Monday 3 October 1994

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

Royal Canadian Legion, Ontario Command

Jack Currie, chairman, veterans' services committee

Health Sector Training and Adjustment Program

Shelley Acheson, chair

Sue Colley, executive director

Ken Waterman

Don Mills Foundation for Senior Citizens

Roy Arendse, board member

Catherine Brookman, vice-president, community services

Carmel Smith, client

Ontario Community Support Association, Areas 5 and 6

David Wartman, president

Dan Stapleton, executive director

Community Agencies in Partnership

Sandra Sillcox, chairman

Jackie Catto, president, VON, York region branch

Deborah Egan, executive director, CHATS

Susan Taylor, regional municipality of York, community services department

Ontario Nurses' Association

Jane Cornelius, vice-president

Carol Helmstadter, government relations officer

Carol Kushner; Michael Rachlis

Victorian Order of Nurses, Brant-Norfolk-Haldimand branch

Don Townsend, president

Cathy Chisholm, executive director

Canadian Co-operative Association, Ontario Region

Kathy Bardswick, council chair

Judy Goldie, manager

Trans-Action Coalition

Janice Tait, project coordinator

Ontario Association of Residents' Councils

Peter Kehoe, president

Mary Ellen Glover, executive director

Bernard Betel Centre for Creative Living

Sheila Zane, coordinator, social action committee

Reta Duenisch-Turner, member, social action committee

Sharon Zeiler, director, La'Briyut Wellness Centres

Families' Association of Oaklands Regional Centre

Catherine Rhodes, representative

College of Dental Hygienists of Ontario

Lynda Mckeown-Mickelson, president

Don Page, vice-president

Donna Bowes, chair, quality assurance committee

Ontario Association of Professional Social Workers

Dan Andreae, president

Lesley Patterson, chairperson, aging committee, Metro branch

Association of District Health Councils of Ontario

Ken Whiteford, chair

Susan Brown, vice-chair

Ontario Federation of Labour

Julie Davis, secretary-treasurer

Adrianna Tetley, coordinator, OFL health research project

Ontario Society of Occupational Therapists

Christie Brenchley, executive director

Linda Marshall, member, long-term care task force

Janet Gleason, chair, long-term care task force

Canadian Red Cross Society, Ontario division, district of Muskoka branch

Barbara Gibbs, manager, homemaker program

Lynn Moore, director, home support services, Ontario division

Sharon Gillespie


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

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

*Acting Chair / Président suppléant: McGuinty, Dalton (Ottawa South/-Sud 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:

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

Marchese, Rosario (Fort York ND) for Mr Hope

Mills, Gordon (Durham East/-Est ND) for Mr Martin

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Also taking part / Autres participants et participantes:

Jackson, Cameron (Burlington South/-Sud PC)

Ministry of Health:

Wessenger, Paul, parliamentary assistant to the minister

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

Czukar, Gail, legal counsel

Clerk / Greffier: Arnott, Doug

Staff / Personnel:

Boucher, Joanne, research officer, Legislative Research Service

Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 0906 in room 151.


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

The Chair (Mr Charles Beer): Good morning. The standing committee on social development is in session. We are again meeting to consider Bill 173. We have two very full days of presentations.


The Chair: I would like to call on Mr Jack Currie, chairman of the veterans' services committee, Royal Canadian Legion. Mr Currie, welcome to the committee. I know you're not a stranger to this committee. We're pleased to see you again. We have a copy of your submission.

Perhaps, just before beginning, I could remind committee members again that given the number of presenters we've tried to include, we will also today be continuing with the system of having one question per caucus, just so that we make sure we hear from everybody and are able to finish by 6 o'clock.

Mr Jack Currie: You've already heard presentations from other members of our veterans' services committee in Ontario Command, who presented a brief to you in Kingston. My brief today will be considerably shorter, and I merely wish to add to the concerns expressed by the District G representatives.

The legion, as you now are aware, has a strong commitment to the veterans and their dependants to ensure that they receive all the benefits to which they are entitled. We are concerned that in times of economic restraint all levels of government are attempting to downsize and reduce existing programs. Our veterans are aging and their needs are increasing as they age and their health declines. We have only a few years left to compensate those men and women who served in wartime and we feel a strong obligation to prevent erosion of the existing veterans' benefits.

The responsibility for veterans rests primarily with the federal government. However, provincial governments enact legislation which may impinge upon the existing benefits available to our veterans. Increasingly, it would seem, there is a need for dialogue between the federal and provincial governments to ensure that the hard-won benefits of veterans are not lost.

As our representatives from District G noted in their brief to your committee, we are concerned that there is no mention of veterans in Bill 173. The veterans' health care regulations provide for the rights of certain eligible veterans to be admitted to the Veterans Affairs contract beds in Parkwood Hospital, Sunnybrook hospital and the Rideau Veterans Home/Perley Hospital. In the past, admission eligibility has been determined by Veterans Affairs on the basis of a veteran's service and the level of care required. With the advent of the placement coordination service, we are concerned that the veterans who meet this criteria may, at the discretion of the placement coordinator, not be admitted to the contract bed. We believe that legislation enacted by Ontario should provide special mention of the rights of veterans under the veterans' health care regulations.

The thrust of long-term care reform is to reduce dependency upon institutional care. While we agree that many elderly people are more content to remain in their home, this is only possible when there is sufficient home support to allow them to live in their home environment. We are concerned that the province will reduce admissions to both the active care and long-term care facilities prior to the availability of appropriate and sufficient home care support.

We read in the newspapers increasingly of situations where elderly people are discharged from hospitals without the needed transitional care required in the home or in another facility. We support the initiative of other groups to request that hospitals use the funds made available under the quick response project for discharges as well. It would seem that the most vulnerable elderly people in our community -- that is, those who have no family and no friends to assist and to advocate for them and who sometimes live in the poorest of conditions -- and that's mostly veterans, escape the notice of the discharge planning teams at the hospitals.

We believe the hospitals should be required to review the situation of every elderly patient prior to discharge to ensure that they are being sent home to a situation where appropriate support will be provided. Often home care is made available but not in sufficient quantity to ensure that the elderly person is not at risk. Family physicians should be notified of all discharges of elderly patients.

Veterans are of course citizens of the province and entitled to benefits as part of the general population. They also have special benefits because of their war service, and we feel that this special right under the veterans' health care regulations should be clearly stated in any provincial legislation.

Before I close, I would like to say a couple of extra comments. Maybe Mr Mills would like to ask -- my comments were that he had already asked me.

The Chair: He has indicated he wanted to ask you questions, but please --

Mr Jim Wilson (Simcoe West): Why don't you do it now?

The Chair: Why don't you go ahead, Mr Mills.

Mr Gordon Mills (Durham East): Thank you, Jack, for coming here this morning. What prompted me was that I read in your presentation here, "We believe that the legislation enacted by Ontario should provide special mention of the rights of veterans under the veterans' health care regulations." The question that prompts it, and it comes to me in my riding a lot, is where people are in a home together, a man and wife, and the man goes off to hospital for an extended time and there's always this fear that his place won't be there when he comes back and that you have a couple who have lived their lives together who are then separated and never get the chance to live together. I think that's a traumatic experience. I guess that's what really your thrust in that paragraph is.

Mr Currie: These are my extra comments that I was wishing to make, that we have this problem in our legion home especially where if a couple is in there and one has to go to hospital and he's there for more than the 31 days, they lose the bed and someone could move into that bed and they may never get back together again because of the placement services. They may find themselves separated for the rest of their time.

Mr Mills: So you'd like to see something put in place that would stop that happening, or the possibility.

Mr Currie: Yes. Also, we'd like to see more contact, especially out of town, where a veteran comes to the hospital here -- not necessarily Sunnybrook, but any hospital -- and then they go home. There is no contact between them and the family doctor. Especially if he goes into a nursing home here -- say he goes for two or three weeks -- and then is sent home, there seems to be a loss. The veteran's up there and he has to then apply for home care, which takes maybe a long time, because nobody knows he's home.

Mr Mills: There should be some continuity between --

Mr Currie: The hospitals here and the veterans who are from out of town, especially out-of-town people.

The Chair: We have just a little bit of time, so I will allow a second question.

Mr Jim Wilson: Thank you, Mr Currie, for again presenting to the social development committee. As the Chair said in the beginning, you're no stranger to this committee and we do indeed respect your views on behalf of Canada's veterans. I think a very good point has been raised in the dialogue with Mr Mills here. I'd like to ask the parliamentary assistant, does this bill give any type of guarantee that people won't be put out of hospitals and discharged into the community to the MSA until the MSA has appropriate services in place? What are the mechanisms of continuity provided for in this legislation?

Mr Paul Wessenger (Simcoe Centre): I'm going to ask a policy person, Mr Quirt, to reply to that. I think the whole purpose, of course, is to provide the necessary supports within the community so that they'll be available for people who are discharged. It's certainly an obligation of the discharge planner in the hospital to ensure that those are in place, but there undoubtedly are some breakdowns, and I'm wondering how we deal with that.

Mr Geoff Quirt: In answer to your question, Mr Wilson, the bill specifically doesn't address the issue of continuity of service upon hospital discharge. Currently in the system, home care case managers are often located right in the hospital, so that discharge planners in the hospital and the home care program can coordinate the appropriate range of services that someone would need upon discharge.

We fully expect that this will continue and that staff responsible for organizing services from the MSA would be hospital-based in some communities and that, as we pointed out previously, the MSA would be in a position to respond to a variety of needs as well as the professional support needs that people leaving the hospital would require.

Mr Jim Wilson: I see the bill advancing the status quo and not making an improvement with respect to the continuity that Mr Currie talked about and Mr Mills talked about. Mr Currie, with respect to your colleagues who presented to this committee in Ottawa earlier, I guess, last month, you've had a chance to, I hope, review the responses that came from the government when they appeared before the committee, and yet again today we're talking about the veterans' rights and ensuring that they're enshrined in this legislation. Were you satisfied at all with the previous responses by the government to your issue?

Mr Currie: We were satisfied on a lot of them, but the one that we're talking about now, we didn't see any response to this time when a veteran could go to hospital and then lose his bed, especially where it's a couple. We're concerned about this because there was no real response to that issue at all.

Mr Jim Wilson: Could we ask the parliamentary assistant to respond to that here today?

Mr Quirt: Not in this bill, Bill 173, but in Bill 101 we established province-wide a placement coordination responsibility so that admissions to long-term care facilities, nursing homes, and homes for the aged are coordinated for anyone who needs access to those facilities. In our policies related to placement coordination, we make an attempt to provide a higher priority for people who are waiting for the facility of their choice. In other words, we allow for people to go into a facility in an emergency situation and not lose their place in line for the facility of their choice.

At the same time, if someone has to leave a nursing home or a home for the aged to go to a hospital for an extended period of time, over 21 days, for the first 21 days their bed is protected. If they are, for example, away for three months in the hospital, they are a high-priority readmission to that particular facility. With that policy we hope that the situation that you're describing, where a couple might be separated because that bed wasn't available again when the person needed to be readmitted, will be avoided. We'll be monitoring how effective that priority-setting process is in trying to ensure our policy results in the optimal use of facilities and clients being able to get to the facility of their choice as soon as possible.

Mr Currie: Since the placement service came on, our Legion home is now full. We've taken on 11 people from the placement service. They're all veterans, it's true, but now the home is full and we're concerned about what happens if one goes out, because there seem to be more and more people needing our care than we had before.

Also, we're worried about our pensioners' apartments. We have low-rental apartments. They rent for $200 for a couple and $150 for a single person and the Legion sponsors the rest of the money. We have veterans that go to hospital and they're discharged. We don't even know they're discharged and they come walking down the street and want their apartment back. We think there should be some system where we should be notified or the doctors should be notified that they're going to be discharged. Back a few years ago, we had a fellow discharged who didn't have any clothes at the hospital and he came walking down the street with bare feet. I mean, this is the kind of thing that we run up against which we're concerned about.

On my own, I'm at a loss to understand why we still have to come see you people on all these bills and why the veterans section isn't put in at the onset of the bills. I've been here for 101, 119 and now 173. It's nice to meet with you people, but I would like to see it in there before a bill arises and we have to go over it.

Thank you very much for allowing me to come this morning and I hope that you will give consideration to some of the things we're concerned about.



The Chair: I call on our next presenters, from the Health Sector Training and Adjustment Program. Good morning. Please make yourselves comfortable. I know you've just come in, and that's all right. The clerk can distribute the documents.

Ms Shelley Acheson: I'm Shelley Acheson, the chair of the Health Sector Training and Adjustment Program. Sue Colley is the executive director of HSTAP, and Michèle Dawson is our labour adjustment analyst on staff.

I'm going to primarily read this, but it's relatively short and I think there will be plenty of time for questions afterwards.

We are of course pleased to be here. We are an agency set up to assist health sector employees adjust to restructuring and train for future employment. Originally, the program was set up in May 1992 to assist public hospital employees, and we have since gone through a major expansion of our mandate, structure and governing board.

Our now much broader mandate is to enhance the employment security of all employees in all health sector transfer payment agencies in Ontario -- I emphasis the "all" because I noticed this had been brought up at one point, about whether we serve non-union employees as well as union, and we do -- to provide effective job retention, training, labour adjustment and redeployment services. This mandate provides HSTAP with the responsibility not only to assist workers after layoff, but to also work proactively with employers, unions and employees in developing training initiatives to prevent layoffs and retain jobs within the sector.

We're governed by a board of 17 directors, selected at our first meeting on January 31, 1994. We are designed as a joint management-union organization. Eight of the directors are drawn from health employer associations and eight from health employee unions, all of whom you have heard from in one form or another over the past couple of months. I, as the chair, am independently appointed by government, and the funding for the program is provided by the Ontario Ministry of Health.

Like many who have appeared before you already, we at HSTAP support the broad principles embodied in Bill 173, yet remain concerned about the effect the legislation will have on health care workers. The wholesale rationalization of in-home service delivery that the bill envisages also entails extensive workforce adjustment and dislocation. We believe, despite assurances to the contrary, that many health care workers are going to suddenly find themselves either in low-paying, part-time work or in no job at all and without adequate qualifications or skills to adapt to a changing labour market. The impact of these changes is serious for both workers and consumers.

Our first two recommendations suggest comprehensive human resources planning as the best and only way to minimize workforce disruption and allow the redirection of long-term care reform to evolve smoothly and successfully.

Historically, health human resources planning has been confined to the health facility. Comprehensive human resources planning has not only never occurred but, until recent years, has never seriously been contemplated in health care. Fiscal restraint, technological change, an aging population and other shifting health care needs are just some of the signs that our health care system has to change. With these changes already upon us, we are seeing their human resource ramifications, which, if not addressed, have the potential to bring reform to a grinding halt.

We assert that human resources planning must be an integral part of any reform. Planning ideally should take place on three levels: for the whole health sector, for each of the health subsectors -- in this case, long-term care -- and at the local level -- in this context, the district health councils. Although HSTAP has long advocated for a provincial health human resources plan, our recommendations below address the more urgent need for human resource planning at the next two levels.

Bills 101 and 173 focus on the long-felt need for greater coordination and integration in the long-term care sector. Health and social services are to be integrated and coordinated, facility-based and community-based services are to be coordinated, and accountability and funding mechanisms are to be standardized. Only human resources planning remains fragmented.

We maintain that human resource planning must also be given top priority. The bill's changes will mean a fundamental shift in the way long-term care is delivered, and the players in the system need to be ready before this happens. For instance, morale and consequently the quality of care are dependent on workers knowing what their future entails, community service employers need workers who will be retrained to be able to handle more heavier-care clients and to undertake greater case management responsibilities, and hospitals need to know that the appropriate resources and community supports are in place before patients are discharged.

Finally, we argue that greater emphasis on human resource planning needs to be present at the local level as well. As it is now, there is no provision in Bill 173 for mandatory human resource planning. The government has left these issues to be dealt with at the time a potential MSA plan is being considered for approval, as outlined in its policy document Guidelines for the Establishment of Multi-Service Agencies. A "human resource strategy" is one of eight criteria that must be present in any MSA plan. Later in the same document, the government identifies five broad areas the human resource strategy must include, yet gives no more guidance as to what exactly is to be resolved, how it is to be resolved and by whom. The five broad areas are volunteer responsibilities and recruitment and retention strategies; collective agreement issues; pay equity and employment equity issues; training and redeployment needs; and employment strategies.

We believe that leaving such major issues to be decided in a fragmented manner by individual DHCs, with no guidance until the approval process, is both inadequate and dangerous. Based on our observations of health restructuring in other communities, it is clear that unless human resource planning is given priority in the restructuring process, the larger objectives -- continuity of service, quality and efficiency -- will not be achieved.

HSTAP believes a set of human resource planning guidelines should be developed for use in long-term care human resource planning at the DHC level. These guidelines would, at minimum, establish common human resource practices throughout the sector, and could then serve as the foundation for system-wide coordination later. Some coordination might be achieved if the ministry incorporated these guidelines into its approval process for MSAs. The guidelines would ensure a smoother transition process on such key issues as transfer, deployment, evaluation, training and compensation. They would be based on fundamental human resource principles, and some examples are:

-- The importance of providing security in employment.

-- The importance of providing all employees with fair access to jobs in the system of care.

-- The importance of open communication of human resource initiatives, supported by training resources and time to allow workers to assimilate to change.

-- The importance of involving unions and staff in non-union workplaces as partners with management in change.

-- The importance of maintaining respect for existing collective agreements.

-- The importance of support, referral and other transition assistance for displaced workers.

HSTAP would be prepared to offer its experience and resources to help develop a set of comprehensive guidelines to aid the local partners in their human resource planning.

Our recommendation then is that government immediately initiate a process with the involvement of HSTAP whereby requirements for human resource planning will be fully developed into clear and detailed guidelines, and that the adherence to these guidelines be one of the criteria in the MSA approval process.

HSTAP is well placed to offer such assistance. We are the only labour adjustment agency that has the participation of all the major health care partners in the province and a mandate from these partners to enhance the employment security of all health care workers.

For instance, we are currently working to develop basic redeployment protocols to govern worker transition issues. Our protocols will drive our jobs registry, which is a comprehensive database designed to match vacancies with available workers as well as track training needs and employment trends. When the protocols are completed, they will provide additional guidance at local levels where negotiations over redeployment may reach impasse.

HSTAP could also assist the planning process in other ways. For instance, we could provide information on health restructuring solutions in other jurisdictions and subsectors, or contribute additional research support to local planning partners. We could also act as a facilitator to bring the local partners together, or share information on training needs and trends.


Ms Sue Colley: Another essential step towards making human resources planning a greater priority entails direction from the Long-Term Care Act to plan at the local level. As we have noted already, there is currently no mention in the act of human resources or labour adjustment matters. Five broad human resource requirements that DHCs must satisfy for approval of their MSA plans are ambiguously outlined outside of this act. This is clearly not enough to avert critical problems during the transition period.

For example, what would happen if a DHC doesn't have adequate resources and decides to relegate human resource planning to the bottom of the heap? Or what if DHCs do not undertake to have fair and equal representation of all workers and employers in the planning process? Who is to monitor this? What level of stringency will the ministry use to determine the appropriateness of the human resource strategy? What effect will the passing of time and the government's desire to get MSAs up and running have on the effectiveness of a district's human resource strategy, as well as the combined effect of all districts' human resource strategies? In short, it is leaving too much to be decided too late.

HSTAP submits that the solution is for DHCs to be mandated to form committees to develop human resource processes and plans for their regions and their MSAs. We also strongly urge the government to require that all community partners, in particular labour, participate in the development, composition and planning of these committees. We firmly believe, and experience has proven this to be true, that unless mandated, human resources and labour adjustment issues will be relegated to too low a priority and be obscured by other urgent restructuring issues. The result can only be a chaotic and inadequate transition process for workers and for the quality of care they deliver.

We therefore recommend that a requirement to develop human resource plans at the DHC and MSA levels be actually spelled out in the legislation. At minimum, the act should ensure that all community partners -- labour, employers and consumers -- will be part of a process for developing a human resources committee and plan at the DHC level.

In addition to research on labour adjustment and human resource issues and implementing a jobs registry for job matching, HSTAP is also mandated to provide workers with funding to pursue training. HTAP and HSTAP have been providing this assistance to health care workers since 1992. We believe that training is a valuable key to successful labour adjustment in the long-term care sector. In our three points below, we offer our training recommendations as well as some examples of the initiatives HSTAP is involved in.

For example, our training-to-prevent-layoff initiatives assist employees who are in danger of losing their jobs unless they upgrade their skills or retrain. Training-to-prevent projects are currently developing or under way in seven different locations. For example, in Leamington, over 20 full-time jobs were threatened as a result of the elimination of switchboard operators at Leamington District Memorial Hospital. To prevent layoffs, the hospital submitted a proposal to provide workers with training in basic computer skills and medical terminology in order to create a new job classification called a unit clerk.

We not only have a great deal of experience and knowledge about the kinds of training workers currently want and need, but are also developing a network of contacts with educational providers to discover what training will be needed in the future.

Finally, we're the only agency in Ontario which is undertaking a trends and training needs analysis for the entire health care sector.

We suggest that the government acknowledge the important roles training and education have to play in labour adjustment. We recommend that the ministry stipulate in its operating guidelines to MSAs that ongoing education and training is an essential budget expense.

We also understand that the government convened a working group in 1993 to oversee the development of provincial training and curriculum standards. We believe HSTAP's experience with training issues to date would make us a valuable contributor to the work of this group, and we therefore request that HSTAP be given representation on this resource group.

Finally, HSTAP is concerned that any requirement by the government to upgrade qualifications or skills of long-term care workers be managed carefully and with enough lead time and financial resources for a smooth transition in care and employment.

Our experience at the Creedan Valley Nursing Home in Creemore demonstrates the necessity and urgency of carefully managing any skill upgrading. The nursing home changed ownership is 1992 and the new owner made policy changes requiring all new hires to have their health care aide certificate. The existing 25 employees who do not have their certificate risk layoff if they do not retrain by the end of January 1995.

In these kinds of situations, the government should be providing greater resources to assist workers to receive the required training. HSTAP recommends that any requirement by the government or an employer to upgrade qualifications or skills of long-term care workers be accompanied by sufficient lead time and financial support to enable existing staff to upgrade to meet the new qualifications.

In conclusion, the government acknowledges that human resources and labour adjustment issues are complex and will take some time to resolve, and we agree. That is why we would like to see structures and processes in place that will help ensure that they are resolved effectively from the beginning, and also that HSTAP's experience is not wasted.

Our final recommendation reflects our overall commitment to this process. Currently the act, in section 56, refers to a number of regulations that may be made in the future. Some of these regulations will deal with human resource matters. HSTAP requests a consultative role during the drafting process of these regulations.

We would like to take this opportunity to thank the committee for allowing us to present our recommendations for changes to the Long-Term Care Act.

Maybe you'd like to read the summary of recommendations?

Ms Acheson: I think they're there. You've heard them. I won't repeat them.

The Chair: Thank you very much. Just to note as well that you have summarized all the recommendations at the end of the presentation.

Mrs Yvonne O'Neill (Ottawa-Rideau): I think your brief is very important. You are a creation of this government. You are a very important element in this whole transition, in my opinion. About 10 years ago, I was involved in a major restructuring that involved a lot less people than this one and we spent two years amalgamating or complementing the collective agreement process. That whole thing has been quite successful and is still in existence today, and I think it's because we took the time and did that.

I wanted to tell you that on September 12 in Ottawa we received a memo from Mr Doug Jackson. I don't see you as having received that memo. Your name is not on the list of people, so I don't know whether you have it, "Governance of Multi-Service Agencies." In that particular document it says:

"The first MSA board will have to select and appoint a senior staff person" -- and I underline singular -- "to advise the board on staffing, program and policy matters. This person will assume responsibility for the implementation of the board's policies, as well as the efficient day-to-day administration of the organization."

I would suggest that person is very powerful, and I would suggest the step you have as an intermediary step regarding committees from the DHCs is much more meaningful.

I'd like to ask you, because I feel you've even been humble in your presentation, what your fears are regarding your collective agreements. The other thing I'm very interested in is what your fears are regarding fair access. Could you tell us a little bit more about what your fears are regarding those two very important parts of your employment?

Ms Acheson: I think on the collective agreements, perhaps the best way to talk about that would be to use the example of the Windsor reconfiguration. It's always easier to discuss these issues if we have a concrete experience to go by.

Mrs O'Neill: Exactly.

Ms Acheson: The report that came out of Windsor in the end is quite remarkable, but I think as probably all of you know, the human resources piece of it and the collective agreements piece of it have not been determined finally. There have been some great difficulties there in bringing the unions together. There have been some great difficulties in hospitals going off on their own to do restructuring and to try to work through their collective agreement problems.

While there have been efforts to pull that together and make that work, there have been real difficulties. I think it speaks to some of the things we have in here, which is that without some guidance around these issues and without saying that there are some redeployment protocols that should be used, this is going to happen all over the province and it's going to be one after the other. These issues are not easily resolved. Everybody has to come to the table, and come to the table early, and work it through. I'm not saying we have all the answers by any means, but I think we could provide some guidance and help people come through this.

I guess one of my other concerns is that consultants are often brought in on these mergers and reconfigurations that take place, and that's understandable and important, because people don't have all of the answers. I think a lot of the consultants who are out there have great expertise in the health sector; they don't often have great expertise in labour relations issues. It's really the combination of those things that is needed here. I think that's what we need to look at in order to enable this to happen with less confusion, less chaos and less pain on all sides. That's not to say that it's going to be easy. The transfer issues, the posting issues, the qualifications issues, all of those have to be worked out, but I think if we can make it work in a couple of areas, we can then broaden that out.

Mrs O'Neill: Thank you very much. I hope you will be able to achieve some of the purposes that your board was set out to achieve. It seems very strange that you're not more involved in such a major, major transition.

The Chair: I regret that our schedule today is very full and I'm afraid we're going to have to move on, but we want to thank you. I would note as well the additional information and material that you presented us with.



The Chair: I call on Mr Ken Waterman. Mr Waterman, thank you for coming to the committee. We have a copy of your submission, and when you're settled, please go ahead.

Mr Ken Waterman: I'd like to take this opportunity to thank the committee for letting me appear before you. I'm here as a former primary care giver. The presentation will outline some facts.

It's most important to read my statement in terms of the overview. It's most important to read my conclusion, what I personally have had to go through as a primary care giver. While I see a lot of good things being done in Bill 101 and Bill 173, I fail to see at this point in time anything being put in place in terms of primary care givers, families. I have given considerable study to both Bill 101 and Bill 173, and I'm sorry, but I fail to see that issue being addressed.

Notwithstanding all the changes that are taking place in the health care system today, what it has done to me personally as a primary care giver, ie, visits to the hospital, has put more of a burden on me. In the last year of my wife's life, 99% of the time I was at the hospital at 6 o'clock in the morning to give her a bed bath. That can be verified by internal documentation. So there's a spillover effect all the way down the line.

My final comment, very brief, is I am literally petrified of what could be in store, ie, my daughter, and her children. What is going to come in the future? Maybe it's a question that cannot easily be addressed today, but I can assure you, with the psychological turmoil that I had to go through in doing what I did do and saving the government and the taxpayers of Ontario I'd say untold thousands of dollars by non-institutionalizing my wife, that a person can only do so much and still be effective in terms of all the other aspects. So I come here hopefully to give some constructive input of what has been seen through the eyes of a primary care giver, not over one or two years, but over 23.

Very short and sweet and to the point. If there are any questions, I'd be happy to address them.

The Chair: I wonder if perhaps you might want to note any of the documentation that you gave us, for Hansard.

Mr Waterman: The document exhibit B: The only reason that was included was because the process on that was started. For some reason it didn't come through, and I've just done some quick calculations in terms of dollars that did not need to be spent.

The Chair: So as we look at the material you have submitted with your presentation, indeed there are ways of going about this in a more efficient way.

Mr Waterman: Yes, there is. I would think so. One of those ways is before you in exhibit B, but for some reason we got stalled, so extra trips to the hospital that I don't think were needed.

The Chair: Okay. Because your presentation has been brief, I think we can allow for a couple of questions on this, as I know members are looking at the material that you've attached.

Mr Jim Wilson: With respect to exhibit B, I gather you were paying out of pocket for the drug?

Mr Waterman: No.

Mr Jim Wilson: Could you explain exhibit B to me, because I'm not quite sure what you're getting at there.

Mr Waterman: Exhibit B is the final letter that was faxed out of my local MPP's office, whose name is on the bottom, to the drug benefit section of the Ministry of Health. Briefly, it states that the original documentation was sent out by my wife's general practitioner on or about April 15, 1992.

Mr Jim Wilson: That was a request for funding under the Ontario drug benefit program?

Mr Waterman: That's right, so that the procedure could be carried on at home as opposed to going into the hospital for five days and tying up a bed.

Mr Jim Wilson: Right.

Mr Waterman: From my conversations with the doctor, he saw, in terms of safety, that there was no question that the procedure itself could be carried out in the home.

Mr Jim Wilson: So your physician filled out a section 8?

