice agencies are designated in each area in order to be able to take on those services and those functions.

The other purpose of having approved agencies in the act is that some of those agencies will continue to deliver services separately from the MSA and be funded to do that. One example is the attendant care programs, as we've discussed. They can continue to be funded by the ministry separately if that's the decision of the group of people who are receiving services from those agencies in that community.

The "Approval of premises" is simply that the minister can approve particular premises and revoke an approval. Again, it's an accountability provision.

Terms and conditions on approvals, terms and conditions on financial assistance and security for payments, these are again accountability provisions between the ministry and the agency.

Part VI, "Multiservice Agencies": These really set out how multiservice agencies are designated and what the expectations are. The minister has discretion with respect to designating an approved agency as a multiservice agency for a specific geographic area, but there is provision for overlap. That's in subsection 11(4), that the minister can designate more than one MSA for the same geographic area. This was specifically to allow for the possibility, for example, of a francophone MSA that might cover the same area as other MSAs or ethnic- or cultural-specific MSAs.

In deciding whether to designate an approved agency as an MSA, the minister is obligated to consider whether the board reflects the diversity of the persons to be served in terms of gender, age, disability and so on. This is the consumer participation provision that sets out the specific factors that the minister has to consider and also whether it includes persons experienced in health and social services.

I might say that the drafting is based on the principle that we need flexibility; that the act is to set out a framework and some guidelines but also be flexible enough to take into account the recommendations of the district health councils and the wishes of local communities. We've attempted to achieve a balance between giving people enough guidance that they know what they're supposed to do and not being too prescriptive, being as flexible as possible.

So that is one of the reasons that there's very little in the way of criteria for designation. It leaves it to the discretion of the minister so that it can accommodate any model that the community comes forward with, with the bottom line that the board must include consumer participation, and that's why this is here.

Subsection 11(3) also expresses a preference for independent, non-profit agencies as opposed to boards of health or municipalities while still allowing the minister to consider boards of health or municipalities in instances where there may not be any other choice. That may be the only alternative in a community, and so the minister can appoint a municipality or a board of health or designate them only if she's considered the suitability of all other approved agencies in that area. Terms and conditions can be imposed on a designation or amended.

In section 12, we have the statement of the mandatory services that are to be provided by an MSA. They're in the four categories. We've discussed that. They exclude the paragraph that talks about supplies and equipment and related services. The MSA must provide those, and we can prescribe additional ones.

Again, these powers to prescribe, both in the definition sections and in this one are intended to allow flexibility. They're intended to recognize that legislation doesn't come up very often and that if the system is going to develop over 15 or 20 years, there may be services we don't anticipate at this point that we can put in the act but may need to be added as obligatory services later on.

We can do that by regulation, and that's why that's there. These do not have to be prescribed in order for the act to be proclaimed. As far as I know, there's no intention to prescribe any additional services in the definition section or in this section at this time. If there were, we would include them here, but again it's intended to provide flexibility for the future.


Optional services can also be provided by MSAs under subsection 12(2) if the minister authorizes these. The intention here was simply that with a plan that's brought forward for an MSA where an MSA may want to have services not mentioned here that are appropriate to the local community, the minister would want to authorize that since the minister obviously is going to be approached for funding on those. Also, where the MSA might be part of a larger organization, such as a comprehensive health organization or other kind of setup, the minister would want to authorize that so as to ensure compatibility and that sort of thing.

In section 13 we have the limit on purchase of service, which is 20% of the amount in each category of the budget. There are then certain exclusions from that which are referred to in subsection 13(3). The equipment one -- which we've discussed already in the committee -- short-term absences, backfill, essentially, and that sort of thing, would not be included in the 20% purchase, and where the service provider is another MSA or an individual -- we've discussed that as well -- that would not count in the 20%.

So the 20% was intended to allow for the need to purchase particular kinds of highly specialized services or services provided by hospitals or other service providers that wouldn't be needed on a regular basis. Also, the purchases from individuals and that sort of thing that are excluded was to allow for the purchase of service from someone, for example, in a rural area where someone may live in a community quite far from the MSA and it wouldn't be cost-effective to have someone in the MSA going out to that person. You could hire someone in the local community, and that wouldn't count towards the 20%.

In section 14, the information and referral functions are basic functions of the MSA, and they're required to provide those.

Section 15, "Exemption": This is what's been referred to I think a lot as the transitions section. This is to allow, again, flexibility, where the minister, in designating the MSA, can exempt it from having to provide some or all of the services. This can be service by service. This exemption can be tailored to the specific plan that's presented to exempt the MSA from the obligation to provide one of the homemaking services or one of the attendant care services or a whole category or all of them, for that matter, and also from the 20% limit.

Again, this can be tailored. So if there's a group of agencies that provide community support services that are not yet part of the MSA, then they can be exempted from the 20% purchase requirement for up to four years. Again, the four years is not mandatory; it could be for a period less than that. But the maximum would be four years from the date of designation.

I just want to be clear that what this says is that the MSA is designated at this point; it's just exempt from some of the requirements that it must meet. It is an MSA. It's not an interim MSA or a transitional MSA or a pre-MSA; it is an MSA. It's just exempt from some of those requirements until the end of the four years.

Part VII sets out the rules governing approved agencies. There are a number of them here. I don't know, I guess I'll just go through them. The transfer-of-assets provision is, again, a fairly standard administrative one that simply allows for accountability for the use of provincial funds to purchase capital assets and so on; that they can't be transferred to another organization except in accordance with the regulations. That might be that some kind of written approval is required or something like that.

In section 17, the employee not being a director of the agency, we've dealt with this. This again is a principle of accountability that employees not be part of the board of directors. It's seen as a conflict-of-interest prevention.

The bylaw requirement in section 18 is that the agency has to pass bylaws that contain provisions prescribed in the regulations for the class of agencies to which it belongs.

This is a provision that allows us to make regulations, if we wish, setting out the kinds of membership provisions we would like to see MSAs or approved agencies have, the kinds of election procedures they might have to ensure consumer participation or participation of a broad range of providers and that sort of thing. It's not intended, again, that this be used immediately. It's there for the future, if necessary.

The filing requirement in section 19, that approved agencies file a copy of their bylaws with the ministry, that these contain the letters patent and the actual bylaws and amendments and a certificate from a solicitor that those bylaws comply with the act and the regulations and so on, is intended to be a check on the governance side of things. That is, if there are any regulations requiring the agency to have particular bylaws, we want to have a solicitor's certificate that they do that, and that would ordinarily be the solicitor that's helped the agency with its incorporation and so on.

Again, it's not intended that these be used, but these are the mechanism for ensuring that MSAs are having consumer participation and so on. This is because you need a follow-up to the provision that the minister can designate an MSA and has to take into account certain things. But the fact is that the organization can have a meeting six months later or a year later and change the composition of its board entirely, because it is an independently incorporated corporation and its bylaws set out the rules which govern it; we don't control that. If they chose to change the composition of their board to something that was very different from what the minister had initially approved, this would be our way of finding that out and our way of having some input into that to ensure that it would change.

The only other option to have a check on that would be to allow the minister to revoke the approval that she had given in the first place, or the designation, based on the fact that the board no longer met the requirements, but that's a pretty drastic thing to do, as I'll talk about in the takeover sections.

We've talked about the plan-of-service requirement in section 20 a fair amount. This was our description of the case management function and the basic requirement about assessment, determination of eligibility and the development of a plan of service that says how much service of each kind of service the person is going to get, an ongoing requirement for a review.

This section again, clause 20(2)(a), reviewing "the person's requirements when appropriate, depending on the person's condition and circumstances," I think we've heard from some presenters that they want this to be more onerous on the agency, that it be required at particular intervals or something. We discussed all that and felt that because of the wide range of services and demands that there might be, we wouldn't want to impose an onerous requirement like that on every agency, and people don't want to have assessments if their condition hasn't changed in five years. So, again, this is meant to be responsive and flexible.

"Participation in plan of service": This is the requirement, as we saw in the facility statutes, where the person and anyone that they choose can participate in developing and revising the plan.

Subsection 20(4) again allows for criteria to be prescribed, procedures to be prescribed for assessing and standards. This is a section that will pretty much have to be used before the act can be proclaimed, because the eligibility criteria which are currently in effect for the home care program under the Health Insurance Act, for the homemakers and nurses services program, integrated homemakers and so on under the Homemakers and Nurses Services Act and other statutes or agreements will have to come into effect under this act when it's proclaimed in order to maintain the existing system until, again, MSAs are proclaimed.

This, of course, is a core feature of the act: having a standard set of eligibility criteria and assessment procedures and so on across the province. This is to allow those to be put in place and also again to be flexible enough to accommodate all the different kinds of programs and the range of programs that are anticipated to come under the act.


Section 21 then requires the agency to deliver the services they put in the plan of service, but allows for waiting lists where the service is not immediately available.

Section 22 is a consent requirement. People can't be assessed or provided with services without consent. That's fairly standard.

Section 23, "Notice," that we just heard one of the presenters talk about, again is comparable to what we had in the facility statutes. This is a consumer accountability mechanism, and a very important one, to give people information about what their rights are under the act, what agreements there may be between the agency and the ministry so that they know what services they are expected to provide and are funded by the government to provide, procedures for making complaints and procedures for getting access to the plan of care and an explanation of the plan of care. I think that point came up in one of the presentations, actually. Also, requests for access to their records.

There's a "Quality management" section, in section 24, requiring approved agencies to ensure that a quality management system is developed.

We've talked about sections 25 and 26. These are the charging sections. Section 25 says that if a professional or personal support service is required by a person's plan of service, the approved agency cannot request payment for that or accept payment for that. If it's a homemaking or community support service in the plan, the only charge that can be made for that service is one that's set out in the regulations. The regulations, if there are any under this section, could set out a range of fees that could be charged for kinds of services. So for meal services or transportation services, we could set out a range for across the province, a minimum and maximum, or a formula or some other means of determining it. Again, it's quite broad how that could be used.

In section 26 we're moving now into the rules that govern service providers. The ones I've just talked about are requirements of approved agencies, ie, MSAs, agencies which will be approved in the interim to continue carrying out the existing programs and others that may be continued as approved agencies separate from the MSA.

The service providers, now these rules would apply to anyone, including commercial providers or others, from whom services might be purchased. They cannot accept payments for services that are community services purchased by an approved agency. I guess that's fairly clear. Again, these are consumer protections so that consumers know what they can be charged for and what they can't be charged for, as well as restrictions on service providers.

Subsection 26(2) allows the service provider to collect a fee, if there is one allowed under section 25, from the person. This is to recognize the reality that where a person gets a meal or a transportation service and there's a minimal charge for that, the service provider can collect that money from the person and deliver it back to the approved agency. You don't have to have a bill collecting system in place, which would be kind of ridiculous for the approved agency to have to collect it separately. So that's what subsection 26(2) is about.

Section 27 is a reporting requirement, and again it's a very general one. If the minister wants to require particular kinds of reporting from service providers, then there's a requirement to do that. Again, there's no intention at this time that I know of to impose that.

Section 28 is a posting requirement to the service provider to post in the business premises a copy of the bill of rights and any agreement between the service provider and the ministry where the service provider is receiving funds to provide the service directly and not purchased by an approved agency.

Section 29 is the access to personal records section. This says essentially that a person who's receiving a service from any service provider has a prima facie right of access to their record, and that includes any information that the service provider may have collected from others in the process of assessment or whatever. Because it's a prima facie right, the service provider has the onus to apply to a review board if they propose to not give the person access. So if they want to withhold part of the record for some reason, they have to go to a review board.

This is comparable to provisions under the Mental Health Act with respect to information in psychiatric facilities, and the same review board is used, that is, the review board under the Mental Health Act, until such time as the consent act is proclaimed and we have the Consent and Capacity Review Board set up. The only grounds on which the review board can make an order allowing the service provider to withhold part of the record from the person is that there might be serious physical or serious emotional harm to the person or another person. In that case, the board can authorize it.

Section 30 allows the person, once they've had access to their record, to request a correction. If there's something in the record they feel is inaccurate, they can request the service provider to make a correction or to include a statement and to let anyone know who has had access to that record in the past year that there has been a statement of disagreement and what it is.

Section 31 is a general compliance section, which simply requires service providers to comply with the regulations and the act. That's for the purpose of the offence provision later on.

Part IX sets out appeals. These provisions are virtually identical to those that were in Bill 101 with respect to facility appeals on eligibility, with the exception that the scope is broader. A person can apply to the board for a review of a decision by an agency that they're not eligible, excluding a particular service from their plan of service -- so they may be determined eligible for nursing services but not homemaking; they can appeal the homemaking decision -- respecting the amount of a service or respecting termination of a service. As I say, these are pretty much the same.

I guess I won't address the issue of alternative appeal mechanisms. There are other kinds of things, of course, that can be done and should be done by way of appeals and reviews of decisions prior to getting to this stage, but this is the final independent tribunal that's available. Again, this is already in place for home care. Under the Health Insurance Act, the Health Services Appeal Board would hear appeals from anyone who wanted to contest their eligibility for home care. So this is not new at all.

Part X, "Revocation and takeover powers": These powers are currently in the Ministry of Community and Social Services Act for those programs that have been funded and provided by Comsoc. In the transfer to the Ministry of Health, they would no longer apply because of the way they're written in that act, so they've been put in this act to apply to agencies, and they apply to multiservice agencies as well. The minister can revoke or suspend an approval of the agency or the premises on the grounds specified here, that they've contravened a term or condition imposed on the approval, they've contravened the act or the regulations, breached a provision of an agreement or they no longer are able to meet the initial conditions of approval that I talked about, not being able to operate financially or not operating with competence and integrity and so on.

The takeover provisions are based on many of the same grounds, that is, if the minister believes on reasonable grounds that those things are happening, she can also take over the agency as opposed to simply removing their approval. It can also be done on an emergency basis, where there is a threat to the health or safety of a person.


Section 45 sets out the procedure, the due process of it; that there has to be a notice, there has to be a hearing and that kind of thing. Where a takeover is done on an emergency basis, the hearing would be held afterwards. I don't know if you want me to get into the specifics of those. Time is kind of marching on here.

Some of the general provisions in part XI have to do with the minister being able to delegate her power. Section 51 is the subrogation provision. If anyone would like me to explain subrogation in detail, I'd be happy to attempt to do that. This is, again, a question of the transfer from the Ministry of Community and Social Services to Health.

Briefly, subrogation is the right of the minister to recover costs where a wrongdoer has been the cause of a person's injury and the ministry is funding services that are provided to this person. There may be an insurer or some other person, usually an insurer, that is obligated to cover the costs of those services. The ministry can recover them. Those subrogation rights were contained in the Ministry of Community and Social Services Act. Our subrogation rights are in our Health Insurance Act, so in order to just maintain the status quo, we had to put them in to cover the community services under long-term care. These procedures that are set out here are similar to the ones under the Health Insurance Act, so that anyone who is subject to subrogation provisions will have to follow the same procedures under this act or the Health Insurance Act.

Section 51 is the exemption under the Public Vehicles Act that will allow community service providers and facilities to have transportation services for people who aren't able to use the regular system or who need some additional assistance without having to obtain a public vehicles licence, but it still maintains some of the provisions of the Public Vehicles Act that apply to safety requirements and so on.

Section 52 is the inspection section. As I mentioned before, program supervisors have the powers to do inspections, and these powers are pretty much comparable to those which we discussed under Bill 101. They cannot enter a dwelling except with the consent of the person. If they need to carry out an inspection and the person doesn't give their consent or there's some other problem, they'd have to go under the Provincial Offences Act to get a warrant.

There are offences listed in section 54. Not every section of the act contravention constitutes an offence, but they're listed there in clause 54(1)(b). They include things like the obligations on service providers that I mentioned to respect the act and the regulations. Some of the provisions under subrogation and the inspection section constitute offences.

The regulation-making power in section 56, which has been mentioned by a number of presenters, includes a number of different powers. I certainly won't go through all of them. I will draw to your attention paragraph 56(1)11, which talks about requiring MSAs "to develop and implement a plan for recruiting and using the services of volunteers." The reason that's there and is written the way it is is because, again, we didn't want to impose on every agency the obligation to have a program or a coordinator or something like that. Again, it's to remain as flexible as possible. This would allow us to impose this requirement on MSAs at such time as it's realistic to do that in their evolution.

The other regulation-making powers, as I say, most of these would not need to be used right off the bat in order to proclaim the act. The one that would be necessary would be the eligibility criteria, in order to be able to carry on the existing system in certain areas and for people to know what their eligibility criteria are, because we would have to repeal the other provisions that are currently in place. Other than that, most of these are for future use in terms of the system changing and evolving and needing to have rules imposed in various ways.

We have a substitute decision-making provision that's transitional, and that ends the Long-Term Care Act. The amendments to the Charitable Institutions Act, Homes for the Aged and Rest Homes Act and Nursing Homes Act, the facility statutes have to do with reinstituting the takeover powers and revocations of approvals for charitable homes and homes for the aged, which were formerly in the Comsoc act, and a regulation-making power for access to records. We didn't put access to records sections in those statutes. That may be something we want to look at.

The amendment to the Health Protection and Promotion Act simply removes, as I mentioned before, the obligation of boards of health to provide home care. That was a mechanism that would ensure that home care services be available in every community in the province. That obligation will now fall on multiservice agencies. So we no longer want it to fall on boards of health.

The Homemakers and Nurses Services Act is being amended to remove the integrated homemaker program, essentially, because that will now be funded under this act. But the existing homemakers and nurses services programs in municipalities and band councils would continue to be governed by homemakers and nurses services.

The only other one I think I want to mention is the Ministry of Health Act amendment, which has to do with district health councils, in section 62. For the first time, district health councils are mentioned specifically in the act. They have been appointed previously under section 5, I believe it is, of the ministry act or section 9 as advisory committees to the minister. This provision specifically sets out district health councils and the ability of the minister or cabinet to establish the council and specify the area for which they're authorized to perform functions.

In making the appointments, cabinet or the minister are to take into account the importance of ensuring that the membership reflects the diversity of the population. Again, this is a representation requirement to ensure that district health councils are representative of their communities.

The functions are listed here: advising the minister on health needs and other health matters; making recommendations on allocation of resources; making plans for development of a system and any other duties that the minister might assign. These are the existing functions of district health councils. They aren't expanded here; they're just articulated in the act for the first time.

Subsection 62(5) allows for the development of aboriginal health authorities in the future where aboriginal communities want to set up their own planning and delivery and management organizations, in which case the district health council would not perform its advisory functions with respect to those services or may cooperate with the aboriginal organization.

Finally, a provider of health services can be required by the minister to provide plans and information to the minister and district health councils. This is to assist district health councils in carrying out their functions, obviously, where they need information from providers in order to do that.

