Assemblée législative de l'Ontario

LONG-TERM CARE ACT, 1994 / LOI DE 1994 SUR LES SOINS DE LONGUE DURÉE

ONTARIO NURSES' ASSOCIATION, REGION 13

ST JOSEPH'S HERITAGE

ST JOSEPH'S HERITAGE, P.R. COOK APARTMENTS

ST JOSEPH'S HERITAGE, ALZHEIMER DAY CENTRE

ST JOSEPH'S GENERAL HOSPITAL

ASSOCIATION OF ONTARIO PHYSICIANS AND DENTISTS IN PUBLIC SERVICE, THUNDER BAY REGION

VICTORIAN ORDER OF NURSES, THUNDER BAY AND DISTRICT BRANCH

COMCARE (CANADA) LTD

CANADIAN RED CROSS SOCIETY, ONTARIO DIVISION, THUNDER BAY AND NORTHWESTERN BRANCHES

ONTARIO COMMUNITY SUPPORT ASSOCIATION, AREAS 13 AND 14

CONTENTS

Monday 22 August 1994

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

projet de loi 173, M^me Grier

Ontario Nurses' Association, region 13

Judy Tinnes, member, legislative committee

Levina Collins, representative, volunteer group

Linda Launderville, member

St Joseph's Heritage

Sister Bonnie Anne MacLellan, executive director

St Joseph's Heritage, P.R. Cook Apartments

Anne Bowd, manager, support services program

Marie Jean, support services client

St Joseph's Heritage, Alzheimer Day Centre

Frances Adderley, manager

Elizabeth Montgomery, care giver

St Joseph's General Hospital

Carl White, chief executive officer

Association of Ontario Physicians and Dentists in Public Service, Thunder Bay region

Dr Ruth Kajander, representative

Victorian Order of Nurses, Thunder Bay and district branch

Harriet Laudadio, executive director

Donna Opie, director, home care program

Comcare (Canada) Ltd

Helen Berry, manager

Canadian Red Cross Society, Ontario division, Thunder Bay and northwestern branches

Sonia Prodanyk, chair, homemaker services committee, northwestern branch

Prue Morton, chair, homemaker services committee, Thunder Bay

Fran Ormiston, chair, homemaker services committee, Kenora-Keewatin

Ontario Community Support Association, areas 13 and 14

Karen Bergman, board member

STANDING COMMITTEE ON SOCIAL DEVELOPMENT

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

*Acting Chair / Présidente suppléante: McGuinty, Dalton (Ottawa South/-Sud 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)

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

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

Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Haslam, Karen (Perth ND) for Ms Carter

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

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: Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 0933 in the Valhalla Inn, Thunder Bay.

LONG-TERM CARE ACT, 1994 / LOI DE 1994 SUR LES SOINS DE LONGUE DURÉE

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

The Acting Chair (Mr Dalton McGuinty): Good morning, ladies and gentlemen, and welcome to the standing committee on social development continuing hearings in the matter of Bill 173, An Act respecting Long-Term Care. The committee is pleased to be here in Thunder Bay and we look forward to hearing from you this morning and maybe this afternoon as well.

ONTARIO NURSES' ASSOCIATION, REGION 13

The Acting Chair: Our first presentation will be made by representatives of the Ontario Nurses' Association, region 13, and I ask those people to step forward, please.

While you are taking your seat, I'll take advantage of the opportunity just to go over some of the ground rules to make sure folks understand that we have allotted one half-hour for each presentation and that time is to be used as you wish, but we would ask that you allow the committee members time to ask questions because we're very interested in this matter. Would you please begin by identifying yourselves for the record and then begin with the presentation.

Ms Judy Tinnes: Good morning and welcome to Thunder Bay. We are pleased to have this opportunity to address the standing committee on social development and share with the committee some of our concerns in regard to Bill 173, An Act respecting Long-Term Care.

Originally, when asked by Mr Arnott, the clerk of the committee, to identify ourselves and whom we were representing, I answered with no hesitation. I am Judy Tinnes, a public health nurse in Nipigon, representing the Ontario Nurses' Association as its legislative committee member, region 13. Levina Collins, on my right, is representing the volunteer sector and Nipigon District Memorial Hospital, and Linda Launderville, RN, is a home care nurse and case manager in Thunder Bay. After much thought and discussion, we sincerely believe we are also representing the consumers who utilize the services of the long-term care system and whom we work with daily. We are presently, and have been for years, our clients' advocates.

We will begin by saying we support the government in its efforts to reform the long-term care system. We believe that community-based, long-term care and support services definitely need to be expanded and improved to serve more people in their own homes and own communities.

We are very pleased to see that the legislation, Bill 173, establishes a bill of rights and an appeals process for our consumers, comparable to the system now available to residents in our long-term care facilities. We are also very pleased to see that the legislation establishes an agency, or MSA as it is referred to, to coordinate community services, provide information on these services and create a desperately needed one-stop access to services for consumers. However, we would like to draw your attention to possible problems that may arise if numerous service delivery agencies are amalgamated and integrated into an MSA.

For example, we must make sure that MSAs do not become another government bureaucracy. Small communities like Nipigon should have control over their long-term care services. Centralizing services in a metropolitan area for a city could be most appropriate. However, an MSA located in a major city which also services rural areas is most inappropriate for the rural area. In our small communities of northwestern Ontario, the hospital is seen as the centre of health care. We have the administrative structure already in place and we believe, at little cost, these hospitals could become our MSAs. We hope the government will consider giving these communities the tools they need to develop and enhance their long-term care services.

We are also concerned that numerous community agencies that are presently delivering long-term care services in a very effective and efficient manner will be dismantled. We see a great number of employees and volunteers in these agencies either being hired by the MSA or being laid off. The government evidently believes that this integration, amalgamation and delivery of services will lead to a more cost-effective system. We believe not enough questions have been asked.

Let us first look at the volunteer sector. Numerous volunteers who have a passionate loyalty to individual agencies and have given hours of devoted service to that agency will now be under an MSA. Will they have the same commitment to this new, large, nondescript agency? Will they still fund-raise for moneys to be put towards the operating costs of the MSA, as they had with their previous agencies? Although this question has not been answered, from our contacts with the volunteer sector in our community, we think not. If the fund-raising doesn't continue, will the government make up the moneys to continue the service? Will this be an added cost the government has not considered?

We also ask if other costs associated with the establishment of MSAs and their boards have been analysed to predict the cost-effectiveness of the new system. It appears to us that the MSA's role of funding, planning and management of health services will overlap the mandate of district health councils. This brings to mind the comprehensive health organization in the Rainy River area, which I believe has been designated as the MSA for that region. Is their mandate of funding and planning for health services not part of the mandate of the Kenora-Rainy River District Health Council? How is this leading to savings and more cost-effective planning? Why would two agencies or councils plan health services for the same region?

We previously mentioned two scenarios for service providers presently working in the long-term care system: working for the new agency or being laid off. We mention layoff specifically in relation to service providers under professional services. On page 18 of the compendium, it states: "The act does not specify what professional or trained non-professional must be employed to provide a certain service. This will permit alternative, lower cost workers to provide services if the task or procedure is not restricted to a specific scope of practice under the Regulated Health Professions Act." Therefore, only the RHPA will determine when a regulated health professional will be required. Will this tempt the MSAs to use lower cost staff for all services except those requiring professionals to carry out controlled acts under the RHPA? Lower cost staff does not necessarily equate to savings in the long term or providing the consumer with the most appropriate care.

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We recommend that the initial assessment of a consumer entering the long-term care system be carried out by a registered nurse.

Many of you on the committee at this point in our presentation are possibly thinking, "Here's another interest group protecting their jobs as nurses in the new system." Are we turf-protecting and trying to advance our professional interests? We think not. Nurses have always been advocates for their clients; consumers of the system deserve the best. Many entering the long-term care system today are frail, elderly persons with numerous acute and chronic conditions. Many of these consumers are cognitively impaired. We believe that if this reform is to be successful in its objectives, the consumers entering the system must undergo a professional assessment by a highly educated and trained registered nurse.

Registered nurses come with a holistic, educational background and a great wealth of experience. They are skilled at developing relationships, both with their clients and families, and have a great understanding of the community agencies and services that exist. They are skilled coordinators. They are skilled assessors. They have been trained and educated to offer a broad-base assessment in regard to physical, emotional, spiritual, psychological and social needs of clients. They are trained and have gained experience to coordinate complex cases and follow clients through the maze of the health care system. Registered nurses are there at all stages of the life continuum, from birth to death.

Registered nurses also accurately receive and process referrals. Dangerous mistakes can be made if inappropriate staff accept these referrals. Nurses have had years of experience with medical language and pharmaceutical terminology and can process physician referrals correctly and quickly. Without the proper training, time and supplies as well as human resources can be wasted. Referrals and initial assessments must be done by the registered nurse if this long-term care system is to be efficient and cost-effective.

Bill 173 must state that the person hired to receive referrals and do the initial assessments of clients must have a registered nurse's background.

Ongoing assessments and monitoring must also be done by registered nurses. Many consumers utilizing the services of the long-term care system become increasingly ill and their health status can change rapidly. Registered nurses have the skills to recognize complications sooner. They can also assess if their clients' needs are being adequately met. This, in turn, will lead to a more cost-effective and responsive system.

Our last comments are related to labour adjustment. If proposed amalgamation of numerous service provider agencies into MSAs does take place, a labour force plan will have to be initiated. We recommend that the committee ensures that there is expertise on the MSA boards to deal with the complex issues that will arise. As ONA members, we also recommend that there is fair representation of front-line workers on the board, as well as on any human resource planning committees. Successor rights must be addressed. We know ONA members will participate responsibly and effectively to ensure the success of the long-term care reform.

In concluding, we would like to thank the standing committee on social development for listening to our concerns. Although indications are that decisions have already been made by the government, we would hope that our submission will be openly considered with a view to revising the original act. We believe government and government decisions can only be improved by involving its citizens. We look forward to working with you in the future.

At the end of the brief, I have attached our conclusions of the bill and also the recommendations.

The Acting Chair: Thank you very much. Committee members, we have roughly 15 minutes for questions and we'll begin the rotation with the Liberals. Barbara Sullivan.

Mrs Barbara Sullivan (Halton Centre): Thank you very much and welcome to our first session in northern Ontario. We're quite interested in the particular issues that you've raised with respect to delivery of services in the north. I should tell you that we have heard the argument for including case management as a professional service and in fact our party, I believe, is putting forward an amendment to that effect. We think that would be an important step forward.

I'm particularly interested in the issues that you've raised with respect to labour adjustment. Our view is, and at the hearings we have heard, that people wanted a multiservice agency rather than a monopoly.

Failure of sound system.

Mrs Sullivan: Just to save time, I'll move on into the query with respect to the labour adjustment issues.

We understand, given the model of the multiservice agency, which will be a monopoly on both services and access, that existing agencies, whether it's Red Cross, VON, Saint Elizabeth or other care delivery agencies, home care, will in fact be put out of business because there will not be an adequate base for which the MSA can purchase services outside. Therefore, there will be little reason and in fact little monitoring sense for those other existing agencies to stay open.

We were told last week by the director of long-term care in the ministry that the government would pay the cost of severances for those people who will be put out of work. You have raised the issue of a different level of services, ie, using a paraprofessional rather than a professional to deliver services.

I'd like to know what you think, what your reaction is to the government putting a whole bunch of money into severances for people who are delivering care in an appropriate way now when in fact any additional money should probably be going into additional services and not into disrupting the system.

Ms Levina Collins: I can try to respond to that. I think you're trying to ask me, do we want the money for a severance package so that the clients will no longer get what we feel is quality or do I feel that you should put the money into providing higher quality, and I don't really think that's totally fair of you, but I do feel that if the government goes ahead and does decide to use lower quality service providers, and you are going to lay people off, it is only fair, if you deliberately do that, that you do offer a severance package.

But I feel that the system at the present time does give quality care. Professionals are used in the assessment and the delivery of service and it's the professionals who do the total assessment and then it is the professional who decides what level of care the consumer requires, in conjunction with the consumer. I certainly feel that the money should be there to be allowed to provide that care.

Mrs Sullivan: Is it necessary there to throw out the existing system to bring in a new system that will cost a lot more money, including in labour adjustment, whether it's the wage parity issues, whether it's in benefits, whether it's in pension plan changeovers or in severance? Wouldn't it be better to enhance the existing system by improving coordination than introducing a new agency that has a monopoly on services?

Ms Collins: I feel that is what we have been trying to tell the government all along, that it is best to enhance the present system, increase the mandate and give the consumer the one-stop access that they have been asking for and that we have been begging to have our mandate increase so that we can offer the system. Don't tie the hands. Increase the mandate and enhance the system, and that probably will be the best, most cost-effective and efficient system you could provide.

Mrs Sullivan: I probably have a little bit of time left. You represent union nurses. Have you spoken with your nursing colleagues who are in non-union situations about how the labour adjustment issues will be handled?

Ms Tinnes: Non-union workers?

Mrs Sullivan: Yes.

Ms Tinnes: I think what you see in community care services is professionals and non-unionized people making less money than people who work already in the institutional section. So I think when the labour adjustment concerns are going to come forward, of course, if this MSA takes places, that non-unionized members have to be taken care of, as well as unionized members -- definitely.

Mrs Sullivan: Thank you.

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Mr Cameron Jackson (Burlington South): I was interested in the comment you made on page 3 with respect to the DHC and its designation as an MSA. I guess the first part of my question, if I can get a short answer from Mr Quirt, is the question I asked two weeks ago: Where's the list of those that are before the minister and have any approvals been made or under active consideration? If I can get a straight answer on that, then I can build on a question I'd like to pursue.

Mr Geoff Quirt: As I mentioned last week, the minister has received only one submission from a district health council on the formation of multiservice agencies. That's the submission from the Metropolitan Toronto District Health Council asking for the minister's endorsement of its work to date recommending 15 to 20 MSAs in Metro. A copy of the Metro Toronto submission and the minister's reply --

Mr Jackson: All right. I'm sorry to interrupt you, Mr Quirt. You've not received anything at all from northern Ontario that's been sent to the Ministry of Health at all around this issue?

Mr Quirt: I know that long-term care planning committees in northern Ontario are working on the MSA issue currently. No, they have not submitted a formal recommendation to the Minister of Health.

Mr Jackson: And none of the pilot projects that have been encouraged to fast-track their proposals, none of them in northern Ontario have had even informal discussions with your ministry?

Mr Quirt: Our ministry staff, including our area managers in the north, are discussing on an ongoing basis the MSA and its establishment in each northern community. So discussions have been ongoing. To date, I'm not aware of any particular proposal for either an early leader MSA or I'm not aware of any district health council recommendation to the minister on the subject. I know a lot of hard work's going on in that regard, but no, nothing's been sent to the minister yet.

Mr Jackson: So the comments on page 3 in this brief are being presented to you today for the first time?

Mr Quirt: I'd ask the member to point out to me which comments he's referring to on page 3.

Mr Jackson: In the first paragraph: "This brings to mind the comprehensive health organization in the Rainy River area which, I believe, has been designated as the MSA for that region. Is their mandate of funding and planning...."

Mr Quirt: No, that's accurate. The minister has endorsed the establishment of a CHO, a comprehensive health organization, in Rainy River, and yes, given the nature of a comprehensive health organization, in discussions with the DHC in the community, it's been confirmed that it was logical for the CHO to assume the multiservice agency function for that area.

Mr Jackson: Okay, fine. I'll use your semantics since the ones I'm using aren't getting me any information. Could you tell me what you classify that and how many more of those you have actively been considering in the province? Because up until this very moment, all we've heard is one little proposal out of Metro Toronto. Now you've confirmed to me that the minister's formally endorsed a CHO becoming an MSA in Rainy River.

Again, Mr Chairman, this is a matter of privilege for members of the committee. As the senior staff member travelling at huge expense in the province of Ontario, we should at least get the facts when we're asking for them.

Mr Quirt: I apologize to the committee if I've misled it. I did not consider the MSA development discussion at the long-term care planning committee level as being synonymous with discussions about comprehensive health organizations that affect a broad range of programs and services, including long-term care, and in terms of specific MSA recommendations, the only thing that's been received has been the one from the Metropolitan Toronto District Health Council and that's been shared with you this morning.

Mr Jackson: Mr Chairman, I'm somewhat distressed to be learning this. I specifically referred to my visit through northern Ontario because I knew I was going to be receiving deputations from similar individuals from when we were here on Bill 101, where their vision of how an MSA should be constructed was shared with members of this committee. There are only a few, but there are some of us who are common to all those public hearings in the north.

Now I'm finding out that such a configuration has been approved by the government and the deputants now come before us with some legitimate questions to be raised and we are at a bit of a disadvantage not having had the time to examine them in more detail. I suspect you're going to tell me my time is running out.

The Acting Chair: Yes, I am. Mr Jackson, there's approximately one minute remaining. The parliamentary assistant wishes to make a comment. It's your time. Do you want to hear that now?

Mr Jackson: No, he can raise it on the government's time. I would simply like to ask the deputants then, to what extent were you involved in the discussions which led the minister to endorse the CHO as becoming the MSA for the Kenora-Rainy River area, and are your questions unsatisfied with respect to those discussions and that's why you've come forward today to try and get some straight answers about what's going to happen?

Ms Tinnes: Yes. As the legislative committee rep for ONA for region 13, and it does cover the Rainy River area, I was not personally involved with the meetings but other ONA members were. I understand that this CHO was designated as the MSA in March of this year by the Minister of Health, Ruth Grier, and I believe that they're still having ongoing discussions. I understand just recently that one of the towns within that area, Atikokan, is not joining the CHO, even though it's in that region.

The Acting Chair: Thank you. Mr Wessenger, parliamentary assistant.

Mr Paul Wessenger (Simcoe Centre): I'll just make a comment, that I think really that it's always been anticipated that the CHO in Rainy River would always involve the MSA function. I think that's always been part of a policy decision, but I'd like to just go to the brief, and I'm going to try to be quick because I think some of my other colleagues would like to ask a question too.

I'm just going to raise one issue and that is your recommendation with respect to the question of front-line workers being represented on the board. By that, are you recommending that they'd be members of the board with voting rights or they'd be members with a voice but no vote or are you recommending some sort of structure that perhaps an advisory committee representing front-line workers be present at board meetings? I wonder what you mean by that. Are you flexible with respect to that recommendation?

Ms Tinnes: We do recommend that front-line workers sit on the board with voting privileges. We know that in the hospital sector there's a fiscal advisory committee, that ONA nurses have been representatives on those committees. I believe that it is in legislation that they are to be involved and it hasn't been too successful. We would like to see this again put into the bill.

Mr Larry O'Connor (Durham-York): The long-term care committee in this area, I know that many of the district health councils are a little further along, and I just wondered whether or not you've been involved in that process at the community level. This isn't a model that's trying to come from the top down -- the local planning that's necessary and the commitment from the community to see this come from the bottom up, from the community level. So recommendations around assessment and what not have to be developed through the MSA, and I just wondered if you've been involved with the long-term care committee of the district health council and what your involvement is in the community trying to work with consumers to make sure that what we have then isn't the model from up top coming down.

Ms Tinnes: This past June, there was a long-term care committee that came to Nipigon with the rep from the Nipigon area, and I was invited to attend that meeting. I and the home care nurse in Nipigon took it upon ourselves to phone numerous citizens, elderly patients, senior citizens in their buildings and senior citizens in groups to come out to the meeting, and had this home care nurse and myself not done that, I think we probably would have been the only ones at the meeting.

Mr O'Connor: So for community involvement then, there hasn't been a way of reaching into the community or it hasn't happened well? Because this needs to be driven by the community. The community needs to know that this process is under way and, if nothing else, the committee hearings are going to let the community know that there is a change evolving here and it needs to have as much community involvement as possible. Do you have any suggestions how that could happen? I guess the district health council will watch what's being said here as well.

Ms Linda Launderville: I think that we need to get more information out to the consumers and let them know ahead of time to come out to the meetings because we were -- myself, too -- running around trying to get people to come to the meetings and things like that.

I'm not so sure that they're even listening to us, though. That's the feeling that we get, that they're not listening to the consumers, especially --

Mr O'Connor: The long-term care committee isn't listening?