Mr Waterman: That's correct.

Mr Jim Wilson: How long did it take for approval? Was approval given?

Mr Waterman: No.

Mr Jim Wilson: That's your point.

Mr Waterman: That's the result. That's my point.

Mr Jim Wilson: So your wife remained in hospital?

Mr Waterman: No, she had to go about every six weeks for a five-day trip because of the bladder irrigation that was what the specialist ordered.

Mr Jim Wilson: So did you ever get a response prior to your wife's passing away?

Mr Waterman: No, that's why that letter's there.

Mr Jim Wilson: How long, again, was it?

Mr Waterman: I originally faxed an inquiry on or about May 1 to find out the status.

Mr Jim Wilson: Of 1992?

Mr Waterman: That's correct. Finally, in November 1992, that was my end letter, sir.

Mr Jim Wilson: Your MPP should have raised this one in the House. That's a ridiculous amount of time for an ODB approval that never did come.

Mr Waterman: Like I say, the numbers, in terms of the VON, in terms of the current fees that were in effect by OHIP, those are the exact numbers. So to me $11,200 is a substantial saving.

Mr Jim Wilson: Can I just ask, because we haven't had a lot of people who are in or were in your position as a primary care giver appear before this committee -- and I am sorry to learn of the passing of your wife --

Mr Waterman: No, I don't expect an apology. That's the way, unfortunately, it worked out. If it had worked out on the positive, that's what the saving would have been to the province of Ontario in terms of health care costs. There's no big mystery about it.

Mr Jim Wilson: Is there anything else about the system -- it sounds like your wife did have some VON assistance.

Mr Waterman: Oh, yes, I had good support services. That's all in the documentation. If you refer to the gentleman in the statement of overview, you will find quite a file.

Mr Jim Wilson: If we were to ask the assistant deputy minister, Michael Ennis.

Mr Waterman: That's right.

Mr Wessenger: If I might just rephrase what your concern is, so that it's clear to all members of the committee, on the record, it seems to me that from the presentation you're making you're saying no matter how good a long-term care program you have in effect with respect to providing care in the community, if the other aspects of the health care system don't work in conjunction with, in this case, the Ontario drug --

Mr Waterman: Not in all cases, no.

Mr Wessenger: That's right. In other words, the problem here was with the way the Ontario drug benefit program was working, and we need to ensure that the whole system is integrated.

Mr Waterman: Yes, but it's going to take time. That's where I'm coming from at this point in time. I don't have anything more to do with it.

Mr Wessenger: Right.

Mr Waterman: I've got two documents that support -- for me, it's over and done with. But my concern is for my daughter, her children. If I'm concerned about that small group, then intangibly it spills out over to -- if you people have any children or grandchildren, it's going to affect them one way or the other, if they're faced with this type of a situation.

Mr Wessenger: Yes, I understand.

Mr Waterman: To me, the way I look at an incurable disease, it's no good no matter how you cut it, and it doesn't matter what the disease is, because it's not nice to see somebody you love die slowly before your eyes.

The Chair: Mr Waterman, I want to thank you very much for coming before the committee. As was noted, to have someone who's gone through the particular experience that you have is very useful for us as we continue in our deliberations.

Mr Waterman: My final comment is that I hope I see something in black and white in terms of rights for primary care givers.


Mrs Barbara Sullivan (Halton Centre): I wonder if the Ministry of Health could do a briefing note for members of the committee with respect to what protocols or clinical guidelines exist for approvals of medical procedures that can be done in the home and how they are integrated with other parts of the system. I think that Mr Waterman's submission to us is a very important one because it really tells how the system actually works, and it turns out to be a non-system. If we could have that kind of documentation, I think it would be helpful for us all.


The Chair: I call on our next presenters, from the Don Mills Foundation for Senior Citizens Inc. If you would be good enough to introduce yourselves, we have a copy of your submission.

Mr Roy Arendse: My name is Roy Arendse, and I'm a member of the board of directors of the Don Mills Foundation for Senior Citizens Inc. Before beginning, I would like to introduce you to the other two presenters, Catherine Brookman, vice-president of community services for the foundation, and Carmel Smith, a client of the foundation.

Given the time constraints, we have submitted in writing a more thorough summary of our concerns for your consideration. Our presentation will begin with a brief overview of the Don Mills Foundation. We follow this with areas of the legislation that are of concern as well as the potential impact of this legislation from the perspective of one of our clients, Carmel.

The Don Mills foundation for Senior Citizens Inc is a not-for-profit community organization of volunteers and professionals committed to serving the wellbeing and social needs of seniors through a broad range of services and a commitment to a continuum of care. The Don Mills foundation operates three facilities in the Don Mills area: Taylor Place Senior Adult Centre, Taylor Place Community Services and Thompson House Home for the Aged.

Taylor Place Senior Adult Centre was opened in 1976 as an elderly persons' centre, offering a range of social, recreational, educational and health programs, serving over 1,000 seniors annually. In 1983, Taylor Place expanded its services to include home support programs. The client intervention and friendly visiting programs were among the first home support services, which have more recently been expanded to include a frail elderly day program, an Alzheimer's day program, a respite care program and a southeast Asian Meals on Wheels program. The home support programs serve more than 1,500 seniors per year.

Thompson House is a 136-bed home for the aged which was opened in 1969, providing both residential and extended care services.

The range of services offered by the Don Mills foundation includes social work; information and referral; Meals on Wheels; transportation; care giver support groups; adult day programs, frail elderly and Alzheimer; home maintenance and repair services; friendly visiting services; security check service; social and recreational services through the senior adult centre; health and special services in chiropody, a legal clinic, a tax clinic and nutritional services; homemaking; home help; respite care services; a long-term care facility.

The foundation has been providing one-stop access to care through the continuum of services it provides: home support services, community support services, personal care services, social recreational services, as well as institutional services. Many of the components of Bill 173 are not only supported but have been implemented by the foundation. As an example, the Don Mills foundation has operated a centralized access process for all seniors in the Don Mills community since 1988. This process includes information and referral services to all the programs and services of the foundation, as well as a comprehensive assessment, case management and case coordination service.

The Don Mills foundation is pleased to have this opportunity to make a presentation to the Legislature's standing committee relating to Bill 173. The foundation has been an active participant in the Redirection of Long-Term Care and Support Services in Ontario with the support of dedicated clients, volunteers and staff. The foundation applauds the efforts of the government over the past two years in working towards building a new long-term care system.

The foundation supports the concept of multiservice agencies and the principles on which they will be developed, namely, to provide one-stop access to care; to amalgamate assessment, case management and service delivery in a single MSA; to achieve administrative efficiencies; to develop an integrated, complementary human resources process; to ensure greater consumer participation and control in planning delivery of services; to build a system that delivers service on a not-for-profit basis; and to develop equity of service delivery across the province.

The Don Mills foundation mirrors these principles not only through the continuum of services it provides but also through an overall operational practice. Over the past 25 years, the foundation has been a leader in the provision of services to seniors and continues to strive to meet the growing needs of the community. Community consultation, collaboration and cooperation have guided us in the past and will continue to guide us in the future. The foundation supports the principles of Bill 173 and through its comments on Bill 173 hopes to assist in the actualization of a truly integrated long-term care system.

The foundation is concerned with the following main areas of Bill 173: definition of services and new terminology; social work services and the functions of intake, case management, information and referral; social or recreational services; health and health promotion; and board composition.

The foundation appreciates the opportunity to share our perspective on the legislation being examined and looks forward to the continued partnership with government and communities in the implementation of long-term care reform.

I would now like to ask Catherine Brookman to take you through specific areas of the legislation.

Ms Catherine Brookman: I will begin my comments in the area of board composition and governance. The foundation is pleased that one of the factors the minister shall consider in deciding whether to designate an approved agency as a multiservice agency is board composition. It is essential that the board be reflective of the diversity of the persons to be served by the agency in terms of age, gender, disability, ethnicity and spiritual factors and that clients, care givers and volunteers be included in this. It is also essential that the board reflect the level of expertise needed to guide and direct an agency, such as financial expertise, human resources expertise and, as mentioned in part VI, clause 11(2)(b), persons experienced in both health and social services fields.

Therefore, we are recommending that in part VI, multiservice agencies, subsection 11(2) be revised to include clients, care givers and volunteers. As well, we would like to see inserted an additional paragraph that would indicate that the agency's board of directors will include persons experienced in the areas of human resources, financial management, legal matters and other related fields which will assist in the governance role of the board.


The foundation would encourage the minister to reflect on the governance issue for those organizations that provide a continuum of care through services identified as outside of the multiservice agency. This would include organizations that, along with providing the core basket of services, may also provide, for example, residential care through a home for the aged or supportive housing and/or even a senior adult centre.

To carve an organization into separate entities does not support the principles of the reform. From the perspective of a client, an organization that provides the core basket of services and also a long-term care facility, for example, strengthens the principles related to a continuum and one-stop access. Likewise, it would be wise to avoid severing the continuum of services that has been developed through the mandate of the community and through the time and energy of thousands of volunteers who have been proactive in planning for their future.

The next element that I would like to bring to your attention is the section of the bill pertaining to definitions. The legislation is not consistent in the presentation of definitions of terms. Definitions have not been provided for "friendly visiting," "security checks" or "reassurance services," "home maintenance and repair" and "social or recreational services." As well, an essential service, respite care, has been lumped in with care giver support services. There is more detail provided for homemaking and personal support services, yet professional services such as social work have not been defined.

Bill 173 introduced new terminology. Personal support services were previously known as "homemaking," and "homemaking services" has replaced the previously referred to "home help services." The distinction between "personal support services" and "homemaking services" is contrary to long-term care reform in general and specifically to the purposes of this act, as identified in part I, purposes of the act, clause 1(c), page 3, that is, "to recognize the importance of a person's needs and preferences in all aspects of the management and delivery of community services."

Clients have indicated to both government and service providers that the proliferation of different workers in their homes has been unnecessary and confusing. Agencies have addressed these concerns over the past five years through the delivery of these services by a generic worker. This combines health care aides, homemakers, home support workers, respite workers, home helpers and attendant care workers. The services outlined in the act under part II, interpretation, subsections 2(5) and 2(6), are in most agencies provided by the same worker. The delineation of these two services separately is a disservice to the client and alarming for the agencies that have developed comprehensive holistic training programs to support the generic-worker-concept mode of delivery of service.

Therefore, we are recommending that clear and well-developed definitions for all services be provided to ensure consistent and equitable access to all community services across the province. Service providers must be involved in the development of these definitions, as they have been doing work in this area for many years through provincial organizations such as the Ontario Community Support Association and the Older Adult Centres' Association of Ontario.

The other recommendation related to this area is that the distinction between homemaking and personal support services be eliminated and that whatever term used to describe these services also include respite care services.

My final comments are on the area of social work services and information and referral. The provision of social work services is an integral part of the long-term care system. The multiple needs associated with one's physical, social, psychological and spiritual wellbeing need to be taken into account when assessing clients. The role of a social worker is more than that of a case coordinator; it is more than managing resources; it involves case management. The role of a social worker is akin to that of a travel companion, rather than that of a travel agent. It is the travel companion who walks along with the client through the journey of care, providing support, guidance, assistance with instrumental tasks of daily living, advocacy, financial management, supportive counselling, as well as linkages to other care providers.

Community-based social work to seniors and the disabled is presently provided by selected home support programs such as the client intervention and assistance program. These services are not recognized in the bill, and therefore we would encourage government to ensure that the grass-roots, task-oriented services provided by this program are included in the basket of services, either through the definition of social work services or as a separate service.

Currently in Metropolitan Toronto the functions of information and referral are provided through the client intervention and assistance program. For those agencies that do not have a client intervention and assistance program, these functions are performed by the independent programs themselves, which often results in a duplication for the multiservice client.

The absence of a defined intake service is the largest and gravest oversight of this bill. The success of the functional aspects of the reform depend on this service. The principles of long-term care reform rely operationally on an intake service. One-stop access, a single point of entry, consistency and availability are essential elements to intake and the success of the reform.

Traditionally, intake has been delivered on the backs of other service programs, which has resulted in multiple assessments, duplication, inconsistency, administrative complexity and the misuse of staff and funding resources. In order to simplify and improve access to a continuum of community services, which is one of the purposes of this act, intake needs to be included in the community support services section or defined under the definition of social work.

Therefore, we make the two following recommendations: that the current functions provided and performed by the client intervention and assistance program must be incorporated into this bill, either within the definition of social work services or as a distinct service, and that the essential functions of information and referral be incorporated into an intake service, either within the definition of social work services or as a distinct service.

Mr Arendse: At this time I would like to ask Carmel Smith to speak to you about her experience with the foundation, which reinforces the concerns that Catherine has put forward regarding the absence of definition of social work and the need to consider the importance of the functions of the client intervention and assistance program.

Mrs Carmel Smith: I was introduced to Taylor Place about seven or eight years ago. At the time, I was in hospital, and I can't recall if it was a social worker or a head nurse, but somebody came to me and told me about Taylor Place. They said it was a very social type of organization and that I would enjoy it. They told me various things about it and gave me the phone number.

At the time I said, "Yes, that sounds fine." I didn't think, "I won't bother," but I didn't get overenthusiastic about it. However, about 10 days to two weeks later. somebody did call me from Taylor Place, a representative, and she asked if she could come to my home to see me, which she did, and which I was terribly pleased about. She explained Taylor Place.

At that time, which was seven or eight years ago, they had a dinner on a Sunday once a month. They also had movies in the afternoon; they would pick you up and take you there. I was very pleased about it. They told me I would be picked up, at a small fee, but that was fine. I enjoyed that.

Then I got better and things began to look up and I went into volunteering for Taylor Place.

I still kept up my association with them. Then about three years ago I was going through a bad time in my life. I was in hospital and my doctor said, "How is your social life?" I said, "Zero." So he said: "Well, we have to do something about that. Do you know of any place? Are you attached to a church group or anything?" I said, "No." He said, "Any other place you know?" I said, "Yes, I do know Taylor Place." "Well, do you know anyone there?" I said, "Yes, I do." "Can you get in touch with them?" So I said, "Yes." He said, "I also want to speak to them."


I phoned Taylor Place and I spoke to the same lady. I guess I can mention her name, Ronnie Brannigan. I explained things to her and she said, "Well, I doubt if I can get out, but I will send" -- to cut a long story short, somebody came up to the hospital to see me. Also, there was a lot of information to give me because in that time Lesmill had opened, which is a day program.

She explained all this to me: "You can come in in the morning and have lunch, and we've all sorts of things going on: crafts, arts and outings and all this. You will have your lunch and we will pick you up and take you home," which to me was fantastic. She did all this in the hospital. This was all arranged before I left. Also, she had spoken to my doctor and had spoken to the social worker at the hospital and they were very, very interested, and all the rest, about it.

I am still there and I enjoy it thoroughly. But I think my point is that if you're not feeling well or you're down or you've lost a spouse or something like that and you hear about Taylor Place, you're not inclined to go, as much as it would appeal to you. I think the important thing is somebody coming to you. It makes it more personal and it makes it more caring, that somebody cares about you at this particular time. I think it's a very good introduction to Taylor Place.

Ms Brookman: Carmel was specifically speaking about her experience through the client intervention assistance program.

How are we doing for time?

The Chair: We're all right. We're getting a little close.

Ms Brookman: I think I will skip the formalities of a conclusion and perhaps open it up.

Ms Jenny Carter (Peterborough): Thank you very much. I certainly think that your organization does a wonderful job. But I'm a little puzzled that you're saying that through what is proposed in this bill we're not getting integration and a continuum of services, because it seems to me that is what this bill is all about and what, hopefully, we are getting.

Although your particular organization may be integrated, if you look at the whole picture, we have a vast number of agencies and organizations, all doing a good job, but there is fragmentation, there is difficulty in a client knowing who to go to, what is available and so on.

What we're looking at here is making that one point of access so that a person can just make that one phone call and find out what the whole range of possibilities is and also making sure that range is available over the whole province. I know that in some places we have excellent coverage already.

Of course, when we look at this Price Waterhouse report, that is based on the assumption that we're going to save a lot of money through better integration, which we'll then be able to be spend on the front lines of service, which is what we all care about.

Also of course, there is going to be a lot of flexibility in the sense that governance will be from the local level, from local boards, and not from the top. So I wonder whether some of the omissions that you see in the bill are rather things that are being left for the local decision-making process as to just how it's going to be done in a given area. I just wonder if you could comment on those points.

Ms Brookman: I'd like to comment first on your remark regarding the Price Waterhouse study. If it's the same article that I read a couple of weeks ago, I would be a little cautious about quoting that. I understand they did a study for about $6,500 and they talked in that study about integration and changing the long-term care system, which will in effect correct some of the 30% of administrative inefficiencies, which is a gross overgeneralization. When you have an organization, for instance, that is strictly delivering Meals on Wheels and you have a coordinator who is also the executive director and the 30 other staff are actually volunteers, then you pretty well have mostly administrative costs. So I'm a little concerned about the generalizations that were made in that article.

With respect to the continuum, I certainly concur with you that across Metro and certainly across the province perhaps the continuum of services that are provided under the Don Mills foundation are not provided in such a format in other areas in the province, and I certainly believe that integration and coordination are really needed and that if you have organizations that are next door to each other and perhaps servicing the same clientele and providing the same services, then maybe there's a rationale to look at sharing of resources and doing things. But that's not to say and I would be very hesitant to conclude that they would be doing something incorrectly, because they may be providing an excellent service. The fact that they are next door, there may be actually a very good administrative and effective rationale for that and it may in fact prove to be cost-effective.

But an organization such as the Don Mills foundation, which is servicing a catchment area of approximately 120,000 constituents now, 16,000 of those being over the age of 65, does provide the one-stop access and not only for the core basket of services. We also have a home for aged and a senior adult centre so that people who are well come.

As Carmel has pointed out, her doctor asked her, "How's your social life?" because he recognized that social and recreational experiences and opportunities are part of wellness. That's part of the preventive mechanism and part of the integration that I think -- and we've spoken to this in our deputation but we weren't able to talk about it here today because of time -- is really an integral piece and needs to be included.

Ms Carter: Definitely.

Ms Brookman: So the person comes into the organization through the senior adult centre, and then as their needs escalate, they perhaps receive some home support services. Then maybe down the road they'd like to move into a facility, and it just so happens that we do have that facility onsite.

I think it would be very detrimental for the community if the implications of this bill are that the Don Mills foundation would have to separate into three separate entities. Carmel asked me this morning: "You know, I'd like to look into getting into Thompson House. How do I do that and who do I talk to?" I said, "Well, things have changed a little bit and we can certainly talk about that."

Mrs Smith: Sure did, and it surprised me.

Ms Brookman: But from the perspective of a client, they've been in an organization, they know it well, they're familiar, they're comfortable and they just walk through the organization. I certainly hope the implications of this reform do not tear down organizations and structures that facilitate integration.

Ms Carter: We're certainly looking for a continuum of care, and I hope and believe that is part of the objective of what we're doing. Of course, it does say in the act, section 20, "When a person applies to an approved agency...the agency shall assess the person's requirements;...for each person who is determined to be eligible, develop a plan of service," and so on, so there is going to be a very careful and personalized assessment of each individual.

As you said, we have had a system where a person could be assessed over and over again, and we're trying to make sure that only happens once, that it's done thoroughly, that the person has input into what they want and what their preferences are. Hopefully, they will have access to that continuum and will be able to be placed just exactly where they wish on it. I think we really want the same thing and you're just concerned that the bill may not be providing that.

Ms Brookman: Which is a big concern.

Ms Carter: Obviously. We feel that it is.

The Chair: The parliamentary assistant wanted to comment on a couple of points.

Mr Wessenger: Thank you very much for your presentation. I'm certainly interested in seeing what comprehensive services you provide. You certainly fit very well in that integration concept.

Two points of clarification: First of all, I'd just like to clarify for you that the definition with respect to services in no way is any policy indication that there should be anything other than a generic worker. In order words, the concept is that the homemaking services and the personal support service should be provided by the same worker. I just wanted to assure you on that.

Second, with respect to your concerns about the client intervention and assistance program, it's deemed by the policy people, the draft of the act, that that's included in the case management definition, so there's certainly recognition that this is a very important part of the whole case management process.

Ms Brookman: Thank you.

The Chair: Thank you again for coming before the committee. At an earlier time I had the pleasure of visiting Thompson House and Taylor Place and I know all you've said about it is the way it is, and I wish you all the best in the future.



The Chair: I call on our next presenters, from the Ontario Community Support Association, Areas 5 and 6. Gentlemen, welcome to the committee.

Mr David Wartman: My name is David Wartman. I'm the president of the Ontario Community Support Association. With me this morning is Dan Stapleton, our executive director.

There has been a variety of interpretations, and I might add misinterpretations, of the position of the Ontario Community Support Association with respect to this piece of legislation. As a consequence, the members of areas 5 and 6 and the board of directors of the association felt it was important that we use the time this morning to attempt to clarify our position. I think it's safe to say that we continue to support the bill in principle but we have some serious reservations about elements of the bill as it stands right now, and without changes, our support would not be forthcoming.

We're pleased to have been given the opportunity to make a final presentation to this committee regarding Bill 173, the Long-Term Care Act. The Ontario Community Support Association, which represents over 300 agencies providing Meals on Wheels, homemaking and home support services, has presented in each of the regional centres with local concerns, as well as a presentation of the association's collective views.

Our detailed response to Bill 173 was previously submitted. However, as I said, we wanted to take this opportunity to reinforce certain key areas based on our understanding of the discussions during the public hearings to date.

There's no question that reform of the long term care system is needed, and we are pleased that the government has taken this task seriously and introduced legislation to guide the process. We support the purposes of the legislation such that a broader continuum of care is made available, that more of an emphasis is placed on promoting health, that there is an attempt to integrate health and social services, that access to a continuum of community services is made easier, and that the quality of community services will be improved.

However, we have concerns that the bill, in its current form, will not meet consumers' needs or expectations because of its overly rigid and prescriptive nature. In fact, OCSA cannot support Bill 173 unless it is amended. What we had hoped for was a blending of the positive components of the health system with its emphasis on accountability, fiscal systems, quality assurance and service standards with those of the social services system, which is marked by adaptability and the capacity for informality along with innovation and creativity.

However, this bill seems to lack the advantages of the social services system in favour of a level of inflexibility with rules and procedures that was neither expected nor needed. We would like to therefore outline our specific concerns.

Multiservice agency: We feel that the MSA model as currently outlined in the act, which involves a consolidation of service provider agencies into one organization, is too rigid. OCSA cannot support the MSA model as set out in the act, but rather we support the alternative MSA models which endorse the principles outlined in the purposes of the act and are a result of a community planning process.

In many areas of the province the consolidated MSA model is appropriate, and in fact in several communities service providers and consumers are actively planning this type of organizational arrangement. This proactive planning should be encouraged and the momentum for change maintained.

However, in other communities the consolidated MSA model may not be appropriate for those communities' needs and unique circumstances. We do not feel that only one model should be implemented in every community, but that flexibility in model design is required.

OCSA's CCCO model: Our association in 1992 recommended an organizational model for the government's consideration called the comprehensive community care organization. We understood that in the hearings which have been conducted since mid-August, the government and others have cited our organization as having recommended the MSA model. We feel we need to clarify this point because what is written now in the act is not what we recommended.

Specifically, what we said was:

"The plans to establish the service coordination agency structure should be abandoned and replaced by the development of not-for-profit, comprehensive community care organizations.

"The government should immediately establish an innovation fund for the purpose of fostering development of no less than 10 demonstration models of comprehensive community care organizations for long-term care.

"CCCOs should provide assessment, case management and a full range of in-home and community services to an identified population or community."

In that submission, we recommended that collaborative community planning was necessary in order to bring about the needed changes to the system. We later recommended that organizational structures should be developed using a gradual planned and phased approach over a period of years. This would therefore allow the development of CCCOs in areas where there was support, and tailored to the unique needs of the local community, with the rate of development being based on the community's current level of integration and ability to implement such a large systemic change.

Our feeling now is that the legislation's one model for all of Ontario may involve too much of a systemic change in too short a time period. The principles of community development require that stakeholders which are involved in the planning process need to come together as equal partners with a commitment to and ownership of the process. We have concerns that these principles are not being observed in the planning approach being used in many communities, and we recognize that some communities are not ready for an integrated MSA model and in fact are working to develop alternatives which will meet their community's needs.

Mr Dan Stapleton: A number of organizations have advocated during the hearings for the removal of section 13 of the act which restricts the amount of services an MSA may purchase from other service providers to 20%. OCSA is prepared to support this recommendation but with a proviso: OCSA endorses the removal of the purchase of service restrictions from the act and further recommends that community boards be empowered to provide or obtain their services from the not-for-profit sector unless this sector cannot provide these services.

Many groups have also recommended the removal of the four-year exemption period since it is felt that this may constrain some communities along with some interim models which may be meeting consumers' needs. We feel that if this time limit is removed in conjunction with more flexible MSA models being allowed, incentives will be needed to ensure that the goals of reform are achieved. Government needs to support communities with appropriate resources and objective facilitation, therefore fostering community development.

Also there will need to be benchmarks established so that communities can be assured that the reform of the long-term care system is indeed proceeding. Indicators of quality, consumer satisfaction and cost-effectiveness would need to be established and reviewed on an annual basis. We do not want to lose the positive momentum which the reform process has already engendered at the expense of introducing flexibility. Reform must proceed, but communities need to be empowered to ensure that the reform system meets their needs.

Human resources issues for both employees and volunteers: OCSA is concerned that the needs of the current employees and volunteers in the system have not been adequately addressed by this bill. In our previous submission, we went into some detail regarding this point. But let us emphasize our recommendation.

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 agencies should be guaranteed comparable positions in new service delivery structures without loss of seniority.


Our association's agencies utilize over 50,000 volunteers in delivering, governing and raising funds for the various community support services. They are the backbone of our sector and therefore must be recognized. The transition to an improved service delivery system will involve many changes regardless of the type of organizational arrangement that ultimately is implemented in communities across Ontario.

We feel that volunteers need to be nurtured and planned for. They are motivated by an array of factors and cannot be shifted organizationally away from their work without careful planning, or we risk their loss in the transition process. What is required is the maintenance of linkages between volunteers, their communities and the agency staff who work with them.

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

The last point we wanted to make concerns the cost of the new system. When we embarked on the reform of the long-term care system, the primary emphasis was on simplified, equitable access to services, reductions in fragmentation, enhancements in the number and quality of services and consumer-centred care. We did not expect that the $647 million earmarked for the reform process would face so many cost pressures which have eroded the government's ability to expand services; for example, earlier discharges of patients from hospitals have led to higher expenditures on acute home care programs. We have also experienced increased costs associated with pay equity.

What has recently emerged as a result has been a focus on cost cutting as one of the primary arguments for organizational change. Claims in this regard have been made in other presentations to the standing committee. We feel it is important to respond and clarify our association's views. A recent report released by the Senior Citizens' Consumer Alliance for Long-Term Care Reform included a comparison of the administrative components of the current and proposed home care systems, prepared by Price Waterhouse management consultants. This report, because of its simplicity, implies that community-based programs are currently administratively top-heavy and are operating inefficiently.

We all recognize that we can improve our efficiencies as we strive for quality. However, what has not been recognized, because it is buried in the report's appendices, is that the administrative costs of community support programs such as Meals on Wheels, homemaking and home support services are already, on average, below the administrative cost being suggested for an MSA. Our agencies are run on a shoestring with minimal administrative overheads.

If you factor in the dollar value of the 2.5 million hours of services delivered by volunteers in our agencies last year, at an average community support worker's wage rate, the real administrative cost drops significantly. Currently, in many smaller agencies, executive directors do some front-line work, and bookkeeping and accounting services are often handled by volunteers. Will these flexible and donated services be as inexpensive in an MSA?

The study attempts to prove that administrative costs in MSAs will be lower and makes the assumption that 70% of the current costs can be recovered through economies of scale. This seems to us to be wildly optimistic and in fact the basis for this assumption remains unexplained in the report. We feel that in some communities an integrated MSA can result in cost savings. However, this is an area that the government has not yet addressed in its analysis of service delivery models.

Enhancing quality and ensuring equitable access to services carry a pricetag. We have argued that more funds need to be fed into the community support services system in order to handle increased service demands that have come about because of the increasing aging population and shifts of clients from the institutional system. The shift to the community needs to include shifts of funds as well as clients. Other than recent increases to the integrated homemaker program, we have yet to see these new funds.

We therefore caution that as the standing committee makes decisions regarding this bill and its recommended organizational components, it should treat the findings of this report with scepticism.

Mr Wartman: We have attempted to highlight some of the key concerns that we have heard from our members since the legislation was introduced in June.

In summary, OCSA cannot support Bill 173 in its current form unless it is amended. Flexible MSA models, which are a result of a community planning process and are based on the community's needs and unique circumstances, should be encouraged. Restrictions on the purchase of services outside the MSA need to be relaxed, provided community boards provide or obtain their services from the not-for-profit sector unless this sector cannot provide those services.