There's a regulation-making power. Some people have mentioned that the ministry should require district health councils to have particular people on their long-term care subcommittees or that sort of thing. There is a regulation-making power that would allow us to make regulations to do that and would also allow us to make regulations regarding the recruitment process in DHCs, because it's recognized that this is fundamental to the representativeness requirement that I previously mentioned.

I think that's all I will say about the act at this point.

Mr Quirt: Would you like to have some questions on the legislation?

Mr Monte Kwinter (Wilson Heights): It seems to me there's a contradiction in one of the provisions. If you look under part X, "Revocation and Takeover Powers," it says, in clause 41(a), "The minister may revoke or suspend an approval of an agency given under subsection 7(1) if,

"(a) the agency is located in a geographic area for which the minister has designated another approved agency as a multiservice agency."

The implication of that is that the minister could revoke your approval because there's another one or you have more than one. Yet, if you back to part V, "Funding and Approvals" --


Ms Czukar: Do you mean the provision which says that there can be more than one MSA?

Mr Kwinter: Yes.

Ms Czukar: It's not contradictory. What this is meant to say, in clause 41(a), is that if the minister has designated an MSA, then those approvals that are out there for certain agencies will be taken back so that you don't have a duplication. That's what it's meant to deal with, a situation where you've had an approved agency delivering some of those services. They're now going to be part of the MSA. You don't want them out there as an approved agency because they're no longer subject to the rules and performing the functions under this act with respect to that. They're now part of the MSA.

This is not meant as a punitive kind of a provision. This is simply a case of making it consistent so that if you have an MSA that's an approved agency doing those things then you don't have another agency approved to do those things as well. It could eliminate a potential conflict or inconsistency.

Mr Quirt: I can see how it would be confusing, however, given that it might imply that designation of two MSAs for one area was problematic when you see it as a reason for revocation. So I think it was a good clarification to make.

Mr Kwinter: My concern is that someone gets designated as an MSA and then another group comes along and wants designation and they refer to this, saying, "Well, this implies that there can only be one." Yet on the other hand, in a previous section, it provides for the minister to provide for more than one MSA in one geographic district. That is where I feel there could be some -- there's no confusion in your mind, I understand that, but this has got to stand alone, and when someone reads it, it could be interpreted that the implication is that there can only be one, if you read this section, whereas in the previous section there is a provision for the minister to provide for more than one.

Ms Czukar: Yes.

Mr Jim Wilson: Well, let's start at the end then. When this act comes into effect, given that I have no doubt it will in some form, will district health councils have to be reconstituted or are they grandfathered, the ones that are currently up and running?

Ms Czukar: My interpretation would be that their existing OICs would be in effect and would continue.

Mr Jim Wilson: What's an OIC?

Ms Czukar: Our order-in-council appointing the members of the district health councils. So it's not intended to do away with the existing ones and start over.

Mr Jim Wilson: But what if the existing ones don't have the mix of membership that's required? Say they're not reflecting their communities now.

Ms Czukar: Well, the provision is that in selecting persons to be appointed the minister shall consider the importance of ensuring these things, so it really refers to appointments as they come up. It doesn't say every district health council must be this way on day one; it says as the appointments are made, these are factors that have to be considered.

Mr Jim Wilson: Okay, and can I just ask what's different, since I don't have a copy of the Ministry of Health Act in front of me, with respect to -- it says, "Clause 12(d) of the act is repealed and the following substituted." It's talking about recruitment and composition. What are you repealing?

Ms Czukar: That's a good question. I'll have to look that up.

Mr Jim Wilson: Because I --

The Acting Chair: I'd like to move along because we have one more presentation, the slide presentation that I mentioned earlier. If we have time at the end of that, then we can ask all of our questions; if we don't, we're going to cut into our presentation and we'll have to cut off, because I think the deputants should be on their schedule. Mrs O'Neill, one short question.

Mrs O'Neill: I get one? Okay. I'll go for a follow-up to Mr Kwinter's then. The geographic areas, when and how will that be determined? I know that we're talking different numbers in Metro Toronto. We had the presentation from East York. They think they could be one, and yet their population is 100,000. I've heard 225,000. Where are we going with geographic areas?

Ms Czukar: These are not going to be prescribed by the ministry; they will be based on the plans that come forward from the district health councils. So in making the designation and designating X as the multiservice agency, the minister will say, "X is designated as a multiservice agency for this area," and it will set it out in the designation. So it's not like the ministry is taking a map and dividing it up and saying, "This is going to be the one for this area, and this one for this area." It depends on what comes forward from the district health councils and what the ministry agrees to approve. So they will be individual.

Mrs O'Neill: It's got no relationship to population?

Ms Czukar: Not so far as I know.

Mr Quirt: At this point, there's no particular policy established that would require an MSA to serve a minimum number of people, and as has been pointed out, we've really asked the district health councils to tell us how many they think they need in their area and what boundaries they should cover. Theoretically, I suppose, the DHC might recommend that 10 people in this one particular township need an MSA, and the minister would at that point have to say: "I'm sorry, I can't take your advice. I'm going to do something a little different." But we don't expect that to be the case.

Mr Jim Wilson: Could I just very quickly run down four concerns, and maybe counsel would want to get back to me?

I still need a clarification of how attendant care fits in. You talked about how it would still continue to be funded separately, but the bottom line is that it would really help a lot of groups if we could somehow get the words into the community service section somewhere.

Bill of rights: As far as I read it, it applies to service providers, but how is it binding on the actual approved agencies or MSAs? I'm a little unclear about the relationship there.

Ms Czukar: The definition of "service provider" includes them. "Service provider" is the most inclusive definition, so it includes MSAs, approved agencies and anybody else who delivers a service.

Mr Jim Wilson: So in cases where MSAs are actually providing services, which will be 80% of the time I guess, they're bound there, and then anyone contracted out?

Ms Czukar: That's right.

Mr Jim Wilson: Okay. Condition of approval: Clause 7(1)(b), with respect to approval, is that a normal wording? It seems to me it's a very broad condition when you're talking about someone having to judge competency, honesty, integrity. I mean, it can go both ways. Approval might be okay in doing that, but then if the minister had a bad day and wanted to revoke one of these things, that gives you pretty sweeping reasons, and loosey-goosey reasons, to withdraw approval of an MSA. It doesn't seem to me to actually fit in with the more legalistic leanings of the bill. I mean, this is rather layman's language, when you're talking about competency and honesty. So, parliamentary assistant, I'll ask for a comment with respect to that. It just doesn't seem to fit with the rest of the bill.

On subsection 11(3), I just want a clarification again with respect to why there is a built-in bias against municipalities and boards of health, and a clarification on subsection 15(2) with the exemption of the 20% rule. My understanding of this is that after four years there is no more flexibility. Is that true?

Ms Czukar: That's correct.

Mr Jim Wilson: So the flexibility that you talk about is only good for up to four years, and then it's a strict 80-20 rule with the exemptions that are in other parts of the bill.

Ms Czukar: That's right. With respect to that one, that's right.

Mrs O'Neill: Madam Chair, if I may just put one thing more in the same manner? Both the news clippings and some of the presenters and the minister herself talked about -- really, "delisting" is the colloquial term that goes on through this bill, that there will be certain services that will no longer be covered under, I presume, the health insurance plan of the province. Could you point out to us the exact sections where the changes are going to take place under that with that particular intent?

Ms Czukar: The home care program, which is in the school health support services programs, are sections of regulation 552 under the Health Insurance Act. That regulation can be repealed at any time, it's not a statutory amendment, and that's why it's not in the bill, because it can be done by a regulation change.

The Acting Chair: If we're going to be able to have the slide presentation and time for questions, I'd like to begin now if that's all right with everyone. If you could keep the slide presentation to about 10 minutes, then we will have some time for questions before the first presentation at 1:30.

Mr Quirt: While we're getting ready I'll reintroduce Jean McCartney, who's the manager of program design in the policy branch, and also Louise Hurst, who is handling the slides, who's been responsible for the preparation of much of the material that you have before you.


Ms Jean McCartney: Geoff, do you want the working group one or the eligibility one first?

Mr Quirt: I think the working group one, very quickly.

Ms McCartney: Ladies and gentlemen, I will just provide you with a very quick update on some of the program design activities that are under way. Last year, last August, we distributed a document that was called Community-Based Services Provided by Multi-Service Agencies, and in this document we identified many directions that we were interested in pursuing. Now, this particular document is being duplicated and will be made available to you. A lot of our working group activity, though, relates to some of the activities we introduced or some of the ideas we introduced in this manual.

First of all, I'll just outline some of the working group activities under way. First of all, we have the nurse continence advisory service. This is a project to design a training plan for a provincial nurse continence advisory service within the long-term care system. We have transportation, adult day program, meals and services, homemaking. These are separate working groups that are designed to undertake program design and more detailed program development of these particular components of the system.

Other working groups feature the role of the volunteer in the long-term care system and also a working group that is directed to study the consumer fee system that should be introduced. Support to care givers and care giver compensation are working groups that have also started up. This is to look at better ways to support care givers in the care giving role.

Last but not least, we are starting to do the design work. One working committee is working on the MSA program design. This looks at issues associated with eligibility, appeals, service allocation criteria, prioritization criteria, some types of program accountability structures. Another working group has commenced that looks at MSA policy from an administrative point of view. This is examining the roles of boards, the functions and responsibilities of boards, and funding.

Now, one of the reasons why at this point we're targeting in on these areas is a lot of the community support policy development was not developed in this book. We sent this out, identified some of the questions we needed some responses and some information on, and now with working group activity we're further developing those components. Neither was the whole issue of case management and eligibility addressed in the context of this manual as well. So these are things that are being developed and undertaken by working groups right now.

That is a very quick summary of the program design activity as it associated to work that was done.

The Acting Chair: I just want to point out to the members of the committee that under tab I in the very extensive ministry briefing book that you received is the information that has just been referred to.

Mrs Sullivan: At least two days ago in hearings the committee asked for copies of the manual, and I'd like to be assured that we would have those very quickly, because we are dealing already in the public hearings and want to understand what some of the intervenors are describing, and much of the information comes directly from the manual. I'd like that manual right away.

Mr Jim Wilson: Yes, that should have been sent to the critics of the opposition parties when it was released to the public.

The Acting Chair: Your protest is noted.

Mr Jim Wilson: Thank you.

The Acting Chair: Can we continue with the presentation, please.

Ms McCartney: The next part of the presentation has to do with eligibility criteria, and what I will very briefly do is outline some of the existing eligibility criteria and the problems that have been posed for community-based services before moving into the eligibility criteria that are proposed for the future.

So first of all, there are the eligibility criteria for the existing home care services. I think we're all pretty familiar with the services provided by home care. They're listed here, and you can make reference to them later on in the presentation. But let's look at the specific eligibility criteria in and around home care.

I haven't included all of them here, but two main points are that it's insured under the Ontario health insurance plan and it's under the medical supervision of an attending physician.

This means a physician has to refer a client to the service in order to receive service. For the acute home care program, the person needs at least one of the professional services, such as nursing, physiotherapy, OT and speech therapy. For the chronic home care program, they need at least three visits per month of one or more of the criterion professional services. Now, after the first month, no minimum visit frequency limit applies. However, to get on the program, somebody must continue to meet the three professional visit criteria.

Now, some problems have come about as a result of that. First of all, until the introduction of the integrated homemaker program, homemaker services were not provided unless the person needed professional services. For acute home care, this was about 80 hours per episode, and for chronic home care if you required professional services, you could get 80 hours the first month and 60 the next.

Another problem was that nutrition and social work services were not provided unless the person needed one or more criterion services. That meant if you needed the services of a dietician, you couldn't get them unless you required the services of a nurse, for example, or a therapist. A major problem also has been that physician referral was required, even if the services provided did not require physician orders.

Then the integrated homemaker program was introduced. Now, this provided housekeeping, marketing, meal preparation, laundry and ironing and personal care. The home care program was targeted to everybody in the province if you met the general eligibility criteria. This homemaker program enabled the provision of homemaker services to some client groups without the provision of professional services. So the eligibility for this program is that the person requires assistance with both personal care and homemaking, the care provider needs homemaking assistance to continue providing care to a sick or disabled person and the care giver is unable to provide care as a result of illness or hospitalization.

Now, this did solve the problem pertaining to seniors who required homemaking service as well as adult persons with disabilities, but some persons are still having to get professional services if they do want some homemaking services. For example, since I am neither elderly nor disabled, if I was leaving a hospital and required homemaking services, I would not be able to obtain them under that particular program.

Another program we have in place is the homemakers and nurses services program. For that specific program, the eligibility criteria are as follows:

-- You must reside in the municipality where the person resides for service.

-- It's a needs-tested program. That means that generally low-income people have been able to benefit from the services of this program.

-- Physician certification is required for the nursing services that are offered by this program.

-- It is also offered on a discretionary basis and is cost-shared with the municipalities.

-- It's targeted to seniors, persons with disabilities, ill or convalescent persons so they can remain at home.

Home support services, on the other hand, offer a varied number of services. I can't really tell you what the eligibility criteria are for each of these services because many of them have been developed on their own and in keeping with local needs.

Attendant care outreach service provides attendant services to individuals with long-term physical disabilities in their homes. Up to 90 hours, 120 hours in some circumstances, can be provided. The emphasis here is the provision of personal support, although some limited homemaking services may be provided. It's targeted to individuals 18 and over, though the primary users are the non-aged physically disabled.

Those are the five or six programs that we have operating right now in the community-based setting. Now, I would like to talk about what we are moving to in the context of multiservice agency program delivery. This is a draft, and it is a draft that we will be discussing with the working group to determine how they feel about this specific approach.

First of all, we're trying to move away from a program approach. We're essentially looking at a person's need for service. For example, if you're eligible for home care, you're often eligible for a whole host of services, but under this what we are looking at is eligibility in the context of just a minimum of one service if that's the only one you need. We're moving away from age distinctions and some disability distinctions that have characterized some of the eligibility criteria for our other programs.


So what are our broad eligibility criteria?

(1) First of all, the person should be an insured person under the Health Insurance Act. This is to demonstrate a residency requirement, that is, the person is a Canadian citizen and resident in Ontario.

(2) The second point is that the person is appropriately served in the service delivery site. This essentially means that some types of support and care cannot be provided in some types of settings, particularly if you're talking about specific types of equipment to support a nursing need.

(3) Assessed needs that can be met by one or more services provided by the multiservice agency. So here we're looking at the client has to have one need or two needs, or whatever, that can be met by one or more services. So we're looking at the need for the service. For example, if you needed a dietician for a nutritional assessment, that is what you could get from the service. Getting a dietician would not be dependent upon your need for nursing or therapy.

(4) Needs cannot effectively be met by other resources in the community or by other programs where they are appropriate and where they exist.

Now, I'm going to chat about criteria 3 and 4 in a little more detail because they're important.

What do we mean by "assessed needs"? First of all, the person must need the service, and need is reviewed in the context of the person's condition and the support available to him or her. So a person may well have a need but the need is not so great that he or she may get the service requested.

So, how do we approach this? Well, we're looking at developing service allocation criteria to determine who will get some types of service and the conditions under which the service may be provided.

What's an example of the type of service allocation criteria we might be developing? I've used homemaking services here as an example. First of all, we've indicated that free homemaking is provided when it is essential to maintain somebody in the community and avoid admission to a hospital or a long-term care facility.

Now, as a general rule, for such services provided in the community to be very effective in targeting the people where it is most essential to provide the service to prevent admission to facilities, we're looking at persons with multiple care needs or care providers who are looking after people with multiple care needs; we're looking at post-hospital discharges, or what we've termed here is hospital diversion programs -- that could be you might get a procedure performed in an outpatient department but need some support when you go home; it could be part of a quick response strategy or a crisis support package -- and lastly, persons who have lost the capability to manage.

We do know that the research indicates that the majority of people going into long-term care facilities have a need for a high degree of personal support, may have mental or cognitive impairments, may be incontinent and may have chronic illnesses. So these are some of the factors we've looked at when we try to design community-based services.

Now let's see how these service allocation criteria could be interpreted. Who might get homemaking assistance or be considered key priorities for service? First of all, care providers who require this assistance to continue to provide support to family members at home; persons who have a high degree of personal support need. This is often an indicator of the fact that they cannot provide or undertake their own homemaking task. This does not mean, however, that if you have a personal support need you automatically get free homemaking if you are capable of undertaking it.

I already chatted about support for post-hospital and hospital diversion programs.

We would also like to see homemaking most appropriately utilized in crisis support for individuals where care provider arrangements have broken down and somebody needs to go in on a short-term basis.

I talked about people who have lost the ability to cope. This could perhaps be persons with cognitive impairments, people with limited coping skills or sometimes individuals with reclusive lifestyles. Essentially, we're talking about a client group that has lost the capability to manage as well as they did beforehand, and last but not least, teaching, teaching somebody the functions associated with homemaking, as that provision exists in the act.

I'll now proceed to the last component of the eligibility criteria. That was in determining eligibility looking at what might be available from other government programs. It's very important we do this as part of the eligibility determination process, as this is to try and ensure the fairest utilization of resources and, in some ways, to look at services that may be available to that person from other systems, so you don't have one person who is very overserviced because they're getting service from two or three different systems as opposed to one who is primarily getting their service from the long-term care system.

So, as part of the eligibility criteria process, we review the availability of services available from other resources and government programs. We'd look at: Are there any like or similar services provided to persons from the mental health system or the system for persons with developmental handicaps? Now in this document Community-Based Services Provided by Multi-Service Agencies we did do an initial cut of what we thought these systems should provide vis-à-vis the long-term care system, and that is additional work that will be undertaken in the weeks ahead, a further refinement of those activities and where joint collaborative action is possible.

There could be programs in the community where some services are already provided by the multiservice agency but onsite. An example here is support service living unit programs for persons with physical disabilities. They receive attendant care onsite and homemaking assistance onsite. Therefore, it would be inappropriate for the multiservice agency to provide those services to people in those settings but appropriate to provide professional services which are not available.

Programs provided by other community resources: When eligibility for multiservice agency programs is determined, it is part of the assessor's job to determine whether this person might be more appropriately served by a hospital outpatient department if they offer that specific therapy service. So, if such a resource exists, it's effective in meeting the person's needs, then that could be suggested as an alternative.

Lastly, programs that the client may have access to that are offered by other provincial ministries or the federal government: Again, this is looking at the resources and support that may be available to a client that others do not have. An example here might be somebody who is receiving an attendant care cash allowance from workers' compensation. It's only one example.

At any rate, ladies and gentlemen, this brings to a conclusion a very fast and quick overview of eligibility then and proposed.

The Acting Chair: Thank you very much. I want to remind committee members that we have over two weeks yet of hearings and opportunities for questions to be answered by ministry officials. In order to make sure of our priority, which is to hear the public and the deputations today, I'm going to ask that you make note of any questions you have.