Ms Launderville: We don't get that impression totally.

Ms Tinnes: We did recommend after that meeting in Nipigon that the newsletter that this district health council is preparing -- the long-term care committee newsletter, which is excellent, but was getting to nobody. So we did make a recommendation that a lot of these people were put on the mailing list and that these newsletters were put in places in the community that people could pick up.

Mr O'Connor: Everyone who's receiving the number of services that are being provided through the multiplicity of agencies out there today should actually perhaps be receiving that newsletter?

Ms Tinnes: Yes.

Mr O'Connor: Good point. Thank you very much.

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

Mrs Sullivan: On a point of order, Mr Chairman: I wonder if it's possible to eliminate the noise.

Interjection.

Mrs Sullivan: Oh, good, it's been done. All right.

The Acting Chair: It's being looked after.

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ST JOSEPH'S HERITAGE

The Acting Chair: Our next presentation will be made by Sister Bonnie Anne MacLellan representing St Joseph's Heritage. Good morning, Sister. Welcome to the committee. Please introduce your guest and begin.

Sister Bonnie Anne MacLellan: Good morning. Thank you. With me here today is Mr Grant Walsh, who is the chairperson of the board of management of St Joseph's Heritage. My name is Sister Bonnie Anne MacLellan and I am the executive director of St Joseph's Heritage, a tricomplex made up of a 109-bed, fully accredited nursing home, a 180-unit apartment complex and a community centre. I'm also the associate executive director of St Joseph's General Hospital, a 148-bed, fully accredited acute care hospital.

Thank you for providing this opportunity to address some aspects of Bill 173, An Act respecting Long-Term Care.

I would like to take this opportunity to commend the present government on proceeding with long-term care redirection legislation. The value of seniors in Ontario is obviously uppermost in the minds of the Ministry of Health policymakers. The government's goal to provide seamless services for all residents in Ontario, from conception to death, is supported. The concepts of wellness and aging in place have been encouraged by most health care professionals for a number of years. It is encouraging to see legislation which supports these fundamental dispositions. Approaching long-term care policy formation from this foundation will encourage individual independence, social interdependence and ongoing self-actualization throughout the lifespan.

Many of the concepts in the proposed legislation support the government's goal to help seniors age in place with appropriate supports and to minimize barriers to community-based service provision. There are, though, some major areas of concern that lead me to the position of speaking against the bill in its present form. These areas include the following: the definition of "adult day program," the impact of multiservice agencies on existing agency service provision, the 20% limit on non-MSA purchased services, shared costs for services and the expanded role of the district health council.

I would first like to address the issue of the definition of "adult day program." In the proposed legislation, the definition of an "adult day program" notes "a program of structured and supervised activities in a group setting for adults with care or support requirements." While the purpose of the legislation is to ensure appropriate access to community-based health services, the definition of "adult day program" is very broad. Would the day programs already established in acute care or long-term care settings, for example, medical day care, psychiatric day care, Alzheimer's and related dementia day centre and support services programs, be subject to this legislation? If these programs were placed under the jurisdiction of the multiservice agency, what would be the role and the authority of a local facility board?

Many organizations in the province have initiated and sponsored innovative and creative community outreach programs, often without government assistance until the program was proven to be successful. The government seems to assume the community outreach programs that are presently within institutions will continue within the institution and carry on the name and the logo of the facility. This is referenced in the government's document, Partnerships in Long-Term Care.

There is no way that communities and institutions will support in their facilities programs that are not part of the established organization. There must be no confusion or misrepresentation on this matter. Programs such as St Joseph's Heritage Alzheimer's and related dementia day program and St Joseph's Heritage support services program of the P.R. Cook Apartments, if they come under the jurisdiction of the MSA, will not remain as a program of St Joseph's Heritage. They would become programs, perhaps housed in St Joseph's Heritage complex, but not having any connection to St Joseph's Heritage. To continue with the name without the philosophy and board support and management of our organization would be ludicrous, and lying to the public.

There is also the issue of staff commitment. The staff of St Joseph's Heritage Alzheimer's and related dementia day program and the support services programs of the P.R. Cook Apartments have as their foundation the philosophy and values of St Joseph's Heritage to create a place for all seasons.

I would suggest to you that Sister Leila Greco, the founder of St Joseph's Heritage, was years ahead of her time when she visioned the creation of an environment where people could come and age in place, not set apart from the community at large. I can assure you that the vision and philosophy of St Joseph's Heritage, which is well known and respected throughout the community of Thunder Bay, will not be transferred to a government bureaucracy. The hearts of the staff of St Joseph's Heritage are committed to the vision and the philosophy of St Joseph's Heritage and it is not associated with programs in and of themselves. This heart commitment is the result of being captured by this vision, being smitten by the love and care that is part and parcel of being a part of St Joseph's Heritage. I cannot support abandonment of these programs and relocation of them to the multiservice agency. The programs, our staff and, of greatest importance, the people we serve, will suffer.

As a member of the district health council's long-term care subcommittee, I am aware of what I believe to be the spirit and the intent of multiservice agencies. Coordinated by a locally elected board which would represent both consumers and other community representatives, the MSAs are intended to provide one-stop access to community health services.

The spirit of the legislation addresses a crying need of many consumers to make the system easier to access. Again and again, clients and their families repeat to me their frustration of not knowing who to call for specific health and support services in their homes.

Simplifying access to a myriad of community services will provide individuals the potential to receive appropriate levels of support and professional care in their home environment. Much of the research indicates most clients progress and heal more readily if they are not removed from their familiar environment and from family who provide physical, emotional and spiritual support and love.

While I support the intent of simplifying access to community services, I must also express grave concerns around the issue of placing all or nearly all community-based health and support services under the direction of one board, the MSA board. Most of the existing community support and health services organizations, for example, VON home care, have a proven track record of efficient and effective service delivery. Governance of these non-profit community agencies has traditionally been through voluntary boards that monitor program direction, implementation, efficiency and effectiveness. These boards have established community credibility and are accountable for the services they provide.

Placing all community-based services under the direction of the MSA board negates the validity and effectiveness of previous governance structures. Are there any data to support the implication that one large board coordinating a vast array of services is more efficient and effective than the existing individual boards of the agencies providing services at the present time? The community, volunteers, staff and clients are aligned and loyal to individual agencies, not to government bureaucracies. Is there any indication that the consumers or providers associated with existing agencies that would be collapsed under the MSA board will transfer their support to the MSA board?

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If the major issue for consumers is access to services, why demolish some very good aspects of the present system, for example, smaller agencies with smaller boards? Smaller agencies and the boards associated with them provide an important catalyst to continuous quality improvement: competition. Amalgamation of community health and support services into the MSA melting pot may simplify consumer access to services, but at the potential cost of quality.

Quality and excellence cannot be legislated or mandated from government. Quality and excellence come from individuals who are committed to the vision, the mission and the philosophy of the organization with which they are associated. With all due respect, these characteristics of commitment and excellence are not frequently associated with government bureaucracies. It would be a tragedy if our present effective community support and health service system was dismantled and replaced by a bigger, but not necessarily better, MSA model.

The question that must be asked again and again, as we contemplate this change or any other change, is: Will this change result in improved service from the point of access to in-home care provision for our clients? If the answer is not an unequivocal yes for all stages of the service delivery continuum, we must rethink our strategies.

In the legislation it clearly states that no more than 20% of the services provided by the MSA can be purchased from other service providers. This limitation restricts consumer choice. The MSA service provider will, in effect, become the only show in town. While the government seems to support a consumer-driven system, the only way the system will be truly consumer driven is if consumers have a choice in service provider. If only 20% of services can be provided by non-MSA agencies, how will consumers be able to choose providers which may, from the consumer's perspective, meet their needs more effectively than the MSA service delivery model?

For example, will a consumer in Thunder Bay be able to request VON as their visiting nurse over the nursing staff employed by the MSA? Will a consumer in Toronto be able to request a nursing visit from Saint Elizabeth Visiting Nurses rather than the nursing staff employed by the MSA? If the answer is, "The VON and Saint Elizabeth will cease to exist and will come under the structure of the multiservice agency," how will there be any consumer choice in this model?

Before proceeding in this direction, it is imperative to reflect our own experiences of monopolies. Did they provide better service than those situations in which there was competition? I think not. Quality and excellence will become a luxury only affordable to those who can pay privately for these services. Like Britain, we will share a two-tiered health system, something none of us could support.

In the proposed legislation, there are no cost-sharing agreements between consumers and providers. A number of years ago, Thunder Bay was fortunate to receive funding for a new and innovative integrated homemaking program. Like the programs noted in Bill 173, IHP was free and available to anyone who requested it. Within a very short period of time, consumer demand outstripped existing human resources and budgets. Some parameters for service provision had to be created. While these parameters were not monetary, they did provide some control mechanism to ensure that clients in greatest need were able to access homemaking services.

Eighteen months ago, the government supported a support services program at St Joseph's Heritage P.R. Cook Apartments. The program was given 70-30 funding, with the consumer paying for 30% of their service contract. While it would have been much easier to establish and provide a program that was 100% funded by the government, consumer copayments did many things. Copayments provided our consumers with a sense of control over the services that were provided in their homes. They were paying something for the services and hence felt they had a right to expect a certain quality and quantity of services.

While cost-sharing is not appropriate for all clients and for all services, failure to include this critical component may result in consumer demands which far exceed our ability to provide these services. This will increase waiting lists and consumer, as well as provider, frustration levels.

I'd now like to turn to the expanded role of the district health council. The Thunder Bay District Health Council has provided support for the coordination and planning of regional health services. Bill 173 expands the role of the DHC to include aspects of planning, implementation and resource allocation. If the authority of the DHC is enhanced to include organizational strategy development and implementation, the legitimate role and responsibility of local governing boards will be in question. It will be important to always place institutional health care planning within a broad systems perspective. An analogy could be considering the role of the DHC as macroanalysis and planning, and the institution's role as microsupport for larger health planning and strategy development.

Over the past week, in specifics, I have heard many people from across this province echo many of the same concerns regarding this legislation that I have today. The government's response has been consistent: "This has been the largest public consultation process ever embarked upon. We have consulted over 70,000 people."

While the number of people consulted may be correct, the question that begs to be asked is: Who made up these 70,000 people who were consulted? I can assure you it was not the frail elderly, who are the true consumers of community health and social services. These are the true consumers who have no voice in this process. It is imperative to take the time to ask them how they feel about the services they are receiving from local service providers, by the VON, by Red Cross homemaking, by St Joseph's Heritage Alzheimer and related dementia programs, by the St Joseph's Heritage P.R. Cook support services program and many, many others. Many, if not most, would say they were very pleased with the present delivery model, so why change the model?

The issue of consultation is raised by this government again and again as a victory flag of social awareness and consciousness, proving that the government is really the voice of the people. The issue here is not an issue of consultation; rather, it is an issue of what the government has done and will do with the information gleaned by the consultation process. To embark on a consultation process and do nothing with the data obtained is both fruitless and frustrating.

Here, I refer specifically to the excellent research completed by the Thames Valley DHC on Britain's and Europe's experience of models of community health and social service delivery models that are identical to the MSA model proposed in Bill 173. Research in these countries has proven that collapsing all community service providers under the one board and banner of the MSA has proven to be ineffective and inefficient. If this is what the research in comparable models is revealing, why would we ever want to duplicate what has been tried and proven to be ineffective?

My final points on this process of the government's consultation for Bill 173 are really a number of questions. This legislation appeared for the first time in print in July 1994. The consultation of the people of Ontario has been scheduled for two weeks in August. Why is it that this government seems to only present legislation that will stir controversy during the summer months when many consumers and providers are away? If the government really wants to consult both providers and consumers, why is the consultation time frame so short? Why have the people of Ontario only received the proposed legislation just prior to third reading of the bill? Once Bill 173 has had third reading it will be law.

Because of the timing of these public hearings, I have absolutely no confidence that any of the concerns raised throughout the consultation time frame will be taken into consideration in any amendments.

In closing, I do support the original spirit which provided the catalyst of this legislation. It is imperative that access to community health and social services be simplified. There certainly should be one-stop access to these services for all who need them. This is where the legislation should stop.

The development of the MSAs model under the existing legislation will destroy a proven and effective system of health and social service delivery in the province of Ontario, create monopolies and eliminate consumer choice in the selection of service providers. There will be only one service provider, the MSA.

I would strongly encourage the government to listen to the concerns that have been raised throughout these public hearings. We will gain nothing by not doing so and will unfortunately lose everything in the process.

Thank you for the opportunity to once again address this committee.

The Acting Chair: Thank you very much for your presentation. Before we move on to questions, I've been informed by our clerk that our technical people are experiencing some difficulties with sound and recording, so we will require a five-minute recess in order to make the necessary adjustments. We'll recess for five minutes and return for questions.

The committee recessed from 1023 to 1034.

The Acting Chair: I understand that they've remedied the problem and we can resume our hearings. There's approximately eight minutes left for questions. The technical people ask that we speak directly into the microphones, that we use our buttons before speaking and hit the buttons again when we're finished. The witnesses won't need to do that, but for those of us sitting around the table here that would be helpful to them. We'll begin questioning with Mrs Sullivan, please.

Mrs Sullivan: I think this is a superb brief and I particularly appreciated the comments with respect to the consultative process. My sense is that there wasn't a huge outcry among those who were consulted during that process to be rid of mission-based organizations, VONs, Red Cross or existing homemaking services. There was a cry for an improvement in the long-term care system, particularly in terms of access and increasing services in communities where they weren't that expansive.

I want to ask you particularly about an issue I think is important that you've raised in your brief. It's a little more technical. It relates to the adult day programs and how they will be provided, what the legislation and the ministry contemplates with respect to those adult day programs which were sponsored through facility-based organizations.

I think of the Alzheimer's programs here. In my own community, we have rehabilitative programs that work in concert with other long-term care programs that come out of hospitals. In Guelph, the new reconfiguration of the hospitals there has just had, as part of its functional plan, adult day programs that are targeted to long-term care clients approved, and I think we need to know more about what happens to those facility-based adult day programs in a long-term care spectrum, if you would like to comment more on the effect of the facility-based programs here in this community and perhaps we can get some response from the ministry. There's an enormous confusion about this area.

Sister MacLellan: I'd be happy to respond to that. I'll respond specifically in relation to St Joseph's Heritage and the two programs that we have, which include the Alzheimer's and related dementia program and the support services program in the P.R. Cook Apartments.

It is our understanding that with the proposed legislation those would no longer be programs that our board will be responsible for. They may indeed be housed at St Joseph's Heritage, but that is where the connection would end. They would be leased tenants only. The staff would no longer be St Joseph's Heritage staff. We have a lot of concerns about that.

In the legislation they suggest that in communities where they see it's important they might continue with the name and the logo of the program if this is what the community wants. I want to be very clear that this will not be the case at St Joseph's Heritage, and in fact I would suggest to you that it's misrepresentation, because it has nothing to do with St Joseph's Heritage once the board has no longer any control over the quantity and quality of services that are provided.

Specifically in the Alzheimer's program, we have a subcommittee of our board that meets regularly that includes consumers, care providers and the Alzheimer's Day Centre, the Alzheimer's program in Thunder Bay. We meet regularly to discuss the program and to ensure that it meets the needs of the people of Thunder Bay.

We also, with the support services program, have another subcommittee of our board that reports regularly on the progress of the program and how we're meeting the needs of our clients. This will not be the case and so therefore it will not be a program of St Joseph's Heritage, which is a tremendous loss from our perspective.

Mrs Sullivan: Could the ministry or the parliamentary assistant or the officials respond to how facility-based programs will fit into this vision of long-term care change?

Mr Wessenger: Yes. I think perhaps I'll just respond briefly and then add Mr Quirt's comments for more details. I understand that we're prepared to look at flexibility with respect to the whole question of the delivery of programs by facilities. We certainly appreciate hearing the comments from the deputants here today and certainly the committee will, I'm sure, be looking at the whole question of dealing with this issue. I'll ask Mr Quirt to add any more particulars.

Mr Quirt: In terms of Bill 173 itself, it would have no direct impact on the operation of the Bethammi Nursing Home operated by St Joseph's. Bill 101, as you know, passed last year had significant impact on long-term care facilities, and the one connection between Bill 173 and the facility legislation is that the placement coordination services established under Bill 101, the placement function, would become part of the responsibilities of the MSA once the MSA is established.

With respect to the supportive housing program operated, there would be no direct impact on it. It would continue to be funded separately by the province. Clearly the MSA or other community agencies may make referrals to this supportive housing program, but that certainly is the case currently.

With respect to the Alzheimer Day Centre, in response to recommendations made by other presenters to the committee, it was indicated that the government is interested in hearing how the bill might be amended to allow for the facility-based day programs to be exempted from perhaps the 20% purchase provision so that those day care programs that are an integral part of a long-term care facility would continue to be funded separately by the government as well.

In summary then, the nursing home isn't directly affected. The supportive housing program is not directly affected. The Alzheimer Day Centre: We're open to suggestions as to whether or not those day programs should continue to be funded separately and there be a referral relationship between the MSA and those day programs.

Sister MacLellan: I'd like to respond to that. I'm very pleased to hear that the support services program will not be included and will be funded separately, and I'm happy to hear the government's openness to negotiate our continued facility-based and institutional governance of the Alzheimer Day Centre program.

I would suggest to you that the bill, then, in its present form is misleading and subject to certain individual interpretation and will need to be clarified in order to address these specific issues.

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Mr Jackson: I had another line of questioning but I'd like to build on this, because there's a third piece of legislation, the Independent Health Facilities Act. If you draw an analogy here to, say, an abortion clinic where it doesn't necessarily have to be private, it can be a non-profit corporation and yet it still falls under the Independent Health Facilities Act -- we're talking about standalone facilities and programs funded through an MSA, and those parts of the program that the MSA doesn't uptake, the balance of that program should, I would suspect, by definition fall under the Independent Health Facilities Act.

Are those limitations cross-transferable or are they not -- Mr Quirt's only answered part of the question, in my view -- and to what extent has the government analysed the implications of the Independent Health Facilities Act and its relationship if in fact some of these facilities are providing a medical model and a social support service model and so on and so forth?

Mr Wessenger: Yes, I'd ask legal counsel to clarify that issue.

Ms Gail Czukar: We're not saying that the adult day programs would fall outside the legislation. They would still be covered by this legislation. What could be done, depending on the feedback -- and it's not really a matter of negotiation; it's a matter of responding to the input that we've had in proposing amendments to the bill down the line at the end of October, in clause-by-clause -- is that these programs could stay under the bill but be given some kind of special status: those that are existing that are run by facilities to be exempted from the purchase limit that's in the bill or something like that. It would be a very limited exemption. We're not proposing to consider taking them outside the scheme altogether.

Mr Jackson: But in the absence of those amendments, at some point the Independent Health Facilities Act has to come into play by definition because, in order to survive, they're charging a fee for a service which exists somewhere in an OHIP formulary but now is going to be provided on a fee basis somewhere else in the system. I don't wish to oversimplify the Independent Health Facilities Act, but I've spent six months of my life running around Ontario dealing with that bill and, as far as I'm concerned, I still see a strong analogy here.

Ms Czukar: I don't believe that we're discussing fee-charging under OHIP that would bring this kind of program under the Independent Health Facilities Act. What the presenters talked about is a program that's funded 70-30, and that's separate funding; that's not OHIP funding. So I don't see where the interface is, but maybe we need to discuss that further.

Mr Jackson: We will. I wasn't using the current example. I'm looking ahead to when they get their back to the wall where the local MSA says, "Look, we don't want to buy any of your service," but the decision is that because the demand in the community is such, they're prepared to provide the service. Well, to provide the service is now 100% fee-paying.

What restrictions will exist in Ontario law from them providing the service at full cost to any person who's rejected, turned down or on an extended waiting list for the services that have been designated by an MSA? I'm just fearful that the Independent Health Facilities Act will be the tool the government uses to say, "Sorry, you must shut down completely or apply to us for the licence in the licensing provisions that are contained in the Independent Health Facilities Act." That's all I was raising at this point. I was not using the specific 70-30 cost-share question; I was looking more to their concern about being phased out completely.