The needs of current employees and volunteers in this system must be appropriately addressed in transitional planning, the potential cost of the new system should not be underestimated, and new models will need to be planned and analysed carefully.

We thank you for the opportunity to present these concerns and recommendations on behalf of our association's members. We look forward to continuing to work in partnership with our health and social service colleagues, and with the government, to bring about the redirection of long-term care.

Mrs Sullivan: I appreciate this particular presentation, which has clarified a number of the issues that, as you know, became a matter of contention during the course of the hearings. We also appreciate having your analysis of the Price Waterhouse report, which was presented by the consumer alliance. We feel that Price Waterhouse did not reach its usual standards of quality in preparing that report, and we will be having interviews with them, but we just think they were way off the mark.

I wanted to specifically ask you about two issues. On page 3 of this report, you speak about incentives that should be provided to ensure that the goals of long-term care reform come to the fore, if the four-year time limit for an interim process is removed. I'd like to know if you could describe the kinds of incentives you feel would ensure that long-term care reform would still stay on the road, while allowing the flexibility for different models and different time lines in moving into another model.

Mr Wartman: I think one of the concerns that our board experienced in recommending this change was the concern that the reform process would go off the rails, because we felt that one of the advantages of the four-year time limit was that it keeps it within a time period and maintains the momentum. We feel that if you combine the relaxing of the time period with more flexible models, there needs to be probably financial incentives. We haven't gone into a lot of detail with regard to the details of that. I feel we would need to have some more discussion about that.

One of the things we felt, too, was that in terms of the planning process, the way in which planning is being done oftentimes doesn't put the partners on an equal playing field, those that are involved in the planning at the DHC steering committees, and we feel there needs to be more resources and an objective facilitation of change so that the smaller players, such as the agencies that belong to our association, feel that their issues are being heard and they're not being railroaded by other power brokers from the past.

Mrs Sullivan: Right. The other issue also in the same paragraph that I think merits a lot more attention than it's being given is your discussion of the evaluative mechanisms, the "indicators of quality consumer satisfaction and cost-effectiveness need to be established and reviewed on an annual basis." Would you like to speak more on that?

Mr Wartman: Maybe I could just mention on that point, we thought that if there's a way of establishing benchmarks so that say on a yearly basis, these indicators of quality cost-effectiveness and so on are reviewed -- so that a community, which is the broader community that consists of not only the service providers but the consumers or potential consumers, can see whether or not that local MSA is meeting the needs and is achieving the goals of reform.

Mrs Sullivan: We raised this question with Dr Naylor when he was in the estimates committee with respect to evaluative mechanisms that would be appropriate for services that are delivered in the community or in the home, and my understanding is that there is some work being done at ICES and it's probably very worthwhile to follow that up to see where that is going. That's useful.

Mr Wartman: Yes.

Mrs Sullivan: Thank you.

The Chair: Thank you very much for coming before the committee. I regret, again, because of our schedule we can only go with one questioner, but we appreciate all the material that you've presented.



The Chair: I call on the representatives from the Community Agencies in Partnership. I want to welcome all of you to the committee.

Ms Sandra Sillcox: My name is Sandra Sillcox. I'm a resident of York region, past president of the Alzheimer Society of York Region and am presently chairman of Community Agencies in Partnership, which will be referred to as CAP. On that behalf I am making this presentation this morning.

I have with me Deborah Egan, who is the executive director of CHATS, Jackie Catto, who is the president of VON in York region and Susan Taylor, who is with the regional municipality of York, community services department.

The Chair: The Chair is always happy to welcome representatives from York region.

Ms Sillcox: Good. Well, we feel comfortable in your environment. Thank you.

CAP is a network of community service providers who provide long-term care services in York region. It was formed in June 1993 by board members who voluntarily came together in support of simplifying access and coordinating services within the long-term care sector.

The membership, and a list is attached, has expanded, and it now includes both senior staff and board members of the following agencies: the Alzheimer Society of York Region, ADAPT, which is the Association for Differently Abled People Together, the Canadian Red Cross Society, Community Home Assistance to Seniors, Ontario March of Dimes, Palliative Care Services of York Region, the VON, York region community services department, York region home care department and York Support Services Network. Several members have been involved in preparing this presentation, and many are represented and have been introduced to you today.

The purpose of CAP, as defined in the terms of reference, is to foster an informal partnership of community service providers to allow them to collaborate on the delivery of health and social services within the long-term system in York region.

CAP is in support of the reform of the long-term care, and we present to you our concerns about Bill 173, An Act respecting Long-Term Care in Ontario.

The role of the board of directors: On the issue of governance, we find the micro-management approach of Bill 173 most disturbing. Specifically, subsection 56(1), the nature of the decisions to be made centrally, appears to question the need for, and the role and function of, a community-based board of directors, that is, of the local agencies. In part VI, the power and authority for operating the MSA appears to be with the ministry. Will this top-down, prescriptive approach allow flexibility for local planning and creativity in partnership with consumers to meet the unique needs of the clients we serve?

Definition, defining long-term care: As a very diverse group of agencies providing a whole range of services to the residents of York region, we would urge the government to define "long-term care." As well, it is imperative that government state what population will be served by the long-term care system. In reading the legislation, we did not find any hint of what long-term care is, nor the population that is intended to receive services. Furthermore, there is an absence of a vision which would provide a framework for a continuum of care. It is not clear how the various components of the long-term care system, including the acute care, are to work together to provide the client with a coordinated continuum of care.

Treatment versus wellness: We understand that the acute care program presently under the mandate of the local home care program is to be included in the long-term care system. We raise the issue of competition for dollars that may be developed when acute care client need is compared to chronic care client need, the former requiring nursing service for a surgical wound and the latter requiring friendly visiting or Meals on Wheels: Which would you choose to fund?

The commitment to non-union workers: The proposed model for an MSA involves a merger of existing agencies. The government needs to consider the needs for all employees in terms of fair and equitable opportunity for employment in the MSA. Such protection must be afforded to all staff, regardless of their affiliation with unions. Employees represented by bargaining agents have been afforded protection through the successor rights under the Labour Relations Act. Similar protection must be afforded to non-union workers.

Where is the community empowerment? Our community partners embrace the promise and vision of long-term care redirection in both the health and social services sector. This legislation has lost the spirit of the social services system, which is known for being resourceful through volunteer participation, fund-raising and community development, as well as being adaptable, informal and innovative. What may be gained in consistency has the potential to lose in responsiveness to changing community needs.

Unfortunately, this legislation continues to emphasize artificial program definitions which currently exist in the health system rather than taking a needs-based approach. With the passing of this legislation in its current prescriptive form, we see little opportunity for community participation and initiative. At no other time than now is the resourcefulness and creativity of communities needed more.

Will the service definitions fit the needs of tomorrow's consumers? Part II lists two pages of service definitions for community support services: homemaking services, personal support services and professional services. The MSA is restricted to the provision of these services only, unless special permission is granted by the minister for the provision of other services. The service definitions are later used in part VII to differentiate which programs may have charges for service.

These specific service definitions will assure the development of a rigid, inflexible and hard-to-change service system. What may appear to be a comprehensive list may in fact be a barrier to the introduction of new services or the redefinition of existing services which may be required in response to changing consumer needs. Tasks carried out by different providers in the system may also change as the service philosophy evolves.

Further fragmentation in the future: A second tier of services may develop for those who are not eligible to receive MSA services. Private services for those who are able to pay or for those who are assisted by charity will develop outside of the MSA in situations that cannot be met by the inevitably competing priorities of the MSA. We see, in time, the MSA becoming one service provider in an array of profit and non-profit agencies that have varying access and eligibility criteria, the very problem that Bill 173 is supposed to resolve.

We feel the legislation need only define services as community support services; home and personal support services, eliminating homemaking; nursing services; occupational therapy services; physiotherapy services; social work services; speech-language pathology; and dietetic services. The term "professional services" is an archaic and hierarchical distinction from the other services defined in the act.


Purchased service limits: Community Agencies in Partnership believes that a limit of 20% on purchased services should not be prescribed in legislation. It is our position that this limit should be eliminated so that each existing community can determine the mix of service providers and agencies that best meets its individual characteristics and future service needs. Each organization in our group comes with a different point of view on this future direction as we work towards a common vision for York region.

Care givers: Particularly family care givers were an integral part of the long-term care reform and should be recognized and supported throughout the legislation. Many were very involved in the long-term care reform groups and discussions held throughout York region and expressed their needs for support and respite care support at every opportunity.

Care givers were very articulate about their needs and were a great asset to the reform process. Therefore, we recommend that the MSA board composition, part VI, clause 11(2)(a), include family care givers as well. We also recommend that the purposes of the act ensure that there are sufficient services provided to care givers to enable them to continue to provide care in the home without putting themselves at risk. Previous documents indicated that care giver support services would be provided at no cost, and this is not guaranteed in Bill 173.

Transportation: York region is a very large area made up of nine municipalities. Some have an excellent transit system and others have none at all. There are many regulations in effect controlling the crossing of boundaries, making access to services virtually impossible for many consumers, particularly for those in the rural areas. Will legislation guarantee access to the service regardless of transportation issues or limitations?

Cost analysis: Has a thorough analysis of the cost of the present system, as opposed to the estimated cost of the delivery of the proposed services in Bill 173, been done?

In conclusion, CAP encourages the Ontario government to enact Bill 173 in order to proceed with long-term care reform. However, we hope that the points raised in this brief will be acknowledged and carefully considered prior to the final reading and that this presentation has not been a lesson in futility.

Mr Cameron Jackson (Burlington South): Thank you for your brief. When I read the next page of your brief, I look at all the participating agencies and it's quite an impressive list as a coalition of resources, in effect. Perhaps if this legislation had not been amended on the fundamental point of the brokerage model, which was the big change, the big surprise for everybody who's been monitoring long-term care legislation, studies and research for the last six and a half years, had that fundamental change not occurred, York region's in an absolutely ideal position to proceed with the brokerage model, given this kind of relationship that you've established.

Would you like to comment on that, because I think that's part of the frustration, that 80% of the entire activities in York region are now going to fall under the civil service and all these agencies are going to be competing, in a sense, for that 20%. It's a simplification but it's a fair reflection of what now is going to happen in York region. I wonder if that is the fundamental concern you have, that without virtually any notice this major 180-degree shift in the direction of long-term care was thrust upon you not too terribly long ago.

Ms Jackie Catto: If I may I respond to that, I'm the VON board chair, so we certainly, from the VON perspective, have concerns about that. I guess we do see that in York region, as you've identified, we have a very strong operation going and we do question the validity of changing something that is working reasonably well. Certainly, modifications are necessary; we don't deny that, and improvements are necessary. But we wonder about the merit in destroying, so to speak, something that we feel is working reasonably well. We would certainly recognize that the changes are necessary and we're prepared to make those. We are now trying to make some of those but we are concerned about, as you suggest, a dramatic change in delivery of services.

Mr Jackson: I appreciate your underscoring transportation, because York region in many respects is like Halton region, where I come from, where we have a strong urban area with the majority of the population that's spread out in a rural area, centred around hamlets and communities and small towns, but still we have not resolved this whole notion of transportation. York region may not necessarily know the shape and direction, the size and number of MSAs that you're going to have in York region. That is still up in the air at the moment, is it not?

Ms Sillcox: Yes, it is. I sit as a chair of the transportation advocacy committee in York region. They came out of a study called Gaps to Options, around the needs for the physically disabled, and so we again have been monitoring. But whether there are 20 MSAs, five MSAs or one, the access is still going to be a problem because of the crossing boundaries plus the rural part of the community, very similar to your area. So we're watching that piece pretty closely.

Mr Jackson: Mr Chairman, given that the deputants are from your region and since there is a little bit of time, could I yield some of my remaining time to you so that you could ask one or two questions? I know you'd like to. Feel free to use a bit of my time, if you'd like.

The Chair: Mr Jackson, you're always too kind, but as the Chair I would allow a question from a colleague from York region.

Mr Larry O'Connor (Durham-York): I appreciate the opportunity. Usually, we only have an opportunity for one caucus to make a remark. I guess the concern that you raised about the rural part of York region is the concern that I've got the greatest, considering my riding is pretty well all rural and contains parts of York and Durham region.

In fact, recently it was brought to my attention that somebody was requiring some home support services from York region and there was delay in getting those services to that client, and in fact a delay in referral to other, different agencies in the community that could have provided those services. The family physician in this case didn't even know about the hospice and what the hospice does. So the gaps out there are humongous.

We have physicians out there trying to refer without knowing whom they should be referring to and who would be the most appropriate people to be phoning. The gaps are large; the services that are available are improving all the time and we're seeing more services. I was quite pleased that we did get a hospice up and running in Georgina recently and I think that it's remarkable. Unfortunately, there are providers in our community that don't know about it.

I know that the district health council will be expecting representations from a number of organizations hoping to be able to perform the services of an MSA and I wondered, if you're going to make a presentation to the district health council, how you're going to reflect the needs in some of those rural communities that are definitely being underserviced today.

Ms Deborah Egan: I think what we've agreed as a group I can say is that we are looking to participate in the district health council's planning process so that we can bring our concerns and ideas forward through that process, and don't see ourselves doing something outside of that. We're looking forward to being part of that.

Ms Susan Taylor: As well, I think that this CAP organization being a group of all of the service providers, and most of the service providers in York region, is an indication that the brokerage model has merit. I'm with the regional municipality and that's certainly our position and that's what we've brought to you before, trying to say that there is an array of service providers out there.

We do recognize that there are some holes and some places where there needs to be better coordination, but this CAP group is evidence that the communities are actually working to do that, and we find this legislation very prescriptive and somewhat interfering in that community development process that is already ongoing.


The Chair: Let me simply note that certainly, since the inception of the organization and bringing together everyone in York region, I think we all have seen that as a tremendously positive step, especially in an area that is so widespread and has urban, rural and a whole series of different communities. So, whatever the future holds, I'm sure that you will all continue to play a very important role in the provision of long-term care. We thank you for coming before the committee today.

Mrs Sullivan: I'm wondering if I could ask the ministry to prepare an additional briefing note for the committee.

I was interested in hearing the discussion about transportation that CAP raised and I note that in our material today we've received a brief from the Ontario Motor Coach Association with respect to the provisions included in the bill regarding transportation and the exemption from the licensing requirements of the Public Vehicles Act.

On page 3 of the brief, the OMCA has recommended that the compendium be changed so that provisions in the act only apply to those entities which own or have a long-term lease for a vehicle. I think we should review this issue and I'd like to know if the ministry would prepare a brief indicating what the implications of that recommendation would be. I understand that it would only apply to the agency and not to volunteers, but I think we should know a little bit more about it.


The Chair: I call on the representatives from the Ontario Nurses' Association. Welcome to the committee.

Ms Jane Cornelius: My name is Jane Cornelius. I'm the vice-president of the Ontario Nurses' Association. With me are Seppo Nousiainen, who is a research officer with the association; Carol Helmstadter, one of our government relations officers; and Noelle Andrews, the director of government relations, research and arbitration.

As vice-president of the Ontario Nurses' Association, I speak on behalf of 50,000 unionized staff nurses working in the province's hospitals, nursing homes, homes for the aged, community health units, developmental centres and industry. ONA is pleased to have this opportunity to comment on Bill 173, the Long-Term Care Act.

We applaud the government's efforts to provide more alternatives to institutional care. We believe this will pave the way for easier access and more consistency and coordination of services. We also fully endorse the goals of the act, and from our nursing perspective particularly support the emphasis on the needs and preferences of the individual client.

We do, however, feel there are two major areas that are not adequately covered by the bill: first, the issue of human resources for the new multiservice agencies, and second, governance and accountability.

In the area of human resources, we are pleased to see that the act facilitates the use of allied health care professionals. It empowers trained MSA staff to make decisions regarding referrals or authorizations for home health services, while MSA referrals can be made by consumers, family members and other service providers as well as physicians.

We are also pleased to see that the act does not specify which health care professional or worker is to be employed for specific purposes. Rather, the scope of practice as defined by the Regulated Health Professions Act will determine when a regulated health professional will be required. We believe this is a major step forward in providing a more flexible and responsive health care system. However, the ministry must consider and include more comprehensive human resource planning. Staff at community health agencies have tended to be less costly than institutional staff because these agencies tend to use a higher proportion of less-qualified workers and have a much lower rate of unionization. Agencies may choose to continue to control costs in this manner because of the RHPA exemptions for personal support workers, who perform "activities of daily living" for their clients, as well as the provision to allow regulated health professionals to delegate dangerous controlled acts to lay people.

This policy, which can result in short-term savings, however is very destructive in the long run. The risk of errors and failure to recognize warning signs of deterioration in health status are greatly increased when those without a broad background in health are delivering the care.

Equally important is the risk of failure to recognize other needs in our growing population of frail, vulnerable clients who are coping with multiple chronic illnesses and who frequently cannot advocate for themselves. Inadequate assessment will place such clients at high risk because of delays in treatment, errors in service planning, inadequate knowledge of service options and therefore poorer outcomes when treatment is finally given. As well, treatment is likely to be far more drastic and unpleasant for the client and far more expensive for the health care system when a client's health status is allowed to reach crisis proportions.

We would also point out that the new legislation does not enable our members, registered nurses, to perform up to their level of education. Every public policy document we read says nurses are undervalued and underused. We cannot agree more and point out the inconsistency in using lower-cost untrained workers while refusing to allow skilled, extensively educated and experienced workers such as nurses to perform to the level of their competency.

Most recently, the Ministry of Health has refused to authorize nurses to draw blood and start intravenous lines independently, two procedures nurses perform daily. This is hardly the way to develop a more cost-effective and responsive long-term care system.

The community system currently has available many highly skilled and experienced workers. In Ontario, there are about 1,700 home care case managers, almost all registered nurses, who have over the past 25 years developed a high level of skill in broad-based, holistic assessment and coordination of services, precisely the function of the MSA. In the Kitchener-Waterloo area, for example, home care case managers use over 1,000 community support systems and programs, exactly the services the MSAs wish to use more fully.

We cannot stress enough that many service providers do not have the interest or mandate to link and coordinate health services in a cost-effective way, while those providers who lack a health care education simply do not have the expertise. We strongly recommend the government make use of the service providers like home care case managers who have the education, experience and expertise to carry out the mandate of the MSA, rather than search for a less expensive equivalent which does not in fact exist.

Nurses are experts in preventive care. As just one example, we would point out the work of the liaison nurses on quick response teams. These teams assess individuals in hospital emergency wards who are over the age of 60. Depending on the assessment results, the nurses may counsel the senior on appropriate health services, discharge them with a referral for home care services or admit them to hospital. In its first year, the Ministry of Health says the Windsor program has saved almost 5,000 hospital stays and close to $2.5 million in hospital costs at a cost of $413,000 for home care. Community health nurses do this kind of work in the community all the time. This is indeed cost-effective health care which both saves the taxpayer money and gives the consumer the kind of service he needs and wants. But it demands professional expertise and experience.


We note that the act provides regulation powers to develop and implement recruiting and using volunteers. We suggest this not only be a mandatory requirement for MSAs but included in the act itself. While we have an enormous appreciation for the very valuable contribution volunteers make to our long-term care system, the legislation must make it clear that volunteers should not be used as a cost-saving vehicle by replacing paid service provider hours.

In our experience, clients have suffered at agencies where volunteers were used in place of paid professionals, because volunteers lack the necessary skills. There is also a concern about their reliability and high rate of turnover, which may inhibit the continuity of care.

To our greatest consternation, we have heard DHC committee members suggest that there should either be a salary freeze or that unorganized workers should not be allowed to join a union at the new MSA. This is illegal. As well, there are many poorly managed agencies within the system that operate with a high overhead cost, a deteriorating corporate culture and poor staff morale. Poor wages and working conditions have led to an average staff turnover rate of 80% at some of these agencies. Again, it is not hard to imagine a resulting lack of continuity of care.

We recommend that the act require that each MSA develop a carefully thought out human resources strategy identifying its personnel needs and the level of training required. The requirement must be specific and incorporated into the act itself. Such provision allows those workers who move to a different setting to broaden their array of skills. As well, long-term planning and a collaborative relationship with staff will enable agencies to restructure without painful layoffs and the loss of skills which have taken years to develop.

In the interest of good client service, the legislation must make the assumption that the rights and job security of the MSA staff are a key to high-quality services. Not only should the clients be treated with respect, but the service providers as well. Their bargaining rights must be acknowledged or the clients will be the overall losers. Experienced people who work directly with clients are the most valuable part of our health and social service systems and represent huge sums of money in terms of education and experience. The new MSA design must reflect this and make effective service delivery its primary goal.

We also have a concern that the act does not make any direct provision for bargaining unit successor rights and strongly feel this point must be spelled out in detail. Successor rights are the continuing rights of employees to be represented by their union and governed by the collective agreement containing their terms and conditions of employment. This is a major consideration with the proposed amalgamation of many agencies under one multiservice organization. The bargaining rights of unionized workers were entrenched in the Labour Relations Act which was amended on January 1, 1993, under section 64, to incorporate a provision regarding successor rights.

With respect to governance, the act itself must spell out clearly how MSA board members are to be chosen and must specifically require the inclusion of front-line providers. It is imperative that adequate union representation be included on the MSA board to ensure that legislative obligations related to successor rights and other rights under the Labour Relations Act are met and that any plan is smoothly implemented.

It has been our experience, particularly with the operation of the hospital fiscal advisory committees, that even when union representation is provided for, effective representation is thwarted by various means. Effective and responsible participation by front-line staff and their representatives will only improve and streamline the process of implementing the MSAs.

We note that the act requires governance at both the DHC and the MSA board levels to reflect the diversity of the population in the DHC's geographic area, including gender, age, disability, place of residence, cultural, ethnic, linguistic and spiritual characteristics of the population it serves. However, the subsection describing the persons experienced in health and social services who are to be included on the board does not specify in any way how these individuals are to be chosen.

For example, the Metro Toronto DHC proposal states that the MSA's governing board will be elected by the voting members of the organization. Without more specific guidance from the legislation with respect to governing the MSA, we feel it is unclear just who will be the members of the board.

We strongly recommend that the act specify what criteria must be met with respect to board participants. We believe they must reflect the diversity of persons working at the MSA and a balance of local interests and perspectives, as well as a mix of expertise, knowledge and experience. All criteria are currently being used for determining the boards of DHCs and their councils and committees.

Despite the DHCs' stated criteria for membership on councils and committees, existing DHCs have been reticent to include labour representatives, claiming they represent a narrow interest of specific organizations or designated communities rather than a broad overall view. This claim is mistaken. Without a labour component, one of the most important elements of the community is unrepresented. Labour is no more biased or self-seeking than representatives of ethnocultural groups, management, boards of trustees or any other constituency.

As well, labour representatives are the only people who have direct contact with the very people the MSA is designed to serve. If the board is to be well informed as to the realities of client care, since the board should be representative of the community, then MSA staff, including direct service providers, must be included.

Accountability should also be of paramount concern and a primary assumption of the health care reform. However, neither the word "accountability" nor the concept appears in part I of the act, outlining the act's purpose. A commitment to accountability must be included.

We are pleased, as always, to contribute our perspective to the government consultations. If we can be of any further help or if you would like more detailed information on our comments, we would be happy to provide it.

Ms Carter: Thank you for an excellent contribution to our hearings. You raised the question of the composition of the MSA's governing board and I just wondered whether we could get a description of just exactly where we're at with that, who is going to be represented, just to make sure that we know what we're talking about here. Could the parliamentary assistant perhaps request that?

Mr Wessenger: The composition of the governing board?

Ms Carter: And how it's chosen.

Mr Wessenger: Yes, how it will be chosen. I'll ask Mr Quirt to indicate, perhaps specifically. There are general provisions, as you know, in the act reflecting the diversity of the community. It will be a board that is chosen by its members. There will be certain criteria set down. One of the criteria, of course, will be a minimum of one third consumer, and I understand that's being looked at.

Ms Carter: Consumers and providers must be represented.

Mr Wessenger: Yes, and also part of the criteria is that there be representation both of the health providers and the social service providers. Mr Quirt perhaps could add something to that.


Mr Quirt: There's not too much more that I can add, other than the MSA has to be a not-for-profit corporation. Generally, our transfer payment agencies are not-for-profit corporations, and normally charitable corporations. They have a membership at the local community level and there's an annual meeting held of the organization. A slate of officers is proposed by a nominating committee, and nominations made from the floor of other interested people, and an election process that tries to make sure that the board of directors is representative of the community to be served.

As Mr Wessenger has pointed out, it's the government's policy position at this point that a third of the members elected be consumers of the service, whether direct consumers or family care givers who consume respite services or other support services. Your point is specifically whether in fact the government should stipulate whether workers should be included, and I think your point is made very clearly in your presentation.

Ms Carter: Sometimes presenters to this committee seem to make the assumption that things are perfect as they are and that therefore, if we backslide from perfection, we're not going forward, as it were. I was interested in your page 7 where you point out that there are some agencies in existence that are poorly managed, have high overhead costs, a deteriorating corporate culture, poor staff morale and very high turnover rates.

The Price Waterhouse report of course has said that by having MSAs there will be a very large saving in administrative costs. It has been suggested to us that this is not the case, that because such agencies as Meals on Wheels rely very heavily on volunteers they are operating as cheaply as is possible. I accept, in that case and others, that we're getting good value at present, but I just wondered if you had anything further to say about the mix of agencies that we have at the moment and the kind of improvements and savings that we're looking at there.

Ms Carol Helmstadter: We certainly don't feel that we have a system which is perfect at the moment. But I think the comment that we were making is that we don't want to lose any of the volunteers. We think that's a very important part, a very essential part of community service. But we also don't want to lose any of the expertise among the professional workers. Of course, being a representative of nurses we're talking specifically about our members, the home care workers who seem to be exactly what the MSA is about: people with both an in-depth knowledge of their individual clients and also an in-depth knowledge of community services and support groups.

I think that was the point that we wanted to make, that it would be easy to say: "Let's move to a lower-cost worker. That's a way of saving money." But in the end, we might very well not save money if we have people who are not trained to recognize all the problems.

Ms Carter: It is crucial that the people who go into somebody's home, whatever category they're supposed to come under, should have the personal qualities and the training that they need to do that properly.

One question that came to my mind, listening to your presentation: What limitations are there on what volunteers can do? For example, I know somebody who was a qualified nurse, was out of it for some years, went back and ended up working in the operating theatre as a volunteer, because after all she was a nurse. I'm just wondering what the guidelines are that control that kind of thing.

Ms Helmstadter: The new Regulated Health Professions Act makes a radical change to what volunteers can do. They can do anything that is not one of the 13 controlled dangerous acts.

The Chair: Thank you. I'm sorry that we don't have more time for questions, but I would like to note as well that in addition to the presentation you also have provided us with another handout that the members have as well.


The Chair: I call on our next presenters, Dr Michael Rachlis and Ms Carol Kushner, if they would come forward. Welcome to the committee.

Ms Carol Kushner: By way of introduction for those of you who may not know, my name is Carol Kushner. This is Michael Rachlis, who is on the faculty at McMaster University and who works as a part-time physician at Hassle Free Clinic. We've written a few books on health care together. I'm going to turn the podium over to Michael to begin our presentation today.

Dr Michael Rachlis: Thank you very much for allowing us to present to you this morning. We have a present for you, members of the committee. If I can give these to the clerk, we have three copies of our new book, Strong Medicine, which we would modestly suggest may have something to do with your deliberations on this act. We'll present them to the clerk. There's one for each of the parties represented on the committee.

We first want to make the point that we're in general support of Bill 173, and we would urge you to recommend its passage. However, we would like to explain our support and make a few comments on matters which we think should be kept in mind during the bill's implementation and watching it over the next few years. In fact, we note that many of the key features of the actual legislation remain to be defined with regulations, and therefore we would like the committee to consider some specific regulations.

First of all, we would like to outline our vision for long-term care because I think that reform of long-term care has always included a vision in this province, over the last decade as several governments have grappled with this. But unfortunately I think it may be fair to say that reform of long-term care has been deflected because of the rather narrow views of special interest groups representing different actors in the health care system. This committee of course is hearing mainly, as I look at who's presenting to you, from what I would call special interests within the system, which I would not include necessarily as consumers but people who work within the system who are very concerned about the way the system will operate once the legislation is through.

I just want to remind people of what a vision for long-term care might look like by describing our favourite model of long-term care, which is the On Lok Senior Health Services in San Francisco. We feel that many people who supported the concept of MSAs had this vision of the On Lok Senior Health Services specifically in their minds, so I just want to describe it again to you and explain why I think we should be pointing towards this program.

On Lok was founded over 20 years ago by Mary Lou Ansak, a social worker. The program operates as a not-for-profit corporation. The full name of the program is On Lok Geui -- pardon my pronunciation -- which in Cantonese means "abode of peace and happiness." The name reflects the philosophy of the program and the fact that about three quarters of the clients are of Chinese ethnic origin.