The Acting Chair: It is almost exactly 1:30, and I'm going to ask the first deputation of the afternoon to come forward. You have received, I believe at the last meeting, the submission from the Ontario Dental Hygienists' Association. You should have it with you now.

I'd ask the Ontario Dental Hygienists' Association to please come forward. Welcome. You have 20 minutes for your presentation. I'd ask that you introduce yourselves to this committee at the beginning of your presentation. If you'd like to leave some time for questions, that's fine; if not, the time is yours. Please begin.

Ms Elizabeth Craig: Good afternoon. My name is Elizabeth Craig. I'm the executive director of the Ontario Dental Hygienists' Association, which is the voice of the profession of dental hygiene in Ontario.

Mrs Sullivan: Point of order, Madam Chair.

The Acting Chair: Excuse me. Yes?

Mrs Sullivan: Is there some way that the volume can be turned up so that we can hear the deputation?

The Acting Chair: Just before you begin, while they're turning up the volume, I have an answer on the request for the manual. If you'll tell Geoff where you'd like it, it can be delivered to you tomorrow. Okay? Thank you for that prompt reply, Mr Quirt.

Please begin again.

Ms Craig: Okay. Is that all right now? Can you hear me better? My name is Elizabeth Craig. I'm the executive director of the Ontario Dental Hygienists' Association, the voice for the profession of dental hygiene in Ontario. The profession now numbers almost 5,000 practitioners. Membership in the association is voluntary and presently represents about 54% of the registered dental hygienists in the province. I believe that our written submission has already been circulated to you.


The Ontario Dental Hygienists' Association agrees with the purposes specified in Bill 173 regarding long-term care and applauds the government's efforts to better meet the social and health needs of recipients of long-term care. Our presentation today may well be a departure from many of the others that you have heard thus far. We wish to discuss not what is contained in Bill 173 but rather what is not.

The ODHA understands that Bill 173 represents a reorganization and coordination of services already provided through the ministries of Health and Community and Social Services. The ODHA also understands that dental hygiene was not part of the previous menu of services and therefore has not been included in this act as one of the professional services listed.

When the Minister of Health, Ruth Grier, introduced Bill 173 in the Legislature, she described it as a commitment to "improve and expand long-term care and support services." The ODHA suggests that the inclusion of dental hygiene services would significantly improve and expand the level of service provided to long-term care clients.

As you know, dental hygiene is one of the 23 regulated health professions. Having just gone through the process leading up to the enactment of the Regulated Health Professions Act, we cannot help but note the similarity in many of the principles of both the RHPA and those of Bill 173. Both speak of placing the consumer first in terms of providing them with a full range of services, having control of the choice of care to be received, having access to that care and receiving quality care.

Dental hygiene was seen to espouse these principles as they applied to regulation of the profession, but the profession is notable in its absence from Bill 173.

In its publication, Health Times, the Ministry of Health defined dental hygiene as follows: "Dental hygienists assess the oral cavity and provide preventive, educational, clinical and therapeutic services in a variety of practice settings." We believe this is an accurate and succinct statement of the profession's raison d'être.

Again, it uses key words which are also implicit in the principles behind this redirection for long-term care, words such as "prevention," "education," "therapeutic services" and "variety of practice settings." There is a clear match between the purposes of Bill 173 and the practice of dental hygiene.

Ms Linda Berry: Good afternoon. My name is Linda Berry, and I am the government relations chairman for the Ontario Dental Hygienists' Association.

Over the years, it's been a source of concern and frustration for our organization to know that many segments of our population are unable to access dental and dental hygiene services. One of the outreach programs which we did conduct was to produce an oral hygiene presentation called Senior Smiles, which received funding from the Ontario Ministry of Health. This presenter-friendly program has proved to be a most useful tool in promoting dental health to the elderly. However, this and many other well-meaning programs conducted by dentists and dental hygienists across the province are but a drop in the bucket in addressing the dental needs of those in long-term care.

A number of dental public health units, notably North York, Simcoe county, Muskoka and Ottawa-Carleton, have extended their existing dental public health programs to include some services for residents in collective living centres. However, lack of funding has prevented the expansion of these programs even though they have set an example of what can and should be done in terms of oral health care.

Is there a need for dental and dental hygiene services in long-term care? Well, we could have brought along this afternoon some slides that could have graphically shown you cases of neglect, cases of oral cancers undetected. We could have brought along dental hygienists who are currently conducting research or are providing care for the elderly, who could have described for you the sorts of situations that they're seeing. However, realizing that we followed perhaps a lunch break, we did not do that. However, I think that most of you have had an opportunity to visit seniors' residences of some sort, and in meeting with the residents there you have seen the outward signs of their oral condition and can only half imagine what the dental needs are that go on behind.

The goal that should be achieved in oral health care for long-term recipients is not to give everybody a Hollywood smile; it is much more basic than that. It is to ensure that each of them is able to properly chew their food; that they are able to eat a variety of foods for proper nutrition; that they are able to speak properly, to enunciate and communicate; that they are able to smile and socialize with others; that they are able to control bad breath; that they're able to wear their dentures and to have those dentures function; and that they are free from pain. All of these factors impact not just on their dental health but their overall health and indeed on their quality of life.

Is oral health care receiving adequate attention right now? Dental and dental hygiene services in long-term care facilities are extremely limited, often only providing emergency service. Dental care for any in group homes or those being maintained in their own homes is virtually non-existent.

Factors contributing to this low level of dental oral care are some of the following: Most dental and all dental hygiene services are of course not covered by OHIP; most long-term care recipients no longer qualify for third-party insurance coverage to assist with covering the cost; facilities do not allocate an appropriate amount of their budget for dental facilities, and those dentists who do attend usually do so on a very sporadic basis or for emergencies only; dental hygienists, unless part of a public health program, are severely limited by legislation in the services that they are able to provide.

Add all of these factors to the fact that many long-term care recipients are no longer capable of providing an adequate level of daily care for themselves, or that their care givers lack the time, the knowledge or the resolve to ensure that oral hygiene is looked after each day. The end result is that perhaps the segment of our population most in need of dental services is receiving the least.

In addressing this situation, the Ministry of Health and the Ministry of Community and Social Services have adopted standards and criteria for both the daily provision of care and for dental services that should be received by those in long-term care facilities. This, I believe, is contained in the manual that you've been talking about. The ODHA believes that these standards and criteria should apply to all long-term care recipients regardless of whether they reside in a regulated facility.

The ministry's recognition of oral care in those guidelines, coupled with comments made from seniors' groups, from care givers such as the practical nurses, confirm in our mind that oral care should have been a specified part of Bill 173. We had hoped to have in attendance with us today representatives of the Ontario Society of Public Health Dentists. Unfortunately, they have not arrived yet, but I would add that they are pleased that we have had the opportunity to speak with you and that they would support the statements that we have made.

Mr Jim Wilson: Would you like to comment on something that's raised on page 9 of your brief, the 20% rule. Given that, under the scheme so far anyway, Bill 173 won't be part of the MSA 80% service model, the services you point out will have to be contracted out at the 20% barrier, which would actually, I think, act as a deterrent to future growth or expansion of dental hygiene in community-based programs. Do you want to comment on that?

Ms Berry: We certainly see dental hygiene as an appropriate practitioner in providing dental care, and the services that they provide will go a long way in contributing to the quality of life of these individuals. If that service has to be purchased within that 20% cap, and other services as well, it's going to dilute a great deal how much dental care can be provided under that 20% cap.

Mrs Sullivan: I appreciate your presentation, and I think that, as have others, you've identified an issue that is of some concern, and that is where the clinical assessment and service delivery fits. For myself, I think it's useful to have a defined basket of services that are the minimum services across the province that those who seek long-term care should have. Certainly, we've heard from the medical community and from the RNAO that the assessments should include medical services, and I'm glad to hear from you that dental and dental hygiene services should be included in the assessment of needs as well.

I wonder if ministry officials or the parliamentary assistant could indicate to us why the clinical areas are not required or referred to in the bill at all. Is it simply a matter of a difference in the route of compensation of those kinds of professional services, whether they're medical or dental?


Mr Quirt: If I might, I'd answer that in two ways, by first of all talking about your concern about clinical assessment. The bill does talk about assessment as one of the necessary components of case management. The bill does reflect, however, a wide difference of opinion as to how much assessment a client requires prior to a particular service being delivered, and it also tries to account for wide variation in opinion about the necessity of health care assessments for individuals.

As we've pointed out before, if the needs of a client warrant, a very complicated, comprehensive assessment would be necessary involving the appropriate health care professionals, physicians and nurses and clinical specialists and so on. However, when it comes to support services, often people representing the community of folks with physical disabilities argue that they have absolutely nothing wrong with them from a health point of view and are quite happy to make their own assessment about what supports they need to live on their own. So the bill tries to accommodate both perspectives and be flexible in terms of the assessments required.

I think the issue that you've brought before us today boils down to one of financing dental care for people who can't afford to pay for it. Clearly, referrals to a dentist or a dental hygienist would be a very appropriate and often expected referral to be made by a multiservice agency or public health nurse or other person in the community service field.

I think the problem we encounter is when people live in a long-term care facility, who do have a right to regular assessment, they may still have difficulty in affording dentures or particular dental treatment, and those in the community as well face a financial barrier in some situations. I'm sorry to say this bill doesn't do anything to address the financing of dental care for those people who don't have third-party insurance or who are not recipients of public assistance, for example, GWA or FBA, that does cover that type of expense.

The Acting Chair: Thank you. There are no further questions, but there are a couple of minutes if there's anything further you'd like to say to the committee to wrap up.

Ms Berry: Just in response to the question, first of all, about assessments, I might read to you from the guidelines that have been developed, or the criteria, which referred to assessment in two places: one, that new residents shall have an oral assessment as part of the admission, medical and nursing assessments -- so it is addressed there -- secondly, that a dental assessment and preventive services shall be offered annually or as required by qualified dental personnel. So dental assessments have been addressed in the manual.

Mrs Sullivan: In the manual for long-term care facilities?

Ms Berry: Yes.

Mrs Sullivan: For facilities, but not for community-based services.

Ms Berry: That's what we're saying here, that we feel it should apply to everybody, not just those in facilities.

In the point about financing, I think what we wanted to stress is the fact that dental hygiene is a very cost-effective way of providing dental care. There is a great deal that dental hygienists can do in a facility where you wouldn't have to refer them out for services, where they could work with the residents themselves both in education in developing daily programs that could help to maintain their oral health and providing therapeutic care if necessary, as well as working with the care givers so that when they can't be there day to day, they can work with the people who are there to try and bring their oral daily care up to an effective level.


The Acting Chair: Our next presentation is from the Victorian Order of Nurses, Guelph-Wellington-Dufferin branch, Halton branch, Niagara branch and Waterloo region branch.

The agreement that has been made, because these are four separate branches of the same umbrella organization, Victorian Order of Nurses, is that you'll have up to 40 minutes for presentation and questions. We can pull as many chairs up as you require. I'm sure you've decided who your lead is, but it might be a good idea if perhaps you could introduce everybody who's with you, and then as a person speaks they could just state their name and where they're from exactly for the purposes of helping out Hansard. Welcome. Please begin your presentation now.

Ms Cherry Cross: My name is Cherry Cross. I'm a vice-president of VON Halton's board of directors and I will be acting as spokesman today, with some expansion on my theme by Dan Toppari, past president of the board of directors, region of Niagara.

The other members of our delegation today are Carolyn Milne, executive director of VON Halton; Jan Lord, executive director of the Guelph-Wellington-Dufferin branch; Cori Phillips of the Victorian Order of Nurses, Guelph-Wellington-Dufferin; Dan Toppari, as I mentioned before; Mary Casey, president of the board of directors of Waterloo region branch; and Elizabeth Allan, executive director of Waterloo region branch.

Our plan this afternoon is that I will briefly go through the proposal that you have in front of you and then be available, board members for perhaps questions around the issues of governance and volunteerism, and the executive directors perhaps around our operational matters.

As an introduction, VON, both Guelph-Wellington-Dufferin, Halton, Niagara and Waterloo branches, appreciates very much the opportunity today to present our joint submission on Bill 173 to the standing committee on social development.

VON is a not-for-profit voluntary health care organization that addresses health and social support needs of the people of Ontario through services provided by nurses, other health professionals, home support service workers and volunteers.

We are four of the seven branches in the south central region of VON Ontario, and we represent a total of 750 employees and 770 volunteers. All of the four branches provide visiting nursing services 24 hours a day, seven days a week, to their local home care programs, as well as service to individuals within the communities they serve.

In 1993-94, over 500,000 visits were made to over 21,000 clients. Two branches -- Guelph-Wellington-Dufferin and Halton -- operate Alzheimer day programs, friendly visiting and hospice volunteer visiting. Guelph-Wellington-Dufferin branch also provides homemaker services to the home care program for both home care and the integrated homemaking program. In 1993-94, approximately 150,000 hours of homemaking were provided to over 1,600 clients. As well, each of the four branches involved in today's presentation operates foot care clinics throughout their respective geographic areas.


VON recognizes the need for reform and is actively involved in the collaborative planning required to implement and enhance a community health and support system that will be able to provide a quality continuum of care within the limited resources available.

We're going to focus our brief on three specific issues: first, a lack of flexibility in governance, uniform rules and procedures, and assessment and eligibility; second, the area of human resources; and third, the area of funding.

I'd like to address first the area of flexibility. This legislation will need to carry us through times of very rapid change and therefore needs to allow for a high degree of flexibility. In its current state, we find sections in the act that tend to be prescriptive rather than enabling.

It would appear that it is the intention of the government to create multiservice agencies province-wide that will result in the total amalgamation of agencies that provide community-based services. For example, there's an important need for flexibility in the implementation of the MSA and the opportunity for communities to develop models that meet and reflect their unique needs. We are recommending that the province accept alternatives to amalgamation, as arrived at by individual communities, that may include a federation of agencies or other models which will achieve a multiservice system and also achieve the goals of long-term care reform.

From the consumer's perspective, there's an urgent need to integrate at the front-line level of service delivery and simplify access to the needed services. There's no doubt that service providers can work as a team, sharing common assessments, charts, care plans and values. Through these efforts, duplication can be eliminated and better coordination can be achieved. Already in many of our branches, interagency committees have been established to immediately tackle these issues.

To our knowledge, we've not seen any evidence that integration and/or amalgamation of service providers in a single agency will result in any savings. It would seem that Ontario is going in the opposite direction to many countries such as Great Britain and Sweden, where an integrated approach has been tried and abandoned. I'll refer you to the Thames Valley District Health Council discussion paper of January 1994. Also at risk would be a potential loss of thousands of volunteers, an essential human resource in our community programs.

We respectfully recommend that the standing committee on social development support our request for flexibility by amending part VI, subsection 15(2) to remove the four-year limit on transition to a fully amalgamated MSA.

As for uniform rules and procedures, VON supports the purposes of the act as outlined in part I. However, we are concerned that the application of uniform rules and procedures, claluse 1(e), may negate the purpose "to recognize the importance of a person's needs and preferences in all aspects of the management and delivery of community services." We support the application of consistent eligibility criteria but believe that rigid rules and procedures must be the exception, and flexibility the rule.

Specifically on assessment and eligibility, VON supports the need for an eligibility test for service provided by the multiservice agency. Subsections 20(1), (2) and (3) of part VII of the act, describing rules governing approved agencies, imply that there will continue to be a high degree of bureaucratic rigidity. This appears to be built into the act's requirements for an assessment of need before eligibility is determined. VON believes the client's own assessment of need for service such as Meals on Wheels or home support should initiate the assessment process. Nowhere in this section of the act is the client described as having any input into the development of a plan of service or is able to determine his or her own service requirements. Clients of VON continue to express their frustration with rigid and unnecessary application of rules and procedures applied in a paternalistic fashion.

Centralized telephone intake utilizing a risk screening tool could allow for the separation of clients into those whose needs require no further formal assessment or service plan than that identified by the client. Other clients could be referred for in-depth assessment. Electronic databases within the MSA with providers on-line could further avoid duplication of information collection and assessment.

VON recommends a less obtrusive system of self-reporting eligibility and self-application for services where this is possible. We also recommend the introduction of assessment and service planning, ie case management, for complex cases requiring clinical as well as resource service coordination and planning.

Human resources is another area that we feel strongly we would like to address today. Other concerns we have relate to the need for protection of current staff jobs. VON, along with its other long-term care community health and support service partners, has requested from the ministry protection for non-union staff similar to the protection afforded under successor rights in the Labour Relations Act for unionized staff. We are requesting that the committee make a strong recommendation on behalf of non-unionized employees for equal protection with unionized employees as this new system is created. VON and the other providers are asking for equal opportunity for all employees in accessing jobs in the MSA.

Severance costs: Unless jobs are protected, severance costs for non-profit long-term care community agencies could be significant. In contrast to for-profits, all moneys of not-for-profits are returned to service in the community, and thus few organizations have equity to pay severance. We recommend that if severing employees occurs, the government, having brought on the said situation by the legislation, should reimburse these agencies for severance.

As to the issue of board appointment, we're recommending that subsection 4(1) be amended to remove the minister's power to appoint directors and that the MSA board have full accountability and responsibility for board recruitment, selection and nomination. There's a strong perception that the MSA will be a bureaucratic government agency rather than a strong community-driven organization. We believe boards will responsibly select and develop their directors to govern the MSA and that the government should remain at arm's length in this process. This is consistent with the belief that the MSA can be an effective community-based organization.


The issue of funding: In the explanatory notes of the Long-Term Care Act, 1994, it states, "The Health Protection and Promotion Act is amended to delete a reference to home care services under the Health Insurance Act because these services will be encompassed in the new scheme for the provision of services under the bill." This explanatory note implies deinsuring of home care services. Currently, the costs of home care services are known and are paid for with OHIP coverage. VON is concerned because the new legislation gives no guarantees of adequate funding for the services to meet the client's needs. The government has eliminated a current safeguard and replaced it with an unknown. If there is not adequate funding for the MSA services, the community health and support system can expect long waiting lists and the further development of a two-tiered system. VON believes funding is a serious issue and recommends that the committee address this issue in the legislation.

At this time, Dan Toppari is going to address the issue of volunteerism as it applies to the act.

Mr Dan Toppari: Madam Chair, honourable members, ladies and gentlemen, I do not pretend to know all the issues surrounding Bill 173 and the reform of long-term care. The focus of my presentation will be on what I do know about, and that is volunteerism. If there is such a thing as an expert volunteer, I'm probably close to being one. I have been volunteering for over 20 years, everything from minor sports to service organizations to the Victorian Order of Nurses. Last year I was presented the Canada 125 medal in recognition of my volunteer activities. Maybe that qualifies me as an expert volunteer.