The Acting Chair: We're beyond our time, but I want to allow Mr Martin some brief comments and a question.

Mr Tony Martin (Sault Ste Marie): It's certainly good to be back in my own neck of the woods in terms of northern Ontario. I represent Sault Ste Marie and certainly have, over my short life, lived in almost every community in northern Ontario, as I'm sure you have, Bonnie, at some point or other in your service. Having lived in the north for a long, long period of time, certainly we've heard of the institution that you presently work for. When it was developed back a few years ago by Sister Leila Greco, we were all very envious of the opportunity that would provide to a small number of people in Thunder Bay, to get those services and to be looked after.

That perhaps was the beginning of our concern around the question of how we get equity into the system, how those of us who lived in Wawa and Elliot Lake and Red Rock and places like that got access to services of that sort. This bill is designed, to some great degree, to respond to that concern that I as a citizen of northern Ontario and that my parents who lived in Wawa and who now live in Sault Ste Marie have brought to the table in many interesting ways: How do we get our needs looked after? I guess the details of all of that will be worked out as it goes on. I think you're participating in a local consultation process and hopefully will involve the people you serve in that discussion, as I will in my community.

My hope would be that what you do at the Heritage and the spirit and enthusiasm that you bring to the Heritage are something that as well, through this process, could be made broader-based, that you could bring into the larger community. People like Leila Greco, who has now come to Sault Ste Marie and just recently retired from heading up the community mental health organization there, I'm sure when she left Thunder Bay, there was a great hue and cry that what she'd brought to the Heritage would be taken with her and brought to Sault Ste Marie.

I'm sure the experience was that in fact the seeds she sowed have produced a lot of good fruit. She came to Sault Ste Marie and, in a community-based organization, brought that same spirit and enthusiasm and developed some wonderful and exciting programs there.

I guess my question is, cannot that happen? Cannot the experience, energy and enthusiasm that you bring to your particular organization somehow be brought to a larger MSA process? Cannot that be helpful, then, to all of northern Ontario in some significant ways through this process?

Sister MacLellan: As you are aware, I am involved in the process of developing the MSA model here in Thunder Bay. When you talk about enthusiasm and commitment and passion in relation to service provision, those are usually related to the vision and the values of organizations. They're not specifically related to the services delivered, be it home care, be it nursing at the bedside etc.

People work for organizations for a myriad of reasons, but I think one of the bases of working for any facility is the organization's philosophy, values, mission and tradition. I would suggest to you that the MSA would have none of those that would entice me in any way.

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I'd also suggest that I've spent a great deal of energy in trying to work collaboratively to develop a good model that clearly meets the needs of the people in the community and I have worked passionately to move away from any kind of a model that suggests a bureaucracy in any way, shape or form.

Can I transpose the enthusiasm, the commitment of St Joseph's Heritage in the MSA model? The short answer is no. I could give you a longer one but I'm sure we don't have enough time. But I'm certainly committed to working at a process that facilitates access to services in the communities. Where I draw the line is when you dismantle existing organizations that have long traditions -- a lot of this is based on tradition and the vision of founders -- and visions of service delivery in the community that can't be transferred to the MSA model.

I'm afraid I don't share your enthusiasm or optimism regarding the MSA. I see it as being fraught with real problems and I would encourage you to read the discussion paper distributed by the Thames Valley DHC on January 7, 1994. There is an excellent literature review that looks at models comparable to the MSA that were developed throughout Europe and Britain and they're now reverting back to a managed competition system.

ST JOSEPH'S HERITAGE, P.R. COOK APARTMENTS

The Acting Chair: Our next presentation will be made on behalf of the P.R. Cook Apartments, St Joseph's Heritage. Welcome to the committee. Please make yourselves comfortable. I want to draw to the committee members' attention that 15 minutes has been allotted for this presentation as well as to the next one. Please introduce yourselves and begin.

Ms Anne Bowd: Good morning. My name is Anne Bowd and I'm the manager of the support services program in the P.R. Cook Apartments at St Joseph's Heritage. One of our support service program clients has come with us today and will give a presentation shortly. Her name is Mrs Marie Jean. We also have the moral support of two of our support service workers, Arlene Baker and Marg Smith.

The support services program provides services to tenants which enable them to continue to live in their own apartments, even when their service needs are quite extensive. The program helps tenants remain independent and delays or avoids placement in institutions.

We offer a variety of services, such as help with activities of daily living, which could include personal care as well as housecleaning. We offer meals, an emergency response system, daily "How are you?" checks, life enrichment and health promotion activities and outings in our van and the use of our swimming pool and sauna. Since the program started at the Heritage, we have served 81 clients, which represents 45% of our block. At the present time, we have 53 clients enrolled in our program.

I commend Bill 173 for the objective of seeking to ensure a wide range of community services as an alternative to institutional placement. Our clients tell us they do not want to live in a nursing home, and we have actually enabled several clients to die in their own apartments, as was their wish.

We would all agree, of course, that it is sensible to simplify and improve access to services. To this end, we feel that the multiservice agency should function as an information and referral centre. We should continue to use the programs that are already established and running efficiently and effectively.

A great deal of careful research and planning were necessary for the establishment of the support services program in the P.R. Cook Apartments. Because tenant needs are important and the services offered should meet individual needs and suit our particular clients, we entered into a consultation process with the tenants of our block. Through this process, we felt that we would learn what tenants wanted, what they needed and what they would pay for it. We were able to organize several packages of services that were consistent with the Heritage philosophy, to treat each person as a distinct individual and to enable each person "to age in a familiar setting while retaining as much independence and private life as possible."

The support services program was difficult to implement for a variety of reasons. Some of these were the cost, the difficulty of tenants realizing that they needed help, tenants not wishing to lose their independence, the presence of other homemakers in our building, incomplete understanding of the services offered and tenants not willing to commit to a program they had yet to see in action. We worked hard to meet these challenges and to gently promote the program to tenants. People joined the program because it was a Heritage program and they knew that the staff would have a working knowledge of the Heritage philosophy and could be trusted. The tenants were aware that the whole St Joseph's Heritage history and philosophy stood behind this program and they so concluded, and I quote several tenants, "It must be good."

Tenants have an intense loyalty to St Joseph's Heritage. Three clients joined at the beginning of the program because they wished the program to be successfully established. I was told the tenants were pleased that the Heritage continued to remain at the forefront of service delivery and is "establishing a program ahead of everyone else."

The enrolment was slow when we first approached tenants, and two persons assured me that they would join even though they really didn't feel they needed the program yet. They were willing to put out the money so that the program could be started and people in the block could benefit from it. That's loyalty you would not see given to an outside agency, I'm sure.

Enrolment continues to be a concern, and it takes considerable time and effort to enrol a new client. This is partly because the program is not mandatory for tenants. They are offered a choice of whether or not to join the program. When a client dies or moves to a nursing home, we do not always fill that vacancy immediately and negotiations can carry on over a significant time period. If the program came under the multiservice agency umbrella, I have no doubt at all that the enrolment would fall dramatically.

The skills of the staff of the support services program combine to serve clients in all areas mentioned in the bill: support services, homemaking and personal support. There is no demonstrated need for differentiated staff for each area of client care.

We at St Joseph's Heritage serve clients in a holistic way. We see the areas where our clients need support, but we also see our clients' strengths, and we try to concentrate on these strengths and to enhance them. By doing this, we actually help clients to minimize their problems and to pursue activities that they have engaged in over the years.

The support services program is basically a cost-effective program. Staff time is used efficiently. Appointments can be booked for only 10 minutes if that is necessary to meet client needs. Travelling time is not paid. Staff response to emergency or crisis situations is immediate because staff are in the block, and this hopefully is able to prevent further complications.

Many students now seek placements with the support services program. This is because they receive a challenging learning experience and are supported well by staff and clients alike. Volunteers come and stay and find that the time they spend in the Heritage is rewarding. Volunteers have told us repeatedly that they have gained as much as they have given. Would students and volunteers be as committed if the program were part of a large bureaucracy? I think not. The personal touch that helps people to feel valued and appreciated would be gone.

Many volunteers come to us because of the reputation that the Heritage has in the community. Without them, we would be unable to offer such an enriching program to our clients. We would not be able to individualize our services as we have done. Again, our clients would be the losers.

The bill states that client assessments and plans of service will include client involvement and that services will be planned, and I quote, in "as timely a fashion as possible." Currently, in the P.R. Cook support services program we are able to assess and enrol a new client immediately, all in the same day if necessary. We are able to respond to client concerns immediately. This is especially important in times of illness or crisis. There is no time lag before services are implemented, and we are in a position to prevent problems from worsening.

As a staff person at St Joseph's Heritage, I have always been empowered to develop my ideas and to try them. The mission statement and the values that we support at the Heritage have helped us to gain a reputation around the country for innovative services. I have communicated with people in Manitoba, Saskatchewan, Quebec and other regions of Ontario who have asked for information on the support services program. I presented a paper on our program at an international conference in Winnipeg in May. The conference was entitled, There's No Place Like Home: Making it Happen.

All the comments that I received at the conference were most favourable. Everyone mentioned the innovativeness of our program and wished that their province or state would fund such initiatives. When we were starting this program, I researched services within the province of Ontario and could find no other program providing services in the way that we were, that is, offering a choice of services to existing tenants in an existing apartment block. We have done something unique at St Joseph's Heritage. We worked hard to establish a successful program and to develop a team of committed and caring staff who provide holistic and compassionate services to clients. When something is working well, why change it?

Thank you very much for this opportunity to speak to you today. Marie Jean would like to add her comments now.

Mrs Marie Jean: Good morning. My name is Marie Jean and I have been a client of the support services program since January of this year.

The support services program at the P.R. Cook Apartments is unique. It has been planned to service the needs of aging tenants who no longer can do everything for themselves.

The support services staff are a group of people who are handpicked for their ability and capability of making people feel secure and safe. They can knock on your door in the morning to see how you are. If you need assistance of any kind, they are there to serve you. Support services have hired people who can be trusted. Activities are carried out by the staff to make the people happy and comfortable in all aspects of life, such as making a bed, helping you with your breakfast, or activities such as crafts, exercises, amusements of all kinds.

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Having been a homemaker and a foster mother myself in my lifetime, I am now extremely happy to be on the receiving end of all this. The cost that I pay gives me control over the services that I receive. I do not approve of the support services program going into an umbrella-type management. I believe too much would be falling through the cracks. This type of service needs a hands-on manager or supervisor in order to see that all needs necessary are covered at all times. I thank you.

Mrs Yvonne O'Neill (Ottawa-Rideau): I wanted to ask a little bit more about the manner in which you've established the fee structure, and is there any means test, are there people in the residence who are on social assistance, or do people really have to be part of the middle class to become tenants and to get into this? It seems to be a wonderful program.

Ms Bowd: It is. No, our building is 50% subsidized rent -- 50% rent geared to income and 50% market rent. When we were setting the fees for our program, obviously we looked at the costs of the program, but we also looked at the income that the senior citizens we're serving have. So we very carefully assessed that income to ensure that they could afford to pay the fees. Don't forget also that they're only paying 30% of the cost of our program.

Our program fees range from $82 a month to $163 a month. The $163 a month could be subsidized down to $108 a month for people who are on the basic pension.

Mrs O'Neill: And the other 70% is paid by whom?

Ms Bowd: By the long-term care -- Ministry of Health.

The Chair (Mr Charles Beer): I'll call on the next presenter, the Alzheimer Day Centre, St. Joseph's Heritage.

Mrs Sullivan: Mr Chair, while the next intervenor is coming forward, I wonder if I could ask the ministry to clarify: Is it the ministry's intention to designate every community health organization as a multiservice agency?

The Chair: Parliamentary assistant?

Mr Wessenger: I don't know whether I can answer that specifically. I don't know whether a policy adviser really can answer that question. I'm only aware of the Rainy River situation and I don't -- Mr Quirt, can you clarify anything further?

Mr Quirt: Just to say that in the two cases in northern Ontario the ministry has taken that position because the comprehensive health organization is designed to allow for the coordinated delivery of a whole range of health care services to a designated population, and the long-term care percentage of expenditure would be probably somewhere around 10% of what the CHO budget would be for that group of individuals being served. In both cases in northern Ontario, the consensus was reached fairly easily that it would make sense for the CHO, if responsible for a range of health care services, to also be responsible for the MSA. The minister has certainly not indicated to the few other areas planning CHOs that this is going to happen. I think there would no doubt be discussion locally to make sure that the same consensus was in existence in each community.

Mr Jackson: Mr Chairman, if I might, I didn't want to raise this as a point of order. I was going to wait until the end of this morning's segment, but the previous Chair bore witness to a line of questioning I gave to Mr Quirt in this area. Is he now suggesting that there are two health service organizations that have received similar approvals to that of Rainy River? And I'm still waiting to have you, Mr Quirt, explain to this committee which MSAs in this province have received formal or informal or quasi-approval or consideration. To date you've only said Metro Toronto, and we discover one while we land in the north and I now sense you're referring to a second one. When will we get this list?

Mr Quirt: Just to clarify, I indicated that the only submission made to the minister, from the DHC, on multiservice agencies formally had been the one from the Metro Toronto DHC.

Mr Jackson: Mr Quirt, if you check Hansard, I asked you, "Any informal approvals for MSAs?" That's what I asked, and I asked for it three times over the course of a week. I don't wish to be argumentative. I've asked a very clear, simple question: Which ones have received this form of informal -- whether they were by a DHC or a CHO or whom?

Mr Quirt: My intention is to try to provide as accurate information as possible, and if I haven't done that I apologize. Once you read the Metro Toronto submission, you'll see that the submission was in effect -- I checked with the minister in kind of midprogress. They were basically saying, "Minister, are we on the right track here?" The minister said, "Yes."

Mr Jackson: I'm sorry. Mr Chairman, on a point of order: We're in northern Ontario. I'm not asking about Toronto. He said there are two of these arrangements that were service organizations. Could I get the list, for the third time?

The Chair: So what you want to know is, is there a list of those that have either been formally designated --

Mr Jackson: He's implied there are two that have been approved. We were then able to discover one of them. What is the other one you've discovered?

The Chair: I wonder if there are others that can be named at this point, or we can come back at the conclusion of this morning, because I do want to get on to our next presenters.

Mr Quirt: Very briefly, there are no others that I'm aware of. I know that the minister has indicated formally to the Rainy River CHO that yes, it makes sense that the MSA be among the services that organization plans and delivers. I'm not sure whether she's given the same assurance or the same direction or confirmed with the Wawa CHO. I'll find that out and let you know.

Mr Jackson: Thank you.

ST JOSEPH'S HERITAGE, ALZHEIMER DAY CENTRE

The Chair: Welcome to the committee. If you would be good enough first just to introduce yourselves and then please go ahead with your presentation, and we'll have 15 minutes from now.

Ms Frances Adderley: Good morning. My name is Frances Adderley, and for the past five and a half years I have been manager of the Alzheimer Day Centre of St Joseph's Heritage. The day centre was established in 1986 and is located in and administered by St Joseph's Heritage, Thunder Bay, Ontario. I was a member of the long-term care consultation committee and therefore have taken a keen interest in the long-term redirection legislation.

With me today is Elizabeth Montgomery. She cared for her elderly mother, who was a client at the Alzheimer Day Centre for one and a half years prior to her admission to Bethammi Nursing Home which, incidentally, is housed under the same roof as the centre. Liz's mother passed away earlier this year and Liz has graciously consented to accompany me here today and present her views. Thank you for providing us with this opportunity to express our feelings and concerns re Bill 173.

The Alzheimer Day Centre, which has been in operation for seven and a half years, is currently administered by St Joseph's Heritage but is funded by the Ministry of Community and Social Services. Our clients are people afflicted with Alzheimer disease or related dementia. Our mission statement, philosophy and values are based on those of St Joseph's Heritage.

The Alzheimer Day Centre not only provides excellent individualized care to each client who attends, but has a reach that extends into the community, serving as an educational resource for Confederation College and Lakehead University through field placements for nursing, recreational leadership, social work and gerontology students.

The staff networks in the community by serving on many community committees. We provide education and training to various community groups and agencies. The program manager has delivered 32 hours of training to these organizations in the past year.

The program manager is directly responsible to the executive director of St Joseph's Heritage and she meets six times per year with the Alzheimer committee, which is made up of volunteer board members, representatives of the Alzheimer Society, care givers and staff.

The Alzheimer Day Centre is at an advantage as it is housed in an existing long-term care facility where we can access the support services available at the Heritage. These services include dietary, accounting, payroll, housekeeping, maintenance, health nurse, health and safety inspections and fire inspections.

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We also have available to our clients the services of a hairdresser and a barber, a dentist, physiotherapy department, doctor's office, psychogeriatric consultant, a store, a chapel to meet the spiritual needs of our clients as well as a very beautiful therapeutic garden that was specifically designed for our Alzheimer clients.

We already meet the criteria which are spelled out in the draft copy of the adult day program manual that I recently received from the long-term care division of the Ministry of Health. Why, then, would the ministry want to transfer an existing day program such as ours, with knowledgeable and experienced staff, to the jurisdiction of a multiservice agency? Why not allow the program to remain as a community-based program administered by St Joseph's Heritage?

The Sisters of St Joseph of Sault Ste Marie have a long history of providing excellent health care and meeting the needs of the people in the community. Their example of love, compassion, caring and community spirit has been ingrained in those who work in their health care facilities. Staff, volunteers and the general public chose to associate themselves with St Joseph's Heritage because of this.

I have worked in other health care facilities which lacked that rhythm or spirit that I find so unique in the Heritage. The staff are caught up in this spirit and are encouraged and are expected to maintain the high standards of quality of care that they provide to the people they serve.

Our volunteer board members give freely of their time because they are committed to the vision and the philosophy of St Joseph's Heritage. Five of these board members as well as other volunteers sit on the Alzheimer committee, which meets six times yearly. These people are dedicated and committed to ensuring that the Alzheimer Day Centre staff meet their goals and objectives in providing excellence in their service to those they serve.

I support Bill 173's assignment of a multiservice agency to provide simplified access, information and referral services related to long-term care and other community agencies. However, Bill 173's intent to change the administration of these support services to the multiservice agency and to establish one large board of management causes me great concern.

The public is aware of and will probably welcome this one-stop shopping approach to long-term care, but have they been told of the extent of this Bill 173? People do not like change, especially older people. Agencies such as the Alzheimer Day Centre, Red Cross and Victorian Order of Nurses are familiar to them, as many have already accessed their agencies at one time or another and they trust them. Will they feel the same way about the services, once transferred to the jurisdiction of the multiservice agency? I think not. People want choices. They want to stay with the familiar, and they will often shun the unfamiliar.

At the present time, there is much confusion and concern over Bill 173. There are rumours among health care professionals about job losses. My staff and I fear that even though together we have 25 years' experience dealing with the elderly, especially those with Alzheimer's disease, we may lose our jobs if the administration of our program goes under the multiservice agency. We fear that we may be forced to compete with those already displaced due to closure of beds in other health care facilities.

We also wonder whether the Alzheimer Day Centre will be housed in another facility if Bill 173 is passed. I personally left a higher salary position 15 years ago to come to work for St Joseph's Heritage simply because I was drawn by the vision and philosophy of the Sisters of St Joseph.

I believe that given the level of confusion and the concern over this issue, the government must inform the public about what is really going on and how far the bill is going.

I want to thank you for allowing Liz and I this opportunity to share our thoughts and concerns regarding Bill 173. Liz will now tell you how she feels about this.

Ms Elizabeth Montgomery: I have been a care giver for three years, and my family member attended two different day care centres throughout that period of time. The first day centre was city-organized. It utilized an old public school basement room which was entered by two flights of stairs. Stacking wooden tables were stretched down the centre of the room and wooden stacking chairs surrounded them. One paid staff and one or two volunteers manned the centre. The agenda for the day was definitely not geared to memory-impaired clients, and the staff was not trained for their needs. My family member became very anxious and pleaded with me to stay home on her scheduled days. These times became very stressful for both of us.