People enter the program if they live within a certain area of San Francisco and have been assessed by a California state assessor as being at a nursing-home level of need. At that point, they can either chose to enter a nursing home, in which case the state of California will pay the full cost of their care, or they can chose to enter On Lok. If they enter On Lok, the state pays the program 95% of what they would have paid the nursing home. Altogether, with state and federal moneys, in 1991 On Lok received about $2,500 US per month for each client, which is not too different from what a semiprivate or private client in an Ontario nursing home would pay, all told, out of their co-pays and public payment.

From this sum, On Lok pays not only for long-term care but for all health care that their clients need, including hospital care, medical care, diagnostic tests and medications, as well as institutional care. The program is at full financial risk for any care their clients need. If their clients get sick and need hospitalization or need surgery, they have to pay for all costs that their clients entail.

On Lok's clients have very high needs: 75% have some incontinence, over 60% have some mental disturbance and 40% are so poor that they qualify for a poverty supplement to their US social security payments. So they are very much a difficult group to care for.

On Lok's funding is not attached to their services. Rather, it is an example of the type of program that many people in health policy these days support, where the so-called funding follows the clients. It isn't that the clients have to follow the funding to get their services; the funding follows the clients where they go. On Lok has complete flexibility in the use of this pooled funding. They don't have to spend their money on institutional services, and by and large they don't.

Most of the services that On Lok's 325 clients receive are from one of their three day-services facilities. At the facilities, the clients come at least once a week, and most come three or four times a week. They get hard services, professional services like medical services, nursing services, dental services etc, but On Lok's focus is on keeping their clients healthy by ensuring that they have adequate nutrition, exercise and social support -- what we all need to remain healthy.

I just want to add that the focus of community services in Ontario mainly has been on delivering services in people's homes, which is necessary at some points; On Lok does do that as well. But on the other hand, when I used to watch that commercial for the Ontario lotteries where a woman brought a meal into this old fellow's home, it was his birthday, and she just stayed for a minute, I used to cry, feeling that this was the focus of our delivery of care to seniors, that on someone's birthday they would only see another person for a minute and that person would be somebody who was paid to provide care to them or maybe volunteering to provide care, but not their family, not their friends. The fact that this could be used as an example of the kind of program that our tax money should be supporting I found to be tremendously sad.


So you can't stay heathy like that, and you won't eat right if you're at home having a meal delivered to you. Mealtimes are social times for us, and that's why many seniors don't eat so well; they get their meal delivered by a very hardworking volunteer and it sits there and goes bad because they don't have anybody to share it with.

At the day centres, the staff pay special attention to the clients' diets. Each client has a graded exercise program. I visited the program twice; Carol's been there once. This is a very frail group of elderly people, but they glow with health. You can be frail and healthy at the same time, and these people's skins glow, their eyes glow. Some people might say, "That's just California; it must be a cult," but they look really healthy. I'm convinced it's because they eat well, they exercise and they see their friends and their neighbours.

The staff do almost anything to keep people out of institutions because On Lok is at full financial risk for their health care. The staff so carefully monitor their clients' chronic conditions that they are virtually never admitted to hospital for the deterioration of a previously identified illness. This is something, in fact, that has been shown in other health services literature, primary care research, that if people have diabetes, heart disease etc, if you're on top of their conditions they should virtually never be admitted to hospital for deterioration of those previously identified illnesses.

The results of the On Lok approach are spectacular. Because of the program's focus on community and home care, On Lok's clients' rates of hospitalization are approximately the same rate of hospital utilization as for the general population of Ontario, probably anywhere from a fifth to a tenth the rate for comparable long-term care clients in Ontario. Although the clients must be rated at a nursing-home level of need to be eligible for the program -- they all have to be at a nursing-home level of need to get in -- on any given day only 5% of the daily census are actually in nursing homes; 94% are living independently in their own homes.

A breakdown of the On Lok budget, which we've provided on page 2 of our presentation, compared to the Ministry of Health in Ontario, for the 1990-91 fiscal year shows that On Lok has managed to turn the traditional funding pyramid on its head. They've been able to put over half of all their resources into community and day programming, compared to only 16% for institutions and 11% for physicians' care.

I just want to briefly highlight the key points that we think bear on On Lok that we should be remembering as a vision for this legislation and beyond.

First of all, the care provided is based on patients' and families' informed choices.

Secondly, the services are delivered by multidisciplinary teams which are not hierarchical. Traditional health teams are sort of last vestiges of the military approach to organization. Outside of the military, it's only in health care where you hear about somebody giving somebody else orders. As much as possible, the team member at On Lok delivering any specific service is determined by objective evidence of cost-effectiveness.

Third, the doctors' working groups in here have clear collective responsibility for their tasks, something we'll mention briefly later, that we're quite concerned about the lack of integration of physicians into the service model. Services that promote health and prevent disease, including self-health and mutual aid, have a very high priority.

Finally, the various levels in the delivery system -- primary care, secondary care, tertiary care and community services -- are all integrated in their financing. It's wonderful to talk about how different organizations try to cooperate with each other. The best way to ensure cooperation is to give them the same budget, and then the dollars are attached to persons, not services.

I'll close my part of the presentation and turn it over to Carol now.

Ms Kushner: I want to talk a little bit about the implications of the On Lok model for Ontario's long-term care reform, because, as we said at the outset, we generally support Bill 173 because we see that it has potential over time to lead to this type of service delivery in this province. However, in order for that to happen, it's very important that this committee and other Ontarians interested in long-term care reform follow the development of the regulations in support of this legislation to make sure:

(1) That multiservice agencies truly have the opportunity to allocate resources according to need;

(2) That MSAs are funded on the basis of individually assessed, needs-based capitation payments;

(3) That other services, such as institutional care, medical care, laboratory services and medications, are eventually included in the funding envelope; and

(4) That different MSAs should be allowed to compete with one another for clients on the basis of quality of care and service.

I'm going to highlight each of these points now in the remainder of my presentation. As for the first point, that multiservice agencies truly have the opportunity to allocate resources according to need, over the past decade government documents have invariably mentioned the need to reallocate resources from institutional care to community-based care and from the treatment of illness to the promotion of health and the prevention of disease, but unfortunately Bill 173 only allows the minimum reallocation of resources within community services and home care budgets.

However, if even these funds are targeted to specific services, as seems to be implied in the way the legislation is drafted, then realizing the On Lok vision will be virtually impossible. We must have a way of being able to distinguish among and between personal care services, home care services, professional services and home support services. Moneys in those envelopes need to be able to flow according to clients' needs, and I'm concerned that perhaps they won't be.

On the second point, that the MSAs are funded on the basis of individually assessed, needs-based capitation payments, the funding of MSAs really should be tied to persons and not to services and not to programs. The best way to accomplish this is by making sure that the initial assessment slots a client into one of a number of categories based on their need for care. Clients of course need to be reassessed periodically in a routine way and also any time their condition changes, and there would have to be some kind of minimum criteria for any services that are received in order to ensure that as much as possible what's delivered goes to those who are most in need. The people with the highest needs should have the greatest claim to the system.

Other services are eventually included in the funding envelope, for example, institutional care, medical care, laboratory services and medication: Other services should be included in the funding envelope as soon as possible. There's not much opportunity, frankly, to reallocate within long-term care, community care and community support services. That's not where the opportunities exist.

It's crucial that these other elements be added in order to ensure effective coordination of services and the efficient use of resources as well. In particular, immediate consideration should be given to the addition of the budgets for institutional care, including long-term, chronic and acute care for these patients.

It's been noted repeatedly over the past decade that Ontario's seniors are being dangerously and expensively overmedicated. MSAs would have a strong financial incentive to encourage better prescribing and to reallocate the drug budget to health promotion and prevention of disease and to encourage community care if the Ontario drug benefit plan payment were added to the capitation sum.

Finally, what we think is the most exciting point in all of this is the idea that different MSAs should be allowed to compete with one another for clients on the basis of quality of care and service. We have some concerns that in an absence of competition among MSAs, we might be stifling innovation instead of promoting it.

To avoid this, we recommend that the regulations allow different MSAs in the same geographical area to compete with one another. We suggest that the province routinely publish outcome information about the performance of all MSAs. This would allow perspective clients and their families to make good choices about where to receive their care. One might imagine, for example, that certain MSAs might specialize in providing care to certain types of patients, and information of that nature would be very helpful to clients making such a choice.

Because the funding for the MSAs would be based on needs-based capitation, the total budget for an individual MSA would depend upon the number of clients they attracted and the sum of the clients' individual needs and costs for care. However, for the region, the budget for all MSAs would be fixed, and that's an important point in terms of your desire to have some fiscal responsibility built into the system.

I think these points also speak to the issue of accountability, that when you are monitoring the performance of MSAs and publishing results about their performance and making those results publicly available, you are in fact creating a climate in which MSAs are going to be very careful about the quality of care and quality of service they provide, knowing that hard measures are going to be documented and published.

Those MSAs which were user-friendly and which provided high quality care within their capitation budget would flourish; those that provided poor quality, unresponsive care would not. We feel that this quasi-market within a public system, with minimal copayments, would lead to improved efficiency and consumer choice.


About 0.5% to 1% of the Ontario population requires intensive long-term care. Therefore, a community with 10,000 persons would have somewhere between 50 and 100 people needing this type of care, the kind of care that's delivered by On Lok. This would provide enough clients to create the economies of scale to start up an On Lok-type model of care.

There would be room for some competition in almost all areas of Ontario, and in southern Ontario most residents could choose from 10 or more options. In northern and remote areas of the province, there would likely only be room for one MSA. While that's unfortunate, I think it's important to remember that economies of scale make that option unrealizable.

Conclusion: Bill 173 is a long overdue reform of Ontario's system of community long-term care. We urge the committee to recommend passage and in addition ask the committee to recommend the regulations that we have outlined. These would allow Ontario residents more choice for more efficient and responsive services. Thank you for listening to our presentation. We are glad to take questions.

Mrs Sullivan: I think your presentation is a very interesting one. I'm quite interested in the capitative model; I think it's an interesting approach. I like, frankly, what's happened in certain of the HSOs in Ontario, although the rules got a little bit out of whack there.

There are a couple of specific questions that I'd like to ask. When you speak about the potential for MSAs to compete, and to basically compete on the basis of their record of quality of service and quality of care, I'd like to know where you see the evaluative mechanisms coming from and whether the evaluations would change if an MSA was varied, say, by condition or by culture, which are not included in this bill, and I would like to see them added to the geography.

Where do you see those evaluative mechanisms fitting? Who would do the evaluation? Where does the client fit? Could you just speak to that for a minute.

Dr Rachlis: We feel that this goes generally to reform of health care. Across the country, as you might know, other provinces are moving to regional systems. In fact, it's only Ontario and Manitoba that have not moved to regionalize their health care systems. Looking at ways in which the province can direct regions, we feel that we don't like the approach in most provinces, where the province is saying, "You need a certain number of beds or providers per 1,000 people." We'd much rather have the province focus on outcome. So we recommend that there needs to be the development of a whole series of evaluative items which one could refer to as health care performance indicators.

In this case, what I'd be thinking of is using mainly routinely collected administrative data to evaluate the performance of the MSAs, looking at things such as if diabetes is such a common condition among the elderly, what proportion of diabetics get admitted to hospital from an MSA over the course of a year because of deterioration of their diabetes. As mentioned with the On Lok program, if you have someone who's been previously identified with diabetes, if you're providing good primary care, first-contact services, good community-based services, then you should be able to reduce the admission rate of diabetics to almost zero for deterioration of their diabetes.

There's a whole range of indicators like that which would have to be adjusted for the case mix that you're dealing with. Dealing with a population where you've got more widows than widowers, you're going to need more formal services because you've got less informal care that's going on.

I should mention that this whole area is one that is of great interest in the health services research community these days. In the United States there was a consortium formed of health maintenance organizations, or HMOs, in the late 1980s to look at developing quality-of-care indicators.

The consortium has for-profit and not-for-profit HMOs, and of course in the American context they're very much focused on marketing. Some HMOs are now developing report cards where they're outlining their performance according to various quality indicators.

We think, however, that this movement, which in the US has a different beginning, could be very useful for Canada in trying to evaluate the performance of different not-for-profit models like MSAs or the performance of regions within regionalized health care systems. It's not something that I could give you a treatise on right now -- "Implement this right away" -- but on the other hand, it wouldn't be difficult to start bringing together some indicators that could easily measure the quality of care that would be delivered by MSAs in the next year or two. Because of the tremendous interest in research in this area, there are going to be some very formal systems of assessing quality that will be brought in soon. As I mentioned, there are some US HMOs, starting two years ago, that are actually issuing report cards for the quality of care they're delivering.

Ms Kushner: Could I just add one thing? I think it might relate to a second part of your question, which was, if I understood correctly, dealing with the idea that perhaps some MSAs will be targeting certain clientele, certain specific clientele, perhaps an ethnic group, perhaps a group with a specific disease. But in addition to the quality-of-outcome indicators work, one could also look at the quality-of-service aspects, which would come from direct feedback from clients of this service, so that one could in fact have some kind of measure of how well the recipients of service appreciated those aspects of service: timeliness, friendliness etc.

Mrs Sullivan: Do you find it surprising that given that affordability issues are very much on the plate in health care and that quality of care is very much on the plate in health care -- the outcomes movement, it seems to me, is a very strong one -- that the government has not moved forward on either a pilot or a demonstration project with respect to this entire area of long-term care reform?

Dr Rachlis: No, because no other government in the country is doing it. It really doesn't matter what you look at. For example, Saskatchewan was first out of the gate probably this round in making some health reforms, but BC, Alberta and Nova Scotia, with three different parties in power, all are taking very similar approaches and are ignoring some of these key issues.

Mrs Sullivan: But how do we know that they're right? Maybe we should test it first.

Dr Rachlis: We don't know whether they're right, but I think that this government's approach to not bringing in the things that you've just mentioned is consistent with what's going on across the country.

Ms Kushner: In fact, even outside the country. When Great Britain introduced its health care reforms, they didn't want to evaluate them either.

Mrs Sullivan: No, but they certainly did have cost measures, though, analysed in advance of setting up their changes.

Ms Kushner: They did. I thought we were talking about quality and outcome measures.

Mrs Sullivan: Both, because affordability is also an issue. I think there have been an awful lot of promises made without any guarantee of service.

Dr Rachlis: If I could, one of the approaches to health care reform that we're quite concerned about is the fact that there's a closure of institutions, there's a cutback in institutional care, which of course is covered by the Canada Health Act, and there's a move to provide more services in the community which are not covered by the Canada Health Act.

So there is an implicit move to privatization when you downsize institutions and develop community-based care, if you don't make explicit that you want this to be within the public budget.

It doesn't matter to me whether I have to pay out of my left pocket in taxes to support my parents in long-term care or out of my right pocket to pay privately; it's still all my money. Any affordability assessment I think has to look at total cost, and that's something that does concern us.


The Chair: I regret that because of our agenda that we're going to have to close, but I want to thank you as well for the three books that you left with each of the caucuses. I don't know whether I should say that every member of the committee will have read every single page before we get to clause-by-clause, but I know that the book will be very helpful as we continue our work.


The Chair: I ask our final presenter for the morning to come forward, the VON from Brant-Norfolk-Haldimand. Welcome to the committee.

Mr Don Townsend: My name's Don Townsend. I'm the new president of the VON branch in Brant-Norfolk-Haldimand, and this is our executive director, Cathy Chisholm.

The Brant-Norfolk-Haldimand branch of the VON is pleased to be given the opportunity to participate in the process that will produce more efficient access to health and social services for the people of Ontario. The local branch has been serving the citizens of Brant county since 1907 and those of the regional municipality of Haldimand-Norfolk since 1970. During this time, VON services have evolved in response to the needs of the communities. VON has been a leader of change in community health across the country and it's from this base of experience that our comments and recommendations on Bill 173 are presented.

It's really difficult to know where to start in the time allotted, but I guess the one thing I wish to convey to this committee from my point of view and from the board's point of view is the feeling of frustration that we are experiencing and that the staff is experiencing because of the tremendous number of unknowns that face us in our decision-making process and therefore by our inability to set a definitive course of action.

I have been a member of the strategic planning committee since its formation. We've worked very diligently to make plans for our future and to increase the levels of quality of service even higher. When it was announced that multiservice agencies would control the delivery of the services we provide in our communities, out of necessity our plans had to change.

We had no doubt that VON would play a major role in the future and that our organization would be a logical sponsor for the MSAs in our area and we worked towards that goal, only to find that sponsorship was not what the government envisioned. We had a glimmer of hope with the suggestion of a federation of service providers and we worked towards that goal of being part of a formal partnership with other local agencies, only to find that federation was also not what the government had in mind.

Under Bill 173, all services will be provided by the MSA itself. We see this as the probable end of our branch, with 99% of our services being taken away. Amalgamation will virtually destroy not-for-profit service providers like the VON. Perhaps the government doesn't feel that these agencies are important and that only the services they provide should be considered. However, there is more to our organization than just the employees and the work they do.

We are concerned that the intangibles that make up organizations like VON are being missed. VON's provincial and national bodies set standards, provide education, innovation, technical assistance and a sense of solidity and purpose which ultimately directs the activities of each and every employee. The fact is that because of its size and human resources, VON is able to set and design clinical procedures and standards of practice that have become industry standards. One questions why the government would want to eliminate those values that are added to the current system by organizations like VON. We are concerned that those values will be missing from the MSAs of the future.

One of the things that gives the current system its excellence is the continual striving of agencies to maintain a competitive edge. VON constantly strives to be better, not only in proficiency but also in efficiency. Our local VON branch has operated with a strong fiscal management for many years. We have not been a burden to the health care system but rather a valuable asset. Over the past four years the fee per visit for the visiting nursing program has been frozen or has gone down, with the result that increased services were provided to the community. The efficiency of our local branch has become a standard for VON branches in Ontario. We are concerned that the MSA of the future will not retain the same dedication to cost-efficiency which is a direct result of having to maintain a competitive position for home care contracts.

In the event of amalgamation of agencies into an MSA of the future, VON Brant-Norfolk-Haldimand will have to downsize dramatically. We will have to lay off a number of staff. We will have to default on leases. Is the government prepared to offer severance packages to staff and is the government prepared to meet the other financial obligations resulting from the cessation of business? As a non-profit charitable organization, VON does not have the resources to meet such obligations.

As the new president of our board, I am faced with the task of giving direction to the board so that it may in turn provide direction to staff. I want to be able to give them assurance for the future of VON in Brant county and the regional municipality of Haldimand-Norfolk. I'd like to know. Is our government prepared to give me a message of hope for the future of VON to take back to my board?

Ms Cathy Chisholm: In particular, VON Brant-Norfolk-Haldimand supports the principles and values underlying Bill 173, and in particular we endorse local planning based on each community's needs, equity of access to services by consumers, one-stop access to a range of services, administrative streamlining, the majority of service delivery by not-for-profit providers, not-for-profit governance and integration of health and social services.

Over the years VON has demonstrated its commitment to the development and implementation of standards of care and the continual improvement in the level of service quality and endorses these as essential components of a reformed health and social service system. As administrator of a large visiting nursing service and an even larger visiting homemaking program, VON Brant-Norfolk-Haldimand is presently completing a reorganization of its structure to create a streamlined administrative process which will support integrated front-line work teams.

Client services will be improved with improved communication between workers who will collaborate on the development, implementation and evaluation of care plans.

However, our branch does have one specific area of concern. Ontario is a large geographically and culturally diverse province with a complex health care system that includes one of the most advanced long-term community care systems in Canada. The complexity of this environment requires that the service delivery system reflect the needs of the communities it serves. Therefore, one would assume that the proposed legislation would be flexible enough to accommodate the diversity of the population and its communities.

VON Brant-Norfolk-Haldimand is concerned with the apparent lack of flexibility in the legislation regarding the multiservice agency in that only one model for the MSA is acceptable, the one that amalgamates all current service providers into one agency. We are concerned about the potential disruption or discontinuation of services to clients that may occur if all providers are employed by the MSA. During the strike of Red Cross homemakers in Brant county in 1993, the home care program contracted with other agencies for the provision of homemaking services to clients. Home care, as a separate establishment, was not in violation of the replacement worker provisions of the Labour Relations Act because it was not the employer of the Red Cross homemakers.

Under a sole-employer MSA, a similar strike could result in no services for clients. The MSA could not contract with external agencies to provide the services normally provided by its own workers, since to do so would put the MSA in the position of hiring replacement workers and therefore in violation of the Labour Relations Act, and that's even assuming that those other agencies would be there to hire staff from.

Since clients generally cannot do without the services they depend on to remain at home, MSA governing boards will want to settle any labour disputes or strikes quickly. This usually means additional cost to the system in terms of employee wages. Ultimately, there may be a decrease in service, since the current informal capping of the home care program budgets across Ontario will be a reality of the future.

For this reason, we believe that the lack of flexibility in MSA models is not in the best interests of communities. From our observations of this hearing process, it is also not what communities want. The challenge that faces all of us -- government, communities, individual organizations -- is to improve the current system without discarding all that is beneficial.

Our recommendation is that the legislation must be flexible enough to allow for different governing and service delivery models to meet the varied needs of Ontario communities while meeting government's requirements for accountability. Preservation of the service delivery system for clients must be of paramount importance in the process of reforming the system.

To that end, VON Brant-Norfolk-Haldimand branch is working within its communities to improve services. Partnerships with other provider agencies are being explored. At the same time, VON is working to improve its own organizational effectiveness and cost-efficiency. We are committed to changes in the health care system that will improve services to clients. Please give us the long-term opportunity to be a partner in the reformed system in Ontario.

Mr Jim Wilson: Thank you for your presentation on behalf of VON in Brant, Norfolk and Haldimand. We've heard similar concerns from other branches, obviously, of the VON and from VON (Ontario). I guess I just have a simple question for you, because as far as I can tell so far in our experience with this government in the past with respect to committees and their willingness to dramatically change legislation as a result of committee processes, in the past the government hasn't been very willing, so I suspect the government isn't going to budge on things like the 80-20 rule. Therefore, that and a number of other things in the bill which are of vital importance to the government's agenda will result in the VON being wiped off the map.

What did you do, or what are you doing, that's so terribly wrong that the government feels the need to get rid of you?

Ms Chisholm: We wish someone would tell us.

Mr Jim Wilson: It's that simple, eh? Because, you know, we've all followed reform -- I've been critic for a number of years, Mr Jackson's been critic for social services over a number of years -- and we too were caught by surprise, as you mentioned in your presentation, with respect to the government not allowing a federated model of any type or not allowing flexibility.

I get a sense from your presentation that if left alone, if simply the government said, "You must create a model in your community that incorporates the principles of this legislation," you would be able to come back in a year or two, or less time, to give the government an option for an MSA-type organization, whether it be federated or otherwise.

Mr Townsend: I don't think there's any doubt that we could work with the other agencies in our communities to do that. Everybody knows everybody in our area and we can work together, and now we're being told, "You're not even going to exist and have the opportunity to work together."

The Chair: We have had a number of presentations from various VONs across the province. We thank you for coming before the committee this morning.

The committee recessed from 1202 to 1405.

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


The Acting Chair: Our first presenter this afternoon is the Canadian Co-operative Association, Ontario region. Welcome to the committee.

I just want to put you folks as well as other presenters this afternoon on notice that we've been allocated 20 minutes for each presentation. Given that this is such a brief period of time, we'll generally be restricted to asking one question only, assuming that there is time permitted for that. That is not by any means an expression of lack of interest on the part of committee members. It is just that time does not permit for us to engage you in more than one question or comment.

Ms Kathy Bardswick: My name is Kathy Bardswick. I am the chair of the Ontario region council of the Canadian Co-operative Association. I'm an employee of the Co-operators Life Insurance Co and am the vice-president of our Metro region. With me today are Judy Goldie, the manager of the Ontario region of the CCA, and Myrna Barclay, director of corporate services for the national Canadian Co-operative Association office in Ottawa.

The Canadian Co-operative Association is a member-based organization of regional, provincial and national cooperative organizations. In total, these organizations represent over two million members in communities through Ontario, have assets of over $12 billion and employ over 7,000 residents of Ontario.

The overall mission of CCA is to enhance and support a united, growing and influential cooperative movement in Ontario. To this end, our organization is involved in government relations, youth leadership development, public education and community cooperative economic development.

CCA has a long-standing interest in health care policy. Along with our member community health care cooperative organizations, we promote the cooperative model as a proven way of delivering cost-effective and high-quality community-based health care to Canadians. Our national policy statement on health care is appended to this brief.

CCA continues to endorse the primary objectives of the Canada Health Act. We are committed to the five publicly stated goals of medicare, including administration by public agencies on a not-for-profit basis. We believe that the health care system should be focused on the consumer, on prevention and that it can be much more effective and cost-efficient. Reform must include community-based health care as an integral part of Canada's health care system.

The financial limitations facing all levels of government, coupled with growing health care demands, lend a particular urgency to the need for health care reform. CCA recognizes that Bill 173 brings major reform to the long-term care system, which should be more effective for users and more efficient for taxpayers.

CCA believes that the cooperative model has something to offer the long-term care sector in Ontario as it reorganizes to focus on the users of the service, becomes more efficient and effective and involves the community in governing the system.

Last October, in a statement to the Legislature, the Honourable Floyd Laughren commented that, "We want more people to know about this model, because we are certain many more people will find the cooperative approach suits their goals." The current and previous two governments in Queen's Park have favoured the not-for-profit community-controlled development of community health care centres as a major thrust for reforming the health care system. There are now 53 CHCs in Ontario, and we urge all members of the Legislature to support the growth of this exciting new component of health reform.

Recently, the Legislature passed amendments to the provincial Co-operative Corporations Act that provide a more flexible framework in which cooperatives can develop. Provisions were added for multistakeholder cooperatives, a cooperative structure which we feel has great potential for both community health care centres and long-term care multiservice agencies.

We support this act's focus on alternatives to institutions, illness prevention, user-friendly service, equitable access, efficient management and community governance. Our comments and recommendations focus on the governance structure of the proposed multiservice agencies. I will begin the discussion with an overview of the multistakeholder cooperative and then point out the advantages which this model has for MSA structure and governance.

Cooperatives are rooted in the mutual self-help tradition. They operate economic, social and service enterprises according to the same principles that underlie political democracy. They are membership-based and governed through the application of democratic principles. Board members are elected and accountable to the constituencies they represent.

Cooperatives can be incorporated as profit or not-for-profit corporate entities. There are many examples of not-for-profit cooperatives without share capital, such as housing co-ops, child care co-ops and health care co-ops. It is this form, that would be appropriate for multiservice agencies.

In the multistakeholder cooperative, each constituency vital to the success of the organization is identified. The stakeholders, either individuals or organizations, become members of the cooperative. The number of seats on the board of directors is then divided up among the identified constituencies to achieve the balance of control desired. Usually, no one group has a majority of board directorships. Each constituency elects its own board representatives from within its membership. Membership meetings with each constituency, held either separately or together, can be used to consult a wider base of participants/stakeholders. All interests are included, with clear lines of accountability.

The cooperative model is already working successfully in community-based health care centres. We refer you to a study prepared by Doug Angus, Community Health and Epidemiology, Queen's University, and Pran Manga, MHA program, University of Ottawa, entitled Co-op/Consumer Sponsored Health Care Delivery Effectiveness. This study assessed the efficiency and effectiveness of this type of health care delivery model. The study identifies economic and non-economic advantages of community-participation health care centres and calls for legislative reforms to recognize that such centres are an important delivery model in the health care system. Major advantages over other service delivery models are included in this brief.

The authors summarize by saying: "These advantages make such cooperative or consumer-sponsored health care centres very good vehicles for carrying out many of the government health system objectives and priorities. Indeed, that is why they have been and continue to be strongly recommended by virtually all the commissions of inquiry over the past two decades."

The Co-operators Data Services Ltd, one of Canada's largest computer service companies, has been operating a multistakeholder cooperative since 1986. Its major stakeholders include the employees, major clients and suppliers of capital.

Control of the cooperative has been divided among these stakeholders, bringing gains in productivity and client-sensitive services. All permanent staff may purchase membership shares. In return, they can run for one of the two staff board of director positions or one of the staff representative positions to the annual meeting. Staff who are members can vote for their representatives and can attend CDSL annual meetings. CDSL believes that the major advantage of the stakeholder model is the "voice option" that provides the means for, and encourages its major stakeholders to be involved in, the enterprise, both in terms of operational improvements and the longer-term direction of the cooperative.

Other advantages include an increased number of perspectives at the board table, which lead to better decision-making, increased staff knowledge of the policies which drive the operational plans and budgets and increased staff focus on the results of the organization.

Stakeholders in the multiservice agency would be the consumer-users of the services, other service agency providers and the employees. The government of Ontario is also a key stakeholder, but it need not have a position on the board. Government will have considerable influence over MSAs through regulatory and fiscal controls.

The cooperative model should receive support from those within the long-term care system who are concerned with strong, explicit lines of accountability and who believe in the long-term benefits of democratic methods applied to institutional governance. The cooperative corporate entity, particularly in its multistakeholder form, is a concrete example of public-community partnership in action. Multistakeholder cooperatives are built on the belief that groups that build and benefit from an agency should be in control of it as decision-makers, rather than just advisers.