Why do I volunteer? I am not wealthy, so why do I work for these organizations for no pay? I have many time-consuming activities, including a young family, so why do I sacrifice my precious time? Why? Because I feel that I am accomplishing something worthwhile with my volunteer efforts, and I like that feeling.

Without exception, I became involved as a volunteer for a particular organization because someone I knew and respected encouraged me to do so. In every case, it was a combination of that respect and the intrinsic value of the particular organization that led to my volunteering.

When I was asked to volunteer as a board member to the VON Niagara branch some 10 years ago, the person who encouraged me to join had himself been on the board for over 10 years. I was honoured at being asked to join one of the best-respected health-related institutions of our country, with its origins dating back to the last century. Over the last 10 years, my time involvement with the VON has fluctuated. However, when I was president, I was very busy with the VON. I averaged between five and 10 hours per week, mostly at meetings, as well as events and presentations. Across Ontario there are thousands of volunteers like myself helping the Victorian Order of Nurses. We are paid not in dollars but, to us, in more valuable dividends such as pride in this institution which we have worked so very hard on behalf of.

What hope do multiple service agencies have at recruiting volunteers of like quality and quantity as those now helping community care organizations in Ontario? They don't have a prayer. They don't have a stock of current volunteers to encourage others to join. They don't have the attraction of a long and rich history. They don't have the appeal of an institution that absolutely needs its volunteers to exist.

I encourage the members of this committee to support long-term care reforms that will not destroy the identity of the individual organizations, so that volunteers like myself can continue to feel good about the work we do and so that the people of Ontario will continue to benefit from our time, freely given.

For our concluding statement, I'll return the floor to Ms Cross.

Ms Cross: In summary, we're very committed to the principles and ultimate goals of the government's long-term care policy. We strongly support the need to further develop a cost-effective system that will increase consumer participation in decision-making, simplify access to service, reduce duplication and improve the coordination of service. Your attention to the issues we have brought forth today will assist to develop a strong, effective and responsible long-term care system.

Mrs Sullivan: I want to say, I think from all of us on the committee, that we appreciate this brief. From my point of view it's a very succinct appraisal of what the difficulties are that will be faced by people, frankly, who will be attempting to seek services and by those who are employed now in the current system, either as workers who are paid or as volunteers.

I think you've pointed out quite clearly that what people want is a multiservice system, not a multiservice agency, not a single monopoly bureaucracy that is put into place to do all of the work that you do and more than that.

You have raised the issue of severance. We have had, in fact, no indication from the government of what its intentions will be with respect to compensating those agencies whose employees will no longer find a place in the system, because the VON will disappear. I would like to ask the parliamentary assistant what the government's intentions are with respect to severance and also what the government's intentions are with respect to those capital effects and compensation for those capital effects that are now owned and used by organizations such as the VON, including, by example, their automobiles and other equipment they use daily to do their work.

Mr Wessenger: I'll perhaps make a preliminary comment with respect to that. I think it should be understood that the process with respect to the whole question of human resources is to be dealt with by the local MSA, and the direction that will be given to that is to bring in a fair human resources plan which will deal with all employees fairly. I also would hazard to say that this matter will also have to be dealt with in respect to the whole question of assets and how they're dealt with.

Mrs Sullivan: Point of order: How can a local MSA deal with the human resources --

The Acting Chair: That is not a point of order. That is a question.

Mrs Sullivan: Okay, a question, then. How can a local MSA deal with human resources of an agency which it has put out of existence? What responsibility will an MSA have for the VON employees?

Mr Wessenger: I think it's been fairly well indicated that the local MSA will be directed to bring in a plan which will ensure that employees who work in the community sector are dealt with fairly with respect to the new operations, and anticipate there will be no loss of employment with respect to the people providing services. Perhaps I'll ask the policy person --

Mrs Sullivan: Do we have a guarantee of that?

Mr Wessenger: -- to add more details to this, but that's certainly my understanding.

Mr Quirt: Just to clarify that a bit, the district health councils, in developing their recommendations to the minister for multiservice agencies, will be required to submit proposals for multiservice agencies. The minister has made it clear that in those proposals there has to be a human resource plan that adequately addresses the issue of job security for front-line workers. It is our expectation that the government will be funding more direct service jobs, not fewer direct service jobs, with the advent of multiservice agencies, given that we are making a substantial investment in direct services.

In the event that an employee of an existing agency either is not able to accept a job with a new multiservice agency, chooses not to, or is not offered a job with a new multiservice agency, then the costs associated with the severance of that individual would obviously be a government responsibility, given that you don't have the resources to pay for it otherwise and it's our policy that has required you to take that action.

Secondly, with the small number of employees that we hope are affected negatively by this -- noting that we expect thousands more jobs as opposed to the opposite, but with those small number of employees affected negatively -- we hope the resources of the health sector training and adjustment panel would be available to them. As I said earlier, the long-term care redirection is a job creation initiative, not a job reduction one.

The Acting Chair: Mr Wessenger next to make a statement and clarify, then Mr Jackson. Then, time permitting, there's another question possible from the Liberal caucus, one from Mr Malkowski, and then Mr Jackson.

Mr Wessenger: Just to make some clarification with respect to some of the comments in the brief, first of all, with respect to the comment concerning the client not having input in the development of a plan of service, if you'll look at section 20(3), you'll note that "An approved agency shall provide an opportunity to participate fully in the development and revision of the plan of service" to the person who is the subject of the plan or service, so it is clearly provided in the legislation for that client input into the development.

Secondly, there is a misunderstanding with respect to your comments on page 7. Subsection 4(1) does not in any way relate to a director of an MSA. It purely relates to the appointment of a director in the ministry. The MSA board will have full accountability and responsibility for recruitment, selection and nominations, so there's no appointment by the government of either any employee of the MSA or any directors of the MSA. It's a non-profit corporation. It will just like the VON does now, very similar. In fact, the VON could conceivably be an MSA.


The Acting Chair: Would you speak directly into the microphone and state your name, please.

Ms Cori Phillips: Cori Phillips, with the Victorian Order of Nurses, Guelph-Wellington-Dufferin, and currently serving in the capacity of president.

Perhaps, Mr Wessenger, that should be clarified in the legislation, because currently, as it stands, there is great concern within the communities and on governing boards that there is the opportunity for the ministry to appoint people to what is supposed to be a community-based board. Obviously, your conditions and limitations that are set out further on in that section, I realize, must apply to a directorship, but what is the position of the ministry if an MSA is unable to meet all the requirements as set out for the directorships on the MSA boards and should they not have sufficient numbers? We have no indication at this time as to what numbers you're looking for in terms of board representation.

Within the community that I'm currently serving in, we may have upwards of 100 people serving on a variety of community-based boards. With the advent of the MSA, I would foresee that this number will drop to perhaps 20 at most, so we will lose the expertise and skill and experience of many people within the community who have devoted a great deal of time to making their community better in the delivery of health service. We just want some assurances that the ministry is not going to be able to turn around and tell us, "This person is not appropriate" or "That person is not appropriate." And what are the numbers going to be?

Mr Wessenger: I can assure you that's the case, but I think ministry staff, Mr Quirt, could probably elaborate further on that with respect to the progress being made in that area.

Mr Quirt: Yes, it certainly hasn't been contemplated that the minister would say: "Sorry, I don't like that person. Would you please have this other person on your board of directors."

Mr Jim Wilson: They do it on police services boards and other boards all the time.

Mr Quirt: It's not contemplated for the multiservice agency. The director --


The Acting Chair: I'm going to ask for order, please, so we can hear Mr Quirt.

Mr Quirt: The "director" referred to in the act refers to currently about 17 or 18 people within the Ministry of Health bureaucrats who make particular decisions if the minister so chooses to designate authority to them. I think you're absolutely right: If that's the impression the act leaves, then we have goofed in creating that impression and we need to clarify it.

I'd go on to say that the minister is obliged by the act, when making the decision to approve an MSA, to take into account whether the board is representative of the community it serves from a cultural perspective or a geographic perspective. If you were going to serve a whole county and everybody was going to be from one corner of it, she might say: "Well, wait a second. That's not as representative geographically as it might be." It also requires her to take into account whether it adequately represents the consumers to be served by the service. It doesn't oblige her in any particular way to decide one way or the other; it obliges her to take into account those factors in making a decision. So she has some discretion there.

Secondly, she has indicated that in terms of consumer participation, our guideline might be that at least a third of the people on the board would represent consumer interests. Some presenters have come forward and said it should be 50%, but the minister's position at this point is she thinks that at least a third might be consumers. That, I think, hasn't been adequately communicated to people as well, and I thank you for bringing forward those things that we need to clarify.

Mr Jackson: I can't help but be struck by the fact that it was three and a half years ago that both Carolyn Milne and Cherry Cross were at a meeting that I was at when we were looking at an entirely different model and vision and collaborative approach than what we have in front of us today. It's just mind-boggling to see how 180 degrees different this legislation is from what we were told by civil servants and the policymakers of the day.

Having said that, I concur with the concerns you've raised. Certainly our caucus won't be supporting this legislation without first submitting amendments, at least trying with amendments that cover most of the points you've raised.

The one that is starting to increasingly give me concern is the issue around severance, because severance can be an imposed factor by a government that governs its labour laws. Also, severance could be imposed as a precondition of the purchase of any services by a future MSA. You could literally punch a hole in your asset base and have that imposed, so that it's basically got a gun to your head saying, "If you would like to do business with us, you must provide severance."

I don't think that's going to happen, because there has been one experience in this province under the current government in terms of this transition adjustment. Nobody has been talking about it, but it's how the government handled the conversion of day care centres. Quite frankly, for the non-unionized workers, even unionized workers in non-profit agencies, their seniority in severance was not acknowledged at all by the government. Of course, that's an official position of OPSEU in terms of punishing those workers. That's clearly on the record for them, and I'm fearful that you're vulnerable in these two areas -- the sense of devotion you have working with your staff, many of whom are non-unionized, but the relationships are incredibly good and the obligations, moral or otherwise, are very strong as well.

The Acting Chair: Thank you for your question, Mr Jackson.

Would you like to sum up in the minute that's remaining? Anything further you'd like to say?

Ms Cross: The only thing I might want to say is that although there perhaps are some obviously negative feelings around some issues of the act, we as a whole are very, very pleased, because had it not been for Bill 173, perhaps some of the things that are happening in our areas now would not have happened. In other words, it has served as a catalyst to bring about partnerships in community-based organizations that traditionally haven't worked together in the past working together to provide better care for those in long-term care.

We thank you for your time and attention today.


The Acting Chair: The next presentation is from the Coalition of Community Health and Social Service Agencies of Hamilton-Wentworth. Please come forward, take a seat, relax, and introduce yourself to the committee. You have up to 20 minutes for your presentation. We have not received anything in writing. You're aware of that?

Ms Norma Walsh: That's right.

The Acting Chair: Okay, that's fine. It's not required.

Ms Walsh: Madam Chairman, thank you for giving us an opportunity to present today. I'd just like to take an opportunity to welcome all of you to Hamilton-Wentworth and to thank you for making this one of the locations in your itinerary across the province.

The Acting Chair: Thank you. That's a very nice welcome.

Ms Walsh: I am the past chairman of the coalition that is presenting today. Our chairman is on holidays, so he asked me to substitute for him. What we're presenting to you today are actually some thoughts around Bill 173, but it's also mainly to explain to you some of the work we have done in the coalition in Hamilton-Wentworth up until now that relates to the redirection of long-term care.

The coalition represents 21 agencies. You heard from three of those agencies this morning -- the VON, the VHA and St Elizabeth -- who have been working particularly with their board members around the health and personal support service aspects of long-term care. Our broader coalition relates to everything that deals with services in the community, be they health or social services. We have prepared a model of MSA for our long-term care committee and our district health council that suggests how these services should be delivered in Hamilton-Wentworth and how the whole organization should be governed. We will leave a copy of that proposal with you.

First of all, I want to say that we too espouse the goals and the principles of the province and our local long-term care committee, and our paper makes that very clear. We of course have read all of the reports, the rainbow reports as they're known, and the principles and objectives of Bill 173, and we don't have any difficulty with them.

One of the common denominators that our coalition members have is that we serve seniors, but some of our members also serve other populations that are to be governed by long-term care. We feel the model MSA that we're proposing can cover those who have HIV/AIDS, the physically disabled and brain-injured persons.


What we propose in our model is a federation. That's something that doesn't seem to be allowed through Bill 173, but we feel that through our federation we can provide all those things the government wants to see provided: simplified access, information and referral, coordination and integration of services, the management and service delivery excellence demanded by the community, the eligibility for facilities, and of course the authorization for admission to facilities. The basket of services that we propose will include all of those services covered by Bill 173.

In our model, we centralize some of those programs, the obvious ones that in our community we feel should be centralized, such as PCS, physio and occupational therapies, because those are specialists who are very scarce. We also centralize some other administrative activities. However, in the main what we're suggesting in our model is that services be delivered through area offices within the region.

None of you are from the Hamilton-Wentworth area, so maybe I can just briefly tell you that the city of Hamilton makes up approximately 70% of the population of our region, and the city of Hamilton is right in the middle of our geographic area. We're surrounded, then, by more rural areas that used to be the old county of Wentworth. For that reason, and because of the history attached to some of the development of programs within those communities, we feel it is very important that the services be delivered on a geographic area-wide basis where people who have been used to identifying with local neighbourhoods can continue to do that, and hopefully the services will become more attuned to what's going on in the neighbourhoods as well. We feel that most of the services can be delivered through these area offices and perhaps also through some suboffices that might exist, and do exist, by the way, in communities such as Dundas, Flamborough and Ancaster.

We spend a great deal of time in our model talking about information and referral because, frankly, we think that's the major problem we have in this community. I think Mrs Sullivan made reference this morning to the fact that our coordinating efforts in Hamilton-Wentworth seem to be known beyond our borders. We're delighted to hear that, because we have worked very hard for a number of years to create that kind of coordination and consolidation and networking among our services. However, we do have a problem with information and referral. It's not a problem that we're totally responsible for, but we do think that's a major area where we must improve our act as community agencies. That certainly would be a major thrust and where we would hope to get resources so that we can develop a one-stop-access situation for the members of our community. I'm not a technical person, but technically I'm told this can be done by incorporating a lot of new technology into our access system. Frankly, that's one of the areas where we want to spend a great deal of time.

The experience of our current information services in the community tells us that they get a wide variety of people calling in, some just wanting information, some who need help in clarifying exactly what it is they do want, and some of course who are phoning in in rather precarious situations and for whom immediate action is requested and necessary. I think the type of one-stop access that we develop would -- must, actually -- cover all of those situations.

We spend a great deal of time in our document talking about the geographic areas, but these are suggestions. The areas we developed are based upon geography, upon population, and also upon the expected growth in population in our region over the next 20 years.

Around the governance idea, as I mentioned to you earlier, we have gone for a federation model. The federation would not only bring the agencies together in some umbrella organization, but of course there would be consumer representation and citizen representation on a board of directors of any umbrella organization. It would not be unlike what has happened in the development of the long-term care committee in communities across the province.

I'll leave my part of the presentation at that and welcome Nancy Long -- the late Nancy Long -- who is a public health supervisor and of course has been working today and who is going to address some of the items that we feel we cannot go along with in Bill 173.

The Acting Chair: Actually, you're not at all late, Nancy. The committee's just been moving along, so welcome.

Mrs Nancy Long: Thank you. Actually, as I was driving down here, I did have that horrible thought that you might be early, and I would be racing in as I was. Thank you very much, though, for allowing us to come and speak with you.

I guess really what I wanted to do was to say four points in closing, or to close Norma's presentation.

One is a reminder of the goals, I think, of long-term care. We've tried very hard in our coalition to keep on reminding ourselves of them. It goes back to a Ministry of Health document which talks about the promotion of health, sustaining wellness, diminishing disability and dependence. I felt it was important to remind people going along with Bill 173 that just a better coordinated system does not necessarily guarantee any of those goals, so it's a cautionary note for all of us. We don't really just want a better coordinated system with a very efficient MSA; rather, what we want is a system that does promote health and sustain wellness within our community.

The second point in terms of our proposing a federation of agencies is that we feel very strongly that this will maintain local identities that our community agencies have realized. We do realize there is a need to amalgamate some of the community agencies and we are very much at the beginning of discussions in terms of what might need to be amalgamated, but we feel we would not recommend amalgamation of all agencies perhaps as Bill 173 proposes.

A concern along those lines is in terms of the governance issue and the use of volunteers. We in Hamilton-Wentworth, as in many other communities, have a tremendous number of volunteers who support our local community agencies. We're very concerned that with the amalgamation we will lose this huge number and the strength that the volunteers give our local agencies. That goes along with sort of the man-hours that they provide, as well as charitable donations that are given to the specific agencies.

My fourth point is with regard to funding. It would appear that through Bill 173 there's a presumption that the funding for local agencies will flow into the MSA. I guess an example of that where we would be concerned would be an agency like Catholic family services, which is currently funded, I believe, 70% through the ministry and 30% through United Way. It would appear there is a presumption that that 30% funding would also sort of flow into the MSA. Quite frankly, I don't think the community agencies are convinced of this, so there's a concern about where that additional funding will come from.

I guess basically, in closing, our consumers are telling us that they need easier access. That seems to be the biggest complaint so far. We feel that through our proposed federation of agencies and improved information and access services, we can address what the consumers are telling us they would like.

I'll close there and thank you very much for the opportunity of coming today.


Ms Walsh: Just one further comment. In addition to the information and access deficiencies of our system, I must bring to your attention that certainly one of the other problems we have is an underfunding of some of our current services. We have a great proportion of our regional population -- not a great proportion, but a significant population -- who live in rural areas, in Flamborough and Ancaster and Glanbrook, which are mainly rural areas. The service provision in those areas is pretty thin, and that's only because the services that are trying to address issues in those areas are underfunded. In addition to improving our information and access situation, we certainly feel we need more resources to cover all of the seniors and other disabled people in our geographic area.

Ms Carter: Thank you for your presentation. I was interested in your idea of federation. I'm wondering in what way it differs radically from what we're doing, because this is a community-driven thing where in each area the relevant agencies are coming together and designing their own plan as to how the MSA will work and how things are going to happen in their area. So I don't see it as a bureaucratic cookie-cutter plan that's imposed from above.

You specified "volunteerism," which is an issue that keeps coming up. I want to point out that there is a joint group with the United Way that is discussing volunteerism, because we want to make absolutely sure that doesn't get lost. I just wonder why volunteers would in fact fall away, because although the agencies will have come closer together and maybe amalgamated, there will be the specific areas of help which is needed. Certainly, Victoria County Community Care, which is an existing group that has brought together a lot of fragmented groups that existed previously, finds that volunteerism is still great.