The following year my family member was enrolled in the Alzheimer Day Centre. Their family-client support worker was very caring and helpful, as were all the staff there. My family member responded so wonderfully to the homey, warm atmosphere and the dedicated, loving staff. Each client was treated with respect and was a unique individual given every consideration. My family member learned to trust once again. The Sisters of St Joseph have a reputation for excellence when it comes to delivering optimum quality nursing care and efficient administration.

Now, I ask you, which day care facility would you consider for your loved family member? I urge you: Do not dismantle and destroy the philosophy of St Joseph's Heritage and the Alzheimer Day Centre of the Sisters of St Joseph. You cannot and must not move the heart and soul of St Joseph's Heritage to a multiservice agency. Thank you very much.

Mr Jim Wilson (Simcoe West): Thank you very much for your presentation. You ask what's going on, and perhaps the government should inform the public as to the extent of this legislation. I think, though, your presentation indicates that you've pretty well figured out what's going on. This is social engineering to its furthest degree, and yes, you will have to worry about your jobs, and you will have to worry about whether St Joseph's can continue with its philosophy and its approach to caring under a new bureaucratic MSA.

I do have to ask you, though, to date, how have the discussions been going in Thunder Bay and in the local area towards establishing an MSA? Can you give us a feel for what's going on here?

Ms Adderley: I have gone to different committees. We've been invited to a long-term care committee, also in the district health council. However, as a member of the long-term care consultation committee, I read every document that came across my desk, and all it was telling the people was that it's going to be one-stop shopping and encouraged -- I myself encouraged them. We had a group of elderly people going all through northwestern Ontario presenting a play on this. But nowhere did it say that it was going to tap in and take away all these agencies, like the day centre and the VON that are going to be under this one MSA, and that concerns me. Do the people really know the extent of it?

Mr Jim Wilson: You're right. What seems to have happened is the government put a peculiar twist. I mean, you're right, originally and what we heard from the public during the consultations was one-stop shopping, in particular one phone number so you didn't have to spend a day or two trying to figure out how to access services. That rather simple idea, by the time the government got hold of it, it also decided, for really ideological reasons, that the MSA should also deliver at least 80% of the services and after four years be delivering 100% of the services in the area. That's where we just have a fundamental disagreement, and I'm glad you've said that somehow things have gone awry from what was in the planning documents to what is actually in Bill 173.

Any idea why the government wants to now deliver all the services? Is there something wrong with the services you're delivering?

Ms Adderley: No. In fact, I think we do provide excellent services. All our evaluations, all our feedback from our clients, our care givers, from all the students, all the volunteers and all the public has been excellent. I think you would hear an outcry from these people to say: "Why, what are you doing? They're doing well. They're doing excellent care. Leave it alone."

The Chair: In terms of the equipment, I'm just asked if you would activate the mike when each member is going to speak. There are still some problems. Parliamentary assistant.

Mr Wessenger: Thank you very much for your presentation. What I'd be interested in knowing is, in particular with respect to the delivery of Alzheimer Day Centre-type services, do you feel that those types of services are best delivered through an existing long-term care facility? Do you feel that there are advantages to having that delivered in that manner as distinct from being an independent-type service?

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Ms Adderley: Yes, I think they'd have an advantage. We have a facility now that meets all the specifications that were in this manual that I just recently received. It had to be accessible. We have everything that anybody needs. It's very easily accessible. We have the use of all the maintenance. The manual states that the director of this day program would have to look after safety issues, that she would have to go and look after health inspections and that. Why would somebody highly qualified have to look after that when that's already being administered under the roof of St Joseph's Heritage?

I also feel that we know that by the year 2000 we're going to have an influx of the elderly generation. In fact, there's going to be a major outbreak of Alzheimer's disease because all these baby-boomers are aging. It's not only a disease of the aging. When a 57-year-old lady who was very well looked upon in the community, very highly qualified, walks in and can't talk, that wrenches your heart. We know that St Joseph's Heritage can deliver an excellent program.

My fear is, if it gets to the multiservice agency, what is stopping them from saying, "Let's have a generic day centre; let's put the psychiatric day centre and the people with Alzheimer-related dementia together"? What's stopping them? They can say: "Funding is tight. Why don't we put it together?" Then we won't have any say. This way I really realize that we're dedicated to these people. We owe these people and their care givers this day centre that is run beautifully. I feel that if you have extra moneys, why not expand and enhance our program that is already available?

I recently had 12 people on my waiting list. I got back from vacation, and we started going through this waiting list. Four of these people are now in an acute care hospital because I didn't have room for them. Now, if we had a day centre with money for expansion, then these people would not be taking up all that money in an acute care centre; we could be helping them. They could be accessing this.

I really, truly believe that going with a multiservice agency for programs such as day centres is wrong. Let them stay with the one-access shopping, but leave the running of a day centre, the admission criteria, doing the referrals and that to us. We're the ones who are working with these people. We should know what's going on. We should be doing the intake, not the MSA, as is suggested in the draft manual of the adult day centres.

ST JOSEPH'S GENERAL HOSPITAL

The Chair: I call on Mr Carl White of the St Joseph's General Hospital. Welcome to the committee, Mr White.

Mr Carl White: My name is Carl White, and I'm the chief executive officer of St Joseph's General Hospital in Thunder Bay, Ontario. I think it's important to point out that it's St Joseph's General Hospital in Thunder Bay, Ontario, because, as you've heard in these hearings, we're a part of a large chain of health care facilities across this province and country, and we deliver health care with a particularly different bent, a philosophy that's different, that challenges what goes on out there in the community. That's sure been demonstrated today by the people who preceded me. It was wonderful to sit here and listen to them.

Our hospital provides a wide range of services, including many rehabilitation programs which are consumed by the client population for which Bill 173 was designed. I read with interest the content of the draft of Bill 173; at least I hope this is a draft form, if these public hearings are really put in place to hear the comments of both providers and consumers.

First, I would congratulate and to some degree support government initiatives to develop long-term care reform and make it easier for seniors and others to gain access to services. All of us in the business of delivering long-term care need to make access easier for the consumer, provide needed services to keep people independent in the community -- we're not in the business of bringing people in and putting them in hospital beds; we want to keep them in the community -- and have all agencies work together to support the consumer.

If you look today at a patient who's in an acute care bed, we're working with other agencies and they're helping us get them out. We get tremendous support from home care in this community when we have to get somebody back to the community. Services are available. Interestingly enough, we don't have a bureaucracy controlling that; we make those arrangements, and we do it.

We have to maximize the amount of money spent on direct services. I think today you have to look at what's happening at the bedside and reduce the administrative and overhead costs as much as you can. Bureaucracy and overhead costs don't exactly translate into good patient care, good care in the community or good care at the bedside.

In reading the proposed Bill 173, I have two concerns related to the administrative arrangements. It would seem that the MSAs would create a new level of unnecessary administrative costs, a new bureaucracy. I'm concerned that the rule on the purchase of only 20% of services from outside the MSA will eliminate the use of many excellent support programs and eliminate many of the providers of those excellent support programs.

I'm always concerned when government attempts to create a new structure such as an MSA to broker services provided to the public by existing agencies that are governed by existing voluntary boards. I think the key is voluntary boards. There's a lot of free work that goes on out there in the health care system. Don't destroy that.

These boards represent the community and are in place to develop and have services made available to those needing them in the community. In fact, as I think about the history of health care in our country, in our province, I do not see much of a role for government in controlling service delivery. Government and district health councils should be concerned with broad social policy issues and direction. Long-term care is one of those things you have to congratulate and support. It puts a policy framework in place. Now people need to provide the services that are needed to address that policy framework.

Local and voluntary agencies should be responsible for direct care delivery and direct service delivery. This is now done, and done quite well, I might add, by voluntary non-profit organizations, which are in a position to meet the needs of the community and have done so for many years. There was health care and social policy care in existence in this province and in this country before governments intervened in it. This is one component of the Canadian health care system which makes us all proud: It is represented by the community and reacts to community needs.

I would suggest that services could be better coordinated through the use of existing agencies and governance structures. Just look at the experience we have with placement coordination services. They'll be replaced by MSAs under this bill, the way I read it.

At present, our hospital and many other acute care hospitals deliver a wide range of services to support the elderly. Take the time to walk through a few hospital wards. You will find many seniors receiving care.

We have been creative in acquiring new programs and in redirecting existing funding to support the elderly population. This has been possible because we are aware of the change in the marketplace and are astute enough to meet the needs of our customers. This comes from responsive administration and responsible governance.

Some of the programs in our hospital -- and this is just an example in our own hospital in this community -- which support the elderly population are medical day care, which was funded by reducing inpatient beds and redirecting funds; psychiatric day care, which was funded in the same manner; special rehabilitation clinics; a reactivation unit, which was funded and put in place reallocating acute care funds; Meals on Wheels, a partnership with a community agency; a large addictions program, which for the most part was funded by redirecting inpatient funds; a quick-response team, from the allocation of our own resources.

Incidentally, we had a quick-response team in a partnership with VON home care in this community about two years before the government thought it was in vogue and put extra funding out there to fund them. I think they could have been done with a reallocation of dollars, but don't cut us off from any cheques for extra funding. The hospice unit was done with the reallocation of funds in our own hospital.

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When you see agencies in a community redirecting funds, that really demonstrates a responsiveness to community needs. You don't always become popular with the people in your own organization when you do that, because it's change, and change upsets people, but we've been able to do that.

Our boards have recognized the need for these programs and have supported their development. Be careful when you impose new legislation. Don't destroy the components of the health care system which were developed through the direction of our volunteer board members.

Will Bill 173 allow for a bureaucracy such as the MSA to take over these programs? Will additional government control encourage people to meet community needs? I don't think so.

I have always been proud to work in health care because we've been able to hear the community and make changes to meet its needs. This has been accomplished by allowing voluntary boards -- and I stress "voluntary" boards; a lot of free time goes into this -- to be creative and to work in the direction needed by our community.

Quite frankly, I don't think additional government control, which I see in Bill 173, will improve the system. I, for one, don't want to work in a centrally controlled environment which begins to resemble a police state. That's not the kind of country or province we live in. I urge you to create enabling legislation to preserve the creativity and strong desire of our agencies to meet the needs of the communities we serve.

The Chair: Thank you very much for your submission. We have time for a question from each caucus.

Mr Martin: Thank you very much for your presentation. Obviously, you and so many others who deliver health care to the citizens of this province do a wonderful job. I don't believe what you do in the hospital sector will be affected tremendously by this particular piece of legislation.

However, you do make some comments that ask me to ask some questions regarding what it is that we're doing here that causes you to make a statement such as, you know, not wanting to live in a police state. Certainly, what this legislation is about is trying to provide greater access and equity across the province. I come from northern Ontario, as you do. As a member of this government, what I'm trying to do is get as much service out to the people of my area as I possibly can, particularly to the smaller remote areas which, up to this point, have not been privileged to receive some of the services that we who live in the larger centres take for granted.

The group before you presented, as well, a wonderful program that is offered through a wonderful organization here in Thunder Bay that the rest of us in northern Ontario would love to access, although I must say that it's probably not the only organization offering very good services.

I guess the question I have, and it goes back to a thread that I keep being hooked on as we go through these hearings, is this whole question of, will people continue to be concerned about people if we change the format so that services to the elderly are being delivered by a more community-based, community-wide organization than the specific ones that are out there now, and will the people who came forward with the groups who presented before you, as volunteers, continue to want to volunteer on behalf of their neighbours and their families if there's another organization in place delivering that service, or will they just walk away from it?

Mr White: I think organizations in communities are able to bring together volunteers because volunteers identify with specific organizations and maybe the specific value or the specific belief of that organization, or they go there because unfortunately someone in their family has been afflicted by a certain condition that brings them to that organization. I think that what you have there is a great degree of organizational identity and pride in the community, regardless of which organization it is.

I volunteer to do certain things in the community on my own time, which I won't bore you with, but I do it because I have an interest in those areas and I'm proud of what those organizations do. That's what the diversity of the organizations we have does in this community. I think when you put together one large bureaucracy to control all the organizations, what you do is lose the identity of the specific organization. So you have to be careful with that. I think that's the bad side of Bill 173.

The good side of Bill 173 has to be that someone takes and coordinates all those organizations so that when I'm looking for a service for my mother, I can phone one number. That's how this bill was sold, but that's not how the legislation works.

If you look at the placement coordination services in Thunder Bay that coordinate the placement of people in the institutional sector, they're run by a voluntary board, and it coordinates the efforts and the pride and the good job that a lot of other voluntary boards do in getting people into the right accommodation. That can be easily transposed to the whole MSA model. You don't have to blow up what's there and hire people to do it and add cost to the system. Cost to the system doesn't do anything to provide care to the people.

I for one, in my personal life, would not volunteer to work in an organization that did away with all that identity and pride that exists in my community. That's what makes me proud to be part of my community. You see, you have to understand that. You can't bureaucratize the good things in the community and expect people to keep coming to help you. They'll go and work in some other sector as a volunteer. Volunteers always volunteer to do something. So don't turn them away with the legislation in Bill 173.

I'll tell you the one place people don't volunteer. They don't quite always get out and volunteer to work for government agencies, and that's what Bill 173 appears to create to me. I don't go and volunteer and work for a ministry of somebody in a government, but I'll go work for many social and health care agencies as a volunteer. I'll give much of my time, and I do.

Mrs O'Neill: Mr White, you're showing us some of the spirit of the north.

Mr White: You betcha. That we've got.

Mrs O'Neill: I found the presentation very interesting. I want you to know before I begin my question that we are certainly going to introduce an amendment regarding the 20% capping of the buying of services.

You, I think more than anyone to this point, have highlighted voluntary boards or volunteers serving on boards and the reallocation of funding that's possible with that kind of governance structure. I think that certainly shows that things can work in many ways the way they are now. Because you've brought it forward, as have two other presenters this morning, I wanted to ask the parliamentary assistant what he could tell us regarding the relationship between the governance structures of the DHC, the MSA and the facilities' governing bodies. Is there a relationship worked out at the present time regarding those structures? It's very fundamental. People do have a right to know how they are going to have their decisions made, what kind of governance they can expect as a result of Bill 173; DHC, MSA, facilities' governing body relationships, please.

Mr Wessenger: I will ask Mr Quirt to answer that.

Mr White: It's not in that bill.

Mr Quirt: If I could run through the three groups that have been mentioned: the DHC, the MSA and facilities. The district health council's role continues to be an advisory role to the Minister of Health. With respect to long-term care, the DHC has been asked to give advice to both the Minister of Health and the Minister of Community and Social Services on what long-term care programs should be in each community and to what extent the government should support them. So, DHCs would be submitting plans to both ministers, making recommendations. In other words, the DHC would provide advice to the minister on how many community service programs should exist, what their boundaries should be and how much their budgets should be; advice and recommendations to the minister developed by the long-term care planning committee and provided through the DHC to the minister.

The DHC would be saying, "Minister, we think you should fund three MSAs in this area, five supportive housing programs" -- and probably including the one that your organization operates -- "perhaps two or three attendant care outreach programs and conceivably some independent day care programs." The minister's job is then to take that advice and make decisions about to what extent she wishes to support each of those organizations to deliver long-term care and, through her staff in the long-term care division, negotiate budgets with each of the organizations to provide that.

The responsibility of the board of the multiservice agency would be very similar to the responsibilities of the board of your organizations or any other transfer payment organizations. In other words, you would contract with the government, receive funding to deliver a range of programs and your board is responsible for establishing a direction and policies to govern the hospital and the supportive housing program and the Alzheimer's day program and so on; I know you have different boards that do that. The board of the MSA would be responsible for organizing the delivery of the range of services that the MSA would provide, primarily in-home support services and volunteer-based services, as you're aware.

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The boards of long-term care facilities would continue to have a direct relationship with the minister through staff of the long-term care division. In other words, they'd continue to have a service contract with the province that would stipulate, from the provincial point of view, how much money was going to be provided and lay out conditions that the facility board would have to adhere to and, from the point of view of the long-term care facility board, they would commit to following program standards and so on, in return for that. They would then go ahead and fulfil that contract by managing the operation of their long-term care facility, setting the policies and monitoring its operation and providing general stewardship and providing direction to a key staff person who would manage the day-to-day activities.

In summary, the DHC role is to develop general plans for health care services and long-term care services in the area; make recommendations to the minister, saying, "Minister, this is the kind of system we'd like. Here are the agencies we recommend you fund and, in addition, Minister, we recommend you give them this much money"; the minister then decides. She may decide, nine times out of 10, "Boy, that's good advice and the community's really influenced my decision here," or she may, in unusual circumstances, say: "Sorry, I can't follow that advice. It doesn't follow the policy of my government. I'm going to make a slightly different decision," and explain why.

But her job then is to fund the system and the MSA boards and facility boards and hospital boards and other boards funded by government, responsible for the overall stewardship of the activities of their organization, setting its general direction and policy and ensuring that the staff fulfil that mandate.

The Chair: We have a real time crunch. I'm going to permit Mr White to make a comment, but I'm afraid we're then going to have to move on. We have another witness and, because of the schedule today in Thunder Bay and plane arrangements at the end, we're just going to have to move on, so if you'd like to just have a question or comment.

Mr White: Just as a point of clarification: I haven't gone over my time so I certainly appreciate a chance to respond. I think your analogy of how things go sounds very good, but what you're saying to us in this committee is not what I interpret in the bill. Now, maybe because I'm from the north and I'm a French Canadian, I read the bill a little differently than you do. But you tell me there's going to be an agency put in place that's going to deliver 80% of the programs out there in the community; then you're telling me that 20% of the programs that are out there that are run by good volunteers -- and they're good programs -- are going to stay and 80% are going to go.

Now, along with your explanation, if you could give me a list of which ones of the 80% are going to, then maybe I'd have something to debate a little more clearly with you. But this 80-20 rule indicates to me that the governance and the responsibility for those programs will become part of a government bureaucracy -- and I've already made my point in relation to that -- and that 20% will remain. I think you need to really look at the wording of the bill, if the analogy you make in the relationship between government and DHC and governance structures is correct.

Mr Jim Wilson: Mr Chairman, can I just add there that I think the witness is correct and we also want to keep in mind that it's actually 100% after four years. The 80-20 rule is even gone.

Mr White: That's right. So there are no more independent boards.

Mr Wessenger: That's incorrect, too.

Mrs Sullivan: Could I have a point of order, please, Mr Chairman?

The Chair: The parliamentary assistant and then Ms Sullivan and then we really do have to move on. The parliamentary assistant first.

Mr Wessenger: I'd just like to indicate, to make it clear, that the board of a multiservice agency is an independent board. It's created by the community. It's not part of a government agency.

The Chair: On a point of order, Ms Sullivan.

Mrs Sullivan: Yes, I want to be certain that the record reads appropriately. Mr Quirt has indicated that the MSAs will be responsible for arranging delivery. In fact, if that's what the MSAs were responsible for, people wouldn't be quite as unhappy as they are. The bill requires the MSA to deliver and when the witness indicates that his view is that 20% of services will stay with existing agencies, don't forget that that 20% of services can only be purchased (a) with ministerial approval, ie, the minister has to say yes, and that will also include services above and beyond the basket of services that is required that's mandatory and may include highly specialized services. So if you think that home care services and respite services that are delivered now by existing agencies will continue to be delivered by them even at the 20% level, then you're under a misapprehension. Agencies will be out of business that are in that business today. This is wrong.

The Chair: I'm sorry that time has become the enemy, but thank you very much for coming before the committee.

ASSOCIATION OF ONTARIO PHYSICIANS AND DENTISTS IN PUBLIC SERVICE, THUNDER BAY REGION

The Chair: I call on the representative from the Association of Ontario Physicians and Dentists in Public Service, Thunder Bay region, Dr Ruth Kajander. Have I pronounced that correctly?

Dr Ruth Kajander: Yes.

The Chair: Doctor, welcome to the committee, and please go ahead with your presentation.

Dr Kajander: Thank you, Mr Chairman, ladies and gentlemen. I am here on behalf of the northwestern section of the Association of Ontario Physicians and Dentists in Public Service, which essentially is the medical staff of the 10 provincial member hospitals.

We welcome the opportunity to comment on this bill, An Act respecting Long-Term Care, from the perspective of northwestern Ontario. We would like to offer some views on this bill from the front-line medical staff caring for the severely mentally ill, and by clinical staff I'm including the other helping professions and in particular our nursing staff, who are the cornerstone of the work with the severely mentally ill.