There are a number of reasons for considering a stakeholder cooperative as the structure of choice for a multiservice agency:

Greater accountability. The cooperative structure explicitly reinforces control by and accountability to the main groups for whom the multiservice agency exists: the users of the service, other service providers in the community and employees. Public accountability, as represented by the government, is achieved through funding agreements and other government administrative or regulatory directives that the MSAs must follow.

The conscious development of an MSA membership through a cooperative structure creates a community base for the MSA. This will strengthen the board, because members will provide a definite constituency for whom the board is accountable. Strong stakeholder boards will ensure that MSAs are not management driven or ministry driven but community driven, the intent of this legislation. MSAs would move beyond community participation to community control. We believe that control is necessary if health care consumers are to be truly empowered. I want to reiterate here that "consumer" refers to the actual service user, in addition to representatives from community groups.

The cooperative model incorporates a commitment to education of the membership, the board of directors and the employees. The cooperative sector, in its commitment to education, has produced educational materials on member participation, board management responsibilities and other governance issues. With education and with a defined constituency, community boards can provide directional leadership rather than simply react to managers and funders.

The government of Ontario has been encouraging the broader public sector to achieve efficiencies by working together to improve services and reduce cost. This is the essence of cooperation.

The co-op model is a logical structure to achieve these efficiencies. The cooperative sector in Canada has built its structure and growth around increased efficiencies through economies of scale and the fact that the whole is greater than the sum of its parts. We know we can achieve collectively what is difficult to achieve individually. In fact, the model proposed here would be most efficient if it reflected the intent of amalgamation underlying Bill 173.

Cooperatives reflect and strengthen the democratic tradition in Canada. The application of democratic principles to our health care system is long overdue in Canada and simply an extension of our democratic tradition.

Our recommendations:

(1) We recommend that the government promote the stakeholder cooperative model to communities as they develop their multiservice agencies. The stakeholder cooperative model is well suited to achieve the purposes of the act as stated in part I.

(2) We recommend that the government amend part VII, section 16, of the act to enable employees of the agency to be directors of the agency. As strong community-owned cooperatives, the MSAs could not be viewed as government agencies. The argument against employee directors therefore diminishes greatly. Community health centres across Ontario have already set a precedent with employees on several of their boards. These organizations are funded by government but operate at arm's length with community boards, much like the MSAs are intended to do.

(3) We recommend the government ensure that MSAs have sufficient funding to keep their stakeholder members informed and participating in their organization and the board of directors informed of its roles and responsibilities. Maintaining healthy democratic structures requires work. Education and training dollars are essential to successful and democratic board operations. Community health centres in Ontario recognize the need for enhanced funding of director education, including diversity training, to improve both community representation and board effectiveness.

(4) Finally, we recommend that the government encourage MSA boards to be of a suitable size for maximum board effectiveness. In our experience, large boards at the local level inhibit maximum group effectiveness. When organizations amalgamate, there is a tendency for the size of the board to be larger than would normally be considered workable.

In summary, we urge the standing committee to consider the stakeholder cooperative structure in designing multiservice agencies. We are willing to provide the committee with more detailed information and would be pleased to work with the government during the MSA implementation phase.

The Acting Chair: Thank you very much for your presentation. The parliamentary assistant wishes to ask a question.

Mr Wessenger: It's interesting to hear a novel approach with respect to an administrative structure. I have some questions, though, about the stakeholder co-op model. I suppose the first question is, do you feel this model could meet for instance some of the eligibility criteria with respect to representation on the board? How do you see that being effected through a multistakeholder model, for instance, the criteria of consumer representation, the criteria of expertise in the social service and health area, plus perhaps we'll say managerial expertise?

Ms Judy Goldie: In the process of creating the stakeholders' model, you have to identify who the stakeholders are and then predetermine what kind of balance you want on that board, taking into account those eligibility criteria.

Mr Wessenger: If I could just follow that up. With, say, a normal non-profit corporation model you would have probably a membership that would be open to everybody in the community. With a multistakeholder model it would seem you would have somewhat limited opportunity to participate in the management of the model. I'm just suggesting that might be a problem, that you'd have a much narrower base of representation on your board in a multistakeholder co-op model than you would with an ordinary non-share, non-profit corporation.

Ms Bardswick: Just to expand on the answer provided, the pool of resources for the board would come from the user community at large for the MSA, which would be a fairly broad pool to begin with. It could also include, if that's the way it was structured, representation from agencies or other suppliers of services, be they technical providers of services or service delivery providers. Management, of course, is sitting as advisers to the board in any board situation, and any other external provider who is seen as providing or having a major stake in that organization. Given that the model is as flexible as it is, you can provide that kind of balance of expertise on the board.


Mr Wessenger: Another question: Can this model be a charitable corporation? Do you know? I think that's very important, that the model have a charitable status so that it can receive donations that are deductible.

Ms Bardswick: Yes, it can.

Mr Wessenger: In your opinion, it can.

The other aspect I'd like just to follow up on, you indicate you believe that the governance model should include the opportunity for employee participation on the board as voting members. Is that correct?

Ms Bardswick: Yes, it is.

Mr Wessenger: Would you agree that there should be consistency among various types of health institutions with respect to this model of governance? If you have employee participation, as you say, on some of the community health centres -- some of them have it, some of them don't -- on a broad-based approach, do you think all sorts of services, all these comprehensive health service agencies, should have employee representation on their boards?

Ms Bardswick: Yes, we do. The fundamental aspect and concept of a multistakeholder organization insists that there be that kind of balance and influence from the major stakeholders of the organization. We believe that in any such model employees are indeed major stakeholders and therefore should be represented on the board.

Mr Wessenger: The reason I'm pursuing this particular aspect is, when I did a number of hearings on the Public Hospitals Act, it was often suggested that the representation by employees be voiced without vote. You don't feel that's an effective model, having only the representative voice but no voting rights?

Ms Bardswick: In fact, we submitted a brief at that point as well that did recommend that employees do have a voice on the board and we feel it would be --

Mr Wessenger: Have a voice?

Ms Bardswick: And a vote.

Mr Wessenger: And a vote.

Ms Bardswick: Yes. We don't believe voice is very effective without vote.

Mr Wessenger: Right. Okay, fine.

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


The Acting Chair: Our next presentation will be made on behalf of Trans-Action Coalition. Welcome to the committee.

Ms Janice Tait: The summary of recommendations is at the back of the presentation. I'm not going to read my brief because in the body of the brief are some rather technical descriptions of transportation matters. I'm just going to talk to some of the recommendations, the ones that I think are the most important.

First of all, I'll just tell you that the Trans-Action Coalition is a coalition of over 100 member organizations working to improve transportation for people with transportation disabilities in the province. The Hickling report, in 1992, estimated that about 10% of the population is transportation disabled.

Second, I would like to say that although I understand that the Ministry of Transportation is supposed to be a partner in this exercise, our impression is that it's more of a silent partner than a partner, with the emphasis on silence. As far as I can tell, and I've had 15 years of close study of the MTO, it's doing almost nothing in this area.

So the first recommendation that I want to make to this committee is that the role of the MTO be identified and defined. We believe that the Ministry of Transportation ought to develop a policy setting out its long-term commitment to people with transportation disabilities in Ontario. They have never developed a policy in this area.

We also believe that transportation is not a social service. There is a good deal of disagreement about this across the country, but we are very firmly of the opinion that transportation is a public service, like water, sewage, garbage disposal, and it should be run as a public service. This puts us in direct conflict with a lot of the work that has gone on in the transportation committee, because there's a very strong emphasis there on volunteer transportation services.

I'd just like to give you an example of what happens when you have volunteer services. Pickering has a public transit service. Pickering, I think, is a city of about 40,000 to 50,000 people. It has public transit, it has a specialized transit service and it has a volunteer service that grew out of the home care, home support. But the public specialized service operates from 9 until 6 and it does not cross a municipal boundary.

This crossing of the municipal boundary, have you heard anything about this? Do you know about this?

Mr O'Connor: Big problem.

Ms Tait: Huge problem. It's a problem that MTO could solve, but it has not chosen to do so because it says it's a municipal responsibility. Well, it's a municipal responsibility and it puts tremendous strain on specialized transportation services.

In Pickering, if you want to travel after 6, on weekends, on holidays or you want to go to Toronto, you use the volunteer service, and if you want public transit from 9 to 6, you use the public specialized transit. But having that volunteer service undermines the public specialized transit and it lets the ministry off the hook on providing a public service.

So there's been a lot of talk in our committee that throughout Ontario these MSAs are looking at volunteer services to fill the gap, and we absolutely disagree with that. We fundamentally believe that is the wrong way to go. It may be necessary in the short term, but it is not sufficient.

We believe that everybody in Ontario has the right to some kind of public transportation service, especially the people who have no cars, which is about 30% of the population. And who are we talking about? The young, the old, the unemployed, the poor.

We feel that there are ways for the ministry to provide transportation to people in small towns and rural areas. We believe that whatever transportation is set up should be available to the people in the area besides those who are in long-term care; that is to say that the public transportation service should be for everybody, and the people who are in long-term care should buy the service, just like anybody else.

That means that everybody pays a fee. We've spent a lot of time on the subject of fees, but in the area of transportation it seems to me to be very obvious: Everybody pays a fare. Now, the fare is not always the same in every area, but equity demands that within an area people pay the same fare.

More important, we think we have a solution to how to provide transportation services throughout the province on a very cost-effective basis, and it's called a brokerage system. Really, it works the way a taxi company works now, but in our view it should be publicly funded and publicly run. That means the Ministry of Transportation has to provide subsidies to local governments and regional and county governments to set up a computerized dispatch system and scheduling service.

With that computerized dispatch system, you take all the vehicles in every community that are available. You know, we have ambulances that are often not in use; we have school buses that sit idle from 9:30 to 3:30; we have Comsoc vehicles that transport people with cognitive disabilities and then sit idle. Presumably, there sometimes is a certain number of specialized transit vehicles. So there are a lot of vehicles in every community that are not being used effectively. If they were all a part of a brokerage system, we could use those vehicles 24 hours a day, everywhere.


The second thing is that besides all these vehicles that are available and not being used, we have in almost every municipality in Ontario some kind of taxi system or a taxi system that's available within 20 minutes, half an hour's call. Our view is that the taxi system should become a much more active partner in providing transportation services, particularly in the rural and small town and suburb environment. It's quite easy to do this. There are several ways to do it, but one of the most effective is not to subsidize the transportation system or the service providers but to give the users a transportation subsidy in the form of what is called "scrip." That's a book of tickets that entitles you to a trip at a standard transit fare.

In Britain, all people with transportation disabilities are subsidized; they all get a transportation subsidy every month. If we want to have equity in terms of access to the service, then this is a very reasonable way to give them that kind of access. They could phone up a taxi, give their ticket to the taxi driver, and the taxi driver submits the ticket with the balance of the cost of the trip to the local agency for reimbursement.

They're doing this in Vancouver, in Calgary, in Kitchener-Waterloo, and they're just about to start it in Hamilton. What they have found is that an average trip usually costs about $10 over 80,000 trips over a year, so also it's a very good way to put a cap on the amount of money you spend on transportation because you've got some control through the sale of these books of tickets.

The other thing we absolutely believe is essential is that more accessible cabs be made available throughout the province, and in order to do that, we believe that MTO must raise the subsidy. An accessible cab costs about $40,000; $20,000 for the vehicle and about $20,000 for the modifications at the moment. MTO offers a $10,000 subsidy, but it is not enough of an incentive for a small company to purchase an accessible vehicle.

If the subsidy was 50%, that is to say $20,000, that would match the subsidy MTO now gives for buses and vans. It seems to us to us it would be fair if they offered 50% on the accessible taxis. If we had the use of the vehicles that are in place in the communities, plus a scrip system to access conventional cabs and accessible cabs, we could probably provide transportation for everybody at a reasonable cost. By the way, most trips that are taken in ambulances at $240 a shot could be taken in an accessible cab at $15 or $20.

Those are some of the recommendations that we are making. Most of all, we are hoping very much that you're going to be able to keep the feet of the Ministry of Transportation to the fire.

Mrs O'Neill: We haven't had a lot of presentation in this area, although we did have one this morning. I wanted to ask you about a couple of your recommendations, if I might.

Ms Tait: Sure.

Mrs O'Neill: "Recommendation 5: That eligibility committees must not include representatives affiliated with the transportation service but must be completely independent."

From what you've just been saying, I felt your group and others have had some cooperation with the transportation providers, so I'm wondering, there must be something behind this recommendation.

Ms Tait: Yes, there is.

Mrs O'Neill: Could you say a little bit about that, please?

Ms Tait: Yes. We feel that the eligibility committee that is operating here in Toronto advising Wheel-Trans is a captive of the TTC. The people who were chosen were chosen by the TTC, they report to an advisory committee which was also chosen by the TTC and is run by the TTC and even the people on the committee get their honorariums paid by the TTC, so they never criticize the TTC.

Mrs O'Neill: Okay. That's a pretty clear answer.

My other one is in the following recommendation: "The Minister of Transportation make clear to the people of Ontario that prioritizing of trips on specialized transportation services is contrary to the equality provisions of the Charter of Rights and Freedoms...."

Ms Tait: And the code.

Mrs O'Neill: Could you say a little more about that? I have also a bit of difficulty with your final statement about the ambulances. Surely there can't be that many trips. You seem to indicate that it was the majority --

Ms Tait: I think the ambulance people themselves estimate that about 70% of the trips could go by accessible cab.

Mrs O'Neill: Is that right? That's much higher than I had heard, but in any case we'll leave that. Maybe you could say a little about this point.

Ms Tait: Yes. On the prioritizing of trips, there was a recent decision -- I don't know if you've heard about it, the Roberts decision -- from the Human Rights Commission.

Mrs O'Neill: I'm sorry, I haven't.

Ms Tait: It basically says that if you're offering a special program, you cannot discriminate within that special program. The public transit doesn't prioritize trips. On public transit, everybody can take any trip they like and nobody asks what the purpose of the trip is. We believe the specialized transit should have comparable service. In fact, the new Ontarians with disabilities act is going to recommend just that, that the service should be comparable, and that means no prioritizing of trips.

Mrs O'Neill: So it wouldn't be just for medical appointments; it could also be for visiting a family member.

Ms Tait: Absolutely, because when it says "community access," you don't define what community access means. You assume that you know, and that means whatever access you want. I had an 80-year-old woman in tears on the phone to me a month or so ago because she had a ticket for Miss Saigon and Wheel-Trans offered her a one-way ride. She could have got to the show, but she could not get home, so she had to give it up.

Mrs O'Neill: Thank you for coming, Ms Tait.

Ms Tait: That's the way it goes.


The Acting Chair: Our next presentation is being made on behalf of the Ontario Association of Residents' Councils. Welcome to the committee.

Mr Peter Kehoe: My name is Peter Kehoe and I'm president of the Ontario Association of Residents' Councils. Mary Ellen Glover is the executive director.

We have prepared a brief which I understand has been distributed to you all. Mary Ellen Glover is going to run through the brief with you, and we will both be available to answer questions and, I hope, be able to explain any points that you may wish clarification on.

By way of introduction, our association represents some 300 facilities here in Ontario where they have what they call residents' councils, which are intended to be a voice speaking on behalf of the residents who live in the facilities. They're supposed to express the feelings of the residents towards the executive director and the management of the facility and also to relay to the residents the intention and policy and the management philosophy of the board of directors and the executive director. So it's a two-way method of communication.

We also act as a channel through which the government frequently relays information and asks us to relay to it information regarding the feelings of residents on particular issues.

Ms Mary Ellen Glover: As Mr Kehoe said, the Ontario Association of Residents' Councils represents seniors living in long-term care facilities. While many of our members will not be directly affected by Bill 173, we do have members living in retirement homes and seniors' apartments who could seek the services of a multiple service agency and, indeed, who would be eligible to represent consumers on a board of directors.


We also believe very strongly that all seniors, whether they live in the community or in a facility, are entitled to have their rights recognized and respected, be treated with dignity, compassion and respect and have appropriate information to allow them to be informed consumers.

As an organization, we have participated in discussions on many aspects of reform and have noted with great interest, and some alarm, the problems that appear to be surfacing. Indeed, our organization has in the past attempted to warn the government about some of these problems. With this bill, we wonder if government is biting off more than it can chew. Does it have unrealistic expectations in the following areas: the protection of client rights, client right of choice, funding and the governance of multiservice agencies?

In this bill, clients are given a bill of rights, but will this bill of rights truly provide adequate protection? It refers only to the client's right to "raise concerns" and "recommend changes." What guarantee do we have that a client who does raise concerns will have a problem resolved? Our experience has shown that it's difficult enough to ensure that residents' rights are respected in facilities where there is a system of checks and balances in place. Who, I ask, will protect frail, isolated seniors?

Furthermore, the bill appears to be at variance to itself. On one hand, clients are given a bill of rights to protect them. On the other hand, Bill 173 appears to deny or limit the individual's right to have access to their own records. It appears that a review board will decide whether or not the individual can have access to his or her own records. All this will be done in the absence of the individual. Is this fair? Will the service provider also be absent? Will there be an advocate present? Who is the review board?

In more practical terms, we would strongly recommend that the legislation require that all personal care/home support workers be bonded and insured to protect both themselves and the client. As well, an appropriate system of monitoring such as the compliance inspection system for facilities must be put in place to protect clients and to ensure that the service provided meets the standards that I'm sure will be set. The bill refers to the compliance adviser entering the MSA place of business, but this will not ensure that the service provided in the individual's home is adequate.

We believe in right of choice. The entire bill says to us: "Big Brother knows what is best for you and will tell you what that is. You will receive the services that Big Brother feels you need."

The bill refers repeatedly to "preference" rather than "choice," two words that definitely do not have the same meaning. The use of "preference" leads us to feel that any choice made will not be by the client but by the agency.

For example, will the MSA be sensitive in their assessments of potential clients? Will assessments take emotional and social needs, as well as physical needs, into account? Will cultural and religious traditions be respected? During facility reform we were guaranteed that placement coordinating services would take all these factors into account when placing clients in facilities. Now anecdotal evidence indicates that placement coordinating agencies are not respecting client choice when making facility placements. Why will multiservice agencies be different?

Furthermore, it would appear that the power of the multiservice agency will be all encompassing. What then will happen to a client who is not satisfied with an assigned service provider. Will the only choice available to the client be to remove themselves from the system and make private arrangements for services? For most people, this is simply not a choice because very few would have sufficient financial resources available to pay for a full range of private services.

We further wonder how the MSA will determine who will be eligible to receive services. We have a real fear that services will be withheld or people will be underserviced as a means of controlling costs.

That leads to the matter of funding, an area in which we have only questions. Where will the money come from? Who will pay for what and to what level? How much will the client be asked to pay? Will the estimate of the amount potential clients will contribute to the system be realistic? Will the necessary revenue be generated from copayments? What factors will be taken into account when testing for subsidization? We would certainly not like to see consumers in the community and consumers in long-term care facilities subjected to different criteria.

Governance of MSAs: The act states that the board of directors must reflect the diversity of the community in terms of gender, age, disability, place of residence, cultural, linguistic, ethnic and spiritual factors. However, it would appear that, at least initially, MSAs will be set up by what are really special-interest groups. For example, our organization received an invitation to develop a proposal to establish an MSA. Initial boards will therefore probably be made up of people who are already active in one or more specific organizations.

In our opinion, this could lead to a great deal of friction as these boards, at least initially, will be torn by internal power struggles as individual agencies jockey for control. Some controls must be put into place to ensure that the community is truly represented.

We spoke earlier about the fact that residents in retirement homes could be eligible for the services of the MSA. How can a resident obtain membership in the MSA so that he or she would be eligible to stand for election to the board of directors. There must be some mechanism in place to ensure that the community as a whole is educated about becoming involved in the establishment of MSAs.

We also question whether it is realistic to believe that a volunteer board can effectively set up such a complicated agency from scratch. The process will require a heavy time commitment if board members are required to be hands on and undertake specific tasks. If the board is not expected to do the work, it will mean they will require staff to assist them and each MSA will end up with its own little bureaucracy. Money which could be used to pay for client services will be diverted to support services.

We also wonder whether the qualifications the individual is expected to bring to the board are realistic. Many not-for-profit agencies are saddled with boards made up of individuals with personal, specific agenda who are not willing to work for the common good or the agency is so desperate that it will take the nearest warm body to fill the position.

MSAs will be not-for-profit agencies. Will they also be allowed to become registered charities and, if so, what effect will their fund-raising attempts have on established charitable organizations?

MSAs are to be set up and governed locally. Therefore, we question whether or not this will provide clients in all parts of the province with the same services provided to the same standard. We have two scenarios to put to you: Can you assure us that both these ladies will receive the same services at the same cost, both to them as clients and to us as taxpayers? If so, we can assure you that we are all in favour of the concept of MSAs.

We have two elderly women, Leona and Hazel, of a similar age, 80-something, and similar financial resources. Both live independently in their own homes. Both are faced with a health crisis.

Leona is hospitalized, tests are performed. It is determined that she has anaemia, but the cause is unknown. She is told that she can go home. However, because she has suffered from breathing difficulties, particularly at night, she's afraid to go home alone. She is declared ineligible for home care because she admits she really doesn't need a nurse to help her take a bath. She is also told she doesn't look like a frail old lady and, if she's not happy, perhaps she should enter a retirement home.

Because her family lives in a different city and her support network consists of friends the same age, she feels her only option is to enter a retirement facility for a period of convalescence. The doctor keeps her in the hospital an extra four days until she can find a bed. Meantime, her daughters take turns leaving their families and their jobs to come and stay with her when she leaves the retirement home. They try again to access services for when they must leave her alone. Meals on Wheels is easy. That's no problem, $5 per day, no charge to the taxpayer. First meal is just yummy -- corned beef and cabbage, no choice. That's just great in the middle of the summer, great for a person who is seriously anaemic and really needs to eat properly.

Homemaker services are a different story. Yes, they're available at a cost of $8 per hour. However, it will be three weeks before the agency can even come to do an assessment. Oh, and by the way, the workers are not insured or bonded so the client had better check with their insurance agent to make sure they have appropriate coverage in case the worker has an accident.

Because Leona requires ongoing monitoring, each week she must make her way to her physician to have blood work done. Transportation, thankfully, was provided by family and friends.

In this scenario, there were minimal services available. The only costs that were borne by the taxpayer were perhaps four unnecessary days of hospitalization while waiting for a retirement home bed, and visits to an MD for something that could have been monitored by a nurse. However, the cost to the individual and her family amounted to approximately $3,200 in cash outlay and perhaps another $4,000 in lost wages.


In our second scenario, Hazel, our client, is hospitalized. Her immediate problems are diagnosed and, after a long hospitalization, remedied. However, she has lung problems which must be monitored. When Hazel is feeling better physically, she is assessed for multiple infirmities and rehabilitation begins. When rehab has advanced sufficiently, she visits her home in the company of an occupational therapist to check for possible problems that she might encounter when she returns home and to make sure they are solved prior to that return. She is given the option of going home for one night on a trial-run basis with support. She doesn't take this opportunity because she feels confident in going home on her own.

When Hazel returns home after a hospitalization of approximately four months, she returns with the service of a visiting nurse seven days a week, a personal support/home care worker twice a week and Meals on Wheels purchased frozen from a weekly menu so that she can mix and match and use as she wishes.

Six months later, she still receives the services of a visiting nurse twice a week to assess her lung condition, therefore she does not need to make weekly visits to her physician. Home care now only comes once a week, but for a longer period of time, and she is still enjoying the frozen Meals on Wheels. In this scenario, the cost to the individual is limited to the cost of the meals she purchases. All else has been borne by the taxpayer.

In closing, we have the following recommendations: MSAs must ensure equitable access to equal services; the government must ensure that the goals set out in this bill are realistic and can be met in terms of funding and the establishment of cohesive boards that will work for the good of the community.

We would lastly recommend that before starting anything new, the government finish with facility reform. Get that working and working well before launching any new initiatives. Thank you very much.

Mr Jim Wilson: Thank you very much for a very comprehensive and, I think, very commonsense approach to this legislation through your presentation here today.

There's nothing you said that I and I think most of my caucus colleagues would disagree with in my party. In fact, you point out a lot of flaws in the legislation that we've also been bringing to the government's attention from time to time, particularly your comments about the elimination of choice under this legislation, and the eligibility criteria, which is a mystery.

It's an absolute disgrace that we, as legislators on behalf of the public, are being asked to pass such a major piece of health care legislation and we haven't got a clue what the eligibility criteria will be which, as you point out, is absolutely key to this whole system.

In fact, I suspect the underlying agenda here is the eligibility criteria, as we saw in the new long-term care facilities legislation with Bill 101, where a very high medical test was put in place to get into those facilities. The eligibility criteria is really the tap the government has in the future to choke off people, some who may be getting services now. There may be people getting snow removal services, for example, as part of community care now who won't meet whatever the new medical tests are or whatever they're going to be.

We're not clear on what the eligibility criteria will be. We're not clear about user fees -- we do know in the first stage of reform $647 million. What the government forgot to tell the public was that $150 million of that was to come out of their pockets in terms of the new user fees that are now in the long-term care system. The government even managed to mess that up so badly that it collected significantly less money than it expected because of the means test that they put in, which was simply an income test and not an asset test.

Your very last point is very interesting where you tell the government to sort of get finished with the facility reform, I think is the way you word it. Perhaps you want to just expand on that because there is a real concern with most of the presenters to this committee that the government's closed 7,200 hospital beds since 1989-90 and yet we haven't seen the beefing up of community-based services. In fact, all this bill talks about, I think, is raising expectations that those services will be in place, but it talks more about governance, creating a monopoly and a bureaucracy and not a lot about the delivery of front-line services.

Can you just tell us what you mean specifically by telling the government to finish with facility reform before it keeps up its social experimentation?

Mr Kehoe: I'll be glad to volunteer a couple of remarks. We, as an organization, generally speaking, endorse most of what was done in Bill 101. We can nitpick and quibble about details, but in principle I think we could go on record as being in support of most of what was being done.

We feel that the criteria for eligibility were moved forward in the right direction. We have misgivings about funding, but that's still being worked on, I gather. We feel concerned about the long-term security of funding for the facilities and whether it's going to be adequate or not, but I gather that's being reviewed regularly. We're concerned about the quality of care being maintained and the quality of life being maintained, but those are our four principal concerns as far as long-term care facilities go.

We think progress is being made on all those points and we don't have any real, serious grievance on those issues, and I think I can speak on behalf of most of the residents of our facilities. They may have apprehension about the future, but up until now they have not really been seriously adversely affected.

But we feel the situation is not yet perfectly clear, that it has to be refined more. We feel that is a priority which should be worked on before they embark too vigorously on an MSA program for the community, as desirable as that program may be. We think it would be prudent to go slow on the MSA, review carefully the experience that has been established so far and to listen with care to the briefs that are being submitted by the various concerned groups.

I notice that the period for which time was allowed was extended, which is an indication of the general concern in the community, and I would imagine it would take a lot of work for your organization to prepare a summary of the briefs that you've received. I think it would be prudent to go slowly on the next step as far as MSAs are concerned until the long-term care has been further stabilized.

Mr Jim Wilson: Thank you. I think the bulk of the presentations -- my guess would be 97% of the people who have appeared before us have such major concerns. Everybody starts off telling us they support the purpose of the bill, they support the bill of rights -- and the way it's worded, frankly, it's motherhood. Who wouldn't support these things?

Mr Kehoe: That's right.

Mr Jim Wilson: But we're running into real problems. In fact, some of the more senior legislators around here indicate that they don't remember a time when the government's taken such a beating on a piece of legislation. So I agree. Would you suggest, as a number of groups have, that perhaps the government should, taking the advice that you talk about in terms of biting off more than it can chew, go the pilot project route or something with this legislation rather than the way we're going now?

Mr Kehoe: I'd be inclined to look at it very carefully as an alternative.

Mr Jim Wilson: Okay.

Mr Kehoe: Particularly as we, as an organization, have misgivings about the cost-effectiveness of the whole exercise.

Mr Jim Wilson: Thank you very much.

Mr Kehoe: If we were reassured on that point, we'd have more enthusiasm.

The Acting Chair: Mr Kehoe and Ms Glover, thank you very much for your presentation.



The Acting Chair: Our next presentation will be made by the social action committee for the Bernard Betel Centre for Creative Living. Welcome to the committee.

Ms Sheila Zane: I am Sheila Zane. I'm the coordinator of the social action committee, and our chief spokesperson here will be Reta Duenisch-Turner, who is a member of our committee. There is also as well Sharon Zeiler, who is director of our wellness centre and our community centre.

Ms Reta Duenisch-Turner: We welcome the opportunity to present the views of the social action committee and the wellness committee of the Bernard Betel Centre for Creative Living on Bill 173, the Long-Term Care Act.

The Bernard Betel Centre for Creative Living is a non-profit, multicultural wellness centre located in North York which serves about 2,500 seniors living in the community. Our mission is to enable older adults to maintain their independence. We provide social, cultural, health and educational programs that improve the quality of life for seniors. This submission reflects the views of members of the Bernard Betel Centre for Creative Living who have a special interest in this reform.