Also, I just wanted to mention the funding question, because this is a concern that's come up several times. First of all, the whole objective of what we're doing is to have not a sort of bureaucratic planning as to what money goes where over the province, but by dividing the province up into areas that will have their separate funding envelope, we're then handing over to local boards and decision-makers as to how that money will be spent.

I was rather unhappy to see on my local news last night the suggestion that Bill 173 was leading to a reduction in funding and that people were going to have to pay for services in their home that they haven't had to pay for before and so on. I'm afraid that idea of alarm and despondency is being spread around, but actually the amount of money that's being invested in community-based long-term care is going up very drastically. It was $550 million in 1991 and $850 million a little more recently.

The Acting Chair: You've used up all the time that's available. Would you like an answer from them?

Ms Carter: Oh, I'm sorry. Yes, all right.

Ms Walsh: Just some comments on your comments: First of all, I think you have heard from other presentations, better than I could express, what motivates volunteers. Volunteers usually have a very personal reason for doing what they do. True, a lot of volunteers currently involved in services might decide, "Yes, I will continue to be a volunteer in this system called the MSA." However, my personal feeling is that a lot of them will not and that the MSA, because it is kind of a no-name agency at this point, is going to have difficulty recruiting volunteers because there won't be that personal attraction that there has been with some of the local agencies like VON and Red Cross.

On the second point, about the funding, I think a lot of our concern is around the private funding that's raised through agencies through donations and things like that that are now going into service delivery. The money raised by agencies today is going into programs. That will be lost under an MSA. I don't think you're going to get those private donations -- that's my personal feeling anyway -- at least not to the same degree that you're getting them now for private organizations.


The Acting Chair: The next one is St Elizabeth Visiting Nurses' Association. If the Wellington-Dufferin-Guelph Health Unit show up, they'll be immediately following this presentation.

Mrs Soluk: Good afternoon. My name is Rita Soluk and I'm president of St Elizabeth Visiting Nurses' Association. With me this afternoon are Ms Bernice King, chair of our board of directors, and Mr Hugh Greenwood, vice-chair of the board of directors.

St Elizabeth Visiting Nurses' Association would like to thank the standing committee on social development for the opportunity to respond to Bill 173.

St Elizabeth's is an incorporated not-for-profit agency delivering nursing and homemaking services in the communities of Hamilton-Wentworth and Halton. As well, we provide a volunteer visitor and driver program in Hamilton-Wentworth. Our agency employs approximately 200 full-time and part-time nursing and homemaking staff and has approximately 130 volunteers.

We support the principles and goals of long-term care redirection. We support a coordinated and integrated consumer-driven system of care that is delivered by locally based, volunteer-led, not-for-profit agencies.

Our purpose today is to share with you our concerns with the proposed legislation, the Long-Term Care Act.

At the June 3, 1994, district health council workshop, the Honourable Ruth Grier stated that the legislation would "support a coordinated and integrated system of care" and that this care would be "delivered by locally based and volunteer-led, not-for-profit agencies." In the Honourable Ruth Grier's statement to the Legislature on June 6, 1994, she said the legislation "enables us to create a coordinated and integrated system."

St Elizabeth's is an advocate of these positions. Our joint presentation today with the Victorian Order of Nurses and the Visiting Homemakers Association is evidence of our support for and commitment to a coordinated and integrated system of care being delivered by locally based, volunteer-led, not-for-profit agencies.

Our joint proposal indicates that it is possible and desirable to achieve a system of care without amalgamation. In fact, our proposal supports a truly integrated system. It allows for the principles and goals of long-term care reform to be realized without alienating long-standing allegiances and devotees to specific causes.

However, this legislation requires amalgamation. We see amalgamation to be destructive rather than corrective. We believe amalgamation eliminates consumer choice of service provider. It eliminates community control and decision-making in establishing a system of long-term care services which will best meet the needs of community members. It creates a monopoly which will, over time, demonstrate a number of characteristics common to monopolies. There will be loss of incentive to respond to changing health trends and consumer needs, to be innovative, cost-efficient or provide quality services in a timely manner. Exclusive control of scarce resources by a concentrated authority will erode the more esoteric services and lead to the provision of inflexible, routine services.


We strongly recommend that the requirement for amalgamation be eliminated. We support community determination of a system designed to best meet the needs of its residents.

It is expected that the ministry will develop evaluation criteria against which to measure the success of amalgamation. Instead, we strongly encourage the ministry to develop criteria from which a community can develop a system plan and against which the ministry can measure its plans.

The 20% ceiling eliminates consumer choice, one of the basic principles of long-term care policy. The only exceptions to this ceiling are purchase of service from individuals by MSAs and purchase of service from any provider by consumers who have received grants. In both cases, it will be difficult to monitor the quality of service delivered. It will be difficult to monitor the appropriateness of services purchased by those with grants.

We recommend the 20% ceiling be eliminated. We recommend that local communities determine their purchase service requirements.

We applaud the development of an appeal process. We are concerned that while appeal boards possess the right to rescind and substitute decisions, they bear no responsibility for the costs associated with these decisions or the impact such decisions may have on the community's ability to respond to overall community needs.

Potentially, vocal groups with established networks could use the appeal process to dictate the allocation of funds and service plans at the local level. Community members who are not members of an established network, such as those requiring acute care services, palliative care services and other transitory services, could potentially fail to have their service requirements met.

The proposed funding formula does not provide for decisions made by the appeal boards.

It is imperative that guidelines be established which limit appeal board powers to functioning within the overall community service plan.

The composition of the appeal board is unclear. We recommend that membership of the appeal board reflect that of other committees proposed in the legislation; that is, "consumer," "provider" and "other" categories.

This legislation does not indicate whether client service will continue while an appeal is in progress. We recommend that this point be clarified, given the potential consequences of such service interruptions to the consumer. While the consumer has recourse through the courts in cases questioning violation of rights, we suggest that this may be too lengthy a process for the consumer as well as having a negative impact on the whole system.

Existing situations contain both union and non-union staff. Both groups, we believe, have rights and deserve equal treatment. Union affiliation should not predispose staff to preferential treatment. The original selection of MSA staff should be based on years of service within existing agencies, not seniority within unions. Staff selection should be based on experience, education and other job-related factors.

The new system will experience considerable costs associated with achieving parity in wages, benefits and changes in pension plans. Staff relationships will become strained as they experience job insecurity, compete for new positions, and are displaced in an evolving system.

In all likelihood, bureaucracies will develop. Bureaucracies usually bring lengthened communication systems. They erode staff loyalty and commitment, reduce staff productivity, and bring management and staff conflict. Bureaucracies cause system and manpower inefficiencies which result in new costs. They often breed staff hostility, animosity and dissatisfaction. Surely the consumer will suffer the consequences of this legislation.

Evolving bureaucracies result in funds being redirected to support administrative positions. The consequence is that existing funds used to support the salaries of staff who provide direct consumer care are eroded. Staff will be forced to join unions or be unemployed. The consumer will lose valuable expertise and knowledge if staff are forced to seek employment in a non-unionized environment.

A number of our programs, such as the volunteer visitor and driver program, could be eliminated. Such programs are financially supported through sources other than the ministry. These funding sources will not guarantee ongoing financial support in light of the proposed legislation.

The costs related to anticipated loss of volunteers are significant. Volunteers are the backbone of many services which have evolved in response to identified consumer needs. Consumers who value and depend on these services will be the ones to experience the consequence of the loss in service.

The distribution of grants to individuals able to manage their care is supported. The criteria for grant application are not included in the act. We appreciate these are under development right now, but clearly that needs to be defined and we need to understand the approval mechanism. However, what is clear to us is that exclusion of any consumer from this grant process supports the evolution of élitism. The appeal process, as pointed out earlier, allows for potential control of MSAs by established groups or networks with effective lobbying skills and knowledge of how to access the system. Hence, the appeal process brings with it, again, the potential for evolving élitist groups. While it might be argued that the legislation enables all community members to have a voice, it is clear from the low attendance at recent community forums held across the province that the general public have very little, if any, appreciation or understanding of the potential impact of the proposed legislation.

The act makes very little reference to the acute care population, a population which constitutes an equal or greater as well as growing proportion of those receiving long-term care services. Despite this fact, they are not now, nor are they likely to be, members of a network of individuals able to influence the system. In the main, acute care clients will not know about long-term care services until such services are required. There is no existing network for acute care clients. Acute care clients are not members of potentially élite groups.

We have articulated our position that unionized staff should not be given preferential treatment. Under the proposed legislation, most non-unionized staff will not receive recognition for their many years of service. Does this approach not then create an élite staff group? Certainly, staff should compete for vacant positions based on experience and job-related qualifications. Staff should not compete for positions on the basis of union affiliation. This legislation supports the formation of opinions about others based on their membership in groups with assumed characteristics rather than on the merits of the individual. Is this not the essence of discrimination?

We support the takeover option. In addition, we would recommend that the external party responsible for evaluating the agency in question be a mutually agreed upon third party by both the ministry and the agency. This recommendation is based on a common model utilized in a number of forums for resolution of difference.

Finally, the sophisticated computerized infrastructure necessary to support evolving community structures is not available at this point at either the community or the provincial level. The costs of developing and implementing such information systems are astronomical. We recommend that the financial resources required to support the development of a new technology be found outside of the existing funding allocation.

In conclusion, we would like to restate our support for a commitment to an integrated and coordinated -- we would add consumer-driven -- system of care which is delivered by locally based, volunteer-led, not-for-profit agencies. We have pointed out a number of potential, but we believe very significant, consequences of Bill 173. We believe amalgamation is not the only answer. We believe communities must be permitted to develop a system of care best suited to the needs of the community.

We are confident that you will give serious consideration to the concerns we have put forward today, and we thank you for this opportunity to respond to the proposed legislation set forth in Bill 173.

This completes our presentation, and we'll be happy to entertain questions.

Mr Jim Wilson: Thank you very much for your presentation. On page 6 you note that "It is expected the ministry will develop evaluation criteria against which to measure the success of amalgamation." In the interest of good government, would it not be up to the government to show us some studies or some rationale or at least some form of justification for their contention that MSAs will indeed save money and be more efficient? If the answer is yes, as I suspect it is, have you, in all the discussions you've attended, heard anything to make you believe the government's claim?

Mrs Soluk: Actually, the answer is yes, and it's supporting what you've heard in the last few days of hearings. No, I've not been able to find anything. I have done a fair amount of reading. In fact, what I've been able to find is that in health care areas that have gone in this direction, they are reversing it. If you look to industry, the same. So I don't know why we wouldn't learn from the experiences of others.


Mr Malkowski: Thank you for your presentation. You were one of many presenters we've heard with the same theme again and again, which is concern about the role of volunteers and the maintenance and the identity, I suppose, of your volunteer corps for fund-raising and those who actually do the on-line work. We've heard that concern time and time again.

Again, we are proposing that recommendations be made that within legislation we spell out where the role of a volunteer coordinator may be placed under an MSA, and also for outreach and for fund-raising; therefore, to preserve some of the traditions, those roles which are now occupying some agencies out there. Would you feel, if we were able to do that, that that could be something you could support, to see a volunteer coordinator and that position therein outlined in the legislation?

Mrs Soluk: I would suggest that maybe you've missed the point. The issue is not a question of whether we might have a volunteer coordinator or a director or whatever. The issue is whether people would wish to volunteer for government-run sorts of activities. I gave you an example this morning of what happened in our local cancer office. I think I suggest to you on a very small scale what you would see happen in the larger amalgamated approach you're suggesting. So I don't believe a position built in that would support a volunteer coordinator or whatever would be the answer.

The Acting Chair: Thank you very much. We appreciate you coming before the committee today.

Mr Malkowski: Can I just clarify? An MSA is not a government bureaucracy. Again, this is going to be coming from the community. These are going to be community people coming from your own community, elected by the community.

The Acting Chair: I thought you had a supplementary question.

Mr Malkowski: This is a supplementary.

The Acting Chair: So the question?

Mr Malkowski: My question is, following this point, it therein being a community-based organization, would it not be appropriate to have a volunteer coordinator? This is not a government bureaucracy. Would you not then support it?

Mrs Soluk: I would suggest to you, on the evidence you've heard in the last few days, that people aren't in agreement or consistent with your thoughts on whether it would be or would not be a community-based organization. The suggestion out there is that it probably won't be; it would be government-run. If you look at what the act says, that's fairly clear. If you draw parallels between this and the ministry in terms of education or any other sorts of things, I think you will see that that's the sort of thing that will evolve.

The Acting Chair: We appreciate you coming before the committee today. If there is anything further you'd like to say to the committee, you're welcome to submit in writing your brief or further comments to the clerk.

Mrs Soluk: Can I make one short comment, since you offered that to others?

The Acting Chair: Yes, you may.

Mrs Soluk: At lunchtime, when I came back, you were listening to a technical interpretation of the act, and nearing the end there was a discussion about the changes in criteria which allow people now to have services without professional services etc. I would like to share with you the fact that that's been the position of the community service providers for a number of years. We felt that was the sort of thing we should have been allowed to do. The legislation did not permit it. I would suggest to you that this sort of legislation was not necessary to make that happen.

The Acting Chair: Thank you very much.


The Acting Chair: The next presenter is Wellington-Dufferin-Guelph Health Unit. Welcome, Dr Kittle. You have up to 20 minutes for your presentation. The committee has received your written submission. Please begin.

Dr Douglas Kittle: Thank you for giving me the opportunity to speak to you today about this bill. I have a presentation which I will basically read, but I'll digress from it where appropriate at certain spots.

Long-term care services and community support services in Ontario are in need of major reform. To this end, Bill 173 is welcome, and parts I and III aptly reflect the purpose and rights associated with this reform. However, our board, which is a public health unit board, finds disturbing a significant section of the act which I wish to bring to your attention. I wish to start by giving you some background to this issue.

Health units across Ontario administer 29 of the 38 home care programs, and I'm sure you know that home care will comprise the bulk of health services contained in MSAs under the Long-Term Care Act. Our stewardship of home care has had its rocky history but has emerged with a strong collegial relationship. In our case, we started with a handful of staff sharing space with public health in the mid-1970s. Today our home care program has a $14-million budget, a staff of 100, and operates from two autonomous sites in Guelph and Orangeville. At any one time, we have about 2,700 patients or clients on the case load who receive a minimum of nursing and/or therapy service.

I want you to reflect for a second. That's the equivalent of 2,700 hospital beds, you might say, run for a program of $14 million. However, each one of these people has, in order to get on to this program, a medical diagnosis, and along with that medical diagnosis are health care records. These people will be transferred to MSA services. What will happen to health care records, what will happen to physician reporting and what will happen to the role of the physician in looking after and attending to the people who will be involved in the care provided through the MSAs? There is no reflection of this in the act at all.

All therapy services in our establishment are provided by in-house staff. All nursing and homemaker services are provided by community agencies on contract to home care. In our case, the local VON provides most of these services.

In 1989, the then assistant deputy minister, Dr Bob MacMillan, commissioned Price Waterhouse to review home care programs across the province. The report was favourable to the local administrative arrangements except for some of the arrangements where it was felt there may have been conflict of interest by virtue of the fact that the agency that provided the service also was the agency that administered the program. A potential conflict of interest was raised as the issue here. The report identified a number of management shortfalls at the central level, most to do with poor centralized planning. I stress that point: poor centralized planning, not peripheral administration of the services.

Administration costs in our program are less than 10%, and the health unit receives $40,000 annually to administer the $14-million budget. Home care does cost-share on payroll and other incidentals, but it is far from a cash cow for this agency.

I think if you were to review voluntary agencies such as Oxfam, you would be hard pressed to find voluntary agencies like this which have administrative costs at 10% or less.

All this said, we are proud of the history and achievements this community-based health service offers. The staff commitment and allegiance to home care must be experienced to be believed.

What I wish to digress on this is the whole issue of goodwill of staff and volunteers. A lot of what is currently happening out there wouldn't happen if it wasn't for the goodwill of the people who provide the program. This present bill is tampering heavily with that goodwill and I do not see an avenue that will come out of it which will salvage that goodwill. I think the previous speaker spoke to this again with respect to maintaining voluntarism.

With all this in mind, our health unit board and administration are perplexed and even angry at one clause of the new act which disregards our chances to be a governing agency for an MSA. It is as follows, part VI, 11(3): "Before designating a municipality or a board of health as a multiservice agency for a geographic area, the minister shall consider the suitability of all other approved agencies in the geographic area for designation as multiservice agencies."

From the clause, it is clear the health units have been designated a last-place priority with respect to governance. You can see that in the face of no previous problems, a good track record and a favourable review -- Price Waterhouse -- this is clearly a slap in the face to our record of hard work developed through 20 years of service.

What is interesting here is how this clause appears to also fly in the face of local decision-making. The emphasis stressed by all the multicoloured documents issued in 1993 is that local district health councils are to lead local discussions on how they wish to proceed on the formation of MSAs. The product will then go to the minister for acceptance. In the new legislation, she has determined in advance what local options she will not accept.


The rigidity of the Health Protection and Promotion Act in determining the construct of health unit boards has also been raised as an issue. I believe this is a red herring in that from the onset, ALOHA, our provincial association, has offered the minister an opportunity to discuss amending the legislation to accommodate for MSA governance. This has gone nowhere. It cannot, however, be for the lack of interest in changing existing legislation. Five acts have been slated for amendments to facilitate this bill. The Health Protection and Promotion Act happens to be one of them, changed in this case for the purpose of deleting reference to home care services under the Health Insurance Act.

That is another area which is alarming. I don't know if people here recognize the complexity of some of the cases that are currently on home care services in the province. Programs look after children discharged from hospital early with tracheostomies, very fragile medical conditions. They have patients on the case load who are receiving intravenous anti-cancer drugs, cancer chemotherapy medications, and many more types of complicated conditions leading up to even palliative care concerns. Yet again I reiterate the point: The medical diagnosis and the role of the physician have totally been lost in this legislation.

The creation of new agencies with new boards appears to be the direction this reform is taking. The cost and time associated with this will be astronomical and are clearly a 1970s solution to a 1990s milieu.

In this way, I read in the legislation that we're throwing out the baby with the bathwater. Rather than starting with what we've already got on the ground, agencies with community-based programs that have been operating, some of us, for over 100 years have been totally pushed aside, with the emphasis on what appears to be new boards, new administrations, which spend hours and months and years establishing themselves in communities.

We ask that the playing field be levelled so community options are not compromised and health units are given equal opportunity with others as potential sponsors of MSAs. If this is not to be the case, then health units and municipalities at least should be apprised of why they have been chosen the agency of last resort.

Thank you for your time.