We're here because the severely mentally ill often cannot speak for themselves, suffering most often from schizophrenia, manic-depressive disorders, Alzheimer's and other disorders.

Bill 173 specifically refers to the elderly and physically challenged and makes no mention of the severely mentally ill, who by the nature of the illness require long-term care.

Schizophrenia, which is the mental illness par excellence, often starts in late teenage, early adulthood and is a lifelong condition and can have a very varied course. We have patients who recover quite well from the first bout and manage reasonably well. They may have further episodes and if they have episodic mental illness there is a tendency to become more and more disabled with each episode and requiring more and more community care.

We have catastrophic courses where a patient from the very first overt mental illness remains so impaired that they will need lifelong long-term care.

You also have the geriatric population but the geriatric population is a very mixed group. You have the ones who are physically handicapped and becoming more so as they become older, and you have the ones who are primarily demented, and Alzheimer is one form, who will become confused, and in your over-85 age group a third of the patients are quite demented. You have psychological consequences of these changes and you also have the mentally ill who have been mentally ill off and on or continuously over a lifetime who then develop the problems of old age. It is very difficult to accommodate these patients in the old-age homes or the nursing homes or at home.

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Northwestern Ontario is unique. Given the distance and the sparse population, health care is more expensive due to the fact that often longer hospital stays are necessary and conditions that are looked after on an outpatient basis for a local patient could not be done for someone from Kenora and other places. The province absorbs the travel costs. Ambulances are extremely expensive. We also have the problem of declining grain shipments and problems with the seaway, the decline of pulp and paper, and younger people have to find jobs elsewhere, leading to an overaging of the population.

The average for Canada is 10% of the population over 65; we have 13%; and 3% does not sound much, but if you put it into absolute figures, it is for Thunder Bay 3,300 more people over 65 than the average of Canada. That, ladies and gentlemen, is a very large group, many of whom need long-term care beginning at various ages for various reasons.

We also know that this group, in general, even if they are still quite functioning, consume more health dollars directly than the population as a whole, and the indirect costs of special housing and support services.

The Lakehead Psychiatric Hospital has 70 psychogeriatric beds, 10 of which are already slated for closure by the end of September of this year, and the rest are in fact threatened with closure. Before a patient gets to it, we have a psychogeriatric team of a physician and a nurse with resources to all other health professions to visit a patient, to interview the family, the staff that's caring for it, trying to figure out how this patient could best be looked after, and this patient would not be admitted to the Lakehead Psychiatric Hospital unless there was really no other space.

The problem with this dual-diagnosed patient population is really the interaction of physical factors and the psychiatric factors, and this is becoming an increasingly difficult area for physicians because with all the modern medications we have, the interaction of these medications becomes a sign in itself, and we are for ever jiggling medication, coping with side effects, trying to figure out what medication does what, and some of the side effects undo the good effects we want from other drugs, and it's a very specialized group of nurses, of RNAs, of physicians and psychiatrists that work together to look after this very difficult population.

In the psychiatric hospital we also have 36 acute care hospital beds and another 36 rehab beds, which are by and large the chronic mentally ill population, and again, closures are in the offing. Our budget has been cut by $5.5 million, and it is very hard to see how this population will be looked after.

As Mr White had already indicated, we have a very wide range of services. I don't quite know how we ever managed without psychiatric day care and medical day care at St Joseph's hospital, and especially the medical day care has in fact been an excellent babysitting service for patients who can't be left alone at home and are not infrequently brought to the hospital in the morning by members of the family where they are looked after and more than just babysat. These people are cared for. They have their dinner. They have their health care looked after. They might get physio. They might get other rehabilitative services. They have their shower.

It is hardly surprising that we have this very multifaceted collection of services that have gradually grown, and grown up with a good deal of volunteer initiative and flexibility, because we're also dealing with a very multifaceted group of sufferers, and sufferers is what "patients" means, to go back to the Latin root.

I would like to remind you that any change to the system may have unexpected consequences and any change has to be approached in a very gingerly fashion. A recent example for us is the closure of the northwestern regional centre. This centre looked after severely mentally handicapped people who, by and large, are brain-damaged people, either due to genetic factors, intra-uterine or perinatal factors, and they had very poor functioning skills. It was decided that this group of patients should be looked after in the community and they're now in group homes.

The very experienced nursing staff we had and the RNA staff were, on the whole, not rehired. None of the nurses were hired for the group homes and we have now in these group homes these patients who adjust only with difficulty to change and who not infrequently have difficulty functioning in the more intimate atmosphere of a small group. An institutional setting can be more impersonal and easier for these patients who are easily overstimulated.

The staff was not as experienced, with the result that many of these patients now surface in the emergencies of the three general hospitals, who have no idea what to do with them, where they create problems, where there's no expertise to help them. They turn up at our emergency department of the Lakehead Psychiatric Hospital, and in outpatient, where I am working, we are spending a good deal of time trying to help staff and trying to help patients to deal with the problems. Our nursing staff goes out and visits, trying to be of support. Obviously, a large amount of direct health care is generated that was not used prior to their being placed into the community, and these are things that have to be thought out. Good intentions may backfire somewhere else.

I think we have to be extremely careful, believing that with a new set of bureaucracy some of the existing problems can be solved. We must remember that the most beautifully designed, well-functioning system, even with unlimited funds, cannot prevent or cure severe mental illnesses such as manic-depressive disorders, schizophrenia or various forms of dementia.

For the chronic patient needing long-term care, rehabilitation often sounds better on paper than it is in practice. There is a conundrum of personal choice, safety and society's tolerance, individual freedom versus social control. Long-term care will not infrequently be an unhappy compromise between what society can provide in the widest sense and what the individual may want, even if the individual is totally competent; in many cases they are not, which creates other problems.

In closing, I would like to thank you for listening to my comments.

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Mrs Sullivan: You've raised a matter that is, I think, of very serious concern to all of us on the committee. There's no question that mental health reform initiatives have apparently been delinked from long-term care reform initiatives and I think that's the basis of the problem. I think that this is not also a new problem but one that has to be faced.

You talk about the dually diagnosed, and many of those people in fact are cared for in long-term care facilities, although some use community services. One of the things that concerns me about this bill is, first of all, we've been told that the psychiatric and other mental health services are not being contemplated in this bill, but as well for those people who do require those services, the only assurance to the patient or client which is given in this bill is that they will be put on a waiting list. There's no assurance of the timeliness of the specialty training in terms of, even in the intake process, in the assessment process, identifying some of those difficulties which may exist nor a continuity of services. I wonder if you would just comment on those gaps that we see in this bill.

Dr Kajander: In part, of course, this is why I am here, because these are the gaps we see and any separation of the mentally ill from other long-term patients is purely artificial because there is a constant overlap and people are shifted from one system to the other system and during a lifetime may have different needs. We are saying, in order to improve on the present situation, it would have to be a far more comprehensive system.

In fact, as Mr White said, in the Lakehead, which in a way is a testing ground, because essentially we are a closed community, somehow this community has to cope with the problems, and we have, in creating different services that do work together. While we would certainly welcome any improvement, I try to caution against certain quick changes, because these are very delicate systems where people have learned to work together, rely on each other, trying to look at the whole picture and see how we can fit in a patient.

You see, the thing that has worried many of us about the mental reform bill is the attempt of finding a bureaucratic solution for a multitude of problems. There's far too much hope that if you have enough pigeonholes, everybody will fit in. In psychiatry, in health problems, that doesn't always work because we are working with too many different problems, with too many individual problems that need a far more flexible, individual approach.

Mr Jim Wilson: Thank you, Dr Kajander, for making us sensitive to the needs of the mentally ill; particularly you mention schizophrenia and those with dementia and then the problems with old age. I just want to pick your brain for a second with respect to the bed closures at Lakehead Psychiatric. Are the community-based services in place now to catch those people who are being deinstitutionalized? Because all three political parties over the last 15 years have been guilty of deinstitutionalizing people without having the services in place. So how are you coping with those bed closures now and what do you see in the future when there's an MSA in place?

Dr Kajander: Well, the overwhelming mood is one of despair and seeing a nightmare, because as far as we are concerned, the community services are not in place and, for many of them, we don't even see how they could be put in place, because many of the chronic mentally ill may show explosive behaviour and may show sudden emergencies, and I don't see how you can do that in a group home with one or two staff.

If we have a sudden behavioural disturbance in the Lakehead Psychiatric Hospital, we pull staff. We call a code and everyone who is not needed that particular moment, meaning particularly the nursing staff and RNAs, will immediately come to that ward and be of assistance. Now, I, for the life of me, cannot see how you could staff community homes for patients who may present sudden emergencies.

Mr O'Connor: An earlier presentation we had from St Joseph's General Hospital, in the brief he had talked about the PCS, and I guess when we came here in the last round of hearings, we heard from so many of the people in the community here how wonderful the PCS was and how well --

Dr Kajander: What is the PCS?

Mr O'Connor: Placement Coordination Service -- for the facility here, and how wonderful it was and the problem was is that not every community had it, and so Bill 101 ensured that everybody in the province was going to get some service that the people here had. So it was important. One thing that we keep hearing is that this is going to create a bureaucracy now by moving forward in providing care for people that isn't the same in every community today, just like PCS wasn't a reality in every community. So what we're trying to do is not dismantle all the good that's out there, but work with all the groups that are out there presently, set up a local advisory board, one that's going to work with the community.

The question I actually have, and I'd like maybe a ministry official to respond to it, to perhaps give you some sense of where the direction it's being taken, because we've heard from the Alzheimer presentation that they're concerned about the services they provide and how they fit into day care programming and what not, and the fact is that there's an Ontario association that's been involved in the working group, and I want to know whether or not from a ministry official the same type of involvement is then going to take care of long-term care as it fits into some of the mental health needs within a community in some of the local planning, and how their dovetailing will work.

Mr Quirt: Certainly one of the ways in which there can be a close connection between the planning that is now going on for improving long-term care services for the generic population, and the planning that has begun to look at the specific needs of the client group who need mental health services in the community, one of the ways in which those two things can be interrelated is at the district health council level, and certainly district health councils have come to us and noted the natural kind of connection in planning and the connection that's possible at the community level in meeting those needs. I would point out that a very large percentage of our clients in long-term care facilities, some would suggest greater than a third of our clients, have some degree of cognitive impairment, and I know that is a logical kind of connection there between the mental health system and the long-term care system.

Certainly, our long-term care system serves clients in the community with a variety of different health problems, including mental health problems. For example, our VON nurses visit people who are in group homes that have been established to help them deal with their mental health needs. We certainly visit group homes that have been established to help people with developmental handicaps stay in the community. I know that the long-term care division is represented within the Ministry of Health on mental health reform in the person of my director of policy, Dr Patrick Laverty, and I think there are ways in which the system can be more closely integrated over time. Our bill, for example, does not preclude the notion of a multiservice agency adding to its range of services, services that are specific to the needs of people who need mental health services in the community.

Mr O'Connor: The planning will still take place at the district health council level and not -- the MSA isn't to do the planning. The planning is to be done by the district health council.

Mr Quirt: The MSA's role in planning is simply like any other transfer payment agency, to plan how best to deliver the range of services it offers, like a hospital or a children's aid society or a home support program now. The planning for the health care system and for the long-term care system and for the community mental health system is the responsibility of district health councils.

The Chair: Doctor, would you like to make any final comment on those comments?

Dr Kajander: Not really, unless you have any other questions.

The Chair: Thank you very much, then, for coming before the committee this morning. We appreciate it.

Mrs O'Neill: Mr Chairman, can I have one point of clarification?

The Chair: One point of clarification from Ms O'Neill.

Mrs O'Neill: What Mr Quirt has just stated is not exactly what I remember from the briefing on Thursday in Hamilton as far as eligibility criteria. So are we hearing now that eligibility criteria of the MSA, at the direction of the DHC, may change over time? This is very fundamental regarding mental health.

Mr Quirt: I'll try to respond briefly to that. The eligibility criteria for the MSA, in determining what kind of services to deliver to the people in the community, the MSA would be required to take into account what other programs and services or supports the client had in his or her normal living situation.

For example, if we were providing visiting nursing to a family where there were a number of teenagers living at home, then the prospect of the government or the MSA providing free homemaking would be less. The MSA would say, "Gee, you really don't need help with doing the dishes and so on because your kids are adequately looking after that need."

Or, for example, if a client who lived in a group home for developmentally handicapped people who had moved from a facility for developmentally handicapped people were to contact the MSA, the MSA wouldn't send in a homemaker because the Ministry of Community and Social Services funding is already providing for developmental service workers in that facility who are helping those clients learn the skills necessary for independent living. But if that client in the group home required a physiotherapist or a speech therapist, then they're as eligible as anybody else is for a service from the MSA because that service isn't provided normally.

Or if I, for example, lived in Sutton Place Hotel and called the MSA for a homemaker, they would say: "Gee, you've already paid for that. When you pay your bill for your room, there are people who come and clean your room so we're not going to do that. But we'd be happy to send you a nurse."

Mrs O'Neill: Mr Chair, my question was directly on mental health. I wasn't the least bit interested in homemaking. I think I understand that. But the eligibility criteria were pretty clear on Friday. Now I want to have it clarified. This is a very fundamental part of this spinoff of this bill.

Mr Quirt: I'm going to have to ask for an opportunity to discuss it with you later, because I'm not sure what I haven't covered. If someone is living in the community with a mental health need and needs assistance with homemaking or with remaining independent, then the supports like nursing and homemaking and so on they are eligible for from the MSA. The MSA won't have psychiatrists or mental health counsellors there to meet the mental health needs, and that's a legitimate criticism for people to make of the bill, that it doesn't cover off for that need. But in terms of someone with any type of disability living in the community needing support to maintain your independence in terms of the activities of daily living and needing the kind of things listed in the bill, it doesn't matter whether you need them because you have a heart condition, because you have Alzheimer's, because you have schizophrenia or because you have diabetes. If you need them, they're available to you.

The Chair: If I could, just before closing, remind everyone if they would check out before 1 pm. The time parameters this afternoon with planes and so on is tight. We will need to begin at 2 sharp because we must end at 4 sharp, and I'd appreciate everybody's assistance in that regard.

With that, we stand adjourned until 2 pm.

The committee recessed from 1215 to 1400.

The Chair: Good afternoon, ladies and gentlemen. I call the standing committee on social development to order. We begin our afternoon session in Thunder Bay, and we're discussing Bill 173, the Long-Term Care Act.

VICTORIAN ORDER OF NURSES, THUNDER BAY AND DISTRICT BRANCH

The Chair: Our first witnesses this afternoon are representatives from the Victorian Order of Nurses, Thunder Bay and District Branch. I would invite them to come forward and, as you do so, welcome you to the committee. Once you're settled and have poured some good Thunder Bay water, if you would just introduce yourselves and then please proceed with your presentation. We have a copy of your submission as well.

Mrs Harriet Laudadio: I'm Harriet Laudadio, executive director of the Victorian Order of Nurses, and accompanying me today is Donna Opie, the director of the home care program.

The Victorian Order of Nurses of Canada is a national, not-for-profit voluntary health care organization. VON understands the need to put caring first: caring through all stages of life and for the best quality of life.

The Thunder Bay and District Branch of the Victorian Order of Nurses has been in existence since 1898. We are located at 405 West Isabella Street in the city of Thunder Bay, with several satellites in the district ranging 350 miles.

Our volunteer board of directors brings expertise, specific skills and commitment to our branch. They represent various community groups and serve as board members because of an interest and a desire to serve the community. The responsibilities of the board are financial and strategic planning as well as policy development.

Our philosophy states that, "All Canadians have the right to comprehensive and compassionate health care and to participate in their health care." The goal of VON services is to promote health and independence and to enable people to live in comfort and with dignity in their home and community.

We continually develop new programs and services to meet the needs of the residents in Thunder Bay and district. We have administered the home care program since its introduction to our community in 1969. We not only share the same physical location, but we also are governed by the same board of directors and utilize the services of the same business manager, receptionist and confidential secretary. Our nursing department offers the visiting nursing program, foot care clinics, the VON adult day centre, occupational health, the school medication program and paramedical assessments. Areas covered by VON nursing are Thunder Bay, Pass Lake and Kakabeka Falls, Manitouwadge, Marathon and Heron Bay.

Mrs Donna Opie: Our home care department offers the home health care and the acute and long-term care programs, the integrated homemaker program and the school health support services program. We have submitted to you a list of several communities throughout the Thunder Bay district in which we provide service. This is not an all-inclusive package. We service any client where we're able to procure the human resources in order to do so.

Through collaboration of our internal departments with other agencies, facilities and providers, we have developed and implemented specialized programs for particular client groups according to their needs. Some examples are the quick response program, mother and child support, the anti-nausea program, not for admission, palliative care, extended care for fragile individuals and reactivation programs.

VON and home care support the Long-Term Care Act's purposes and general direction. We can support simplified access, a consumer-focused system and greater flexibility in service criteria and delivery.

Our historical involvement in this community, however, necessitates that we speak to you today regarding the implications that Bill 173 will have on our health care system and our community as a whole. The concerns we will be addressing are: absence of case managers, exclusion of physicians, lack of acute care focus, protection of current staff jobs, loss of volunteers, dissolution of boards of directors and education and skill loss.

The case manager is not mentioned in the long-term care legislation. Section 20, dealing with the development of a plan of service and the revision of the plan of service, discusses one of the major case management roles in today's operations. Who will be doing this role in the new MSA?

The government should recognize the skill and the expertise of these professionals, the case managers, in assisting the client in identifying service needs. Understanding family systems, being knowledgeable about service provider roles and the availability of the service providers in their specific community, as well as coordinating the care for some individuals on our case load, is imperative. In many cases, the clients we are involved with today have more complex needs, are more acutely ill and require the services of both health and social disciplines. These clients often need someone who is able to see the whole picture and to orchestrate the participation of these external care givers and to share the pertinent information in order to meet the goals of the individual and his family.

The exclusion of the physician as a member of the interdisciplinary team is also evident. One of the stated purposes of this act is "to improve the quality of community services and to promote the health and wellbeing of persons requiring such services." The physician is an integral member of the health care team and cannot be excluded from participating in this process and in development of the service plan.

Lack of acute care focus: A key consideration in future planning regarding the MSA is the inclusion of acute or short-term care. The administrative-organizational implications of this integration are significant. The current fiscal climate in the health care system as a whole, and the acute care facilities in particular, necessitates that an efficient, cooperative relationship between our two components be sustained.

In Thunder Bay and district, there are approximately 6,000 clients per year utilizing our acute care and support services. The relationship of the proposed multiservice agency will be linked to the hospital. Ultimately, the consumer will be impacted by service delays and waiting lists if organizational process impedes our effective communication process.

Mrs Laudadio: Protection of current staff jobs: VON has requested from the ministry protection for our union and non-union staff. If organizations are going to lose their identities, VON and home care strongly believe that the government should protect current home care workers', VON workers' and provider agency workers' employment.

Our staff is concerned about the displaced hospital personnel replacing the community personnel in this new multiservice agency, as was committed by the Minister of Health during the social contract negotiations. The government must recognize the expertise and commitments of the present community workers and guarantee them first option of future positions.

Loss of volunteers: This government states that as the MSA unites existing services and provider agencies, it will affect volunteers and staff of those agencies. It recognizes that fairness to workers and encouragement for continued volunteer involvement are essential throughout this period of change and MSA development. What happens after to these volunteers?

Volunteers are an integral part of many organizations in our community. They give hours of unpaid time, expertise and dedication. The value of not only VON's volunteers but all the volunteers who augment our services in the community should be recognized.

Is the government aware of the number of volunteers in Ontario participating in serving the health and social needs of the individual? Is the government aware of the number of donated hours of time these people contribute across Ontario? Have there been any inquiries across the province as to whether these individuals would be willing to volunteer for a large MSA? If the answer is no, this will have major ramifications for our community both financially and emotionally.

Dissolution of boards of directors: "Each MSA will be a non-profit incorporated entity operating at arm's length from the provincial government. It will be governed by a single board of directors."