We applaud the government for reforming the system that for many years has been fragmented and has not adequately met seniors' needs. We support the following principles in Bill 173: a single entry point to access services through the MSA, a continuum of service, a high-quality service, racial equality and cultural sensitivity, flexibility in MSAs, and consumer involvement.

We believe the objectives of the Long-Term Care Act to be most commendable. We are concerned with the realities of implementation.

Will there be enough money to provide quality and quantity of care at home for the seniors and disabled as need arises? Already we see there are waiting lists for services in the integrated homemaker program. Some of those who are receiving services are finding that their needs are not being adequately met. For instance, the average homemaker visit is only two hours per week, which barely allows time for laundry or housekeeping, not both. At present, there are waiting lists for homemaking services. Being on a waiting list means no service at all. How can the government plan to ensure that there are sufficient funds to provide the quality of care that has been promised?

We worry about the apparent assumption that there is a family waiting and willing to care for our aging seniors. This is often not true. Many seniors live isolated lives, alone for a variety of reasons. Lack of adequate home care can be life-threatening to a frail or sick senior.

To improve distribution of homemaking service, one suggestion is to provide regular housekeeping and professional support service in seniors' apartment buildings. Thus, seniors requiring assistance would have it available onsite. Such personnel could accommodate the changing needs of the convalescent senior and aid those who require just a little help to remain independent and out of institutions.

We are concerned about the lack of institutional beds, both short- and long-term, for seniors if and when they need them. Patients are being discharged from acute care hospitals quicker and sicker than in the past. Ill seniors at home cannot manage with inadequate home services. Elderly family care givers, if available, are often unable to cope with the strain of meeting the care-giving demands. Elderly individuals have enough problems just caring for themselves. We'd like to suggest that an organized program of trained visiting volunteers from community agencies might supplement professional visits to convalescent seniors.

Another option is to increase the number of beds for convalescent care, either within existing hospitals or in any other care facility. Unused hospital beds and underemployed trained personnel should be utilized for people who do not need acute hospital care, yet cannot manage at home. I've had a bad personal experience where a friend of mine, a disabled person, was sent home from hospital alone when he should have been in a convalescent bed.

We are concerned about the inadequate number of long-term care beds available for seniors when they cannot be cared for at home. Today, people are living longer and, as a consequence, may be subject to many debilitating diseases which require more care than can be given at home. A person who has had a long and productive life has the right to spend her or his last days in dignity where they can receive appropriate care. How will the government ensure that a sufficient number of institutional beds will be available that will provide a high quality of care for people at the end of their lives?

We would also like to emphasize the importance of respite care for primary care givers. Primary care givers work long and hard hours and often need a break. Primary care givers must have support. In particular, there should be a contingent emergency plan for those care givers/providers who become ill while providing care. Respite care for care givers should include in-home services so that the care giver can have a short break, and respite care beds must be made available to the ill or frail person so that the care giver can have longer relief. Unused acute care hospital beds must be made available for this purpose.

At present, many agencies depend a great deal upon volunteers to help man their programs. Will the MSAs be able to retain the loyalty and commitment of volunteers to their programs? We are concerned that the heart of the volunteer's commitment will be lost within an arm's-length organization like the MSA. The government should provide support, recognition, incentives and training as encouragement to volunteers. Volunteers should be compensated for out-of-pocket expenses such as transportation, conferences and administrative support. On the other hand, there should be volunteer education management by the staff of the MSAs so that it will be understood that volunteers are part of the team, not just there to be used.

We believe the Long-Term Care Act does not recognize the importance of preventive wellness programs that keep seniors mentally and physically active in the community. We believe the continuum of care begins with the well elderly. Elderly persons centres and wellness centres provide valuable social, cultural, health and educational programs that improve the quality of life for seniors in the community.

Older adult centres often help to alleviate the loneliness and isolation that can lead to mental and physical deterioration of seniors at home alone. Preventive/wellness programs can help to delay the onset of disease which requires expensive medical costs. Many studies show that physical activity helps seniors stay healthy and moderates the complications of such major illnesses as osteoporosis, arthritis, heart disease, diabetes etc.

Mental stimulation is as important as physical activity in keeping seniors well. Dr James Birren of the University of California states, "Mental activity is more necessary to successful living in old age than even housing or income." Another study, by Aseneth LaRue and Lissy Jarik from Brentwood Veterans Hospital in Los Angeles, California, studied people between the ages of 60 and 90 and concluded that memory loss is more the result of a lack of vocational and intellectual stimulation and the effects of depression than old age.

Because we believe so strongly that the continuum of long-term care should start with the well senior, we ask that older adult centres be considered part of long-term care and be funded accordingly. The programs at the Betel Centre for Creative Living, ranging from current events to t'ai chi to crafts, have made a world of difference to many of our members who have suffered from severe illness and mental depression. Many people come there every day and it's just like a second home.

An example of the depth and breadth of programs offered by senior centres and wellness centres can be found in the attached newsletter, the Monitor. We are also attaching excerpts from letters to our members that were quoted in the Bernard Betel Centre for Creative Living's submission to the Ontario Royal Commission on Learning in November 1993.

In closing, we support the government's initiative in reforming the long-term care system. We applaud the ideals expressed. While seniors recognize the importance of a streamlined and cost-effective system of long-term care, we hope and pray it will not be achieved by sacrificing the dignity and personality of each individual. We want the government to have a system whereby bureaucratic red tape will be at a minimum and personal contact will be maximized. Seniors do not want a cookie-cutter approach. Personal needs must be recognized. We want to have choices and we want to maintain control of our own lives.

We thank you for the opportunity to present our views.


Ms Carter: Thank you for your presentation and your concerned interest. I have been to the Bernard Betel Centre a couple of times, and in both cases you were doing your part in stimulating people by having panels and discussions. That was good to see.

I just wanted to comment on some of your concerns and maybe have your comments back. You're worried about money. Who isn't? There's never enough money for what we'd like to do, but I think part of the motivation of what we're doing is to make sure the money that's in the system is used for front-line services and not wasted on duplicating administration and getting lost in the system in that way. Of course, we are putting quite a lot of extra money in.

I think, quite rightly, you are especially concerned about homemaking services. I believe we've already put quite a large amount of extra money into that, and I believe as many as 5,000 extra people have been employed as homemakers. So whatever the situation is now, it would have been a lot worse if we hadn't done those things. I certainly hope it's more adequate than you seem to suggest.

Another thing that strikes me about your presentation is that you're talking about acute care beds on the one hand, and the need for wellness and keeping people well and stimulating them and so on on the other. We had a presentation this morning which pointed out something called On Lok, in California, which you may have heard of, where apparently they only take on people who are at the point where they would normally be admitted to an institution, and yet 95% of those people are not in an institution as a result of all the other assistance that they're given.

I don't think we can get straight to that, but I think what we're looking at here is a tradeoff between having sufficient acute care beds but nevertheless working on not needing so many because of all the other things we're doing. So I think we all agree that we don't want to cut beds that are actually needed, but on the other hand, looking at the long term, we shouldn't need as many because hopefully we're going to help people to keep well. Do you have any comment on that?

Ms Duenisch-Turner: My friend was sent home alone -- he's completely paralysed all down his left side -- and nobody knew he was coming. He had been resuscitated back to life and, from the medication they had given him, he had acute diarrhea. I took him to the hospital at 2 o'clock in the morning, stayed with him until 9 o'clock, then went home -- I live in the same building as he did -- cleaned up his apartment and went home to bed. The manager of the building came and knocked at my door to say he was there. I felt quite disgusted at this kind of care. It's like a body being dumped, as far as I was concerned. I'm still very angry, and we did approach Ruth Grier about that.

Ms Carter: Obviously you're right that that shouldn't happen.

Ms Duenisch-Turner: He maybe didn't need an acute care bed, but he certainly wasn't ready to go home, and there needs to be something in the middle.

Ms Carter: I understand that the ministry has set up quick response teams to deal with that kind of situation. I wonder if we could have some comment through the parliamentary assistant on that.

Mr Wessenger: I'm going to ask Mr Quirt to indicate how a quick response team might have responded in this type of situation.

Mr Quirt: We have established, I believe, 20 new quick response teams across the province where we attempt to avoid hospital admission for someone who shows up in an emergency situation at the emergency department. If there's any way that resources can be quickly pulled together to allow someone to be served at home, that's what we're able to do. For example, immediately sending someone home on a 24-hour basis with a client might be an alternative to admitting them.

But in terms of your comment of an alternative place for someone to go or convalesce prior to them going home, we certainly are making that type of short-stay program available in each of our long-term care facilities, in that there is a separate set of policies that apply to people who would be admitted to a nursing home or a home for the aged for a short period of time for the express purpose of regaining their strength and moving back home. That's something that wasn't possible in the previous system and it's something that's gaining importance in the system currently.

Ms Sharon Zeiler: Is it possible for me to just add that apparently right now there are people who are on waiting lists. They are ready to be discharged to a more convalescent type of situation, they don't need the hospital bed, but there are still long waiting lists for people who cannot get into them. I know of several cases personally. Our suggestion and our submission was that we do already have hospital beds that are closed, we have underemployed staff in hospitals, so could we not use resources we already have in a more imaginative way so that we could help people, say, for a short stay of a week or two, just to help them get on their feet so that they could come home, have resources in the community which would help them?

Ms Carter: Of course your comments on respite care are very relevant too, so that the care provider, if they become sick, can be looked after, or they can be given a chance to go on vacation. I believe that is built into Bill 101, that all nursing homes must keep some beds vacant for temporary use so that somebody can go in for two weeks or whatever. I certainly believe that is being built into Bill 173 as well.

Ms Duenisch-Turner: I'd like to ask about that, because I've a friend who had needed respite care -- she was taking care of her Alzheimer's mother -- and she couldn't afford it. I think there shouldn't be a fee for service when people simply -- I mean, she had practically gone bankrupt. She didn't lose her house but she came very close to it by giving up her job to take care of her mother, and then she found when she needed the care that she'd have to pay for it. I just don't think that's fair. She lost in every way. She cashed in her RRSPs. That's a typical woman. She's going to live the rest of her life penniless, because she's now 66.

Ms Carter: I agree with you that we mustn't overburden the mostly women who take on care of elderly relatives.

Ms Duenisch-Turner: There's a physical and a financial burden, a great financial burden.

Ms Carter: Are there any comments as to how this is taken care of in Bill 173?

Mr Jackson: Or a year later it hasn't been fixed in Bill 101. Mr Quirt might like to comment on that.

Mr Wessenger: Certainly, Bill 173 provides for respite care. Respite care is not only the care within institutions but also would include in-home respite care. The new structure would hopefully provide this type of in-home respite care more effectively than we have under the present system.

The Chair: Thank you for coming before the committee this afternoon and making your presentation.



The Chair: If I could call on our next presenter, from the Families' Association of Oaklands Regional Centre. I believe it's Miss Rhodes who's here, and your colleague is not able to be with us today, I understand.

Mrs Catherine Rhodes: I am Catherine Rhodes. I'm the parent of a resident at Oaklands Regional Centre. Kit Nero was supposed to be presenting with me this afternoon. She is also a mother of a resident at Oaklands Regional Centre, but something came up very suddenly last night which has prevented her from attending.

Oaklands Regional Centre, as many of you here already know, is a schedule 2 facility serving people with developmental disabilities. It's located in the heart of Oakville and it's run by a board of directors from the community. The Families' Association of Oaklands Regional Centre is a group of 127 persons whose purpose it is to act in support of Oaklands Regional Centre and its residents. Each member of this organization is a relative or legal guardian of an Oaklands resident, and I present on their behalf today.

There are just two areas that I'd like to touch on this afternoon; the first one has to do with a review. In March 1993 our group made a presentation to this committee in which we expressed concern that people with developmental disabilities were being denied access to the provisions of Bill 101. The following month, in April 1993, Partnerships in Long-Term Care, which is a policy framework publication of the ministries of Health, Community and Social Services and Citizenship, made the following statement:

"For a long time people with developmental disabilities and their families have urged that there be greater equity in serving their wide range of needs.

"Beginning within the next three years there will be a review of the two systems, long-term care and services for those with developmental disabilities, to produce a better-coordinated efficient system that reflects the concerns of the consumers, their families and providers."

The Families' Association of Oaklands Regional Centre would like to learn about the progress to date of the announced review.

We commend the action of the Ministry of Community and Social Services in arranging a grant to the Centre for Health Promotion of the University of Toronto to conduct a province-wide, four-year longitudinal study assessing the effect on quality of life brought about by different changes of environment in the lives of about 450 to 500 people with extensive ranges of levels of developmental disabilities.

The University of Toronto is an institution of excellent reputation. The findings, based as they will be in Ontario, will be a most valuable resource in the future. There is, however, a great deal of activity taking place in the province now whereby many people with developmental disabilities are being moved to different settings and environments. This includes from facility to community-based as well as from one community setting to another. A great deal can happen in the lives of a great many people in the next four years.

There are research publications and outcome studies which also deal with the issues involved in such moves which are available now. One example, a British longitudinal study from the University of Kent completed in 1992, examines, in addition to the effects on quality of life, the cost-effective issues of moving from a hospital to a community setting as well as factors contributing to the failure or success of such a move. We submit that currently available information from such well-founded academic sources is needed and should be included in the triministry review process from the early stages.

We further maintain that consultations with senior clinical professionals in the field of developmental disabilities are an essential component of an effective review and should be included in this process. The disciplines of these specialists in developmental disabilities should include psychiatry, psychology, social work, physiotherapy and other related specialties. Their knowledge and experience of the special needs of those with developmental disabilities, combined with their abilities to interpret and apply related research, will contribute greatly to the goal expressed of "a better-coordinated efficient system."

The participation of family members representing those with complex and severe disabilities is also needed in the review, not only because of their experience but also because of their direct knowledge of the choices and preferences of those consumers who are unable to express these things effectively for themselves.

Touching on Bill 173, the legislation proposed in the present Bill 173 addresses provisions for persons with long-term care needs as well. It does not make a distinction between physical and developmental disabilities. In part XII, the continuing need for facility-based alternatives for some individuals is acknowledged in the proposed amendments to existing legislation relating to this level of care.

We ask from government the assurance that well-designed and appropriate specialized facility-based care, such as we have at Oaklands, will be available in the future for those persons with developmental disabilities who need such care. These persons would include people with complex and severe disabilities who require consistent and continuing involvement of a multidisciplinary team of clinical professionals and trained direct-care staff in an environment adapted to their special needs. This level of consistent specialized care and environment has been demonstrated to be difficult and also much more costly to replicate adequately in a community-based setting. There is documentation for this available.

Moreover, for many individuals with complex and severe handicaps of this degree, an appropriate congregate care setting provides ongoing opportunities for accepting, meaningful social interaction with other residents, staff from many areas, as well as volunteers and visitors from the community, combined with vocational and leisure activities out in the community.

The Families' Association of Oaklands Regional Centre strongly supports community-based alternatives for the many persons with developmental disabilities for whom this is certainly the best choice. We continue, however, to maintain that well-designed, appropriate congregate care settings which actively promote community involvement and support while providing the required individual specialized care are the best alternatives for the other individuals with more complex and severe disabilities.

Long-term care and a variety of other services for people with developmental disabilities are primarily the responsibility of the Ministry of Community and Social Services. We expect the Ontario government to reflect consistently in every ministry the principle of equity of access to the full spectrum of whatever special services and care best meet the individual needs of its citizens. We submit that the concept of coordinated access to a full range of care and services, as outlined in Bill 173, whether community-based or facility-based, should be applied to all citizens according to their individual needs and must include people with severe and complex disabilities characterized by highly specialized needs.

The summary is pretty well what has gone before. The ministries of Health and Community and Social Services were jointly involved in Bill 101, which also dealt with long-term care and services. They published a related policy framework statement in April 1993, Partnerships in Long-Term Care, in which they announced a review of long-term care and services for those with developmental disabilities. Current, well-founded academic research available now and directly related to the purposes of the review, as well as consultations with clinical professionals specializing in developmental disabilities, need to be an ongoing component of the review process from the early stages. Families of people with severe developmental disabilities who cannot express their choices and preferences effectively should also be included.

Bill 173 proposes a coordinated continuum of long-term care and service options ranging from numerous community-based services to facility-based care. Citizens of Ontario with developmental disabilities have the right of access to a full continuum of specialized services and care which their individual needs require, regardless of the nature of their disability.

So the recommendations from the Families' Association of Oaklands Regional Centre include that the right of access for citizens of Ontario with developmental disabilities to a full continuum of specialized long-term care services and facility-based care which meets their individual needs be affirmed by the ministries of Health, Community and Social Services and Citizenship and that the regulations and policies of all Ontario government ministries reflect this affirmation.

We recommend that information be made available to consumers, their families and providers on the content, the participants and the progress of the review of long-term care and services for those with developmental disabilities, which was announced in the policy framework statement Partnerships in Long-Term Care in April 1993.

We recommend that consultations with clinical professionals specializing in developmental disabilities be included as an essential and ongoing component of the triministry review process.

We recommend that well-founded longitudinal research studies directly related to the triministry review and currently available be included from the early stages and as an ongoing component of the review.

Finally, we recommend that family members be included in the review process to represent those individuals with developmental disabilities who are unable to express their choices and preferences effectively.

The Families' Association of Oaklands Regional Centre asks you to consider our recommendations and support their implementation. We thank you for your attention to our presentation.


Mrs Sullivan: Thank you very much. Mr Chairman, as you will know from other sessions, the Oaklands Regional Centre is located in Halton and serves many people from my constituency as well as those constituencies which are to the south and to the north of mine.

I have been meeting with the parents' association for several years with respect to their fundamental concern, which is that as changes occur they are made on the basis of the ability and the capacity of the individual to take advantage of change rather than being forced into change. I think the parents' association has been very forthright with respect to its requests and demands that the needs be met as well as just a policy directive being implemented willy-nilly.

I'm very interested in the first point that you've raised in your recommendations with respect to the study which is being done. I wonder if we could have an update now from Mr Quirt or from the parliamentary assistant with respect to the status of the study of the long-term care reform and the needs of those with developmental difficulties and indeed also what clinical expertise and new research is involved in that review process.

Mr Wessenger: I can only answer some of the questions. First of all, people with developmental disabilities can access the long-term care services such as home care on the same eligibility criteria as any other person. With respect to the review, this review is not being conducted by the Ministry of Health but is being conducted by the Ministry of Community and Social Services, and unfortunately we don't have the expertise here available of anybody from the Ministry of Community and Social Services who can give an answer as to the status of that review. Mr Quirt would be unable to give you any more information than I have. The review is under the jurisdiction of that ministry, and to what extent it has progressed I can't give you any indication.

Mrs Sullivan: I find that very disturbing in that long-term care reform will fundamentally affect those with developmental delays and handicaps and a facility such as Oaklands Regional Centre, although it has traditionally been funded under Comsoc and so on and it's Comsoc policies that are under review. In fact, surely in long-term care the fundamental premise is that the health and the social services areas of long-term care will come together in the long-term care secretariat.

We raised this issue during Bill 101. We were told at that time that the developmentally delayed were simply left out. So I guess I'm going to have to ask the question again. You say they're in, but are they truly in? Are they really a part of long-term care reform?

Mr Wessenger: I think we should remember that the services under the Developmental Services Act are provided under the Comsoc ministry, and they have a budget of approximately $1 billion, which is somewhat similar to the community budget in long-term care for all aspects under the Ministry of Health. So we have existing services provided at a budget equivalent to what is almost being provided for long-term care in the community.

I don't know whether the presenter wants to see those two systems integrated. Certainly that's, I understand, the purpose of the review, to look at the question of integrating the two systems, but it's a very substantial, separate provision of services to the developmentally handicapped under the Ministry of Community and Social Services.

The Chair: Mrs Rhodes, did you wish to comment?

Mrs Rhodes: Yes. I suppose, Mr Wessenger, we received some encouragement that the announcement of the review came not from any one ministry but from the triministry group which was behind Bill 101 and which issued this policy statement. So we thought just what Mrs Sullivan was suggesting was coming into play. If we had a bit more information on what was going on, perhaps we could respond in a different way. We haven't had anything since this in April 1993, and then Bill 101 was proclaimed. So we wait to hear a bit of the progress, who is doing it, who is participating. Except for that one research study, which sounds wonderful but it won't be ready for four years -- and there is, as I mentioned, so much going on now, moving people about, that we're concerned.

Mr Wessenger: I certainly understand your concerns.

Mrs Sullivan: Could I ask the parliamentary assistant to undertake to provide the committee a report, through the interministerial triministry committee, with respect to the status of that review and what components are being addressed in the review.

Mr Wessenger: Certainly I think the committee could request that from the ministry.

The Chair: We will make that request. Mrs Rhodes, thank you very much for coming before the committee this afternoon. We appreciate it.


The Chair: I call on our next presenters, representing the College of Dental Hygienists of Ontario. I just note for committee members that the college has also provided us with some background information and material, which is with the research staff.

Ms Lynda Mckeown-Mickelson: We are here today to present on behalf of the College of Dental Hygienists of Ontario. My name is Lynda Mckeown-Mickelson. I am president of the college. On my right is Don Page, the vice-president of the college and a public member, and Donna Bowes, who is the chair of the quality assurance committee and a professional member of the college.

Dental hygiene has grown up over the past 40 years and is now independently regulated under the Regulated Health Professions Act; it's no longer controlled by dentistry. The mission statement of the College of Dental Hygienists of Ontario is to develop, advocate and regulate safe, effective dental hygiene practice for the promotion of oral health and the wellbeing of the public of Ontario.

Dental hygiene is not dentistry. Dental hygienists are trained and educated to emphasize the prevention of oral disease and the participation of the client in their own health. Therefore, dental hygiene is consistent with the paradigm shift from the medical treatment model of dentistry to the disease prevention, health promotion, wellness model.

Leaders of dental hygiene recognize that since its inception dental hygiene has emphasized the prevention of oral disease and the role of the client in controlling factors which cause disease. The uniqueness of dental hygiene as opposed to dentistry is its commitment to promoting human health, welfare and quality of life through knowledgeable oral hygiene services. Clients are encouraged to become actively involved in the health care process, not through compliance or dependence on the professional but in the form of a partnership or collaboration with health care professions.

Under the newly proclaimed Regulated Health Professions Act and the Dental Hygiene Act, the scope of practice of dental hygiene is the assessment of teeth and adjacent tissues and the treatment by preventive and therapeutic means.

I am now going to turn to Don and Donna to expand on our concern that oral hygiene services be included in long-term care.


Mr Don Page: Before proceeding, I'd like to emphasize I'm not a health professional. I'm an engineer by training. In the mid-1980s I was a member of the Rideau Valley District Health Council for six years, and for most of my term there I chaired the health promotion committee. I became very aware of the need to redirect our health expenditures more into the health promotion area if we are going to get our costs under control in the future. I think that's why we're here.

In my recent experience as a public member on the College of Dental Hygienists I have become very aware of the role that this new profession of dental hygienists can play in health promotion. I will follow our letter to you. We won't read from it entirely, but we'll take out the important bits.

The College of Dental Hygienists was established under the Dental Hygiene Act to regulate Ontario's 5,178 dental hygienists, with public interest as the guiding principle. The council of CDHO is composed of 12 members, six professional and six publicly appointed.

The council of the CDHO, having reviewed the Long-Term Care Act, Bill 173, wishes to bring to the attention of the members of the standing committee its concern regarding the omission of dental hygiene services from subsection 2(7). We consider this a serious oversight and one that calls into question the efficacy of the long-term care program as a whole.

The purposes of the act as stated are consistent with the scope of dental hygiene care, in that the primary focus is on prevention and health promotion. One of the goals of this act is to provide care and support to people in their own homes by ensuring "a wide range of community services" is available, thus providing an alternative to institutional care. Inherent in this goal is the assumption that the range of services and care will be comparable to those provided within the institutional setting. Residents within the institutional settings are provided with oral assessment, preventive services, as well as referral for treatment, and these same services should be available to persons being maintained in the community setting.

A further purpose of this act is to "simplify and improve access to a continuum of community services." The CDHO strongly supports the need for access to a continuum of services but stresses the need for oral health assessment as part of the continuum of health care services to be provided through the multiservice agencies.

Ms Donna Bowes: An additional goal of the act is concerned with the efficient management of services. Dental hygiene and dental hygienists provide a cost-effective, non-threatening, user-friendly and largely portable entry point into the dental care delivery system. Much of the long-term care population has difficulty accessing full dental care for cost or proximity reasons, or is fearful of the prospect of a visit to a dental office. Dental hygiene services delivered in the home would be far less intimidating, would effectively provide routine oral hygiene care and would identify conditions that require a dentist's attention, thereby making appropriate referrals.

The intent of the act is to support the home-bound, who are predominantly seniors, and a published study of the dental needs in some of Ontario's senior population demonstrated the requirement for dental hygiene care. Out of 607 dentate seniors -- seniors with teeth -- examined during the study, approximately 448 required dental hygiene services, and a further 75 required advanced periodontal services.

In the same study, it was reported that only 64% of the seniors interviewed had visited a dental office in the previous year. Not surprisingly, the majority of the seniors in need were in the more rural and northern parts of the province.

Having worked in public health for a number of years, where I was coordinating a geriatric dental program, I delivered care to the institutions but I also did some home visitations. I also did some work with hospice and palliative care. I've circulated some photographs to give you some idea of how very portable dental hygiene services can be. They can be as simple as carrying a bag of tools upstairs to visit the person in their own bedroom. We can provide services chairside, bedside, however they may be required.

The delivery of these services in the photographs that you have took place in Simcoe county under a pilot program that I developed and implemented. That pilot program is a one-of-a-kind program in the province of Ontario. Simcoe county is the only health unit that has a program of this nature. It's been highly successful and highly touted as the program of the future. It's the way we should be going.

The program is extremely cost-effective. I spoke with Dr Terry Hicks, the dental director at that health unit, last Friday, and we reviewed the costs for the program for last year. The costs come out to $25 to $30 per client per year.

That client receives oral screening. They receive two preventive appointments a year. They also receive in-servicing; in other words, instruction in the care that's required on a day-to-day basis. That's a very cost-effective program, and that's the kind of program a dental hygienist can deliver into a facility or into a home.

In future, with the focus on hospice and palliative care, I see there's going to be a great deal more need for oral services and oral care. Hospice patients and palliative care people have very specialized oral care needs, and those can be delivered at their bedside by a qualified and registered dental hygienist.

Ms Mckeown-Mickelson: There's a large body of literature on the positive impacts of routine oral health care for the aged, the mentally and physically disabled and for those in hospice care. Studies, particularly among the aged, have found high percentages of oral soft-tissue lesions, a high incidence of fractured, decayed or sensitive teeth, gum disease, ill-fitting dentures and poor levels of general oral hygiene.

One US study found that all of the hospice patients in a survey sample had gingival inflammation -- swelling of the gums -- and 75% evidenced some kind of pathological change in the oral mucosa. These conditions affect a person's ability to consume and enjoy food, affect social interaction and appearance, contribute unnecessarily to pain and erode the individual's morale and overall attitude. There is an abundance of scientific literature and research showing that the major cause of gingival inflammation, gum disease, oral disease is just poor oral hygiene. Bringing people to oral health and general health is good dental hygiene.

There's an interesting study that's been done in Ontario. The research indicates there are a good number of admissions to acute care facilities as a result of upper respiratory infections that appear to be directly related to the mouth and there are possible deaths resulting from aspiratory pneumonia, which is related to the mouth.

Ms Bowes: Even basic oral hygiene care can prevent or reduce the effects of many of these oral complications. Regular oral hygiene care also has positive and measurable effects on basic health and on specific medical conditions. For example, another US study found that regular oral hygiene care for patients with acute renal failure significantly reduced the occurrence of non-specific stomatitis -- that's a redness and swelling in the mouth -- but the benefit was neutralized if patients did not receive oral care for extended periods of time.

I'm the picture lady. The next picture is also mine. The picture really just demonstrates to you a typical senior's mouth, before and after dental hygiene care. This is one month apart, with four treatments from a dental hygienist. There was no dentist involved in this care and in this treatment. This was a senior. This is an example of what can be done with regular dental hygiene care.

Mr Page: The CDHO requests that oral hygiene care be included in regulation as one of the personal hygiene activities under subsection 6(1). We've made a number of recommendations pertaining to Bill 173. I won't refer to them in detail, but they're in our letter.

If a multiservice agency is required to assess the needs of an individual, it would seem to us that the oral needs of the person are equally as important as other physical and social needs.

The CDHO would like to point out that the regulatory colleges are responsible for setting standards of practice for regulated health professionals. The regulations must indicate that any standards set by or for a multiservice agency must be in accordance with professional standards set by the appropriate college established under the Regulated Health Professions Act.

While we recognize the government's wish to contain the costs of the long-term care program and the concomitant wish to avoid setting a precedent by adding to the list of professional services, we believe that few professional services are as universally required in long-term care as oral hygiene.