Mrs O'Neill: I presume the Wellington-Dufferin-Guelph Health Unit has been involved to this point in the planning towards an MSA with the district health council. I'd like you to comment on that as well as how you see the Health Protection and Promotion Act changes that are going to be coming with the changes to the Health Insurance Act.

Dr Kittle: The health unit has been involved from the inception of the formation of any of the organizing committees, both in Dufferin county and in the Guelph-Wellington area. We are at the table, myself personally or a representative from the home care program, the director of the home care program.

Let me say that in my 20 years in public service as a community physician, community health specialist, I have yet to come across a piece of legislation that is as woolly and difficult to get around. I will speak frankly. The district health council's planning committee is flummoxed -- I believe as flummoxed as I am -- on how to proceed with this cumbersome, hard-to-get-into and hard-to-get-around type of legislation. We're at the table but I'm not so sure we're making great progress.

I'm sorry. Your second question was something to do with the insurance act?

Mrs O'Neill: Your third-last paragraph regarding the Health Protection and Promotion Act and the changes to the Health Insurance Act under this act, and how you see that affecting your clients.

Dr Kittle: As I stated earlier, this is de-insuring the home care services. Currently, all services that are provided are insured services and we have to provide them if the patient-client is eligible for the service. Under the new formula there will be a funding envelope, and no matter what comes forward, we will have to take from the envelope and be unable to go beyond that, to the best of my understanding.

My point in that particular paragraph, however, was that the Health Protection and Promotion Act has been used -- the rigidity of health unit boards is stated in the health protection act. In other words, the health protection act proscribes how health unit boards should be structured. Some have said that structured rigidity would make us poor governance agencies for multiservice agencies.

My point is that we have attempted to talk this point out with the government through our parent association, and this has gone nowhere. They have gone into the act to change it in order to de-insure the services, so it's not not wanting to go into the act. That's my point.

Mr Wessenger: Thank you very much for your presentation. I certainly note your concerns about the problems of confidentiality, particularly in the question of absence of consent, and that will be taken note of.

I'd just like to ask you a couple of questions with respect to your concern about why a public health unit could not be an MSA. The first question is, in view of the other major responsibilities that public health units have, how would we ensure that the public health unit would have the focus on long-term care that's absolutely needed? Secondly, what would you recommend with respect to restructuring with respect to public health units in order to ensure that a public health unit had the true consumer input that is really needed in the management of long-term care, that true consumer community input?

Dr Kittle: Those are excellent points. The first is that if you read the act, it is possible to have community membership on the board one less than the municipal membership. In our case, we have members from the city of Guelph, county of Dufferin and the county of Wellington. If they total 10, it is possible, under the current Health Protection and Promotion Act, to have nine community-based members. It's how you choose those members, which is at the discretion of the minister, for appointment. So it is possible even under the current legislation to have good consumer input.

However, we have recognized that there are restrictions with the act and we're very interested in opening dialogue, discussion, with the minister about that. In other words, our parent association, the Association of Local Official Health Agencies, has been willing to look at going into the act, changing it, and restructuring the board structure so that it could reflect some of the parameters required under this legislation for more consumer input.

Mr Wessenger: Fine. Thank you.

Mr Jackson: Doctor, we have not received much input from physicians individually during the course of the early part of the hearings. Could you perhaps help me with an understanding of how you envisage the relationship to physician referrals as they now work and how physician referrals will have similar responsibility and linkages under the new system? Obviously you've been able to put your mind around that, given where you're coming from and where you're currently serving the public.

Dr Kittle: Currently, all clients who are on the program have to have a physician referral. In order for the services to be provided, that physician referral has to be there.

The new approach is to have clients on the program, but there is no comment as to what will happen with the referrals and what is the liaison, networking relationship between the physician who has the patient -- the patient is on the program -- and the relationship with the program back to the physician. Currently, there is an accountability factor. That accountability factor appears not to be in place under the new legislation. The concern here is that in our area, if we have 2,700 people currently being serviced on a daily basis, those are the same kinds of people, plus a few others, who will receive the services under the MSA. The style is not going to change, and yet where are the assurances on accountability confidentiality with respect to reporting and records maintenance? I don't see it.



The Acting Chair: Is the Hamilton-Wentworth District Health Council here? Please come forward. You have up to 20 minutes for your presentation. You've probably heard me say this to others, but please begin by introducing yourselves, and if you'd like to leave a little bit of time for questions, we'd appreciate it.

Ms Barbara Mahaffy: Madam Chairman, honourable members, it is my pleasure and privilege to be present today to submit comments in response to Bill 173, An Act respecting Long-Term Care. I am Barbara Mahaffy and I speak to you today as chair of the long-term care committee of the Hamilton-Wentworth District Health Council. With me is Posie Poushinsky, the long-term care planner with the health council.

Just over two years ago, the ministers of Health and Community and Social Services charged DHCs with the responsibility for planning long-term care services in general, and multiservice agencies in particular, in our communities. The district health council of Hamilton-Wentworth accepted that responsibility and began to develop a long-term care committee that has the mission, the authority and the credibility to consult with the community and to represent the community's wishes and needs in developing appropriate systems for this area.

The process of establishing the committee itself was consultative as we sought advice from the community on both committee structure and terms of reference as well as membership.

Provincial guidelines at the time allowed us to be creative in our membership. It was recognized early on that there were not enough seats around the table to accommodate all the expertise in our community without overwhelming the voice of the consumer or making the committee so large as to be unmanageable, so we created an advisory committee of experts from various areas of long-term care. They have provided us with invaluable input in our discussions to date.

As a committee, we continue to support the development of a multiservice agency system and support the intent of the legislation that provides a basis to establish it. However, we have several areas of concern on the growing restrictions to our community planning and our local vision.

When the Minister of Health first talked of MSAs, we were heartened to hear that within certain guidelines they could be developed to reflect community needs. In Hamilton-Wentworth, we have spent the last four and a half months talking to groups all across our geographical area and asking them what is the best way for them to access service and how we could design an MSA system to best meet their needs. We now have legislation before us that does generically define an MSA but concludes with an onerous listing of very specific areas in which regulations will be established that cannot help but restrict our flexibility in planning. We encourage you to respect the ability of our community to plan appropriate models and to allow both legislation and regulations that are flexible enough to permit a local flavour to the final product.

In our reading of the act, it appears from sections 12(1) and 13(3)(c) that there will be some flexibility for an MSA to provide services through another MSA. On the other hand, there is some indication through the minister's revocation powers that two MSAs may not be allowed to exist to cover the same geographical area. We have a concern that the legislation may be contradictory in interpretation and may hamper efforts in some communities to develop an ethnospecific MSA where the needs of a significant ethnocultural population can only be met in this way.

Another area in which flexibility of planning for our community has been limited by the legislation is the area of mandated services. We recognize in these times that there are not always resources to support all the goals we wish to achieve. We urge you to look at the mandated services and consider whether the government will be able to provide the funds to support all the services in all the communities.

We ask that you consider establishing a smaller core of required services that are essential to sustain independence and allow each community to decide which additional services are most essential to meet the needs of their particular community. When resources are limited, it would seem better to do fewer things well than to be all things to all people poorly. Moreover, when we promise a comprehensive list of services and then are unable to deliver them in sufficient quantity, we may leave people at risk in their homes, with services that are too limited to maintain safe independence.

We strongly support a bill of rights for clients and ask you to consider two adjustments to the process. The first is to make the bill of rights a collaborative contract between client and service provider. Allow the bill of rights to be written by the consumers and providers in each community and legislate only the areas of rights to be included, such as access equity, dignity, information and confidentiality. This allows an atmosphere of cooperation and supports the mission and philosophy of most service providers rather than setting up an environment where one needs protection from service providers.

The legislation needs also to protect the valued role of the volunteer in both service delivery and resource generation.

The final group needing protection and recognition in legislation includes those whose jobs are at risk through development of MSAs. Help us to work at ensuring that the rights of all employees, both union and non-union, both management and front-line worker, are respected, and that equal opportunities are available in work reallocation.

We support the appeal process and encourage that it be used to strengthen the bill of rights by allowing clients to take a denial of their rights to the appeal process. The appeal process also needs to respect continuity of service to the client and ensure that service is not disrupted while the appeal is ongoing.

We ask also that you support our need for time to do our planning work well. As a standing committee, you appreciate the time needed to consult effectively with the community. Our planning has not occurred in a vacuum, and consulting with our community takes time as well. We are committed that our community's input will impact on our decisions and will not be in name only. The four-year time frame for fully developed MSAs is restrictive, and we feel it will not allow sufficient time to try and test a model, to work out collaborative or amalgamated systems, to manage employment relationships and to resolve court challenges and succession issues.

An overriding principle of long-term care reform has been the integration of health and social services to provide consumers with a coordinated, comprehensive long-term care service continuum. The policy framework of April 1993 supported this principle in the partnership among the ministers of Health, Community and Social Services and Citizenship and their respective ministries.

Our community, throughout our consultation process, has expressed concern that long-term care service system reform is in danger of being based on a medical model where consumers are viewed as "sick." In an attempt to strengthen linkages between health and social services, our community requested that our local process ensure balanced health and social service involvement on the long-term care committee, in local consultations, and in all activities associated with long-term care planning. We request that Bill 173 be amended to reflect the partnerships, roles and responsibilities which exist between the ministers of Health and Community and Social Services and their respective ministries.


In summary, we request that the legislation (1) build more flexibility for local perspectives on MSA structure; (2) indicate a commitment to local community-based planning and development of the MSA, and (3) indicate a commitment to establishing an MSA which has the capacity to govern as an autonomous organization with responsibility for program planning and service delivery according to consumers' needs and local circumstances.

The document distributed more specifically defines our recommendations. We, like you, are committed to achieving a system which is consumer-focused and tailored to the unique needs and characteristics of communities across Ontario.

The Acting Chair: Thank you very much for a very comprehensive presentation. I was listening. We do have time for a couple of questions.

Mr O'Connor: Thank you for your presentation. I was just noting -- and then I tried to follow up in your other document, and didn't realize that you had this appended to it. I like what you've suggested here with the bill of rights and the appeal process, and in fact one of my colleagues has brought this up a couple of times. In making the bill of rights something that's appealable, it gives it then some more strength, and I wondered if you might have anything that you'd like to add to that, because I think first of all we want to make sure that this is something that's taking care of the needs of the consumer, and so the appeal process is going to be important. We don't want to make it too cumbersome for the consumer yet serve the needs of the consumer.

Ms Mahaffy: I think it's important, when we're looking at the bill of rights, that the consumer has some input into the bill of rights so that both the consumer and the provider have ownership of the bill of rights. Then they become partners in ensuring that the bill of rights is maintained within the service delivery system. Given that, then when a consumer feels that their rights haven't been maintained and it's based on a contract with a provider, there's an opportunity to take it to the appeal process and to appeal that provision of service which hasn't fulfilled the bill of rights.

Mrs O'Neill: I believe you're the first district health council that has come formally before us, although we've had contact with others. I'd like to ask you to say a little bit more about the difficulties you've having with the terminology "geographical area" and how that relates to the guarantees within the bill and the guarantees that no doubt have been put before us over and over again in long-term care reform about guaranteeing cultural and spiritual values and, in some cases, the disease-oriented focus as well. So could you tell us a little bit about the struggles you're having with trying to balance those two phases of the bill?

Ms Mahaffy: I'm not sure that the geographical issue is a particular concern in the Hamilton area. With respect to cultural issues, one of the difficulties that we're having which I'm sure is a difficulty in many communities is the urban-rural mix as well as cultural differences within our community.

The variations in culture tend to be within the Hamilton core, but there's a great deal of difference between the Hamilton core and the rural areas which we also are planning services for. The rural areas tend to have fewer services presently and we have enormous difficulties with transportation to either get services to them or to get them to services. So it's more a rural-urban geographical issue that Hamilton has. The cultural issue is certainly large in Hamilton, but it's one that isn't a geographical issue.

Mrs O'Neill: Do you foresee more than one MSA for Hamilton-Wentworth?

Ms Mahaffy: Yes, although we haven't decided on a model that we're going to carry to the community yet. We're still looking at a number of different options, but I think it certainly will involve more than one MSA.

Mrs O'Neill: Thank you.

The Acting Chair: Thank you very much for coming to the committee today.

Is Mr Farnham here yet, Care Plus?

In that case, I'll call St Joseph's Villa. Please come forward.


The Acting Chair: Is that Care Plus that has just come in the door? In that case, thank you for being so understanding. Please come forward, Mr Farnham. The clerk will distribute copies of your written brief. If you'd like to just sit down, speak right into the microphone -- either one, it doesn't matter; Hansard will turn on the one in front of you. There we go. If you'd just give us your name, relax and you've got up to 20 minutes for your presentation.

Mr George Farnham: That's a little difficult. I'm just walking in -- I'm a little bit early.

My name is George Farnham. I'm from a local company called Care Plus. I'm also an active member in the OHHCPA, which is the Ontario Home Health Care Providers' Association.

Thanks very much to the committee for allowing me to speak today. If I can speak for a little bit of preamble, some of what I have to say today I'm sure you've heard from other representatives of our association. However, what I'd like to do is perhaps put a little bit of a local flavour on what my company and the other agencies in Hamilton feel about this Long-Term Care Act.

I have about a 10-page written proposal here. And I'll try to keep it as brief as possible. I'll read through it. Seeing as it's double-spaced and quadruple-spaced and so forth, I'm sure that this shouldn't take too long.

As you're probably already aware, our association represents 115 offices across the province of Ontario. We provide substantial government-funded home care annually to the various people who require it, being seniors, disabled etc. We employ approximately 20,000 people through our agencies.

Some of the figures that have been shown in texts that I've read say that our agencies represent about 40% of the publicly funded homemaking hours. However, in this community it actually represents in surplus of 50%, and has for the last several years.

What I would like to say today is that unlike some of the other communities in Ontario which are genuinely in favour of restructuring the whole system, I believe in our community, in Hamilton-Wentworth, the present system that has been in place has worked very, very well. All the agencies, including the not-for-profits, the home care program, have worked extremely well together in the areas of trying to increase quality, provide flexibility as well as cut costs. In the past, we've worked together and we've done an excellent job I believe in meeting those needs.

We believe, certainly in this community, that a multiservice agency will not save us, as taxpayers, any money. And in fact, we believe that all it will do is create less responsive approaches to the needs of the community.

Some of the issues that we want to bring forth are issues that I'm sure you've heard before. However, we think that this legislation will hurt not only the clients who require home care but the workers as well in both the profit and non-profit agencies, and, last but not least, businesses in Ontario.

The government's policy to restrict our agencies to 10% most assuredly would put my business out of business.

Apparently there's been a change in the original proposal from a 90-10 proposition, that being 10% limitation as far as commercial agencies were concerned, to a 20% portion of the business. Even at this rate, this will cripple and certainly put a good many of the commercial agencies out of business. Some of these businesses are founded and run by Ontario people, largely a female population, entrepreneurs, and a lot of effort and time has been put into putting together a good solid business that serves the communities.


The MSA, as was stated by the Minister of Health, is supposed to provide one-stop shopping for Ontario consumers. However, that's in fact what it does. It only provides one place to shop, and we feel that we've taken away not only the competition that should be in place, but also the consumer's choice. A good example would be that if the MSA does not meet someone's needs, no matter what those needs might be, the consumer will not have anywhere else to go if there will only be one choice.

People who are unhappy and would like to voice their dissatisfaction, the majority of these people, I think, are in a vulnerable position in that they're going to have to take their issues to the same people that provide the service, and we feel that in fact they may be fearful to represent themselves because their service may be taken away. I'm sure at other presentations you've been given all the data about this very same or a similar format that's been provided in other areas, Great Britain, Sweden and even in our own country in Manitoba, where this model has been rejected and in fact in many places has been replaced by the type of system that has been in place.

Our recommendation, obviously, is that Bill 173 be amended and that section 13 be taken out in its entirety. From an employer's standpoint, we've invested a great deal of time and effort in training, creating a good working environment, lots of support as far as supervision is concerned, and it's our feeling, based on what we've been told, that a lot of the new jobs created in MSA will be filled by laid-off workers from hospitals, and that our employees who may be seeking other employment will not have a place. Therefore, I think that we're going to lose not only the experience but their expertise, and in that vein we believe the consumer will then suffer.

We also agree that a more coordinated information system would also be beneficial, as long as the local people would operate this system on a daily basis and that it is not in fact dictated or run by the provincial government. In section 12 of the legislation, we talk about what the MSAs will do, what services they'll provide. There'll also be funding restrictions and possible waiting lists, and we think that in addition to some of the services that will be provided, there may be others and in fact this bill does not allow the local people to make those approvals.

Again, as you're probably aware, in other communities around Ontario, administrators in the home care realm are challenging this particular piece of legislation, and are denying the government and saying that, "We're not going to implement this because this is not in our best interest or for the community." The examples, of course, are Ottawa-Carleton, Hastings, Prince Edward, Kingston, and Haliburton-Kawartha. They believe that the non-competitive policy will hurt not only the consumers but their community.

We'd like to see the government provide the local authorities as much freedom as possible, develop some policies perhaps, set out some guidelines for realistic services, provide financial resources, and then make those moneys available to the local community so they can determine the priorities for their community.

It's also our belief, particularly in the Hamilton-Wentworth community, that there is a major restructuring being done here to a program that essentially met the basic needs and was very workable for all involved, including the consumers and the companies like ours, and we're very frustrated with the fact that a massive change is being proposed as opposed to perhaps working with what we have and making a minimum change and less interruption in the system.

I alluded to earlier that, in the Hamilton-Wentworth area, the private sector has contributed to the success of the home care program here and in fact provided in surplus of 50% of the business, and I think that speaks well for our companies. One of the reasons why we have increased our volume to that level is that we were more responsive to the needs of the community: working 24 hours a day, seven days a week, giving clients what they needed as opposed to what they were told they could have.

As far as the funding issues are concerned, we receive the same dollars for funding as any of the non-profit agencies do. As you're well aware -- at least, I haven't seen any studies that say that in fact the quality of care or the value of the services provided by commercial agencies is any different than that of the not-for-profit, and therefore we believe that we should not be taken out of the system.

The minister has also stated that funds should go into care, not for profit, and again there's been no research or no studies to show that the not-for-profit agencies provide more or better care then we do.

The client issue is a very close one as far as I'm concerned, because we establish with our clients a good rapport with the people who look after them on a daily basis. We feel that any change in this policy or an MSA will most certainly disrupt provision of care to these people. One of the points that provide for a better relationship and an ongoing wellness program is consistency. So we feel that removing our worker or perhaps upsetting the situation in anyone's home will be detrimental to our clients.