This legislation forces the dissolution of community boards. VON is concerned about the loss of the individual boards from the organizations in our community. These individuals have donated their time, dedicated interest and expertise over the years. People volunteer for a board because of a genuine interest in the philosophy and values of a particular organization. As well, the size and composition of the board of the organization meets their individual comfort needs. Is there a role for these individuals on the large, bureaucratic MSA board? Finally, it is an unrealistic expectation for individuals to donate the amount of time required to direct a large multiservice agency without some method of financial compensation.

Education and skill loss: The Registered Nurses' Association of Ontario stated that there are 5,000 unemployed nurses in Ontario who are educated and skilled. The legislation refers to educating the unskilled worker to work in the community. Why are we training new workers when we have the expertise of 5,000 unemployed nurses? Our cases are more complex, more challenging and require more technological skills than we have seen in the past, and the expectation is that the nurse can be replaced with a less skilled worker. Deprofessionalization may create losers, and in this case the loser could be the consumer, and it may also interfere with reaching the goal of quality care.

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Secondly, our national organization, VON Canada, drives our standards and procedures as well as participating in research. This has to be promoted. With the possible destruction of our provincial body, VON Ontario, we will lose the expertise and equality of standards across Ontario. Collaboration and sharing through the current organization ensures equity throughout the provinces. VON has historically been the leader in community nursing. We are good at what we do. Our local branch has proven to be efficient and cost-effective. What guarantees do we have that this will continue?

As representatives of the Victorian Order of Nurses, Thunder Bay and District Branch, we submit the following recommendations be considered when accepting the Long-Term Care Act, Bill 173:

(1) Acceptance of flexible models stressing partnering of agencies as opposed to devouring agencies, their staff and their volunteer component;

(2) A system-wide database be developed to eliminate duplication and promote ease of information sharing;

(3) The inclusion of all members of the multidisciplinary team.

(4) The jobs of current staff of community agencies be protected; and

(5) A strong communication plan be developed educating consumers regarding realistic expectations of the capabilities of this system.

VON believes that the valuable skills and experience of all community-based agencies which for many years made significant contributions to the community should be recognized and respected.

In summary, we believe that by partnering we can achieve the redirection goals without destroying the solid foundation already in place.

Thank you for giving us this opportunity to present.

Mr Jackson: Thank you for an excellent brief. You've provided additional focus on what have already been some outstanding briefs from VON in other parts of the province.

I wanted to focus a question with respect to the possible dissolution of your chapter and/or your provincial parent organization. My question might best be directed to legal counsel, because my understanding is that in any charitable non-profit corporation that issues tax receipts and whatever and conducts itself in that manner, upon its dissolution very clear guidelines have to be followed with respect to the disposition of assets and where they can be transferred to. I wonder if there's anything in this legislation that legal counsel can point to which assists organizations like the VON to transfer their asset base, without getting into the description of what that is, to an MSA. Currently, I think the rules don't identify an MSA, but would an MSA qualify for the current generally accepted agreement between the federal and provincial governments as to what constitutes a legitimate transfer agency of those assets?

Ms Czukar: The legislation addresses this in that the MSA can be, and is expected to be, an independent non-profit corporation under the Corporations Act. The legislation doesn't address the issue of charitable status, which of course is a question of federal law under the Income Tax Act and being tax-exempt and so on. If an MSA does obtain charitable status, and it's anticipated that most would, then the rules governing the disposition of assets of both a non-profit and a charitable corporation would apply and they would have the usual reporting relationships and so on.

I don't think there's anything special that needs to be done about that. The general law would take care of the disposition of assets from one charitable organization to another. What the act says about that is just that if the bylaws of the existing organization don't have any provisions that specifically address disposition of assets on dissolution, then the general law would be that it's supposed to go to another non-profit charitable corporation that has similar objects, and the MSA would have similar objects.

Mr Jackson: It was on the point of -- in two stages. Are MSAs going to be applying, which would be a provincial application, for a non-profit corporation? A charitable non-profit corporation is limited in the province of Ontario if applied to Ontario, but if its extended definition requires federal approval, are we expecting MSAs to do this in a haphazard manner, or will they be constructed legally to receive the transfer of these funds? Well, the transfer of funds: It's a transfer of funds and assets. You've got money in the bank and you're dissolving a VON and those funds have to be somewhere. Potentially, they could go to an MSA. That's the point I'm getting at.

I ran into this when I set up some food banks in Burlington, and we had a range of options of the charitable status and its implications. I just wonder if the legislation anticipates that and prescribes a receptive, legally binding host for those funds.

Ms Czukar: The legislation doesn't address the issue of charitable status. I'm not aware of particular problems that would be encountered by an organization that is charitable and wants to transfer to another charitable organization. If there are special problems that the legislation needs to deal with, I'd be happy to hear that, but we expect that MSAs would obtain charitable status. We haven't required them to. But I think the short answer to your question is yes.

Mr Jackson: Finally, why I'm trying to bring this around is from the concerns of the deputants with the potential for their dissolution, but also the very cogent argument they make about the loss of volunteer base. Volunteers also contribute money, because they believe in the actual extended work they're doing. Therefore, depending on the status of the MSA, they might not even be able to provide volunteer cash donation to receive a full charitable tax receipt in the province of Ontario.

So not only are their fears legitimate, but you're constructing the MSA in such a way that you couldn't make a contribution to it. That's all my point is, and maybe you'd like to comment on this notion that the way this thing's configured -- although you do cover it well in your brief.

Mrs Laudadio: The only comment I'd like to make is that administering the home care program, all our donations that come in come to the Victorian Order of Nurses.

Mrs Karen Haslam (Perth): I'd like to again thank you for coming. I'm going to take up a couple of points.

I agree with some of the comments around case managers, and I've heard this before when I was out on my own and visiting with nurses. I think they are saying, "We would like to be the case managers," and I know there are professional case managers and courses for professionals to do this kind of job, so I hear your concern around having someone in a professional mode to take care of that case management.

What I'd like to address, though, is to take a look at point 5 of your concerns, and that was loss of volunteers. I think we take a look at the patchwork of services out there and say that is a result because there were groups that saw gaps within the system and that's why we have the patchwork out there. So I see Bill 173 as setting the stage for local volunteer initiatives, but more along the planning of the health care that's necessary in a community rather than another volunteer board -- not that they don't do good work, but that it's time we took a look at the overall picture and did a little more planning.

So when we talk about VON, and you're talking about loss of volunteers and how an MSA will affect that, I see VON as being a rather large organization, larger than a local MSA, and you have not had problems -- at least you don't tell us you have problems -- in keeping your volunteers when you are a rather large organization.

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In my community I see the volunteers who volunteer in many committees. I don't think I know one person in my community who volunteers only once or only in one of those agencies out there, and I see their commitment to their community as well as their commitment to perhaps one or two of the volunteer organizations they serve on. I see that they're serving on more than one board or they're serving on only one board as a display of their commitment to the community that they're in. So I question the loss of volunteers on two avenues, both of those avenues.

But you did raise some very interesting questions about, do we know how much and are we aware of the number of donated hours? Yes, we are. I would draw your attention to the volunteer service awards and the stats that are kept within the ministries around the volunteer hours and around the benefits of having volunteers in all communities and around the accolades they receive, both from governments and communities.

So I think I can answer yes to some of your questions. Yes, we are quite aware of the number of hours that go into volunteerism, but I just question where you see your total loss of volunteers in a community, because I know those volunteers are there in hospitals, a larger entity than some MSAs will be; I see those volunteers in many areas in the community. I don't see them being lost.

Mrs Opie: I think one of the points we wanted to make here is, certainly we're concerned about VON volunteers, but we're also concerned about the volunteers as a whole in our community who provide a front-line service that's provided by volunteers; not the individual who sits on three different committees within the community, but the individual who believes in palliative care and so joins an organization whose only focus is palliative care and that's their main direction and that's where they're putting the time.

The friendly visitors, the people who transport clients: Those are people in the community who have great commitment, have great belief in whatever organization they're joining and the base of that organization and the purpose of that organization. There are a lot of free hours we don't pay for under the home care program. That's one of the thing we access. In frugally looking at our system and how we could do it, that's one of the things. We try to refer people to organizations that will provide it free, and that's a fear that we have, that we will lose those organizations out there. Within the city of Thunder Bay, within the small community of Manitouwadge-Marathon, they each have their own little resource group that has its own particular focus, and those are the ones we're afraid of losing.

Mrs Haslam: Actually, those are the same ones I'm talking about. It's the gentleman who drives for friendly services or for neighbourly services in my community, and he also volunteers at the hospital for the hospital work in the canteen, or the lady who works as a volunteer for friendly services is also a volunteer for the Heart and Stroke Foundation. What I'm saying is, I know one lady in my community, when she ran for council, gave up 11 volunteer associations and work in the community. What I'm saying is, I can see that commitment still being there. I think Bill 173 is trying to say those traditions are important, and we do want to see them continue.

Mrs Sullivan: There are a number of reasons that volunteers volunteer, and some of those reasons may be that they have a specialized interest in a certain kind of service. They may have a special attachment that's mission-oriented, as we see particularly in the faith-based charitable organizations. They may have a personal attachment due to an experience in their family. There are many reasons that a person volunteers.

But one of the things that has to be very clear is that the work that volunteers do is associated with the actual care of clients of agencies, but also it's fund-raising work, and 30%, on average, of the revenues of volunteer organizations comes from volunteer fund-raising, and we on this side just can't imagine people volunteering to raise funds for what will appear in the community to be a gigantic bureaucracy.

I want to know, as a follow-up to an earlier question, if it's the expectation of this government that the Victorian Order of Nurses, that the Red Cross, that organizations like St Joseph's Heritage and other agencies that are currently involved in the delivery of long-term care, will transfer their funds and their capital assets to an MSA and on what basis the government has that kind of an expectation.

Mr Wessenger: I'm going to refer this to Mr Quirt, because I think that with the planning process under way, each community may come up with different scenarios relating to organizational --

Mrs Sullivan: It has nothing to do with the communities. It has to do with the government's expectations regarding what are now self-governing bodies, independently incorporated bodies, and what will happen with their assets and their funds. Does the government anticipate and is the government planning that those assets and those funds will become part of the assets and funds of the MSA?

Frankly, I don't believe that St Joseph's, by example, or the VON are going to automatically turn over all of their assets. If they don't, then the MSA is left to purchase, to spend a whole bunch more dollars, on capital assets when in fact we should be spending money on care instead of on buying assets and on severing people who are doing a good job already.

Interruption.

The Chair: Order, please. If I might just remind everyone, this is a legislative committee and the rules we must follow are those as if we were in the Legislature. I appreciate people have feelings about these issues, but I would ask if you not react to the different comments that are made by way of applause or any other manner.

Mr Wessenger: Before referring the question, I think it should be clear that if, for instance, the local MSA was created by means of an amalgamation of existing agencies, legally all the assets would vest in the new agency. If there's another mechanism, then undoubtedly a different situation would occur and I'll ask Mr Quirt to refer to those situations.

Mr Quirt: There's nothing in the bill that would require the VON or any other organization, the Red Cross, a not-for-profit organization, to do anything that they didn't choose to do with their assets. So it's totally up to the board of directors of the VON or the board of directors of the Red Cross or whatever organization may be affected to decide what to do with their own assets.

As was pointed out earlier, there may be some constraints on them placed by their charitable status in terms of what they would wish to do with them, but there's nothing in the bill, nor is there any expectation on the government's part, that the assets would be expropriated or the assets would be transferred. It's a decision for those boards to make.

Mr Jim Wilson: Just a point of clarification on that: What good are their assets if you're expropriating the service? I mean, you're gutting their services that they're currently delivering, and they're going to be left with assets and no services or funding to deliver. You may say there's no expropriation of property or direct assets, but you're expropriating the service, so you're pulling the rug right from underneath them.

Mrs Sullivan: That's right.

Mr Jackson: Can I just demonstrate? I'd just like to illustrate in one sentence the concern. You take the VON, and they drive cars.

Mr Wessenger: -- opportunity.

Mr Jackson: No, but listen. I understand that.

The Chair: I'm sorry. We're very tight on time. Mr Quirt will respond and then we are going to have to move on.

Mr Quirt: With respect to expropriating their service, the intention in the creation of MSAs is to provide more service, not less, and it's to use the valuable workers and their expertise in the system now and to build on that and to have more direct service workers through a local planning process; if in fact the MSA is formed from a new organization, to plan the orderly transfer of valued employees from one organization to the MSA and to the greatest extent possible protect their benefits and rights in that process.

The Chair: Thank you. I'm sorry. As Chair, I'm under greater constraints this afternoon because we have to finish at 4 o'clock and we've had our half an hour, but I want to thank you both for coming before the committee and for making your submission.

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COMCARE (CANADA) LTD

The Chair: I call on Ms Helen Berry, manager of Comcare (Canada) Ltd. Welcome to the committee. We have a copy of your presentation. Please go ahead.

Ms Helen Berry: Thank you for giving me this time to make my presentation. I am Helen Berry, a registered nurse and manager of Comcare (Canada) Ltd, a nursing and home support provider agency that has been a member of Thunder Bay's health care network and corporate community for the last 12 years.

I would like to express my opinions and concerns regarding Bill 173, specifically section 13, which requires the MSA to limit its purchases of community support services from other service providers to no more than 20% of the amount budgeted for specific services, such as homemaking, personal support services and professional services.

In order for me to express my concerns and make my point, I need to turn back the clock 12 years and tell you about how Comcare has served and benefited this community. It is my hope that you will understand that it is important for the system to have a healthy component of competition which brings innovation, flexibility, cost control and consumer choice.

Twelve years ago, Comcare was welcomed as a provider of homemaking services by the Thunder Bay Home Care program. At that time, and over the last 12 years, the Thunder Bay Home Care program was experiencing growth and the only not-for-profit homemaking provider was unable to accommodate the increased referrals. Comcare, with our training programs and commitment to becoming a partner within the health care community, began meeting the increased need.

Comcare brought in more evening, night and weekend coverage for Thunder Bay's frail elderly, disabled and ill clients. Comcare also introduced shorter shifts and, later, one-hour shifts at the request of the home care program. A client's 60 hours, allotted monthly, could then be better utilized. Even though shorter shifts are much more difficult to coordinate, one knows how much this service means to someone requiring daily care services.

Over the years, Comcare has also worked very hard to keep an available supply of trained home support workers on hand as they were required by the Thunder Bay Home Care program. Our home support workers and the clients they service have also greatly benefited from Comcare's special training programs on palliative care, Alzheimer disease and AIDS, and our investment in home support training through Confederation College.

Comcare also has had a very extensive field supervision program for our homemaking services. I cannot emphasize enough the importance field supervision plays in the provision of a quality home support service.

Our presence in Thunder Bay has resulted in increased provider capacity, flexibility, quality and a fresh responsiveness. Currently, Comcare employs over 105 community care staff and delivers over 100,000 hours of in-home care annually.

In April 1993 the government of Ontario announced the redirection of long-term care. As part of this redirection, the government announced and implemented a policy requiring home care programs to reduce the amount of service being provided by commercial firms to 10% of budget within a specific time. This decommercialization policy, in essence, required home care programs to formulate transition plans to achieve 10% limits.

The VON-run Thunder Bay Home Care program, like many home care programs, began implementing the not-for-profit preference decommercialization policy. All referrals to Comcare were stopped as of June 28, 1993. Even readmissions were directed to the Red Cross. A referral base that had taken Comcare 11 years to build up was just handed over to the local not-for-profit provider. Over the last 12 months, Comcare has had to lay off or cease employing over 55 community care workers. Very few of these employees ended up working for the Red Cross; actually, none that I am aware of. They left the community care field confused, angry and disillusioned.

The clients to whom we were entrusted to provide care also felt the impact of the decommercialization policy. These clients faced disruption, lost their care givers and complained openly. Some even stated that they would rather just pay privately rather than face the loss of a valued care giver or be forced to switch to a provider not of their choice. Unfortunately, the change in policy, to stop the decommercialization, came too late for many clients and home support workers.

Meanwhile, a very rigid not-for-profit referral preference continues to be practised. As a result, we continue to downsize and lay off workers while trying to maintain our reputation for quality. Our company and, most importantly, our staff are getting squeezed out of the system, hardly fair treatment for front-line staff who have worked for years providing home support services for our community.

As mentioned previously, we have lost over 55 community service staff and Comcare's monthly volumes have decreased over 30% monthly in the last 12 months. I cannot begin to express to you how demoralizing and disruptive this downsizing has been. I have not seen, the clients have not seen and the community has not seen any benefit from the decommercialization efforts or from the not-for-profit preference policy.

To summarize, I sincerely feel that the difficult lessons the government has learned in 12 months of decommercialization can provide us a glimpse of how the system will respond to consumers' needs under an MSA model that does not have room for a balance of not-for-profit and commercial providers.

(1) Consumers will lose choice. Consumers are both the clients and the case managers who must select agencies according to their strengths and abilities.

(2) MSAs that are direct service providers will essentially be monopolies. Innovation, flexibility and cost control will be dampened.

(3) MSAs that are full-service providers will experience higher costs per unit of service delivered, regardless of the limited efficiencies to be gained by an agency amalgamation.

(4) The system will lose its flexibility to meet the diverse scheduling requirements of clients.

(5) The capital and investment brought to the community by the private sector will be lost.

(6) Lastly, non-unionized community care staff from both the not-for-profit and commercial sectors face tremendous disruption.

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In Thunder Bay, if the MSA is implemented in accordance with current Bill 173 provisions, Comcare will cease to exist. After 12 years of hard work and positive contribution, our employees will be gone, our commitment eliminated, our local investment lost and our proud presence forgotten. This is not necessary and I urge the panel to listen to my recommendations.

(1) The government should allow local communities to structure their MSA service delivery mechanisms in accordance with local needs and provider abilities and in ways that ensure the most effective use of financial resources.

(2) Section 13 and the requirement that MSAs be direct service providers must be changed to allow for continued contractual relationships without limits.

(3) Providers should be selected according to quality and standards criteria.

(4) The current not-for-profit preference should be relaxed to allow programs to meet the needs of consumers.

(5) Comcare fully supports the concept of one-stop access. One-stop access can still be accomplished without dismantling an effective system of provider agencies, charities and volunteer groups.

(6) Lastly, provider agencies should be governed by province-wide standards and be held accountable to local boards and the consumers to whom they are entrusted to provide care.

Thank you for giving me this opportunity to speak.

Mr Dalton McGuinty (Ottawa South): Thank you very much for your presentation. I think the comparison you make between the government's decommercialization policy and the ultimate effect of Bill 173 is a good one. I think there's a lesson there for us to learn. I have never personally felt that people who earn a profit are somehow excluded from being able to deliver quality, compassionate care. I just fail to see that argument. I don't see any merit in it. I don't see how there's any reason why people who make money, who run a business, cannot deliver that kind of care.

You make reference to the fact that consumers will lose choice. I heartily agree. I think one of the important rights they're going to lose is the right to fire somebody who's not providing the kind of care they feel they're entitled to. The act, in kind of an effort -- and I think there's some merit to it -- talks about rights that are going to be given to clients through its bill of rights. It says, in particular -- and I think I'm leading up to a question here to legal counsel -- that there's going to be a contract, I guess a formal, legal contract, will be deemed to exist between a provider and a client.

I'm just wondering, and I'll direct this to legal counsel, if I'm 73 years of age and I feel that one of my rights has been breached, what remedy do I have? Whom am I suing and what am I suing for?

Ms Czukar: The provision in the bill which addresses the deemed contract says that the contract is between you, the consumer, and the service provider, so you would be suing the service provider and you would be suing them for the breach of contract. You would refer to the seven, I believe it is, points in the bill that describe what the terms of that contract are and you would have to establish that one of those rights had been breached.

Mr McGuinty: Am I suing, though, for -- am I entitled to money?

Ms Czukar: You would attempt to translate that breach into money, yes. You would seek money damages. You might also seek some kind of specific performance, something that would say that if you felt you hadn't been treated with dignity and respect, or something like that, you would seek an order against the service provider that they do that.