We also believe that few professional services would have such a beneficial and cost-effective impact on a person's overall health, morale and outlook on life. Therefore, we strongly urge the committee to include dental hygiene as a professional service under subsection 2(7) of Bill 173.

We have provided one copy of each of the background papers referred to in our letter which are available for your use.


The Chair: Thank you very much. I know those of us who have been through the RHPA hearings have built up a marvellous collection of slides, particularly from those in the dental field. You'll notice how carefully we scheduled you for later in the afternoon, not immediately after lunch.

We'll go to Mr Wilson.

Mr Jim Wilson: Thank you for your presentation on behalf of the College of Dental Hygienists of Ontario. I have a very simple question. You make a very persuasive case with respect to oral hygiene and you make the point that oral hygiene services are provided to people in institutional settings. Why do you keep getting left out of health care reform?

Ms Bowes: Excellent question. We ask ourselves that all the time. I think part of it deals with tradition. Dentistry has kind of divorced itself from the rest of the health care field, to a point where it's almost, "If it's in the mouth, it belongs to us," and nobody else wants to deal with it. That's probably partly our own fault. I do believe that we have to become much more interdisciplinary in our approach to health care.

I would hope that in the future, as health professionals are trained, there will be a method of coordinating their education so that people understand that oral health is a part of the entire body's health.

Mr Jim Wilson: Maybe we could ask the parliamentary assistant with respect to two areas here. Very generally, what is the ministry's intention with respect to oral health? It isn't mentioned under this legislation.

More particularly with respect to assessments, one would think you would want to make sure, if you're doing a thorough assessment of a client, that oral health would be included. As part of what I assume you will adopt, which is a multidisciplinary team approach, how will hygienists or dentists, for example, be included in that approach?

Mr Wessenger: If we look at the act, there's no requirement of any mandatory provision with respect to dental services. However, I would suggest that certainly an assessment could be involved as far as requesting the expertise of someone, either a dentist or a dental hygienist.

With respect to the whole question of providing services, of course that's really the whole question of whether we extend our health care system to provide dental services. Certainly I would suggest that maybe there are other alternative methods. As indicated by the presenter, the public health unit under Dr Terry Hicks has a very cost-effective method of providing dental care to seniors.

That might be the question I'd ask the group. Maybe that might be the preferable model, rather than under the provisions of long-term care, because that would give a broader coverage for seniors. If you provide it in the long-term care aspect, you're really only covering those seniors who would be entitled to long-term care. So just a comment and a question that if we're going to move in that direction, which I think we'd all certainly like to do if financial circumstances permit, then it would be better to have a more comprehensive coverage than just those who would be eligible for long-term care services. That's just my comment.

Mr Jim Wilson: That's interesting, if I may just interrupt, though. You're making it very clear that this bill is restricted to the sick elderly, which is something we get conflicting comments about from the government. But surely, given that the evidence has been around for many years about the need for good oral hygiene services, that they've been contemplated by the ministry under this act -- because you're setting up a monopoly called an MSA, and if they're not part of its basket of services, then I don't know how you'd be extending funding for these services in the future, if not through the MSA model that you're setting up.

Mr Wessenger: I'd suggest there are various models for delivery and the MSA model is one that could be considered.

The Chair: Did you want to comment on the earlier comment?

Ms Bowes: I suspect you're alluding to turning everything over to public health, and having been involved in the field, I know very well public health is terribly underfunded. They don't have the staff to carry out these kinds of programs.

If you're going to implement programs like this, at this point anyway, it's a rob-Peter-to-pay-Paul kind of thing. We managed in our county to produce this program, but at a cost. We had to discontinue a number of other public health programs in order to fund this particular program, but we decided it was a requirement. We needed the service and we did it.

I'm afraid that out of 42 health units in Ontario, I would hazard a guess that about 15% are prepared to undertake anything like this. Unless the funding is going to increase to public health, I don't think you're going to see these kinds of services across the board.

Mr Jim Wilson: Can we just make it clear for the record? Who's paying for the oral hygiene services that are provided now in the institutional settings? For instance, in our local nursing homes, now called long-term care facilities, in Simcoe county there are services provided. Is the consumer paying for those on a user-fee basis, or is the county picking it up?

Ms Bowes: In Simcoe county they're provided through the public health unit.

Mr Jim Wilson: Is that the case in most areas?

Ms Bowes: I understand that the few health units that are involved, such as North York, Scarborough and Ottawa, are doing very minimal services, but again, they are also being provided through the public health sector. I'm not aware of any private people providing services at the present time, not through not wanting to, but through legislation prohibiting them from doing so in the past.

I understand the Ministry of Community and Social Services and the Ministry of Health have produced the newest standards for accreditation for institutions, and my understanding now is that the institutions are scrambling around saying: "How are we going to meet these accreditation standards? Who's going to provide this care?" It's been kind of left up in the air as to how it's going to be provided.

If you can persuade your health unit to do it, wonderful. Otherwise, I understand some of the community colleges have been approached to have students provide it. There will be a variety of ways in which these institutions will get out there and try to meet these standards.

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


Mrs Sullivan: Mr Chairman, I wonder if I could also ask the ministry for an additional briefing note and comments. We've had at least two representations with respect to children's services and how they will be dealt with under this bill, and I'm quite deeply concerned that we have not had information about where the children's treatment centres fit and how other children's services will be delivered when young people require long-term care services and facilities, whether in the home or in the community.

We apparently won't have time during the public hearings for an additional briefing from the ministry, so I'm asking therefore to see something quite definitive on paper before we get into the clause-by-clause, because I think there are some major public policy issues there.


The Chair: I call on the Ontario Association of Professional Social Workers. Welcome to the committee.

Mr Dan Andreae: My name is Dan Andreae and I'm the president of the Ontario Association of Professional Social Workers. I'm joined by Lesley Patterson, who is a social worker at the Baycrest Centre for Geriatric Care. She has been the chairperson of the OAPSW Metro branch's aging committee for several years and is currently serving on the association's provincial aging committee. Lesley will present the association's position on Bill 173.

Also in attendance is Joan MacKenzie Davies, our esteemed executive director of OAPSW, and Gillian McCloskey, the associate director. I believe there will be no major decisions made in the association for the next 20 minutes because we're all here to support the important presentation you're about to hear.

As many of you know from previous appearances at the standing committee on social development, OAPSW is the body representing professional social work in Ontario. We are an active membership organization and there are currently in excess of 3,100 social work members representing all areas of Ontario.

One of the major tasks that we are involved in is social advocacy, and it is in this capacity that we are presenting today, drawing on the extensive and intensive experience of the profession in dealing with this issue and the elderly in areas such as counselling, program planning and policy development. We've had a considerable amount of experience, as many of you know, with dealing in this particular issue for a number of years.

Ms Patterson will outline in the next several minutes the ways in which OAPSW supports this legislation. She will raise certain concerns that we indeed do have and will also demonstrate the ways in which social work, we hope, will play and should play a major and crucial role with the quality care that's required for this legislation.

Ms Lesley Patterson: The OAPSW continues to follow with interest the reform of long-term care in the province. We endorse the government's commitment to developing a coordinated system of services to meet the needs of the elderly and of people living with disabilities. This is reflected in Bill 173, An Act respecting Long-Term Care.

In order to create a more equitable, accessible and effective service delivery system, OAPSW supports initiatives aimed at strengthening and consolidating community services. We regard the provision of social work services as an integral part of long-term care, in accordance with the profession's focus on addressing the interaction between the individual and his or her environment, and the belief that this interaction affects the individual's ability to accomplish their life tasks and maintain quality of life. Social workers are attuned to the multiple needs associated with one's physical, social and psychological wellbeing, and therefore strongly advocate for a more holistic service delivery system.

In January 1991, OAPSW produced a response to Strategies for Change: Comprehensive Reform of Ontario's Long-Term and Support Care Services and, in 1992, to Redirection of Long-Term Care and Support Services in Ontario. In January 1993 our association also submitted a response to Community-Based Services Provided by Multi-Service Agencies. These documents are all enclosed for your information.

Our association fully supports the spirit of Bill 173 and the comprehensive nature of this proposed legislation. We are also pleased to observe how feedback gleaned from the consultation process is reflected in the bill. For example, the social work profession is no longer restricted to illness, disability and bereavement, as we had suggested in our response to Community-Based Services Provided by Multi-Service Agencies.

Regarding Bill 173, the following points reflect OAPSW's main concerns and our recommendations as to how implementation of this major piece of legislation can be fine-tuned.

Our first concern is around consumer needs and funding. The OAPSW supports the major tenets of Bill 173. However, we are concerned that economic pressures may result in significant altering of the fundamental principles and, further, that funds may not be available to implement the legislation in its entirety. Such a reduction could place the vulnerable elderly and disabled groups in an untenable position, with reduced institutional care and inadequate community care.

If the government decides not to follow thorough on its proposed increase for community care funding, home care services may not adequately replace the disappearing institutional and medical services. There are two major issues regarding the implications of this.

First, if formal home care is inadequately funded, care givers will undoubtedly suffer from major repercussions. As has been well documented in the gerontological literature, the vast majority of care for the elderly comes not only from the formal health and social care system, but informal care givers -- for example, family and friends -- and the vast majority of these are women. Cutbacks in medical care will further increase the demands on the care givers and may put many at risk with respect to their physical, mental and financial wellbeing. Many already suffer from "care giver burnout."

Second, the reduced institutional care and inadequate community care would severely restrict consumers' choices and control of their use of services. Consumers and their families could find themselves struggling with case managers who'd be forced to fit the individuals into whatever resources were available. Anyone who expressed needs that did not fit the available services could potentially be identified as problematic. Thus, it's imperative to increase community home care services in order to compensate for cutbacks in medical service. Further, it is essential that effective and adequate care and support be maintained in both the institutional and community care networks so that the needs of the elderly or disabled adults and their care givers will be given paramount consideration.

Because Bill 173 is a response to consumer needs, implementation should reflect this direction. MSAs will now be recognized as the sole information and referral sources regarding long-term care services. However, there's a potential danger that seniors will now be assessed and advised on the services they need instead of determining for themselves what services they want and how they should be provided. There may not be a choice for consumers and their families between facility- or community-based services.

Finally, regarding consumer needs, we urge that special attention be given to those people wishing to access resources within the long-term care service delivery system. These people often constitute the most vulnerable in society and include a large number of women. These individuals are often both the recipients of care and also the informal or formal care givers, and frequently they are visible minorities and below the poverty line. Each of these disadvantaged consumer groups faces a unique set of barriers to accessing long-term care services.

For example, recent literature suggests that ethnic minority seniors have unequal access to both health and social services, mainly because these services cater to the needs of the dominant culture in Ontario. Access to knowledge about these services is restricted for ethnic seniors since service providers seldom publish materials or advertise in languages other than English or French. In addition, interventions that are offered tend to be culturally inappropriate to the expressed needs of these consumers. The government is urged to take into consideration the literature available regarding the special issues that each of these consumer groups faces and to adapt practical recommendations made by experts in the appropriate fields.

Our second concern was regarding social work role and definition. The OAPSW is pleased that in the compendium social work was included in the list of health professionals. Social work is a key component in the long-term care system because it's the only discipline where training, education, basic principles and the professional activities specifically target maximizing individuals' personal strengths. The systems approach inherent in all social work practice is ideally suited to viewing individuals within the context of their families and the broader communities in which they live.

OAPSW is concerned about how the flexibility of providing low-cost, non-professional staff may be applied. Our association has developed parameters for the scope of duties recommended for graduates at the bachelor's and master's level. One related area of confusion noted in the bill relates to a certain blurring in the use of the terms "social work" or "social work services" and the term "social services." The term "social services" rather than "social work services" may be used to justify the use of untrained personnel to engage in social work practice. Unfortunately, the lack of a social work act has led to rampant use of this strategy. To clarify, enclosed are the social work definition and the scope of practice as developed by our board of directors in 1994.

Our third concern is the case manager role. The role of the case manager is central to implementing the content and the spirit of the act. The practice of case management involves a number of functions, namely, intake and assessment of needs, setting goals, developing a plan of action which may include counselling, referral to appropriate resources, advocacy on behalf of clients, monitoring and reassessing the client's situation and needs, and, finally, systems advocacy.

Training in counselling and the ability to address psychosocial needs in a timely manner, combined with skills in resource-finding and efficient utilization of existing resources, make social workers particularly suited to matching clients with the most cost-effective and least intrusive services to meet safety and independence needs. Our wellness-oriented focus on competency building and preventive action encourages clients' independence. Our consumer advocacy adds to the match of social work skills with the defined case manager role. We believe that these factors combined make trained social workers the natural choice as case managers.


Our fourth concern regards facility reforms and fees. Eliminating the discrepancy between the fees and the services offered at nursing homes and homes for the aged is a welcome reform. Recent fee hikes, however, have placed a burden on residents who were once able to pay for private or semi-private accommodation and must now scale down. It had also created a backlog of residents waiting for semi-private rooms or ward beds within facilities. This makes entry to facilities at the ward level more difficult for applicants who are applying from outside. Also, if it is intended that the fee hikes will be contributing to the $200 million that was to be allocated to nursing homes and homes for the aged, we would suggest that the government explore the percentage of residents who are actually paying for the new rates for ward, semi-private and private accommodations in long-term care facilities.

In summary, OAPSW supports and applauds Bill 173's intent and direction, although we are concerned that economic restraints will adversely affect the implementation of this legislation. We strongly recommend that cutbacks not be made, since this would have adverse effects on consumers and their families. In practice as well as in principle, Bill 173 should empower the elderly and the disabled and their care givers by giving them flexible choice over their use of services.

Consumers can be empowered only if there are adequate sources of institutional as well as community care support. Disadvantaged groups such as those who are particularly frail, vulnerable, fall below the poverty line or are visible minorities have very limited access to services and policies, which should be given special consideration.

It is recommended that the government incorporate policies which would work towards dissolving the barriers that these consumer groups face. Attention also needs to be given to the implications of recent fee hikes for current and prospective residents of long-term care facilities.

Our association is also concerned about how the flexibility of providing lower-cost, non-professional staff may be applied. Based on academic knowledge and training, professional skills and expertise, social workers carry out daily case management functions, including assessment, coordination, counselling and advocacy.

In light of this, social workers have a unique and vital contribution to make to recipients of long-term care and to a more effective and efficient delivery system within this province. With a view of serving the best interests of Ontario's citizens, OAPSW sees the social work profession as a key player in the implementation of this legislation and we look forward to participating in a continuing dialogue with government.

The Chair: Thank you very much for the presentation and also, as you indicated, copies of both your submissions in 1991 and 1992 and the definition of scope and practice for social work in Ontario that you prepared in February of this year. We'll go to questioning.

Mr Gary Malkowski (York East): Thank you for your presentation on the role of the social workers, and I feel that is a very key role in long-term care, as we're aware. I have a social work background and education, and so I think the social work field is very important. In my private member's bill I'll also be recognizing the importance of social workers.

But anyhow, talking about your concerns related to the freedom of choice for consumers and your concerns about limitations in the institutions and in the community care services because of the funding situation, I want you to know that our government has already spent $850 million -- that's an increase in community-based services -- during 1993-94. Then next year, in 1994-95, they'll be spending over $1 billion, and that's an increase of funding to community-based services. Currently, though, at the same time the federal government is thinking about cuts in transfer payments to the provinces and that will have an economic impact, so we have to be concerned about that.

Can you tell me about the impact for coordination of service? Do you feel that the MSA legislation will broaden the choice for people for community-based services? What do you feel will be the impact there?

Ms Patterson: We haven't come up with an official response to the MSA, but I think, speaking as a social worker, one of our concerns is that by consolidating all the services in one basket, it could have a number of detrimental effects on clients. They might be intimidated, depending on the nature of the agency that ends up distributing the services. Naturally, there'll be competition for resources within that agency, and there's a whole question of who will have -- I'm not quite sure how to phrase this -- more strength within the agency. Will it be by demographics, the number of people in that area, or will it be by interest group, or just exactly what?

I think that one of our major concerns about the MSA is more around the area of assessment. There are a lot of seniors I have contact with who are looking for a very simple service, such as snow clearing or Meals on Wheels. They're not needing to be processed by a large bureaucracy; they're simply looking to call and get their simple service. We have some concerns around that. Is that clear?

Mr Malkowski: In my riding, the borough of East York, there are various services, although the community services are working together towards this goal, and it's not a competitive environment. The seniors and disabled people are working together to work on a model, work on an assessment process, and the consumers feel that it's beneficial that the assessment be holistic. I wonder what your recommendations are related to that for the assessment process and how it would alleviate your concerns in that area.

Ms Patterson: We'd certainly support a holistic approach. That's one of the things we're very strong on. In regard to assessment, I don't want to restate myself, but certainly we see the voluntary social worker as very integral to that, because we are trained to have sensitivity to the community and to the needs of the individuals.

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


The Chair: I next call on the representatives from the Association of District Health Councils of Ontario. We want to welcome you this afternoon.

Mr Ken Whiteford: I'm accompanied today by John Court, the assistant executive director of the association, and the vice-chair of the association, Susan Brown. My name is Ken Whiteford and I'm the chair of the association. John Butler, who I think was shown on your program as being present, was not able to attend. You have got a copy, I believe of our submission. I will simply try and highlight that, as opposed to going through it word for word.

Our association, which is called ADHCO in the acronym, is the collective voice and collective agent of Ontario's 33 district health councils. The DHCs, as you probably are aware, are schedule 3 agencies which advise the Ontario Minister of Health on matters relating to health needs in the community based on the principles of good planning and community consultation. The first DHC was created approximately 20 years ago and the most recent one, and the last one, was created just six months ago.

Since I think many DHCs have already spoken to you on a variety of topics related to the long-term care legislation, we would like to focus this afternoon specifically on those parts of the legislation referring to DHCs.

First, let me say that we generally support these provisions within the bill. We believe that embedding the role of DHCs in the legislation helps to both empower us and provides the residents of this province with a little bit of better understanding of the roles and responsibilities of DHCs.

We also believe that this legislation reflects a partnership among communities, DHCs and the Minister of Health. Most of our comments are directed at improving the language of certain sections so that they better represent that partnership. We acknowledge very clearly that DHCs are in fact the creation of the government of Ontario, but if DHCs are seen only as the arms of the government and not as the agents of their communities, we believe our credibility would suffer.

First, in terms of the details of the legislation, we would like to refer to subsection 62(1), subsection 8.1(3), which deals with the criteria for appointments. We feel this section shows a keen understanding of the need to have DHC members who reflect the diversity of their communities. DHC members do not represent specific narrow interests, but the breadth of background is important to all of the members. We believe this particular section of the legislation does ensure that breadth of background is recognized.


Secondly, in reference to 62(1), clause 8.1(4)(c) refers to the planning functions of DHCs. We feel this particular section should refer not only to the DHC planning for development of a better system but also to the need for the implementation of such a system and the planning for that implementation. Clearly, DHCs do not implement the results of their plans. However, one widespread criticism of planning in both the public and private sectors is the failure of good ideas to become implemented. We see planning for implementation as an activity which binds together planning and implementation, and we see it as consistent with the advisory nature of DHCs in general.

Another function cited under this section is the performance of "any other duties assigned to it under this or any other act or by the minister." We suggest that words be added to this section to state that these additional tasks would be based on an agreement between the minister and DHCs on the task. I think you can appreciate that any organization only does a job well if it believes in the value of the job and if it is helped to define the job in the first place. We see that being consistent with partnership.

Ms Susan Brown: Subsection 62(1), subsection 8.1(5) of the legislation refers to the aboriginal communities and the minister's ability to direct a DHC not to discharge one or more of its functions with respect to that community.

We respect and understand the need for aboriginal communities to plan for their own services. Nevertheless, much of the planning done by DHCs in a district or jurisdiction will be for generic services which are meant to help the population of the area, both aboriginal and non-aboriginal populations. Since it may prove very hard for any minister to make before-the-fact decisions on whether a piece of planning impinges on aboriginal autonomy, we would hope the minister would seldom use this legal option and that instead the minister might simply choose not to accept those DHC recommendations which may impinge on aboriginal autonomy.

Subsection 62(2): Clause 12(d.1) authorizes the minister to pass regulations on several matters, including recruitment of members of committees of a DHC. We view it as quite appropriate for regulations to be passed concerning membership on the actual boards of district health councils, but we believe that a reference to regulations on committees should be removed. DHCs need the freedom to create whatever structures they need, filled with whatever members they deem appropriate, a community mix for their community to do the work that needs to be done. Regulations governing this aspect of DHCs could stifle local creativity and responsiveness and might become the cookie-cutter approach which we believe the minister would like to avoid.

Lastly, we are aware that the legislation does not mention regional planning. We acknowledge that in its brief to you, the Ontario Hospital Association expressed concern about the creation of a southwestern Ontario regional planning body which OHA describes as a layer of bureaucracy to which DHCs would be subordinate. OHA wants it made clear that no regional planning bodies will be created under the sections of this bill dealing with DHCs.

We, on the other hand, feel that regional planning has been done for years by district health councils as a cooperative activity. We do not feel that regional planning needs to be mentioned specifically in this legislation, since such mention is not needed to allow district health councils to continue this cooperative regional activity. Conversely, the absence of it in the bill should not be used to prevent district health councils from planning cooperatively with each other.

In summary, we support those sections of Bill 173 related specifically to district health councils. Although we propose a few changes which will help reinforce the idea of partnerships between communities, district health councils and the minister, we also appreciate the minister's expressed support for the involvement of DHCs in development of any amendments or regulations which might be passed in the future that pertain to them.

I also point out that we are not legislative experts. While we do propose specific wording changes, we are quite happy with alternative wording which might work equally well to express the concept of partnership which is so vital to the district health council system.

Mr Dalton McGuinty (Ottawa South): Thank you for your presentation. I want you to expand a little bit on the role you see aboriginal communities playing. We have heard from at least one representative of aboriginal communities, and I have a copy of another written submission, with respect to section 62 of the bill, subsection 8.1(5) of the act. I'm not sure if I've got the numbers right, but it's the one that's got "Aboriginal communities" marked in the column:

"If health services for an aboriginal community in a district health council's geographic area are planned, managed or delivered by the aboriginal community or by an aboriginal organization, or if resources for health services for the aboriginal community are allocated by the aboriginal community or by an aboriginal organization, the minister," and then it goes on in clauses (a) and (b) to say, "may direct the district health council not to exercise one or more of its functions..." and "may direct the district health council to cooperate with the aboriginal community...."

The aboriginal representatives are telling us that we should remove the "may" and replace it with "shall." I want to get your response to that, please.

Mr Whiteford: Let me fully understand, then. They wish to make it very clear that we not be involved, or involved?

Mr McGuinty: They want to make it mandatory rather than permissive on the minister's part: the minister must. If that condition has been satisfied that's set out at the beginning of subsection (5), then the minister must direct a district health council to cooperate or not to exercise one or more of its usual, I guess, powers.

Mr Whiteford: I don't think the district health councils would have any problem with that in terms of the use of the word "shall" instead of "may," if that was satisfactory to the aboriginal community. Our understanding is that the ministry is working with the aboriginals to determine exactly how they want their health care needs met in terms of planning and implementation.

I guess our point today was simply that if we're doing the planning for a broad general area, especially with generic services, it's very difficult to plan for islands within those regions or districts. Our point is that we feel we should be able to do the planning, but if certain parts are ignored, that's fine as well. And if they on the other hand feel that if the condition is met, that we "shall" do the planning, we would have no problem with that.

Mr McGuinty: Just to make it perfectly clear, would you object to an amendment which substituted the word "shall" for "may" in the section that I was referring to?

Mr Whiteford: You must appreciate that we haven't had an opportunity to study this in great depth and it may be something that we would wish to --

The Chair: The parliamentary assistant wants to make a comment on, I guess, the legalities of where that stands right now, which may help in your response.

Mr Wessenger: I thought it might be of some benefit to have legal counsel explain the significance of replacing "may" with "shall" and how it would relate to what your submission relates to.


Ms Gail Czukar: The question that Mr McGuinty is putting with respect to subsection (5) of the district health council section would then say that as soon as there is planning, management or delivery activity on the part of an aboriginal community or an aboriginal organization, the minister then must direct the district health council not to do any planning or not to cooperate with the aboriginal community, that they're on their own.

It's difficult to see how the recommendation of that organization could be implemented when there are two alternatives in the section: One is to say that the minister can direct the district health council not to do one or more of the things that it does with respect to planning and recommending to the minister, or she can direct the district health council to cooperate with an aboriginal community to come to some agreement.

It seemed to me that your recommendation was that there could be some joint planning, and in fact aboriginal communities have asked that there be some joint planning in certain cases. It was meant to be a flexible section, so it's hard to see, legally at least, how you could do what was recommended, because the minister would have to, as soon as there was some activity on the part of that community, tell the district health council not to exercise its functions.

Mr Whiteford: I gather from your comments, then, that there may be some concern with the word "shall." I guess, from our standpoint, cooperation was the name of the game. We simply wanted to ensure that there was cooperation and coordination between the aboriginal communities and the DHCs within that district. If in some cases, which might happen, the aboriginal community decides to go off and do its own planning and the minister agrees to that, then we would appreciate and recognize the fact that our recommendations with respect to that aboriginal community may not be adhered to.

I think from our standpoint, in response to the original questioner, it might be best if as an association we got back to you on that point as to the "may" or the "shall," perhaps in writing to the clerk, and commented on it. Obviously, as just indicated, it has a number of different meanings and interpretations, so perhaps that would be the best. There are no lawyers on this side of the table.

The Chair: It's always nice to have lawyers in the room somewhere to ensure that we don't do all sorts of horrible and pernicious things. Sorry, it's late; the Chair is wandering a bit. Mr McGuinty, did you have anything further?

Mr McGuinty: No, those are my questions, thank you.

The Chair: If indeed there are any further thoughts you have on that, by all means send us a note and we'll take those into consideration as well. Thank you for coming here this afternoon.


The Chair: I call on the Ontario Federation of Labour, Julie Davis, secretary-treasurer. Ms Davis, welcome to the committee.

Ms Julie Davis: I also have with me Adrianna Tetley, who is on the federation staff. I figured the submission would take too long to read. That's why I reduced it to the key points in my speaking notes.

The Chair: We appreciate that.

Ms Davis: On behalf of the Ontario Federation of Labour, representing over 650,000 workers, I'd like to thank the standing committee on social development for the opportunity to present our response on Bill 173, the act to implement long-term care. The OFL represents both the users of the health care system and the front-line workers who deliver the care.

I'm proud to say that over the past year our movement has developed an action plan and strategy for genuine health care reform. We've brought health sector unions together in precedent-setting unity. We have reached out and joined hands with other labour federations and health care reformers across the country. In the appendices to our brief you will find labour's plan as well as a copy of what we endorse as the "10 Steps to Better Health in Canada."

Today, seniors' organizations, and we should all be grateful to them, are in the forefront of the struggle for better health care. We are pleased to stand with them in their call for the immediate passage of Bill 173. The government must pass Bill 173 in this term of your mandate so that Ontario can move forward on the long-term care system that seniors have been demanding for years: a seamless, one-stop system that offers a continuum of care.

To seniors and care givers, multiservice agencies are the way to go. We must free ourselves from the current fragmented, uncoordinated and costly patchwork of services. We can't afford to waste over $200 million a year administering this seriously inadequate system.

With MSAs, we calculate that we stand to save at least $90 million in administration costs that must be applied to the delivery of much-needed front-line services. With a new name, new mandate and new identity, MSAs will not only create more jobs for front-line workers and dedicated volunteers, but will also make community fund-raising much easier to coordinate.

The OFL, along with the Ontario Coalition of Senior Citizens' Organizations, the consumer alliance and other seniors' organizations, calls on the Ontario government to muster the courage to stand up to the agencies who oppose the changes. We believe these agencies are engaged in a destructive turf war to maintain control over small pieces of the long-term care delivery system regardless of the social or monetary consequences.

Having given our support to Bill 173, though, we feel that the legislation as it is currently drafted falls short or is silent in several critical areas. Tomorrow you will hear from two of our major affiliates, the Canadian Union of Public Employees and the Service Employees International Union, who share our support for the other concerns about Bill 173 that they will bring to your attention. Today I will bring to you our recommendations, but first I want to highlight the following points.

First, the OFL strongly supports the seniors' organizations in their support of Bill 173.

Secondly, the legislation must include the rights of consumers to choose to receive services in their homes, in the community or in long-term care facilities.

Third, the long-term care system must be adequately funded to provide mandated services without user fees, contracting out or excessive waiting lists.

Fourth, MSAs must be limited to purchasing a maximum of 10% of MSA budgets, and these services must be purchased from non-profit agencies.

Fifth, the imminent formation of MSAs in the long-term care sector will mean extensive workforce dislocation. Many health care workers are going to find themselves in low-paying, part-time work or with no job at all. They will be left without adequate qualifications or skills to adapt to the new jobs in the MSAs. Unfortunately, Bill 173 is strangely silent on the entire issue of labour adjustment, workers' rights or human resource planning. There is nothing in the legislation that indicates that existing front-line service providers will form the core staff of the MSAs.