I'd like to mention that I'm a very active member of the OHHCPA and certainly share their views and have been involved in some of the changes that we would like to propose. I know you've heard these before, but I'd like to read one more time what our proposal would be, or the following initiatives that we'd like to propose:

(1) We feel that the government should determine what services it can afford to provide and then fund those services in an equitable and consistent fashion across the province.

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

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

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

(5) The government must give local communities responsibility to allocate resources at the local level in response to local needs, and the Ministry of Health must stop trying to manage the operations of the home care program on a daily basis.


In conclusion, I would like to assure the panel that in all cases, both profit and not-for-profit agencies, we're here to meet the needs of the consumer. However, we do want to maintain the essential qualities of the current system, which again are competition, consumer choice and a program that fits the community. It's my belief that Bill 173 in its current form will remove all the positive qualities of the present system, and ultimately, home care consumers will have fewer services and less choice.

Mr Jim Wilson: Thank you very much for your presentation. It's no secret, we've been saying it all week, that I and my caucus colleagues will certainly move an amendment and hope that the government supports it on this committee to delete any reference to the 80-20 split. We think it's a ridiculous, arbitrary game that the government has decided to play. You're absolutely right in your presentation; there are just no studies to back up any of this.

I'd like to know, though, because you talk about the crippling effect this will have on all agencies and it will have an effect on your business, how many employees will be affected in your company alone.

Mr Farnham: From the standpoint of homemaking, it would be in the vicinity of 250 employees, as well as administrative people, who represent probably another 10. So I'd say about 260 employees.

Mr Jim Wilson: Thank you. Could I just mention for the record that you mentioned that the private sector is providing about 50% of homemaking in this part of the province. Just for the record, the provincial average is just under 50% across the province. So you're an important player in the system and the government shouldn't be trying to put you out of business.

Mrs Sullivan: I also wanted to ask about the 10%, 20% rule. There's been evidence before our committee that while the government's first policy was that only 10% of services would be allowed to be purchased from commercial operations, indeed the 20% that's included in the bill isn't a matter of only the for-profit services that can be purchased but relates to any and all services that can be purchased outside of an MSA. That 20% then would include anything that an existing agency now provides; in other words, 80% of services that would be taken away and put into the MSA.

The 20% would not provide a critical mass of service needs, and therefore virtually all of the existing agencies would fold without compensation. Now, that compensation issue is one that was addressed earlier with respect to severance for workers in non-profit agencies. I wonder if you would address the same issue with respect to the commercial sector; severance, the benefit plans, pension plans, as well as capital costs. Have you had any promises or any assurances from government that you would be compensated for the loss of your business?

Mr Farnham: Well, no. Absolutely no promise at all from government. In fact, if I may elaborate a little bit on this, obviously we offer nursing services as well which are not government-funded, and our research shows that a full 80% of the palliative care that we do in this community is originally derived from home care, homemaking services, and in fact this fallacy that that private business will still be there does not exist. So we haven't been given any assurances.

The Acting Chair: Thank you. Ms Carter, very short.

Ms Carter: I have several points I wanted to raise --

The Acting Chair: Maybe can you wait until the next --

Ms Carter: -- but I'll stick to one. You get the same allocation of public funding for the unit of service that you deliver as a non-profit agency does, and, as I believe you mentioned, the minister has raised the question of, where does your profit come from out of that? Does it come from the service delivered, does it come from the wages of the people you employ? I would like to ask an expert opinion as to whether there is any distinction between the earnings of people employed by not-for-profit agencies and for-profit agencies in the delivery of long-term care.

Mr Wessenger: The question raised is did we have any information on the earnings of people between the non-profit as distinct from the for-profit sector.

Mr Quirt: Specifically related to homemaking, you're quite right that the amount paid by home care programs to for-profit or not-for-profit groups is the same. There are 38 different rates, I believe, that apply in each of the home care areas. It is my understanding that on average, and I would not want to mislead the committee so I would like to confirm this with my staff, the wages generally paid to commercial homemakers are marginally lower than the wages paid to not-for-profit homemakers. I will ask my staff to confirm that that's the case. If that's an inaccurate statement, then I'll certainly inform the committee tomorrow -- or, I'm sorry, on Monday when we reconvene.


The Acting Chair: I call St Joseph's Villa, who've been very patient. Please come forward. Begin your presentation by introducing yourselves, and you have up to 20 minutes.

Mr Paul O'Krafka: Madam Chairman, members of the committee, good afternoon. My name is Paul O'Krafka, and with me today is Margaret Lambert. We're here representing the board of trustees of St Joseph's Villa, the board of the SJV senior centre and the St Joseph's Villa and Rotary Club of Dundas respite care program. Mrs Lambert is the director at St Joseph's responsible for our major community support program, the SJV senior centre. I am the executive director of St Joseph's Villa.

We appreciate the opportunity to appear before the standing committee this afternoon. We're especially pleased that you've made the effort to come all the way to Hamilton-Wentworth. We at St Joseph's have been encouraging successive ministers of the province who have had the responsibility for long-term care to visit our facility and services since 1988. While we realize the minister is unable to be with you today, we are pleased that at least one of the previous ministers has arrived in our community.

We do not have a handout for you today that details our presentation to the standing committee. We will be providing a complete written submission once it's been reviewed by all members of our volunteer board, our residents' council, CUPE Local 1404 and other interested consumers of our service. What we have provided for your information are the key documents that guide all our services and programs at St Joseph's Villa. Those documents are our mission statement, our role statement and our management and organizational philosophies. We believe these documents outline the difference that we as Catholic service providers bring to service for seniors in our community.

The major purpose of our presentation is to encourage you, as the standing committee, to rethink and rewrite the legislation which has been introduced. We want to encourage you to allow an adequate opportunity for full consumer and community input into this essential piece of legislation.

St Joseph's Villa provides services to seniors through the SJV senior centre, respite care and supportive care programs, community outreach services and through our 370-bed home for the aged.

The SJV senior centre meets the needs of 173 seniors through a six-day-per-week program. This important service provides nutrition, recreation, therapy, spiritual and social stimulation to the participants, as well as much-needed respite relief to family members, who in most cases are the primary care givers for our participants.

Two years ago our program was serving approximately 20 people per day. In 1994 five of our six program days are fully occupied at 35 people per day, with growing waiting lists, over a 60% increase. Despite this increased demand for service, provincial, regional, municipal and United Way dollars continue to be reduced for this important program.


The St Joseph's Villa respite care program has been in existence as an experimental project since mid-1990. It has been developed through the assistance of the long-term care division of the Ministry of Health, community donations through the Rotary Club of Dundas and extensive volunteer efforts. Respite care has been available to the citizens of Hamilton-Wentworth because our volunteer board of trustees is committed through the villa's mission to responding to current and future unmet needs of seniors in our community. This program served 103 seniors in this past year. During that same time we had to turn away an additional 97 seniors who came to our door after our beds were already full.

Despite the commitment of the community, the demand for service and an excellent service having been provided, respite care has become a casualty of a long-term care system which is overly committed to planning, legislating and regulating and has lost the ability to be responsive to the needs of seniors. The St Joseph's Villa-Rotary Club of Dundas respite care program falls between the massive crack left by the creation of Bill 101 and the new Bill 173.

This is one of the reasons we wish to address your committee today. It is our hope that before you pass a significantly amended Bill 173 you will consider putting in place safeguards to ensure that current successful and consumer-responsive services are not lost to those seniors and their families who rely on them.

Bill 173 in its current format appears destined to destroy many valued and needed programs and services before rebuilding a new basket of services through the MSA process.

We commend the government on its desire to create a full and appropriate array of services for seniors. We would, however, strongly urge you to consider the limited remaining time available to many of the seniors who rely on services today. The three- to five- to seven-year planning time frame that it will take to put in place a fully working system will extend beyond the remaining lifetimes of many existing seniors. Please do not forget today's seniors as you pass legislation that plans for the seniors of the future.

As a component of our respite care program, the villa has been successful in conjunction with St. Joseph's Hospital in Hamilton in providing supportive care to seniors who no longer require the expensive services of an acute care hospital bed. These patients simply require a period of convalescence before being able to safely return to their own home. Our program has saved the province hundreds of thousands of dollars. It has been able to demonstrate the benefits of community collaboration between the acute care sector, the long-term care sector, placement coordination service and home care.

Having proved the need and our ability to meet this need, we approached the province for support. The only response available from the province through Bill 101 and its regulations and Bill 173 as it has been introduced is to displace long-term residents in order to provide funding and service for those seniors who wish to return to the community. We raise this example simply to highlight the fact that although extensive planning and consultation has gone into the existing long-term care act, Bill 101, when it comes to being responsive to the needs and care requirements of seniors, the flexibility still does not exist.

In addition to advising you of the threats to some existing services, we at St Joseph's Villa have a significant interest in the future. We have developed our strategic plan with input from the community, input from our volunteer board members and with significant input from seniors and their families. Coming from our 1989 strategic plan, we submitted three new programs to the long-term care division of the Ministry of Health.

Seniors and their families told us they could not get very basic health care assistance in their homes at night. Families of the victims of Alzheimer's disease told us they need a special day program for their loved ones. Senior participants and families in our SJV day centre told us they needed more relief than we could currently provide with our existing program.

In 1990 we responded. We submitted proposals on the appropriate forms to the appropriate ministries. Each year since that time we've been advised that no new funding was coming for seniors and their families in the Hamilton-Wentworth area because new community planning would take place after the new legislation was introduced.

Much collaborative planning has already taken place. It's crucial, as you look at this new legislation, that those efforts in our community not be lost. When we look at eliminating waste and inefficiency, the best ideas for services to this community are already before the long-term care division. Let's utilize some of the work that's already been done in this community.

We commend the province for recognizing some of the efficiencies and economies of scale that can be created through collaboration among a number of community agencies. In our own organization, we collaborate extensively with other community agencies in the planning and delivery of services we provide.

Most importantly, we have been able to successfully do this while maintaining our own mission and governance structure, which we consider to be the most essential component driving the services we deliver to this community and have delivered over the last 115 years.

Since 1985, in addition to collaborating with other community agencies, we've worked very closely with other member facilities and services that currently create the St Joseph's Health Care System of Hamilton. You heard earlier this morning from Sister Joan O'Sullivan on behalf of the health care system and I would simply reiterate that we have already taken those steps to ensure that all available dollars are used to provide services to seniors. We would hope once again that Bill 173 could build on the strengths already developed in organizations like St Joseph's Health Care System.

If there is an urgency to pass this legislation, it is because it has been used as an excuse by the current and previous governments to delay taking any significant action in response to consumer and community needs in the long-term care area.

Mrs Lambert will now cover some of the specific areas where we feel this legislation, if it is to go forward, needs to be amended.

Mrs Margaret Lambert: The areas I would like to focus on are as follows:

The provision in the legislation for MSAs to purchase only 20% of their services from private agencies, including existing non-profit agencies: The SJV day centre would have to be absorbed by the MSA if it is to receive funding. This would pose a great problem in that the commitment of our staff and volunteers and the many non-government dollars that we currently contribute would be lost. This would probably result in the community losing a valuable service that is currently available and serving 173 seniors.

We appreciate Mr Quirt's comments from this morning when he advised the standing committee that you, as a committee, could choose to recommend revisions to Bill 173 which would exempt seniors' centres which are part of a facility-based continuum from the 20% rule and provide sufficient funding outside the MSA system to ensure continued services to seniors. We would strongly encourage you to make this amendment.

Secondly, the ministry's role in ensuring quality management, and I quote from the act, "An approved agency shall ensure that a quality management system is developed and implemented for monitoring, evaluating and improving the quality of community services provided or arranged by the agency": In our experience, the development of an extensive quality management program has taken over eight years. The program was developed with major input from consumers, volunteers, the governing body and staff. We certainly feel that this is not a ministry role and would be looked at as micromanagement on the part of the ministry. The time just would not be available for such an in-depth program.

Thirdly, funding of new services under Bill 173: It is important to recognize that many existing services to be absorbed by the MSA are already being underfunded. The SJV senior centre had to cut an activities-of-daily-living position due to the fact that the budgets have been reduced. This has forced us to provide less service for our senior centre members such as bathing and nail care. Bill 173 states that services provided by the MSA would not be charged to the seniors using the service. Presently, seniors, if they can afford it, are paying for most of these services. It would be important to not stop the charges until all the funding is in place. This will ensure the system will have enough dollars to cover the cost without more cuts. It is important that we do not repeat the underfunding which is being experienced by long-term care facilities under Bill 101.


Fourthly, the artificial barrier created between acute care hospitals, long-term care facilities and community support services for seniors under Bill 173: We are very concerned that the approach being taken serves to isolate long-term care from other aspects of the ongoing reform of the health care system in Ontario, particularly hospital restructuring and the long-term care facility redirection. Although the current reform process talks of integration, it encourages isolation. It does not encourage the development of a true continuum of care.

Bill 173 is committed to the important principle of reducing reliance on facilities and strengthening care in the community. We support this principle. We believe the preferred place for care is in the home; however, we recognize that this goal is not always an achievable one for every individual for a variety of reasons including the inadequacy of support services in some communities. The facility-based system of care and the community-based system of care should not be isolated from one another. There's a clear need for equitable treatment of facilities and community services in the reformed system in terms of standards, funding and accountability and levels of care.

Fifthly, the bill of rights, as included in the legislation: St Joseph's Villa has a bill of rights and responsibilities for our residents and community outreach clients that was developed collaboratively with residents-clients and the villa. The bill of rights and responsibilities strongly reflects the mission and values of our organization and, at the same time, addresses such issues as equity, dignity, information and confidentiality. The legislation should not have to provide a bill of rights but only ensure that one exists and meets certain criteria.

Finally, consumer choice: Under the current system the public has a choice in the services that they receive and from whom. Under the new system there may be one-stop shopping, but consumers are not aware that criteria will be put in place which will actually limit their access. There will also be no choice of agencies to provide services as they will not exist if the MSAs are established as currently outlined.

In closing, I would like to emphasize five points:

The board of trustees of St Joseph's Villa supports the goals of the long-term care redirection and the goals stated in the development of this legislation. Our disagreement is with the method of proceeding with the reform as put forward in Bill 173.

We support a full array of services being available to seniors in all areas of the province. We support these services being provided by a diverse array of volunteer agencies who come from and are part of the community they serve.

We do not support or encourage the creation of yet another large government bureaucracy which we believe will discourage volunteerism, will not be responsive to consumer needs and wants and will be significantly hampered by lack of available government funding.

We believe that the consultations to date on long-term care have indeed been extensive, but we believe those consultations have missed the target.

We believe that seniors and their families need to be part of the consultation on long-term care redirection and Bill 173. We do not believe that the seniors you have heard from to date are representative of the seniors needing services in the province of Ontario.

The Acting Chair: Thank you very much for coming to the committee today. We appreciate your presentation, your warm welcome and your patience.


The Acting Chair: The next presentation is from the Alzheimer Society for Halton-Wentworth. Welcome. We'd appreciate it if you'd start your presentation by introducing yourselves to the committee.

Ms Gertrude Cetinski: The Alzheimer Society for Halton-Wentworth really appreciates the opportunity to present its position with regard to Bill 173 to this committee.

My name is Gertrude Cetinski. I'm the education director for the society, and with me today is Dr Jim Galloway. He's a board member of our society and a long-standing member of our community involved in the delivery, management and planning of health services.

This is a verbal presentation, but we will follow up the presentation with a written submission that will elaborate our point of view and also will make some specific recommendations as to --

The Acting Chair: What you're saying is being recorded by Hansard, so you shouldn't feel an obligation that you must submit something in writing. If you want to, that's fine, but everything you say becomes part of the official record.

Ms Cetinski: We want to.

The Acting Chair: Okay.

Ms Cetinski: We share the concerns and the views expressed by the joint presentations of the St Elizabeth Visiting Nurses, the Victorian Order of Nurses and the Visiting Homemakers Association earlier in the day; also, the submission by the Coalition of Community Health and Social Service Agencies of Hamilton-Wentworth, of which we are one of those 21 members; also, presentations by the VON in Halton and some of the other communities. We will not repeat them, not at this stage in the proceedings. Rather, we want to, in this short presentation, focus on two of the issues that we see around the MSAs in the current legislation that concern us the most.

The first one is, we feel there's a need to protect special services for cognitively impaired individuals and their care givers, and second, we want to draw your attention to some of the real costs that we see to our community when we lose voluntary agencies such as the Alzheimer Society under a fully amalgamated MSA.

Let me briefly tell you who we are. The Alzheimer Society for Halton-Wentworth was incorporated by volunteers in 1982 to serve both Hamilton-Wentworth and the Halton region. In 1987, the society received funding at the rate of 70% through the Ministry of Community and Social Services, Hamilton area office, to provide counselling and family support services to families affected by Alzheimer's disease and related disorders. We hired our first full-time staff person and opened our resource centre in Hamilton. By 1994, the society had grown to employ four full-time and five part-time staff people who in 1993 made over 10,000 contacts with clients with families in the community.

In 1991, after serving Halton as well as Hamilton with donor funding to make up what we received from the ministry, the society finally obtained operating funding for Halton through the Mississauga area office of long-term care, and with the help of the community, a satellite resource centre was established in Burlington. This gave the society a presence in the community in Halton and facilitated access to our services for Halton clients. In addition, however, our location in the rotary health care centre side by side with Red Cross homemaking and the seniors' help line enabled us to collaborate effectively with other agencies providing services used by our clients. The sharing of common facilities and resources has proven to be cost-effective but also to provide better service to our common clientele.

Now let me tell you about our concerns with the proposed MSA legislation. I would have liked to have a family member alongside with me to share with you the challenges of living with and caring for a loved one who's gradually losing short-term and long-term memory, the ability to think and reason and, over time, will lose the basic skills to look after themselves on a daily basis that we take for granted.


However, care givers find it very difficult to break away from the task of 24-hour supervision and from a job that is both physically and emotionally taxing. You will hear from some of our care givers by letter as to what their needs are and the way they feel the legislation does not address those needs. We've helped our care givers become familiar with the legislation, which does not take away from the burden of care provision which is their primary focus.

So based on our experience with care givers, let me speak on behalf of 4,700 persons with dementia within our chapter area and their family care givers who are providing 90% of community care. Alzheimer's disease is the most common type of dementia and it affects about 5% to 10% of people over age 65, but it can occur earlier. The disease can last from two to 20 years and it is always fatal. There is no known cause or cure. Statistics indicate that by the year 2000, the number of people affected by the disease in our region will double.

The disability of the mind created by dementia is cognitive impairment, which results in a dependence on others to carry on the simplest tasks of daily living. In addition to help from general health professional and support services, persons with cognitive impairment require special approaches to care to affirm their personhood as they and their families live with this disease. The needs of their care givers are closely linked to the highly individual, changing manifestations of the disease in their relative.