Mr McGuinty: My reaction to that is that, if we use my example, if I'm 73 years of age, there's an excellent chance that I am not familiar with the legal system, I'm not familiar with our system of justice and it would be impractical for me probably to retain a lawyer, to wait the one year to two years it would take to resolve this matter in court when at the present time, under the existing system, I have the right to fire somebody who's not looking after me properly. Yet, if my service is being provided by a multiservice agency, I have effectively no choice to go elsewhere.

Ms Berry: That's exactly it. Right now, under our present system in Thunder Bay, for instance, clients have a choice of four agencies that they can access for homemaking services. That's the way it was. Right now, it's basically the not-for-profit that is being accessed for homemaking services.

Mr Jim Wilson: Thank you, Ms Berry, for a very excellent brief and in fact one of the first briefs to give us some numbers with respect to the effect to date of the government's preference for the not-for-profit sector and its 10% rule. As the Health critic for the Ontario PC Party, I just want to tell you that you can take it on my word, on behalf of our caucus, that, first of all, we will introduce an amendment to get rid of all reference to the 80-20 rule in this legislation.

Secondly, over the last 10 years, we've not in any way supported this social experiment of the other two parties to dictate market forces. We think the local community and the market, the consumers, should clearly have the choice and dictate to local service providers to whom and by whom services should be provided. That was the policy for many, many years and as a result we had a balance.

Ms Berry: It worked very well.

Mr Jim Wilson: It worked very well and service gaps were filled by private sector and the not-for-profit or more public sector. They got along very well and we had a balance. Government just has no business dictating market forces in this case.

Ms Berry: I'm happy to hear that.

Mr Jim Wilson: The second thing is, and I want to ask you on that line, at what point do you lose the critical mass in your business and eventually are forced out of business, and if this ridiculous policy continues, how much longer can you hang on?

Ms Berry: That's exactly the point. When there was a total loss of referrals to Comcare at the start of the not-for-profit preference policy directive, we felt we would be out of Thunder Bay within six months. At the rate we're going right now, it looks like we'll be down to zero in two years. We've lost one third of our volume so far.

Mr Jim Wilson: That's probably because we hear from a lot of commercial agencies that in fact in many areas of the province local managers of the Ministry of Health or Comsoc have actually not enforced the 10% rule because it would lead to too large of a service gap. Otherwise, many more employees from the commercial sector would be on the streets. Have they been very stringent on the 10% rule here or have they found that it's unworkable?

Ms Berry: I'm not quite sure just what you're --

Mr Jim Wilson: In some areas of the province, although the law right now is that you're to be limited to 10% of the market, if they did that, there certainly would be a number of citizens out there with no service whatsoever. So they've been flexible on it.

Ms Berry: Right. Thunder Bay had a deadline of March 1995 to come down to 10%. The Thunder Bay Home Care program, I imagine, had felt they should be meeting that deadline, and so commercial agencies here were going down fast.

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Mr Jim Wilson: The other thing is, on page 3, point 3, it says, "MSAs that are full-service providers will experience higher costs per unit of service delivered, regardless of the limited efficiencies to be gained by agency amalgamation." I just want to tell you that, to date anyway, the government has not been able to provide any proof whatsoever that there will be any efficiencies at all as a result of amalgamating all of these agencies.

In fact, history -- if we've learned anything in this province -- is that bigger isn't better. Regional government has been more costly in this province. School boards, when we amalgamated those, have been more costly. Now this is sort of regional government in health care. I would even suggest that perhaps you were being kind in point 3 by saying that there might be some limited efficiencies by extrapolation here. In fact, the government in no way seems, in spite of all of our challenges, to come forward with any efficiencies at all.

Ms Berry: Our research has found also that in other places that have tried bureaucracies such as the MSA it just has not worked.

Mr O'Connor: I appreciate your presentation. I guess that's one thing that we have heard clearly, that the bureaucracies in other jurisdictions haven't worked. That's exactly why, for example, the limitations on the 20%. It's important that we work towards achieving that and that the planning take place, that the district health council subcommittee on long-term care actually does the planning that is necessary, so that we don't have a need to create bureaucracies or support the patchwork that is in place today.

My colleague suggested that it's ideological, the reason we want to move with a limit of 20%. The fact is, it's a very pragmatic move and it's one that is going to make sure that the planning that's needed takes place. Not every jurisdiction's had placement coordination in the past; a lot of them do now as a result of Bill 101. Quick response teams that are around the province now have come together because their communities have recognized a void and a lot of partnerships have taken place that didn't take place before. It wasn't there in the past.

So, for all the long-term care reform that my colleagues opposite have talked about for over a decade, there's finally a movement to see that take place, and the movement is necessary.

The dollar commitment by the government is important; $850 million this fiscal year is going to be placed in long-term care on the community side. They may balk at that, but when we took power, the very first year, it was $550 million; $300 million more is going into it this year alone. There is a huge commitment to see that this takes place.

There are 5,000 more jobs being provided in long-term care in the community now than there was then. There is a commitment. It's real, it's tangible and it's taking place. I think that one thing that your organization has done probably -- and the Red Cross is up next -- has been that by you being there and offering services it has probably made them a little bit more efficient in delivery, and they'll probably point that out to us when they make their presentation.

The fact is, there are a lot of pragmatic reasons for all that needs to be done in this legislation. Quite often, what we don't hear about are the consumers and the consumer involvement in establishing what can develop locally in their own communities and making sure that the services that they need, that are there today in a good many communities but not in every community -- the patchwork that's there now can be eliminated by putting down something in enabling legislation.

Mr Jackson: Do you understand who you're talking to?

The Chair: Order.

Mr O'Connor: I appreciate you coming here and presenting your views and we've got quite a bit more --

Mr Jackson: You should apologize for taking her job away.

The Chair: Order.

Mr Jackson: Just apologize for taking her job away.

The Chair: Order.

Ms Berry: I'd just like to --

Interjection.

The Chair: Mr Jackson, order please. Mr O'Connor had the floor and now the witness will respond.

Ms Berry: I would just like to comment on the 10% that this government had in last year. It's now been changed to 20%. If last year 10% didn't make any real common sense, I don't really think that 20% will either. They should change it back to a mix of not-for-profit and commercial providers. There shouldn't be any not-for-profit directive preference policy.

Mr O'Connor: I appreciate hearing that. We've heard a lot of people in the past make a presentation saying they didn't want to go to the brokerage model as prescribed by previous governments. There's a mix. All this is going to be recorded and we'll take a look at that as we evaluate and get into clause-by-clause.

The Chair: Thank you very much. The parliamentary assistant just had a point of clarification he wished to make.

Mr Wessenger: Yes, I'd just like to make a point of clarification. I'd like to thank the deputant. I have some degree of concern about some of the points made. Because, as I understand, what happened when the legislation was introduced in May 1994 was that the commercial volume was frozen at May 1994 levels and that there'd been no reduction of levels of the commercial sector since that time. That's certainly the information we have, so there's a certain degree of concern about your comments about the number of layoffs and the volume decrease.

Ms Berry: It's certainly been a concern of ours, losing this many trained homemakers.

Mrs Sullivan: Point of order, Mr Chairman: The minister announced a policy in 1993. Many, many home care agencies around this province began to implement that policy, which was supposed to be fully put into effect in 1995, in the early part of 1995. Thunder Bay clearly started to implement that policy soon after it was announced by the minister.

The Chair: Order.

Mrs Sullivan: For the ministry and the parliamentary assistant to suggest --

The Chair: Mrs Sullivan.

Mrs Sullivan: -- that they don't know of anyplace where it happened -- we've just had a full deputation --

The Chair: Order, please. The parliamentary assistant asked to make a few comments about the presentation. I'm going to allow the deputant to respond to that, but then we must move on.

Mr Wessenger: Just to reiterate, it was clear the point was made that volumes were frozen at May 1994 levels. Has there, in your opinion, been any reduction in volume overall since May?

Ms Berry: A 30% reduction in volume to our agency since May 1993.

Mr Wessenger: Oh, May 1993.

Ms Berry: Yes.

Mr Wessenger: So most of the reduction would have occurred in the period prior to 1994 then?

Ms Berry: Yes.

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

The Chair: If I could then call on the representatives from the Canadian Red Cross Society, Thunder Bay and Northwestern branches.

Mr Jim Wilson: Mr Chairman, while the deputants are coming forward, could I just ask for a clarification from the parliamentary assistant on the $850 million? Is that --

Mr O'Connor: A 54% increase.

Mr Jim Wilson: How much of that, though, is made up of consumer user fees? I only ask that because when you announced $650 million at one time a couple of years ago for the long-term care institutional side, facilities, $150 million of that turned out to come out of the pockets of residents of those facilities in the form of user fees. What's the breakdown of the $850 million?

Mr Jackson: Tommy Douglas would be real proud of you guys.

Mr Wessenger: I don't know whether Mr Quirt can reply to that now or whether it's something we will provide you with.

The Chair: Can we get that information just so we can -- I'm just concerned about our time. We have a real time problem.

Mr Jackson: Point of order, Mr Chairman: This committee has still a standing request for a detailed explanation of the economic breakdown. In the briefing that occurred the other day, it was not included. There are holes to be plugged in these figures that are floating around and they're being misrepresented, and to delay the full briefing of the financing is a dishonest approach on the part of the government, which has these facts. I think it's the responsibility of the Chair to get them forward for us so that we don't engage in this nonsense.

The Chair: I will take it as Chair of the committee to work out with the parliamentary assistant --

Mr Jim Wilson: You say it's a 54% increase, but the last time you did this you had seniors with a 47% increase in user fees.

The Chair: Order, please. We need to move on and we can have this discussion at another time, because I know we have limited time.

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CANADIAN RED CROSS SOCIETY, ONTARIO DIVISION, THUNDER BAY AND NORTHWESTERN BRANCHES

The Chair: We want to make sure to provide you with all of your time. Welcome to the committee. If you'd be good enough to introduce yourselves, then please go ahead with your submission.

Ms Sonia Prodanyk: Good afternoon, Mr Chairman and committee members. My name is Sonia Prodanyk and accompanying me this afternoon are Prue Morton from Thunder Bay and Fran Ormiston from Kenora. Prue and Fran will provide a few words of introduction prior to their presentation.

My name is Sonia Prodanyk. I have been a Red Cross volunteer for the past five years. I serve as the northwestern region homemaker representative on the Provincial Homemaker Services Committee. My duty is to bring the northwestern perspective to Ontario division. I also sit as a member on the local Thunder Bay Red Cross homemaker committee and on branch council. I am the program coordinator and instructor of home support levels 2 and 3 delivered by Confederation College.

My father was a recipient of homemaker services and I am a very strong supporter of the services provided by homemakers enabling clients to remain in their homes rather than being institutionalized. I would like to take this opportunity to share with you what Red Cross means to the people of northwestern Ontario.

Northwestern Ontario has a large number of remote and sparsely populated communities. Geography, road, and weather conditions are an ongoing challenge to service delivery in this area. Red Cross has a long tradition in providing service to this vast geographical area. Homemaker services are provided by two main branches, one located in Thunder Bay and one in Kenora.

From our Thunder Bay and Kenora offices, we provide services to Nipigon, Red Rock, Terrace Bay, Schreiber, Marathon, Manitouwadge, Geraldton, Longlac, Fort Frances, Rainy River, Emo, Dryden, Ignace, Red Lake, Ear Falls and their surrounding areas. In all of these communities except Thunder Bay, Red Cross is the only provider of homemaker services. Thunder Bay has provided services for 46 years, and in its district area for eight years. Kenora has provided services for 25 years, and in Dryden and Fort Frances for well over 10 years. As community needs have been identified, Red Cross has readily expanded its services to these remote communities.

The development of suboffices has enabled Red Cross to provide a cost-effective and efficient way of delivering homemaker services in this area while maintaining provincial standards. Administrative functions are supported from the main branch office, while service delivery and supervisory functions are delivered in the suboffices. Across the province, the Red Cross operates 78 local branches that provide more than five million hours of service annually. Red Cross is unique in the manner in which we deliver and support our services.

At the provincial level, we pool the resources and experiences available to us from our local branches to create comprehensive provincial standards and tools: for example, quality management and risk prevention, proactive occupational health and safety programs, and relevant and timely training. This ensures that our clients receive the same standard of service in the north as they would from any other Red Cross homemaker program in Ontario.

In some areas in the north, the cost to deliver service exceeds the fee we receive. It is very expensive to provide services to very remote and sparsely populated communities. Red Cross has demonstrated its commitment to provide services to these areas.

More than 5,000 people in northwestern Ontario -- the elderly, the frail, and the vulnerable -- depend on the society, our volunteers and staff. Each month in northwestern Ontario, Red Cross provides 22,000 hours of homemaker service to over 1,400 clients by 335 homemakers in more than 17 communities. Let me take a moment to describe some of our client needs.

Example 1: a male client, 93 years old, blind from a stroke, with no bladder control. He has been a Red Cross client for 15 years. He lives alone and he is determined to remain in his own home. He receives seven-day-a-week service, 8 to 9 in the morning, 12 to 3 in the afternoon, and 8 to 9 at night. He requires assistance with activities of daily living such as bathing, changing Attends, meal preparation, guidance when walking -- he utilizes a cane -- housekeeping and laundry. This client would have been hospitalized years ago without homemaker service.

Example 2: a female client, 43 years old. She had a radical mastectomy and chemotherapy for breast cancer. She has five children under the age of 12. We provided service five days a week, nine hours per day, for over two years. Our services included child care and home maintenance. The father had to work to support the family. Red Cross assisted in keeping this family unit going until she regained her health.

Example 3: a female client, a 79-year-old widow who lives alone in a rural area. Legally blind, hard of hearing, she came on the program with a fractured ankle a year ago. She uses a cane now. She requires a homemaker for personal care, housekeeping, laundry and meals. Her family is supportive and provides evening and weekend care but cannot do more. We have prevented institutionalization and care giver burnout.

Example 4: Homemakers have assisted in caring for quadruplets for a period of six months, spending six hours per day, seven days a week, to support this family.

The goal of the Red Cross homemaker service is to assist individuals and families to attain or regain their independence, to maintain themselves whenever possible in their own homes, and to enhance the quality of their lives.

You will also note that our services are provided not only during the day, but in the evenings, during the night and on weekends. When homemakers are in the field working, they must have access to a supervisor should they require assistance. Therefore, we have supervisors on call in the non-traditional hours. Through technology, we have linked branches and suboffices, allowing us to develop a regional on-call program. This enables one supervisor to be on call for the entire northwestern region. This has dramatically reduced our on-call costs while maintaining our quality management for our clients and homemakers. We have had to be particularly innovative in our approach to service delivery in northwestern Ontario in order to meet our standards cost-effectively.

While strongly supporting the principles of long-term care reform, we have grave concerns about the current draft of Bill 173, An Act respecting Long-Term Care. Prue Morton will summarize the position taken by the Red Cross on the creation of MSAs.

Ms Prue Morton: My name is Prue Morton. I've been a Red Cross volunteer for many years, first as the regional representative for northwestern Ontario homemakers and now as chair of the Thunder Bay Red Cross homemaker committee. As a former registered nurse and a secretary of the Thunder Bay chapter of the Patients' Rights Association, I am well aware of the important role that Red Cross homemakers play in this community.

I'd like to present the Red Cross position on MSAs.

Although we support the principles underlying the reform and the purposes as outlined in Bill 173, we're not able to support the creation of MSAs as described in the act. We're concerned the proposed system will not improve the delivery of services to consumers. We're also concerned that the legislation is trying to fix problems with the service delivery system through the creation of complex and highly bureaucratic organizational structures.

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

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

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

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

-- Independence, which states that each national Red Cross society must retain its autonomy.

-- Unity, which states there can only be one Red Cross in each country.

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

In summary, Bill 173 specifically excludes the largest provider of homemaker services in northwestern Ontario, the Red Cross. We have provided homemaker services, a cornerstone of long-term care, in an efficient and economical manner for decades. To specifically exclude the Red Cross from participating in long-term care may be a regrettable decision and causes me great concern. Don't throw the baby out with the bathwater.

Now Fran Ormiston will comment on specific aspects of Bill 173.

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Ms Fran Ormiston: Good afternoon. I'm Fran Ormiston. I'm a physiotherapist and I've been involved with health care for the past 25 years. Presently, I work in an acute care hospital in Kenora. I am well aware of patients being discharged early from hospital and the need to have support in the home.

My involvement with the Red Cross homemakers includes being a volunteer member of the KenoraKeewatin Red Cross branch, teaching the home support level 2 program, providing in-service to homemakers, and serving as the chairperson of the Red Cross homemaker committee in Kenora. I believe homemakers have a vital role in long-term care. I see Red Cross as one of the essential providers allowing patients to be discharged successfully back to their homes. As we discharge people from the hospital, we must invest in the community to support not only the individuals, but also their families who must cope with their return.

We welcome the opportunity to comment on Bill 173.

The Red Cross recommends that three sections of the legislation be amended. We believe these amendments would in no way adversely affect the purposes of the act; rather, they would enhance flexibility and allow the existing strengths of the system to be augmented.

I would like to comment on three sections of this legislation. The submission prepared by the Ontario division of the Red Cross contains three specific recommendations for amendments to this legislation. A copy of this submission has been distributed to you.

Looking at part II, subsections 2(3) to (7), inclusive, this section designates the community services which are to be provided by the MSAs. The bill describes four categories for these services and specifically delineates the services that fall under each category. The bill describes community support services, homemaking services, personal support services, and professional services. The basic premise underlying the breakdown appears to be to separate personal care, or hands-on care, of the person versus the non-personal care and services. We have two concerns with this aspect of the legislation.

The division between homemaking and personal support services is inconsistent with current practice and emerging future trends. It has taken concentrated effort over the past few years to erase the apprehension that homemakers are nothing but cleaning ladies, subservient to the other members of the health care team. The wording of the legislation significantly devalues the role of the homemaker and may lead to a reversal of the growing appreciation of the homemaker as an integral member of the health care team.

The separation of personal care versus non-personal care and services appears to be impractical and may create serious difficulties for the management of service delivery. The delineation of services between two categories is inconsistent with the way services are usually delivered in the client's home. Many functions routinely provided by the homemakers cross the boundaries between what the legislation classifies as "homemaker" and that called "personal support."

We are also very concerned that the uncertainty arising from the reform has created significant anxiety for our staff. We must protect the interests of the almost 400 staff, mostly women, we employ in northwestern Ontario.

Part VI, section 13: This section stipulates that an MSA may not spend more than 20% of its budget to purchase community services. The government appears committed to moving away from the brokerage system. In our opinion, the problem with the current delivery system is not brokerage, but lack of coordination and poor access. We feel that in many situations brokerage can be an efficient and effective system for delivery of service.

Presently, many services are provided efficiently and effectively by a number of established agencies such as the VON, St Joseph's Heritage, and of course the Red Cross. These agencies have long histories of service to their communities. They are often supported and governed by volunteers who are part of the community. Stable relationships have been developed between provider agencies, care givers and the individuals they serve. Rather than replacing the existing system, effort should be made to improve coordination and enhance efficiencies. One example would be to contract with a provider agency for blocks of service rather than the less efficient client-by-client contracting that now occurs.

Where MSAs are declared, and as they move towards assuming 80% of a given service, the critical volume necessary for the alternative provider to exist will be lost. The MSA will then be forced to assume responsibility for providing service before it is ready or, alternatively, clients will have to wait for service. The Red Cross is very concerned that clients may face waiting lists, a decline in quality of service, or limited -- maybe even no -- choice. Those who wish to purchase services outside of the MSA system will be unable to do so if there are no alternate providers in the community.

In many remote and sparsely populated areas like northwestern Ontario, the Red Cross is the sole agency providing this service. Our corporate structure and fundamental principles preclude us from providing services within the proposed MSA structure. We are concerned that if MSAs are imposed in these areas, the declining volume of service allocated to us, in combination with increasing deficits due to the high costs associated with travel, will ultimately force us out of business. This will leave many clients without service. Where the local MSA plans to assume responsibility for directly providing the necessary services to these clients, accommodation will have to be made to offset the deficit inherent in servicing these areas of the province.

Looking at part VI, section 15, this section says that MSAs have just four years to comply with all the provisions of the legislation. Under the tight strictures of this draft legislation, communities will not have the flexibility to identify and implement the models of service delivery that best suit their needs. The government has repeatedly stated that this is not to be a cookie-cutter approach. This provision appears to be contrary to that statement.

As the government reforms long-term care, it must look at building on existing successful programs such as the Red Cross homemaker program. The provision of high-quality service requires more than a set of manuals and the requisite number of staff. The Red Cross service is greater than the sum of our parts. Our strength lies in our ability to utilize our collective resources and expertise. The legislation must permit agencies such as the Red Cross to continue to provide excellent and necessary services to the residents of the province.

The Chair: Thank you very much. I'd just note for the record as well the attachment that you have given us with your brief. We have a number of questioners. I could just remind members of the committee that if we could direct the questions at the witnesses and keep our conversation moving that way, it would allow us to get in more questions, I think, to expedite our hearings this afternoon. We'll begin with Mr Malkowski.

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Mr Gary Malkowski (York East): Your presentation was very pointed, and we're very happy that you've come forward to list your concerns with us. We listened very carefully. Your feedback to us is important.

I've also been hearing feedback from some of the non-profit organizations. They talk about concerns of issues being that of volunteers and preserving the tradition of that volunteerism. So that has been identified.

You've mentioned that resources are scarce in the north, and it may be hard to secure some of these services. You're fearing of that since you in many ways are the only organization in some of these areas providing services to people. Well, we also value that.

I'd like to know a little bit, in this part of the section where it talks about the coordination of volunteers: If we were to strengthen that in terms of service delivery and service provision, have some kind of built-in mechanism within the legislation that would preserve and expand upon that whole role of volunteerism, is that something you'd like to see within the legislation? I'd like your comments on that.

Ms Ormiston: Volunteerism obviously is incredibly important, but so is professionalism, and the Red Cross has a unique balance of professionalism and volunteerism. You have to be careful that you don't have a volunteer going in to do brain surgery. As a result, this balance, and the balance in the north -- again, as I said, the Red Cross homemakers often travel quite a ways. From Kenora, they may travel an hour into the Sault Narrows area. You can't always expect volunteers to do that form of travelling.

The volunteers certainly have a wide range of scope of helping the board and helping the homemakers in a variety of ways, but as I said, you have to be able to dissociate between volunteerism and professionalism, and I think the Red Cross does do this well.

Mrs O'Neill: Thank you very much for coming. As you likely know, the organization has presented in Toronto as well from their perspective.

I'm so impressed with your first page and the number of communities you serve. I wonder if you could just give us an idea of how many volunteers would be involved in that and how many clients in all those communities you mentioned. If you haven't got that, you can send it later.

Ms Ormiston: We'll send you that number, yes.

Mrs O'Neill: What I really want to know is, do these people, the people you serve and the people helping the professionals do their job, realize what's going to happen with Bill 173? Do they really realize the Red Cross is out of business, even though it won't be out of business a few miles down the road in Manitoba?

Ms Ormiston: I honestly do not believe the clients realize the impact of this bill.

Mrs O'Neill: I think we've got to get that message out. As I say, I think you're being very gentle today in your presentation.

Mr Chairman, I'd like to have the staff provide, maybe not now but in writing, the implementation that is expected from the announcement that was made in 1993 in the Legislature by the Minister of Health. There seem to be conflicting interpretations about that. I think it's important to groups like the Red Cross, and I think this committee has to know what's going on out there. Is it universal across the province? Is each community making its own decision about how it's picking up this directive? What are the time lines, and the specific time lines? I think we have to have that as soon as possible.

The Chair: I'll take that as notice and we'll work out through the parliamentary assistant the response to that question.

Mrs O'Neill: Thank you.

Mr Jackson: Thank you for an excellent brief. Could you tell me, has your service been expanded in the last year or two years? How much has it expanded by in the last year?

Ms Morton: I can't hear the questions. Sorry.

Ms Prodanyk: He was just wondering if our service has expanded in the last couple of years.

Ms Morton: I don't think it has, not in our -- has it in your area?

Ms Ormiston: Our population doesn't grow incredibly, you know; the numbers don't come up a lot. But we are certainly meeting very crucial needs.

Mr Jackson: Well, let me ask the question a little differently. We've just heard from Comcare and they've laid off 55 employees. In theory, one would suspect that there is work for 55 other people in that field if they've lost market share. If not, have we just seen that much reduction of access to this service in this part of northern Ontario as a result of -- I mean, we listen to the government. They said they've been pouring all sorts of money into home care in this region so there would be an expansion of employment; in other words, expansion of service. Did you not expand your service to meet -- so you didn't have occasion to hire any people, because you weren't hiring?

Ms Prodanyk: In the Kenora area they now are receiving services from the integrated homemaker program, and with that particular program being implemented in the northwest, the extreme northwest, yes, services have increased up there. In Thunder Bay we have received, again, more services because of the decline to the for-profit agencies.

Mr Jackson: So did you hire additional people as a result, or were the VON and St Joseph's the beneficiaries of the expansion? Or did you just remain the same? I'm trying to establish: There were four agencies and one's in radical decline. That leaves three that have the potential for the uptake of workers. I want to know if you hired additional workers in the last year.

Ms Prodanyk: Okay. I cannot give you specific numbers on the number of employees we did hire, but there were some employees who were hired and we certainly can provide you with that information from the staff.

Mr Jackson: I just wanted to establish, because the point was made that they were not hired by your agency and I'd neglected to ask the other agencies if a similar --

Ms Prodanyk: Okay, if it was the Thunder Bay area, or if it's in northwestern Ontario?

Mr Jackson: No, it was a Thunder Bay question, and the reason I wanted to raise it is that you make reference in your presentation to "many services are provided," but then you listed only those three. I just wondered if it is in any way prejudicial to the private sector, because once you get past who owns the service, these are still women who need to work to put food on their tables. Many of them are single women trying to raise families. I would hope there's no discrimination occurring in terms of hiring these women simply because they took jobs they had to have.

I certainly would hope that's not the position of the Red Cross, although I've seen it occurring in other parts of the province. That's why I was pursuing that line of questioning, because I just really don't think it is fair to someone who's lost their job because the government made a decision and then when they go with those skills to get hired, they are discriminated against in terms of hiring.

Ms Prodanyk: Exactly. We can certainly provide the committee with the information from the staff.

Mr Jackson: Thank you.

The Chair: The additional information has been requested, if that can be conveyed to the clerk of the committee, and we'll distribute that.

Ms Prodanyk: Certainly.

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The Chair: Last, the parliamentary assistant had a point of clarification. Last comment, please.

Mr Wessenger: I'd just like to clarify that with respect to the functions between homemaking and personal services, there's no intention to divide the functions between different individuals. It's understood that those functions will be delivered, in many cases, by the same individual.

I just have one little question. The Red Cross, as you've indicated, has what might be called a very rigid, centralized governance model. I was wondering how successful you are with that type of legal model in providing for community governance at the local level through your branch system.

Ms Ormiston: If the community can become involved in a volunteer basis they can come to -- we have an annual meeting every spring and any members of the community are certainly welcome to participate in that annual meeting, in any of the branch activities or in any way they wish to come forward. The Red Cross doors are always open to the community to come in and to participate in whichever way they feel meaningful to themselves.

Mr Wessenger: I suppose, to be more specific, what I'm referring to is the question of governance; for instance, decisions pertaining to who is employed as executive director, directions of policy -- is that done by the local branch?

Ms Ormiston: We have input to that.

Mr Wessenger: Input to it but not final decision-making?

Ms Ormiston: A vote.

Ms Prodanyk: That is also handled by -- we have a regional policy council and there is also Ontario division. So they are all involved in that; it is not just a local decision.

The Chair: Thank you all very much for coming before the committee and for your submission and attendant documents.

ONTARIO COMMUNITY SUPPORT ASSOCIATION, AREAS 13 AND 14

The Chair: I then call on our last presenter for this afternoon, Ms Karen Bergman, from the Ontario Community Support Association.

While Ms Bergman is coming forward, just to remind committee members that I will have to play Scrooge at 4 o'clock and end the proceedings; otherwise, we won't get to Sault Ste Marie and as much as I know we'd like to stay, we have to get to Sault Ste Marie.

Welcome to the committee, Ms Bergman. We've received a copy of your notes. Please go ahead.

Ms Karen Bergman: It's nice to be here this afternoon and to have the opportunity to present on behalf of the Ontario Community Support Association. My name is Karen Bergman, as you know. I am a director on the board of OCSA for area 13 -- actually a very recent board electee, as of June. As well, I am manager of the Red Cross homemaker service for Thunder Bay and district.

My work with OCSA is as a volunteer. I am a volunteer; I am also a care giver in our community and a lifelong resident.

I am presenting on behalf of area 14 as well, Kenora and Rainy River area. However, that includes Dryden, Fort Frances, Emo and all the surrounding community. Area 13, Thunder Bay and district, includes Marathon, Manitouwadge, Schreiber, Terrace Bay, Nipigon, Red Rock, Longlac and Geraldton.

Our presentation will begin with a brief overview of who we are and then we will give you the areas that we support and then our areas of concern.

The committee has already received a detailed written submission from OCSA at the recent hearing in Toronto, so in honour of our northwestern trees I did not reproduce it again because you have that in your possession. I do have a couple of extra copies should anyone wish them.

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

OCSA was created on April 1, 1992, by amalgamating three provincial organizations. We hope that with the combined skills, knowledge and experience we would better serve seniors and persons with disability in Ontario. The associations that amalgamated are Meals on Wheels of Ontario, the Ontario Association of Visiting Homemaker Services and the Ontario Home Support Association. All of us have recognized a common interest in supporting community services and we have a long tradition of service in the community. In fact, 1993 was a special year for two of us; it marked the 25th anniversary of Meals on Wheels in Thunder Bay and also the 45th one for Red Cross homemaker service. These are well-respected and established services whose dismantling would be a tragedy.

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

We have 300 member agencies across the province. We have 10,000 dedicated staff, an army of 45,000 active, hands-on volunteers working diligently to provide a wide range of service. Many of our volunteers are seniors themselves. In 1993 these volunteers donated over 1.2 million hours of service. In northwestern Ontario our community support services include Meals on Wheels, homemaking, home maintenance, friendly visiting, telephone reassurance, home help, care giver relief, emergency response and transportation.

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

OCSA is subdivided into 15 areas which form the foundation of the association. Through this, members have an equal voice in the association, while each area has some flexibility to respond to needs identified by its own membership. Areas 13 and 14 encompass community agencies providing service in an immense geographical area, west to the Manitoba border and east to Manitouwadge. One of the challenges facing our member agencies is the isolation and sparse population of many of our communities, and the travel required. Often innovative approaches are used: In Manitouwadge the Meals on Wheels service has elected to try to deliver library books at the same time as meals and pick them up after. These are things we must do in the north.

One of the great strengths of a provincial organization like the Ontario Community Support Association is the direct, concerted voice provided. We work on behalf of seniors, disabled adults, member agencies and volunteers to ensure the issues which affect community service and seniors are heard and addressed by government policymakers. We have been an active participant in the redirection of long-term care and support services in Ontario, so we appreciate the opportunity to share our perspective on this legislation. We do endorse several areas.

The association endorses the principles and values enunciated in Bill 173. We support not-for-profit service delivery where the principles of community-based planning, equity of access and equality of services prevail. We are committed to the development and implementation of standards of care and the continuing improvement in the level of service quality. We do agree with the purposes of the act, because the act does set out consistent criteria and accountability provisions governing service delivery designed to ensure accountability to the consumer, to the government on behalf of consumers, and to the general public.

As to the bill of rights, yes, we are committed to a service delivery mechanism that is driven by individual consumer needs, which responds to the requirements of natural communities and their cultural diversity and that will support the development of equity of services across the province. OCSA supports alternative MSA models which endorse the principles outlined in the purpose of the act and which are a result of the community planning process.

Linkages with other social services and health providers is essential. Mutual respect among key stakeholders in the long-term care service delivery system will facilitate and encourage linkages among community service agencies with physicians, pharmacists, other health and social service professionals and community organizations. The act must ensure that services are planned, delivered and evaluated from an integrated health and social service perspective. OCSA also supports the changes to the public vehicles act which will allow a service provider to operate for the purposes of transporting persons determined eligible by an approved agency.

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However, we do have areas of concern. I will be presenting the six key areas. First of all, areas not covered in the legislation: There is perceived preferential treatment of unionized employees in the new MSA. Subsequently, in Bill 173 there are no references regarding the protection of not-for-profit, community-based employees as a result of implementation of long-term care reform.

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

Although there are similarities between clients in institutional settings and those in the community, the environments are quite different. Therefore, special consideration is required when hiring staff from facilities for community-based agencies. Training resources are required.

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

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

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

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

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

The second concern is under the general regulations. Bill 173 has taken an overly prescriptive approach to the provision of community-based services: 42 regulations have yet to be produced. Much is unknown. It's very difficult to respond when you don't have the detailed information.

The province is moving quickly to put MSAs into practice, yet major components need to be in place first. Where are the eligibility criteria? Where are the program standards? Where are the guidelines? Where are the regulations?

OCSA must be actively involved in producing and approving the regulations for 173. Furthermore, OCSA recommends that extreme caution needs to be applied in setting retroactive dates of application.

Our third area of concern, which has come up this afternoon, I note, is volunteerism in the reformed long-term care system. Volunteerism is an essential component in the delivery of community-based services. The volunteer base must be recognized as being deeply rooted in the community and potentially fragile. Some of our agencies in northwestern Ontario are totally volunteer driven and they have no paid staff whatsoever. Meals on Wheels services in Marathon and Manitouwadge are totally volunteer. This needs to be recognized.

If they are not properly maintained, costs will skyrocket. This is essential service. Someone has to provide it and therefore multiservice agencies will not be cost-efficient and the ability to meet existing consumer needs will be jeopardized.

There is a lack of detailed planning regarding volunteers and long-term care, and there's also a concern about an inadequate number of volunteers currently in our area.

Our response from OCSA is to let you know that volunteers have been the backbone of community support services and they must be recognized and the issue addressed. The relationships presently existing between service agencies and their volunteers must be fostered and nurtured.

Volunteers must be kept well informed and actively participate. We need sufficient resources to support a volunteer management structure at each community level and on an ongoing basis.

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

It is essential to maintain the linkages. Volunteers are motivated by an array of factors and cannot be shifted organizationally away from their work without risk of loss.

Fourth, multiservice agencies are a concern. It is essential that there be sufficient flexibility -- and that is the key word -- to allow communities to develop an MSA system to meet local needs. It is unclear what this final model will look like in each community until the community planning process is over. It is premature to assume that the same model will meet the needs of all residents in Ontario.

One-stop or single access does not necessarily mean that all services and care providers have to be assembled under one roof and that consumers have only one point of contact in the community. OCSA supports different models for MSAs which endorse the principles outlined in the act and which are a result of the community planning process. OCSA believes that MSAs must not be allowed to develop into large bureaucratic organizations; they must be small enough to be able to be responsive to local community needs. OCSA believes there must be consistent standards developed.

Improved coordination and access to available services are highly desirable. Communication among providers is key. We in the northwest have been very proud of our ability to work together. There is very little duplication of service in our smaller communities. There is one Meals on Wheels; there is one homemaker service; there is one home support program.

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

Our fifth point is the separation between community support services, homemaking, personal support services and professional services. This reinforces a hierarchy of services ultimately geared to medical needs rather than fostering a continuum of care. It reinforces a split between health and social services and moves away from wellness, health maintenance and prevention. This is inconsistent with the purposes of the act.

The distinction between personal support services and homemaking services is contrary. The province is pushing a generic worker which would combine health care aides, homemakers, home support workers, home helpers and attendant care workers. In most agencies, personal support services and homemaking are given by the same person. These services are provided concurrently.

There are concerns about how these two services will be operationalized. This separation will be an administrative nightmare for the service provider. If you're bathing a client, and that's personal care, can you wash the tub out after? Can you clean the sink? How do you split those two services? How can you go in to someone who is so frail that they need help with the bath? They must need help to vacuum, to dust, to get their groceries. How can those be split? I can't understand it.

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New terminology is being used as well and this may lead to some confusion. Personal support services were previously known as homemaking, and homemaking is now being used to describe what's now home help. It is very confusing.

We question the use of the four categories. We recommend that the artificial distinction between homemaking and personal support services be ended by combining them. OCSA would like to be involved in that development. We also recommend that community support services, homemaking, personal support services and professional services be combined into one category.

Our sixth area of concern is the definitions. For example, definitions are not provided for services such as respite care, social or recreational services, security checks and reassurance services, friendly visiting, home maintenance and repair.

There is extensive detail provided for homemaking and personal support services, yet professional services are listed and not defined.

Also under the definition, this draft of the legislation refers only to incorporation under the Corporations Act, Ontario, and the Co-operative Corporations Act. However, there are nationally incorporated bodies where special consideration needs to be given. For example, since the Canadian Red Cross Society, whose Ontario branches are members of OCSA, is nationally incorporated and governed, it does not comply with the conditions for an MSA, as outlined in the legislation. OCSA recommends that incorporation under the federal corporations act be added. That recommendation will be found in your detailed submission on page 6.

We believe OCSA must be involved in the development of definitions of services to be provided.

In conclusion, OCSA applauds the leadership demonstrated by the provincial government through the development of Bill 173, which establishes a key building block in the foundation of the new long-term care system. We appreciate the commitment to building partnerships within the community to effectively plan and implement meaningful change. We do look forward to a continued partnership not only with the government but with our fellow community colleagues.

Mr O'Connor: I appreciate your comments. I think they really hold together quite well and we have heard about the personal support services -- I'm trying to be quick here because you did actually make quite a few good suggestions.

In the regulations section, you referred to the volunteers. Could you point to a spot where you thought maybe we should incorporate some of what you suggest into the body of the bill, or do you think we should just enhance the regulation section that you pointed out to us? Page 8 of your brief.

Ms Bergman: They believe that the long-term management in regulation 11 should be expanded in that area to include all of the recruitment, training, scheduling, supervision, retention, recognition --

Mr O'Connor: Within that section.

Ms Bergman: Yes, within that section.

Mrs Sullivan: I'm interested in the point you make with respect to the separation of homemaking and personal support services. My understanding is that the reason they are separated in the bill is to allow fees for some services and no fees for other services. Clearly, the same individual could be delivering those services. I'm wondering if you've considered how your member agencies or your workers would separate costs -- it would make it accounting -- and what the government's intention is with respect to how those services for which fees would have to be paid would be accounted for if the person delivering them is doing some things out of one category and other things out of another category.

Ms Bergman: We believe that would be an administrative nightmare and there's no other word for it. We believe there has to be a clarification of what is essential, and essential in remaining at home is not only personal care, but it's some of the upkeep of your home. If it's not upkept and you get maggots and cockroaches and whatever, you cannot live at home; you will eventually be institutionalized. The government needs to readdress what is essential and should be paid for by our government.

Our IHP program is currently providing personal support and the other services as well along with it. To go back retroactively, I think, and tell some of our IHP clients, "Well, I'm sorry, now we'll pay for your bath, but we won't pay you for going to get the groceries or we won't pay for tidying up your apartment for that hour," administratively, that's going to be very difficult.

Mrs Sullivan: There's another issue that I want to ask about and it hasn't come up today. It's with respect to paying bills and doing banking. Many agencies, I know, are withdrawing from those services because of some of the liability questions that are associated with them. I wonder if you'd like to comment on whether in fact that should be a mandated part of service delivery.

Ms Bergman: Again, I'm addressing this as an OCSA board director, so I really don't know the response from that aspect. From my position as a homemaker manager, it is certainly part of our program. It is an essential part. If a person living in their own home does not have a family member or a close neighbour to go and pay their bills or do some banking for them -- it has to be done and you cannot eliminate that need. It's a need so, yes, it has to be part of a service, but it also has to come under quality management guidelines. There have to be regulations or rules in place by the organization that say how money will be handled for a client, how much you are allowed to take to the store. There have to be guidelines in order to handle it appropriately.

The Chair: Members of the committee, that ends our hearings here in Thunder Bay. The committee stands adjourned until 9:30 tomorrow morning in Sault Ste Marie.

The committee adjourned at 1538.