The Alzheimer Society both at the chapter and the provincial levels is concerned that specialty services for those with cognitive impairment and their family care givers are not addressed specifically within the proposed legislation which will, however, affect the care provided to the ever-increasing number of persons with dementia in our aging society.

We fear that the funding of dementia-specific programs such as those provided by our society, by day programs and in-home respite programs may be lost to a more generic, general type of programming under the MSA. Those of us who work with the cognitively impaired and their families are convinced that generic programs are inappropriate for those suffering from dementia. We have been working for years to achieve the level of dementia-specific programming now available in our community.

In part II, sections 3 to 7 of the proposed legislation, there's a categorization of the types of services that MSAs will be mandated to provide. It seems that our clients' needs will have to be met by providers in any or all of those generic service categories without any assurance of continuity of care, the special training of those providers and timely availability of specialty programs.

For example, the finite list of homemaking services includes ironing, mending and menu planning but does not specify behaviour management, which is germane to any care and to any of those tasks delivered by the homemaker, or specify sensory stimulation of cognitively impaired individuals.

What we mean by that are planned activities that build on the remaining abilities and enhance life, prevent unsafe behaviours or help in managing those behaviours. Homemakers and support workers are essential in providing those services and special training is essential to help them do that.

We therefore recommend at least that part II, sections 3 to 7, be amended to add a category called "Services for persons with dementia." In our opinion, it would even be better if detailed specifications of the services were dealt with in the regulations to the legislation to allow some open-endedness and flexibility and some rethinking of service categories and the range of services to include specialty programs that presently exist and that are very beneficial to those participants.

Respite is another key service that is not listed as a service category but rather is assumed to be a side benefit to the services of the listed programs. But respite cannot be relegated to the sidelines. It is absolutely crucial to families attempting to continue to care for their loved ones at home and so prevent premature placement in long-term care facilities.

The Alzheimer Society for Halton-Wentworth has just received a federal New Horizon grant to survey the respite needs of families caring for a person with dementia in the Halton region and also the adequacy of existing respite services in that Halton region.

The study will also explore the feasibility of a model of an Alzheimer's respite care centre that we have developed that would provide a home-like, enabling environment and provide continuity of care through a full range of respite services.

Contrary to what you may read in the Globe and Mail that states that in the United States dementia services are the third most costly service category, we seriously question those results of the survey. You have to think that not only the people receiving the respite care are benefiting from it; their care givers, at least one, the primary care giver, but many times the whole family, benefits from those services. The cost allocations, figuring it out, have not considered that.

In fact, models now exist throughout the world that have generally proven -- these are specific Alzheimer-type models -- to be not only more satisfactory care but also more cost-effective. We would be glad to share those with the ministry and also with the district health councils, and we also plan to share the results of the Halton survey with regard to respite care needs with the ministry and the district health council.

In the meanwhile, we're concerned that the establishment of MSAs will not allow the necessary flexibility to establish the service mix and the funding to operate the type of respite care centre that we envision.

What about our future in the MSA? In both Halton and Hamilton-Wentworth, our experience confirms that collaboration among providers serving the same clientele allows us to deliver service that is integrated at the client level. We support the principles of the reform of the long-term care system and the concept of service delivery through MSAs and we want to participate. Our vision would provide for further sharing among agencies in the areas of administration, human resources, data and records, education and training. We certainly, I want to emphasize that again, support a fully integrated service system.

However, we believe that there will be a real cost to the community if existing volunteer organizations do not retain a place in the long-term care system. Our chapter has a mission to alleviate the personal and social consequences of Alzheimer's disease and related disorders in the regions of Halton and Hamilton-Wentworth. Our funded services presently include, and these would be the services that would be going to the MSA:

-- Personal and family information and counselling.

-- A library of publications, videotapes and sensory stimulation materials.

-- Regular information series for family care givers.

-- Drop-in groups for spouses and other support groups.

-- Wandering patient registries that we operate together with the police forces in both regions.

-- A loan program of in-home wander alert systems that are very helpful to families, and are totally innovative. We developed those systems. We did the research and development on that.

-- And our latest program, started at a time when there are absolutely no extra dollars available; we call it Special Steps. We operate it with the VON in both areas, and it provides a volunteer visiting program for cognitively impaired individuals.


But in addition to services to families, those that would move into the MSA into the basket of service, we also provide information and education to professionals, students and care workers in community agencies and long-term care facilities. We present information sessions -- public lectures -- to community groups to raise the awareness of Alzeimer's disease among the public. We support biomedical and care research and we monitor publications for any progress in managing the disease.

We have a strong presence in the community. Our volunteers and donors contribute significantly to the services we provide, and they associate closely with the chapter's mission, focused around these services. In order to keep volunteers and donors, we believe that existing agencies need to retain a degree of their own identity and mission. We fear that if services are mandated, funded and governed by fully integrated MSAs with no role for individual agencies, neither the volunteer hours nor the donor dollars will be forthcoming, and those donor dollars now make up about 40 per cent of the services we provide.

In addition, we all know that there will be important programs and services that will not be funded or mandated under the MSA. If voluntary organizations like our chapter have no role in the MSA, will they be viable to carry on these extra but crucial functions? We therefore suggest a continued role for individual agencies within the MSA model. In terms of governance, we suggest that the agency's board of directors could be transformed into service advisory committees that direct the activities within each service category, and to provide proportional representation on the MSA board that would manage the funding envelope. We will elaborate in our written submission on a possible model, and we have a nice diagram that outlines our vision.

Thank you very much for your attention at this time of the day, and Dr Galloway and I would be pleased to answer questions.

The Acting Chair: Thank you very much for your presentation. We appreciate your coming before the committee today. There's time for really only one question, and if all of the committee members are willing to pass, that would make life a little easier because I know that all caucuses would like to have some time, unless there's somebody that really has an urgent, burning question. Mr Jackson, urgent and burning?

Mr Jackson: Urgent and burning, since I made a request of Mr Quirt about those MSAs' plans which have been filed, and I've not as yet seen that plan, and the question has to do with the degree to which much of what you shared with us, Gertrude, and is being looked at by those committees that are currently working in Halton, which is more the civic reference point, with respect to some of the points you've raised and an alternative model, because the political answer is, it's all up in the air and there could be some flexibility. Have you shared that with the local planning and is it included in the one that's been submitted to the minister? At least the draft, I'm told, may be already at the minister's office.

Ms Cetinski: We have submitted our ideas about the MSA to both the Halton District Health Council and the Hamilton-Wentworth District Health Council, and since I'm a member of the long-term care committee in Halton, I know that the call for ideas and those submissions have been looked at.

The Acting Chair: Thank you very much for coming before the committee today. We'll look forward to receiving your written presentation as well. Thank you.

The last presentation of today --

Mr Wessenger: I wonder if Geoff could clarify that.

The Acting Chair: Geoff, did you want to make a --

Mr Quirt: Just to clarify, Mr Jackson is quite right. I promised to provide the MSA submission made to the minister from the Metropolitan Toronto District Health Council and the minister's reply. To date, that's the only recommendation the minister has received specific to MSA development. But that will be coming to you and will be available Monday for you.

The Acting Chair: Okay. Just to reiterate again, before Dr Deadman comes forward, I think everybody heard that the -- what was the booklet?

Mr Quirt: Manual.

The Acting Chair: -- manual is available, and if you will tell Mr Quirt where you'd like it delivered tomorrow, it can be delivered to you tomorrow. If not, you'll receive it on Monday at committee.

Mr Quirt: May I presume that people would like it delivered tomorrow to their Toronto office? If you'd like a different location, then let me know. So it will go to your Toronto office tomorrow unless you would like it somewhere else, and we'll send it anywhere you'd like as long as you let me know where.

The Acting Chair: Just talk to him privately and tell him which you prefer.

Mr Jackson: Bring it to Thunder Bay on Sunday night, please.

The Acting Chair: For those who are going to have to leave before, the committee will be sitting on Monday, August 22 at 9 am in Thunder Bay.


The Acting Chair: I'd like to ask Dr Deadman to come forward, our last presentation of the day. Welcome, Dr Deadman. You represent the Association of Ontario Physicians and Dentists in Public Service, Hamilton branch. Welcome. You have up to 20 minutes for your presentation. It's nice to see you again.

Dr John Deadman: Thank you very much, Madam Chairman. I appreciate the opportunity to be here, and I think it's perhaps timely that I followed the Alzheimer Society because we have a number of concerns in common.

My name is John Deadman. I'm a psychiatrist employed at Hamilton Psychiatric Hospital and I've been with the Ministry of Health for over 30 years. For most of that time I've been doing community work rather than institutional work in the conventional sense of that term, even though I've been employed by a large institution over most of that time.

My reason for wishing to make a presentation to this committee concerning Bill 173 is that I'd like to make the point that most of psychiatric practice is really long-term care, and therefore I think that psychiatry has a vital interest in the kinds of legislation and the kinds of systems that are being established for long-term care.

Between 1977 and 1983, I was part of a team in the Ministry of Health which set up and managed the adult community mental health programs which were later known as the community mental health branch. I make that point because I've really been doing community work, and I really don't see that one can make a clear and formal distinction between institutional work and community work. If they don't work together, they don't work.

I don't have a written submission myself, but our association will be presenting a written submission because other members of our association will be presenting to this committee in other venues, and so a written submission is being prepared and will be presented at that time.

I'm speaking partly on my own behalf but partly and perhaps largely on behalf of the Association of Ontario Physicians and Dentists in Public Service. This is an association which represents physicians and dentists who work in various parts of the provincial government, but most, if not nearly all of our members, work in one or other of the ten provincial psychiatric hospitals. So this is the context from which I will be speaking.

These hospitals have undergone tremendous changes in the past 30 years, as have all other areas of mental health care. I'd like to present our perspective on long-term care and try to explain how it relates to mental health care.

Mental health care has been a government service for far longer than any other area of health care. We even existed before there was a Department or a Ministry of Health. In 1846, the Legislature of Upper Canada passed the Asylums Act which provided for the setting up of a provincial asylum for the care of "lunatics and others who could not care for themselves." It was really the beginnings of the mental health system in Ontario. That's almost 150 years ago.


In the 1950s, there were 14 hospitals with over 20,000 beds in Ontario. The system now has 10 hospitals and a little over 3,000 beds. That's quite a dramatic change over the last 30 years or so. In the past 30 years, we've done an awful lot to move care to the community.

I would suggest to the committee that as an organized service run by government, we've been in long-term care longer than anyone else. I'm talking now about organized services run by the provincial government. I would therefore hope, and I would certainly want to make sure that our experience becomes part of the planning for long-term care, and I really think it's important that we do make this point.

Bill 173 unfortunately, as I read it, seems to completely ignore mental health. In fact, in places it refers to "physical disabilities," and it's quite clear that services for the mentally ill are not included. But my patients need these services too, and my reading of Bill 173 suggests that they could very easily be systematically excluded for care under the long-term care system.

My special interest is schizophrenia. This is a disabling illness that affects almost one person in 100. That's somewhere close to 100,000 people in Ontario. As with any illness, the degree of disability varies from person to person, but almost all of the sufferers from this condition can expect to have episodes from time to time in which they are quite unable to think clearly and have horrifying, frightening mental experiences which can sometimes drive them to suicide.

They are disabled in every sense of the term. This illness strikes in the late teens or early 20s, and unless they die by suicide or perhaps some winter are found frozen in a back alley, they can live a reasonably normal lifespan. This means that they can have 50 years or more of disability. If that's not long-term care, I don't know what is.

There seems to be a presumption that all of these things will be taken care of in the mental health system. I'd like to make two comments on this. The first comment is that going back the 150 years almost that I mentioned a few moments ago, we've had to set up our own complete system because many years of stigma and discrimination against the mentally ill have meant that they really were not able to access the services that everyone else used.

I thought that under the health reform initiative, which has been going on over at least the last five years, we were supposed to reduce discrimination and duplication of services and the kinds of exclusionary clauses that prevented particular classes of consumers from accessing services they need.

In mental health, we've had to maintain parallel systems for most of that 150 years. I thought we might finally be getting to the point where we could begin to merge systems and work more closely together. My concern is that Bill 173 may make that more difficult.

The second point I'd like to make is that there's really no clear dividing line between mental and physical disabilities or problems. Many mental disorders have physical problems associated with them and vice versa. For example, people with Alzheimer's dementia, which the group just prior to my presentation were talking about, which is a clearly defined physical problem, all seem to develop some behavioural and mental problems as part of the course of their illness. These must be managed, and they can't be effectively treated if we've got two parallel systems that are essentially separate and unfortunately don't talk to each other enough.

Not only is the continued separation between physical and mental health discriminatory to the people who happen to suffer from, particularly, I would suggest, mental health problems, but it's rather impractical as well. My concern is that Bill 173 may serve to perpetuate this division rather than bringing people together on these matters as I hoped the health care reform initiatives were intended to do.

I might say that the ministry seems to recognize this point because under the mental health reform initiatives which are presently very much preoccupying us in the mental health area, a working group has been established by the ministry to look at the interface issues between mental health and long-term care.

As I read Bill 173, I don't see any acknowledgement that this sort of process is going on. I wonder what the Minister of Health will do if she is presented with a set of recommendations from the working group which are in conflict with some parts of Bill 173. It is possible that by the time this group presents its final recommendations to the minister, Bill 173 may have already been passed by the Legislature and that would mean that it couldn't be easily changed at that time.

My concern is that if this were to happen, the mental health reform initiative may have been rendered somewhat pointless, because as I said before, long-term care is a central part of just about everything I do as an institutional practising psychiatrist and as a great many of other psychiatrists do as well. At the very least, it's going to create some awkward difficulties for the legislative process.

But perhaps our biggest concern is that the bill is far too detailed and prescriptive. As everyone I'm sure around this table recognizes, legislation is extremely difficult to change. Once it's passed into law it becomes really quite difficult and could take years to bring in even the simplest changes.

That is why it has been customary to place in legislation only the general principles that we must follow, and the detailed prescriptions for the actual carrying out of the act go into the regulations. These regulations, of course, can be changed by order in council, and that's a much easier process if it turns out that there are really serious problems with some of the provisions and they prove to be unworkable in practice.

However, if something that's in the legislation proves unworkable, it can be an albatross around all of our necks -- and I'm thinking of myself as somebody who has to carry out legislation -- for many years to come.

Many other presenters have commented on the "arbitrary" -- and I use the word "arbitrary", so I'll put that in quotes -- the "arbitrary" limit of 20% on the amount of contracting out for service that can be done by MSAs. I don't want to go into that in detail because this is much more of a concern for other agencies than it is for us. But my opinion on this is that it's going to prove absolutely unworkable and it's going to prove that way very quickly if the law is passed in its present form. The enforcement of it would be very difficult -- I certainly wouldn't want to be the bureaucrat that would have to enforce it -- and if it were rigorously enforced, it could be very disruptive to the existing system. It might even have the potential to cause collapse of services, because at the present time, long-term care is very dependent on a range of rather large and well-organized community services, and if they were restricted to 20% of the service provision, a good many of them effectively are going to go out of business. I don't see any alternative to that.

However, as I said, this is not perhaps as much a concern for us in psychiatry as it is for the people in those particular agencies. I might say that our own mental health reform process is also encountering many problems and much criticism as well. We haven't even attempted to write legislation yet. I certainly hope, though, that by the time we get to that point, we will be very carefully trying to avoid some of the pitfalls that I sense may be contained in Bill 173, and I thought therefore I really appreciate the opportunity to make a presentation to the committee because we do feel that Bill 173 in its present form makes our task in mental health reform much more difficult.

Mrs O'Neill: Dr Deadman, thanks so much for coming. We did have one group present to us on geriatric needs and we really felt that they were not attended to, as did they. We received a technical briefing at lunchtime, you might be interested. It's eligibility criteria we had asked for, and it states in it, "Eligibility for Community-Based Services, Broad Criteria."

And number 4 of that broad criteria is, "Needs cannot effectively be met by other resources in the community or by other government programs where appropriate." The explanation of "other government programs" is the "mental health systems," whatever that means. I will certainly give the ministry staff a chance to explain that more broadly if they feel they can, but it looks like mental health is just completely eliminated from Bill 173 at the present time.

Dr Deadman: That was certainly my reading of it too, and our concern is that there are many things that we might be able to provide through the mental health system, but we're really talking duplication of service here at a time when costs are such an important factor that we're really trying to avoid duplication of service.

Mr Jim Wilson: Thank you, Doctor. I just along the same line wanted to ask you for a couple of examples of things that the mental health working group might recommend that would be in conflict with what you've read in Bill 173. Can you think of anything off the top of your head?

Dr Deadman: Well, the one thing that they are working on is how we can get better working relationships between -- well, I'll use the example of Alzheimer's patients, because that is probably the best example I can think of right now. These are people who have a progressive dementia which can progress very, very slowly, maybe over quite a number of years, and during that time they get various kinds of behaviour disorders. Some of them can show psychotic symptoms -- which are often confused with schizophrenia, although we can usually tell the difference; I'm not sure we can always tell the difference -- and if they get put in a mental health system, they're really treated for their mental health problems, but it's difficult then to get services for their many physical problems. And they have a lot of physical problems. It means transferring them back and forth between institutions, which can become very difficult.

The one thing that the working group, and I have no idea what they're going to recommend because they haven't got to that point yet, but one thing that they could very well recommend is that specific institutions be set up that would deal with both kinds of problems at the same time. And unfortunately, if they're going to be under the rubric of long-term care, I wonder how they would fit with the multiservice agencies. I wonder how they would be put under that because they certainly, at least for those patients, would represent not more than -- well, there are a lot more than the 20% that's stipulated. They would be, for those particular patients, 100% of their care.

Ms Carter: Dr Deadman, you have said that you are aware of the long-term care mental health interface work group, and also I understand that in the fall of this year this will be a consultation with key stakeholders to seek input on implementation strategies, so the government is well aware of this lack and is working on it.

Now, it's my impression that there is nothing in the act that makes it impossible to add to the basket of mandated services. Am I correct in that, that this could be added without us having to go back to new legislation? Could that be confirmed?

Mr O'Connor: The basket as described in the legislation is the minimum.

Ms Czukar: As long as the minister approves.

Mr O'Connor: As approved by the minister, yes.

Ms Carter: Yes, so that if it were agreed that this should be added, that could in fact be done without delay or a cumbersome process. So I think you can be reassured on that point.

The Acting Chair: Dr Deadman, thank you very much for making a presentation. The committee will look forward to the written presentation from your organization, and I know that according to the schedule we will be hearing from them in other locations.

Dr Deadman: Yes.

The Acting Chair: For all of you who've sat here for the day of public hearings, I hope that you've found it interesting and enjoyable. I know that all the committee members enjoyed hearing the presentations. The committee stands adjourned.

The committee adjourned at 1645.