The labour movement has repeatedly called on the government for a provincial, enforceable, comprehensive employment security agreement that would facilitate the redeployment and retraining of workers displaced in the health care sector. This agreement would guarantee workers who are displaced as a result of health care restructuring the right to comparable employment and retraining. It would establish a protocol to move workers to those parts of the health system which are supposed to be expanding, like multiservice agencies. So we would suggest that Bill 173 must be amended to include employment security and labour adjustment protocol. Wage and benefit parity between front-line workers in institutions and in the community health care sector must be entrenched as our goal. Good working conditions and decent wages and benefits are, we believe, integral to quality health care.

During the forums that the federation held in May and June -- these were forums that were held across the province -- we repeatedly heard from front-line workers that they no longer enjoy their jobs, that they run and run each day and it's not enough. They go home at the end of a shift feeling guilty because they could not give good quality care. We believe we owe it to our front-line workers, to the people who provide service to the sick and the elderly, to provide them with secure employment, good working conditions and the respect they so deserve.

I would also like to set the record straight on labour's view on volunteers. The labour movement values and understands the role of volunteers. After all, our labour movement has been built on volunteers. However, we strongly oppose the use of volunteers to do work that should be done by full-time trained staff. Volunteers should complement the system, not provide the cornerstone.

We have a long-standing agreement with the United Ways of Canada and the Canadian Labour Congress which has been followed up with local agreements between individual United Ways and local labour councils. In these agreements, we have clearly outlined the role of full-time workers and the role of volunteers, and we believe that Bill 173 must be amended to reflect this perspective.

The Ontario Federation of Labour also calls on the government to amend Bill 173 to allow front-line workers on the boards of MSAs and district health councils. We also feel that MSAs and DHCs must be required in legislation to operate in a spirit of openness.


Finally, I cannot conclude my comments on the long-term care reform system without adding comments on the downsizing of the acute care system.

The downsizing of the acute care system is out of step with the long-term care reform. Since 1989-90, over 7,900 beds have been closed in this province, but the community services have not been put in place to pick up the increased work. Therefore, the OFL calls on the government to stop the closure of hospital beds in the acute care sector until the MSAs are in full operation. Hospitals must ensure that appropriate community care is available before anyone is discharged. We would call upon the government to investigate the rise in readmissions because of premature discharge, the stories of people being sent home to fend for themselves without any support services, and the increased difficulties of being admitted into hospitals for serious illnesses.

Finally, doctors already are by far the best paid, best organized and most secure workers in the health system. We oppose the introduction of any legislation that will allow doctors to incorporate as private businesses. Such a move will cost taxpayers over $65 million, moneys we can't afford to throw away, moneys that could be well used to increase front-line delivery of long-term care services.

The Ontario Federation of labour is on public record in opposition to doctors' incorporation, and I today call on the standing committee and the people in this room to join the labour movement in ensuring that legislation for doctors' incorporation is not introduced.

I'll just quickly move through our recommendations:

(1) That the purpose of the act be amended to read: "To ensure that a wide range of community services are available to people in their own homes, in other community settings, and in long-term care facilities."

(2) That a clause be added in the bill of rights stating that a person receiving services has a guaranteed right to make the choice of receiving services in the community or in a long-term care facility.

(3) That Bill 173 be amended so it's clearly stated that MSAs will be appropriately funded to ensure they can provide the services they are mandated to deliver without user fees, without contracting out or without excessive waiting lists.

(4) That Bill 173 be amended to ensure that home care program services, currently insured under OHIP, continue to be insured whether provided in the home, other community settings or long-term care facilities.

(5) That means-testing and user fees for long-term care services not be legislated in Bill 173.

(6) That under the section of approval for agencies, the following conditions be added: first, that the MSA will strive to provide 100% of the mandatory services without relying on purchase of service; second, that the MSA will provide secure employment and good working conditions for its employees; and third, that the MSA is required to table, as part of its approval process, a human resources plan.

(7) That subsection 11(3) be deleted. Boards of health and municipalities should be allowed to compete along with other organizations seeking to become designated as MSAs.

(8) That a clause be added under part VIII, section 27, concerning financial accountability. Regular financial reports using accepted accounting procedures such as audited financial statements, balance sheets, income statements and statement of change in financial positions need to be included. A section should also include the financial arrangements made with any purchase of service agreement. All financial reports should include a section on the impact of the financial arrangements on quality of care and quality of work of the employees.

(9) That Bill 173 limit the purchase of services to a maximum of 10% of MSA budgets.

(10) That Bill 173 clearly legislate the preference for non-profit agencies. It should stipulate that where services are available from non-profit agencies, MSAs should provide such agencies with the opportunity to provide such service prior to purchasing them from a for-profit agency.

(11) That all exceptions to the rules governing maximum limits, clause 13(3)(b) and (c) for the purchase of services should be deleted. These include purchasing services due to short-term absences of employees due to illness, vacation or other unplanned event or from a self-employed individual.

(12) That the current program distinctions in Bill 173 be deleted and replaced with a comprehensive list of mandatory services.

(13) That Bill 173 be amended to include: The Community long-term care sector will be fully staffed by properly trained and qualified employees and supported by appropriate complementary services and programs offered and run by volunteers. Work previously provided by any employees in the health care sector will not be displaced by volunteers and volunteers will not work in positions which provide ongoing service for which funding could and should be made available.

(14) That the Ministry of Health develop a protocol on the role of volunteers in consultation with organized labour.

(15) That a section be added to Bill 173 requiring MSAs to develop a human resources plan that includes a labour adjustment strategy.

(16) That a section be added to Bill 173 which outlines the rights of workers in the system. These rights to be developed in consultation with organized labour.

(17) That the standing committee on social development urge the government to implement a provide-wide comprehensive employment security agreement that provides the framework for a redeployment system that ensures that workers who are displaced by health care restructuring are placed in comparable jobs at comparable pay and benefits in other parts of the health care system.

(18) That a mandatory redeployment protocol be enshrined in Bill 173. The elements of this protocol to include:

(a) front-line service providers who are currently working in community long-term care jobs be guaranteed the right to move to the new MSA with their jobs at no loss of salary or benefits;

(b) that employers be required to register all laid-off workers and post all new positions in vacancies with the central registry;

(c) employers be required to hire from the central registry of laid-off workers; and

(d) workers be provided appropriate training to prevent layoff and to be moved into the new community jobs.

(19) That the health sector training and adjustment panel be mandated in Bill 173 to administer the redeployment protocol and any necessary training to prevent layoff or assist workers with the move to new jobs in the community sector.

(20) That Bill 173 enshrine the goal of equalizing the wages and benefits of front-line workers in community health care with the institution sector.

(21) That the Ministry of Health establish a plan to implement this plan.

(22) That section 17, prohibiting employees at the agency from being a director on an agency, be deleted.

(23) That conflict-of-interest guidelines for all directors of MSAs be included in the regulations.

(24) That the standing committee on social development urge the government to accept labour's position that labour nominate the labour names to DHCs through joint OFL-ONA nominating process.

(25) That Bill 173 be amended to entrench labour's position that labour nominate four labour appointees, two labour consumers, two labour providers on each DHC.

(26) That Bill 173 be amended to ensure that board members of MSAs and DHCs be remunerated for any lost wages and expenses they incur in order to attend meetings.

(27) That section 11 and section 62 be expanded to require that MSAs and DHCs hold open meetings, hear deputations, answer questions about finances, administration and delivery of services, and make all records including financial records available to the public.

(28) That the standing committee on social development urge the Minister of Health to do the following actions:

-- Stop the closure of hospital beds until the MSAs are fully functioning and prepared to take the increased work.

-- Require the hospitals to ensure that the family physician has been notified that a discharge plan has been approved and that the appropriate care is available in the community before any individual is discharged.

-- Investigate immediately the stories about the rise in readmissions due to premature discharges, the stories of people being sent home without any support services in place, and the increased difficulties of getting admitted into hospitals for serious illnesses.

In conclusion, the government must find the resources to appropriately fund the system. If not, Bill 173 will only remain an empty promise and the hopes of many seniors will be shattered. It has been said that a measure of civilization is how it treats its elders and its young. I hope when it's time to reflect on health reform in Ontario that we also use this measure as a way to judge its success. I hope we conclude that we have treated our elderly well and that we have not sacrificed them to the gatekeepers of the health system -- the rich and the powerful.

Mr Jim Wilson: Thank you, Ms Davis, for your submission to the committee on behalf of the Ontario Federation of Labour. You may be surprised, but I agree with a number of your amendments. I have one overriding question here: With 28 amendments, some of which cut to the core of this bill, how do you support your statement that you're still supportive of this legislation?

If I may make a caveat to that, we've not seen major change by this government after the committee process, so I'm wondering if you know something we don't know.

Ms Davis: One always lives in hope that a public consultation is exactly that, and that the reason for the consultation is to hear what people have to say about the changes they think are necessary. I guess what it comes down to is whether the glass is half full or half empty, and we take the view that the glass would be half full if the bill was to go ahead without these reforms. We would prefer it to be entirely full, but we still think that a step forward is needed in this area.

Mr Jim Wilson: Part of the half-full optimism, I gather, is your contention that MSAs and the new administrative structures will save $90 million. Do you back that up with documentation that you can provide to this committee?

Ms Adrianna Tetley: We believe that the Price Waterhouse study that came out -- the consumer alliance report they released -- and that's where we got our figures. If you don't have it, we could make it available.

Mr Jim Wilson: Oh, we have it, thank you very much. We're enjoying looking at it.

Interjection: We even have the bootlegged version.

Mr Jim Wilson: As I said, some of the stuff we can agree with you on. I have one overriding question though, and I do apologize to the committee and to yourselves, I can't remember the exact union. They said they were the third largest. They were the Christian labour association or union. They presented a couple of weeks ago.

They wanted to know why the government was so hell-bent on its not-for-profit preference because the example they gave -- and I'll say at the beginning, I think they were a little wrong on their figures. They said, take for example the not-for-profit nursing home sector, homes for the aged, where the administrator -- they said the average was $136,000-a-year salaries. They compared that to nursing homes where they said -- I think they're wrong on the figures -- that the administrators there made half as much on average as those in the not-for-profit sector and they were mad that the money the not-for-profit administrator was making, what seemed to be excessive dollars, should be going to front-line services. How do you respond to that even if the figures are a bit skewed?

Ms Davis: It may be that the money's not going into the pocket of the administrator in the for-profit nursing home, but I assure you it's going into the pocket of the owner, and our experience has been over many, many years that any time you bring the profit motive into the delivery of care, whether it be for our children in child care or our seniors in nursing homes, the quality of care suffers, and that's something I've worked on personally since 1975. The evidence is overwhelming that you lose in the quality of care when you bring the profit motive into it.


Mr Jim Wilson: As you can imagine, we might disagree on that point.

Ms Davis: I would be astounded if we didn't.

Mr Jim Wilson: I'll leave it at that. Thank you for your presentation.

The Chair: Thank you both again very much for coming before the committee this afternoon and for your submission.


The Chair: I next call on the representatives from the Ontario Society of Occupational Therapists. Welcome to the committee.

Ms Christie Brenchley: My name is Christie Brenchley and I'm the executive director of the Ontario Society of Occupational Therapists. With me is Janet Gleason, herself an occupational therapist working in long-term care service delivery at the Sunnybrook Health Sciences Centre here in Toronto. Janet chairs the OSOT long-term care task force, and with her is Linda Marshall, who is also an occupational therapist working in the long-term care community-based delivery system with COTA, Community Occupational Therapists and Associates, also here in Toronto.

The Ontario Society of Occupational Therapists is really very pleased to have an opportunity to present to you the views, opinions and recommendations of Ontario occupational therapists. We are the professional association representing occupational therapists in the province, of which you may be aware there are approximately 2,400 registered occupational therapists.

OSOT represents approximately 1,300 OTs, and although it is difficult to gather data on exact numbers because of how our current long-term care delivery system is organized, we are aware that over 400 of our members indicate a focus of their clinical practice to be in the area of long-term care, so this reform initiative is indeed important to OTs, and we bring to you the voices of a significant group of stakeholders in this whole process.

By way of a brief introduction, occupational therapy is a health profession that is concerned with developing skills, restoring function, maintaining ability or preventing disability, promoting health in individuals whose lives have been disrupted, who are experiencing limitations in the areas of self-care, leisure or productivity: A term that OTs use to describe work-related skills whether they be in the office, home or student sector.

OTs treat clients whose lives have been disrupted by a variety of conditions, physical injury or illness, congenital or developmental limitations, the aging process, mental illness and/or social or emotional problems, and clients are treated across a lifespan from the neonate to the frail elderly. It is a client-centred and holistic practice that strives to maximize a client's ability to function independently within their unique environment.

I think perhaps a unique perspective that an occupational therapist brings to the long-term care intervention is an analysis and application of functional and goal-directed activity as a therapeutic medium to prevent or remediate disfunction, as well as the holistic concern and attention to the development of the functional ability important to the individual to meet their daily living needs.

I will let you speak to our long-term care expert at the moment.

Ms Linda Marshall: Having worked in the community for 15 years as an occupational therapist, I come with a community perspective. OTs are particularly interested in the reform of long-term care because of their extensive experience in this area. Presently, occupational therapists are either employed by home care or, as in Metro Toronto, are separate from and contracted by home care, to provide occupational therapy services.

In the present system of home care, a medical referral from a doctor is required. As well, service providers are required to provide a minimum number of visits, despite individual client needs. We're very pleased that the present government is planning to eliminate some of the criteria that, in fact, we see as hampering service provision, including medical referrals and a minimum visiting number.

The Ontario Society of Occupational Therapists supports the basic principles and goals of long-term care reform and its client-centred approach. We also support the five main objectives: one-stop access, an improved community-based system, a consumer focus, improved and consistent accountability, and local, community-controlled planning through district health councils.

Occupational therapists recognize inadequacies in the current system of service delivery: inequitable access, prolonged waiting lists for service, lack of coordination of care plans and services, and inefficient use of public funds. We believe the MSA model will simplify and enhance consumer access to long-term care service in Ontario. However, we do identify a number of concerns related to this model as defined in Bill 173. I'll ask Janet to outline those concerns.

Ms Janet Gleason: OSOT identifies the following concerns and recommendations for your review and consideration. We have identified issues which we believe will put the model at risk and urge the committee to take action to address these points. I'll be reading from our response, and if you'd like to follow along, I'm starting from the last paragraph on page 4 of our submission.

Occupational therapy delivery in the multiservice agency; occupational therapy as a core professional service: It is appropriate and important that occupational therapy be included as one of the core professional services. Occupational therapists are regulated and, as previously mentioned, provide a holistic, functional and client-centred approach to assessment, treatment and interventions. Occupational therapists also include education and wellness promotion as part of their treatment. This approach fits well with the government's long-term care reform.

Provision of occupational therapy services: It is OSOT's position that occupational therapy services must be either directly delivered by an occupational therapist or delivered by support personnel who are directly supervised by a registered occupational therapist. OSOT is concerned that Bill 173 does not provide assurance to the consumer that occupational therapy services will be provided by a qualified occupational therapist. The concept that someone else other than an occupational therapist could be responsible for delivering or directing occupational therapy services is not acceptable. In such a case, there would be little accountability to the public, nor the ability to ensure quality occupational therapy services.

In Bill 173, in the compendium, on page 18, it is stated that:

"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."

We are very concerned that lower-cost staff will be used by the MSAs for all services except those requiring professionals as stipulated under the Regulated Health Professions Act. This means potentially, that paraprofessionals would provide services best provided by occupational therapists. We do not believe this is in the public's best interest.

OSOT recommends that the bill be amended to clarify that professional services should be provided by registered members of the regulated professions.


Need for access to specialized services: OSOT is concerned that all the rehabilitation needs of MSA clients must be addressed. Because of the complexity and the unique needs of many long-term care clients, demands on MSA occupational therapy staff will be significant. It should be noted that within the profession clinical experience lends to the development of expertise. For example, occupational therapists working with large numbers of seating clients develop unique skills in this area.

In order to capture appropriate expertise for all clients without the expectation that the MSA staff provide all specialty services, OSOT recommends a blend of both onsite occupational therapists located within each MSA as well as access to external specialized services. Services such as orthotics, prosthetics and wheelchair seating may be more cost-effective if they are out-sourced from agencies outside the multiservice agency.

These services often require an extensive inventory of both equipment and tools, and it would be quite costly to maintain such inventories, especially in remote areas where the services are required. Access to such specialized services would be a practical solution that would enable a more universal accessibility. It should be noted, however, that this solution may have serious consequences on the 20% external funding cap.

Cost-effectiveness: Occupational therapy services can be extremely cost-effective in the long run. An example is the following: A woman who returns to her home following a stroke is unable to make her own meals. She is referred to the MSA and could be referred to either an occupational therapist or a homemaker. It would be more appropriate to refer this woman to an occupational therapist who would help the client develop the skills that would ensure that she reached her maximum level of functioning. If she received homemaking only, it is conceivable that she would not regain or develop the skills necessary for her to be independent and that she would then require homemaking on an ongoing basis.

Alternatively, if an occupational therapist provided the service, the woman, for example, would be taught energy conservation techniques, adaptive strategies for meal preparation and safe use of kitchen appliances with the intent of eventual discharge from the program. Although in the short run this might be a costlier approach, in the long run it would provide the client with an improved quality of life and reduce costs to the program.

Other areas or roles for occupational therapists within the multiservice agencies: Occupational therapists have expertise to contribute to the multiservice agencies in addition to direct-patient care. Some examples are planning service development, advocating for individual clients or a group of clients, public education and health promotion activities. Occupational therapy assessments focused on function and life skills performance will be critical components in the identification of support services required for clients.

Evaluation and professional standards: Currently, the proposed act does not describe a mechanism for the maintenance of professional standards and supervision of professionals and support personnel. As the MSA assumes the role of employer, provisions must be in place for the assurance of potential for professional service development, professional education etc. Evaluation models to study the effectiveness of all the MSA services should also be defined.

Out-sourcing of professional services: OSOT is concerned that the limited proposal for out-sourcing of professional services is restrictive and shortsighted. Bill 173 proposes a cap of 20% on the out-sourcing of professional services, thereby requiring the vast majority of services to be provided within the MSA itself.

OSOT proposes a more flexible approach to accessing external services with a requirement that the procurement of external services be closely monitored and evaluated in order to assure the cost-effective use of funds and provision of service excellence. We make this recommendation for the following reasons.

As previously described, occupational therapy and rehabilitation services for long-term care clients are diversified in nature and focus, often requiring professional expertise, specialized equipment and resources etc, to meet individual client needs. The requirement that services be provided internal to the MSA requires that the MSAs secure the appropriate professional and equipment resources to meet all the specialized rehab needs for their clients. We believe this could be an unrealistic target for many areas and very costly to the service agency.

This would be particularly true in rural or outlying agencies where it may be difficult to access enough therapists with diversified specialized expertise. Furthermore, the client population may not require the specialized services at a frequency consistent enough to staff for them. We reiterate that these types of services may be most efficiently accessed outside the MSA.

It is unacceptable that clients experience delays in accessing long-term care services due to the cap on out-sourcing of services. Rehabilitation interventions are only effective if they are timely, and effective rehabilitation is cost-effective by reducing the client's long-term requirement for hospitalization and support services.

There exists a critical shortage of occupational therapists to meet the needs for services in Ontario. This is noted particularly in northern and rural parts of the province. A more flexible approach to accessing external services would promote maximal usage of limited resources.

OSOT is not convinced that limiting access to a for-profit market is cost-effective. On the contrary, we would argue that providing for participation of the for-profit sector in this system would introduce a constructive competition into the marketplace which may ultimately facilitate cost-efficiency. We further promote that participation of this sector may provide a continuing catalyst for service delivery development and increasing quality of service. A system working in isolation of competition has more potential to become stagnant, inefficient and complacent.

OSOT suggests that this issue be thoroughly reviewed. Related to this is the impact the bill will have on outreach services currently provided by existing health care institutions and specialized community-based programs.

Bill of rights: The proposed bill of rights in part III is a concept occupational therapists can support philosophically and ethically. We believe in its intent. However, OSOT is concerned that by capturing such a code in legislation MSAs can be held to fulfil the literal interpretation of the bill. This we believe could be quite costly and in some cases impossible. For example, will consumers come to expect that all services should be delivered in their language of choice or with input from professionals who share their cultural background?

OSOT proposes that the bill of rights be modified to reflect the intent but with provisions for "reasonableness." The bill of rights could provide for assurances to regions that have particular cultural characteristics where a density of population makes a demand for services reasonable.

Case coordination: OSOT advocates that mechanisms around coordination of cases be clearly defined to avoid what is often the single most troublesome aspect of interdisciplinary or multidisciplinary care for the consumer and the service provider: the lack of or poorly coordinated care.

The bill outlines how a plan of service is to be developed, but it remains unclear as to who has the final say regarding the services provided to a particular client. What exactly is the client's role and decision-making power in this process? Who sits on the Health Services Appeal Board?

OSOT recommends that program planning and coordination is most effectively managed when a case coordinator is established who is responsible for consulting with involved service providers, the client and other components of the system. Occupational therapists have skills that lend well to this role.

The regional geriatric program currently exists and offers a model for consideration. An assessment team of two or three persons visits and meets with the client and makes recommendations regarding which are the most appropriate services for the client. The team is responsible for assessing the client and then forwarding the case to the appropriate services. This system facilitates team discussion to best determine the best services for the client.

The voluntary sector: The voluntary sector provides a valuable array of services to the community long-term care sector of the population. OSOT believes this is an important component of community-based care, not only because of the financial benefits but also because of the community and social responsibility it brings to life. Measures to protect voluntarism are important so as not to diminish these services through the transition period or through union restrictions with making services that were traditionally provided by volunteers -- and an example would be friendly visiting -- mandatory.


In conclusion, OSOT supports the thrust of the legislative changes proposed. Our holistic, functional, client-centred practice corresponds well to the reform strategies presented. Our presentation hopefully includes constructive feedback which we hope will be of assistance.

In summary, we believe that the following can ensure that Bill 173 will more effectively achieve its targets of reform:

-- The provision of occupational therapy should be provided by a registered occupational therapist.

-- More flexible access to professional services and special services outside the MSA.

-- Clear mechanisms for case coordination within the MSA.

-- Modification of the bill of rights to ensure it can be implemented.

-- The development of evaluation mechanisms to test service delivery efficiency and effectiveness.

-- Protection of the voluntary sector in the long-term care sector.

Ms Carter: Thank you for your presentation. I certainly welcome your general support for the bill.

I note that occupational therapists are listed under professionals in the bill, as far as that goes. I understand that the 20% purchase rule doesn't apply to individual practitioners or various professionals. Is that correct?

Mr Wessenger: Yes, that is correct. It doesn't apply to purchase from an individual who provides professional service or any other type of service.

Ms Carter: So in so far as you're independent practitioners, that proviso won't affect the freedom with which an MSA would employ you. Is that how you had seen it, or were you not aware of that point?

Ms Marshall: I think we certainly see, the way the MSA structure is set at the moment, that occupational therapists would be employed within the MSA. One of our concerns is the variety of occupational therapists that we have. Occupational therapists specialize and usually go into one of two streams, either into psychiatry or physical medicine, and within each of those streams there are a lot of subspecialties. We're having difficulty conceptualizing how all of these specialities could be employed in an MSA, how an MSA could afford to employ all these specialities' or whether the specialists, since there's a small pool of them, would be better to be outside the MSA and providing consultations. It's not that we feel that OTs can't be employed by MSAs; it's just the complexity of it.

Ms Carter: But if there were several MSAs, maybe in a heavily populated area, then they would certainly be able to draw on the same pool of different types of specialists, wouldn't they? Whereas I imagine in a remote community they would probably have to employ somebody who would have to cover that range.

Ms Marshall: Yes.

Ms Carter: We had a previous presentation -- I'm not sure whether you were here for it -- where the question of volunteers was raised in a rather novel way. I think we all accept that volunteers are highly essential and that we want to keep them. Obviously the system is so heavily dependent on volunteers, it couldn't run without them. The Price Waterhouse report certainly states that fears that voluntarism will be undermined are unfounded, because there will be a great deal of local participation in the development of MSAs and that will obviously involve a lot of grassroots input. Existing multiservice agencies have been very successful in maintaining volunteer loyalty.

But what I wondered was, do you have any feelings about the range of activities that volunteers should be able to provide? Do you feel there should be any limitations on that?

Ms Gleason: I think what we were thinking of is things like friendly visiting, what is normally being done right now with the voluntary sector. I guess we're hoping that with legislation and making this mandatory there won't be union restrictions etc which make it so that it's now a cost factor.

Ms Brenchley: The other point that we would like to raise is a philosophical point, and that's simply that involvement of a voluntary sector in health service delivery is an important social concept which we would embrace and would hate to see destroyed in any way because it embodies the sense of commitment that as a community, or as a province or a region, all participants in the community bring to the service delivery model. Long-term care, being as embracing as we perceive it to be, and likely to grow in terms of its client population as our general population ages, is one where we feel the voluntary sector can contribute very constructively, and gain itself as well.

Ms Carter: You also raised the question of how quality will be maintained in the absence of competition. We had another presentation today which suggested that multiservice agencies should compete with each other, that maybe they would have different focuses -- for example, ethnic background or specialization in certain types of treatment -- and that people will be able to go to the one that they thought would best suit their needs. I just wondered if you had any reaction to that sort of concept.

Ms Marshall: My reaction to it is wondering about the logistics of it and MSAs getting a certain amount of funding, and if a lot of people in one MSA area want to go to the other MSA, what the cost questions are for the MSAs. If you're getting a lot of people from various surrounding areas coming to a different MSA, that must be a real cost factor for the MSA that they're changing to or going to, I would think.

Ms Carter: The suggestion was the total funding would be set within a given region. I guess the more competitive MSAs would get a bigger share of it because they get more of the patients.

Ms Marshall: I philosophically don't have any problem with individuals going from one MSA to another. I think it should be a fairly fluid boundary, that people can have some decision-making power themselves about where they can best get services.172

Ms Gleason: My only concern with that would be with the outlying areas where the geographical distance between MSAs would make competition even more difficult.

Ms Carter: It would only be possible in densely populated areas, obviously; in a rural area you couldn't do that.

Ms Marshall: Even in a densely populated area, the clients who would be seen in an MSA, a lot of them would be far too -- I was going to say impaired -- to be able to -- if it meant travelling, but I don't know whether you're envisioning travelling.

Ms Carter: No, I don't think so.

Ms Marshall: Envisioning the MSA travelling to them.

Ms Gleason: Also, that could become even more costly, if the MSA services would have to move from one area to another; for example, an occupational therapist from one MSA goes right across the town to service someone, in so far as a lot of the clients whom long-term care serves aren't able to get to the services themselves.

Ms Carter: Maybe that would work in Toronto, but nowhere else.

Ms Gleason: Possibly, yes.

The Chair: Thank you very much on behalf of the committee. We still have a couple of presentations and I know the clock is ticking away, but we do want to thank you very much for coming before the committee this afternoon.



The Chair: I ask for the representatives from the Canadian Red Cross Society, district of Muskoka branch. I want to welcome you to the committee. I can only assume you have come from where the colour is magnificent and where we should all be sitting, but maybe we'll get there this weekend. Welcome to the committee.

Ms Barbara Gibbs: My name is Barbara Gibbs and I am manager of the Red Cross homemaker program in Muskoka. Norma Bustard, who was going to present today as a senior citizen member of our advisory committee, is ill. In her place is Lynn Moore, who is the director of home support services for Ontario division.

Ms Lynn Moore: I was honoured that Norma trusted me enough to give me her notes to present to the committee.

Homemaker services began in the Muskoka district in the late 1970s with eight homemakers and has grown to the point of employing 140 homemakers today. The service is valued by the community, and particularly by those who are able to receive care in their homes, rather than be institutionalized.

The role of the homemaker has evolved from that of the house maid to a well-trained member of the community health team. Through an ongoing educational program and on-the-job training, our present homemakers are prepared to provide personal support services as well as basic housekeeping activities. The homemakers' increased responsibilities allow us to make the most use of limited funds allocated to community-based health care.

The Red Cross Society supports the efforts to proceed with long-term care reform. While we strongly approve of the principles and goals outlined in Partnerships in Long-Term Care -- they were, after all, decided on after many hours of consultation with key stakeholders -- however, there are still some recommendations in Bill 173 that we cannot accept.

The current draft of the legislation and the movement to create multiservice agencies will exclude us, the Red Cross, from providing long-term care services because the Red Cross is federally incorporated and because our fundamental principles of independence and unity would be compromised.

Norma has specifically asked that I highlight three of the society's fundamental principles: independence, which means that we must be able to maintain autonomy of governance to act within the principles of the Red Cross and Red Cross movement; voluntary service; and unity, which is important to permit the society to carry on its humanitarian efforts throughout its territory, which in this case is Canada.

From years of experience, community-based organizations such as the Red Cross homemaker service with local boards have a successful record of accomplishments in the delivery of services in the health care field. It is difficult to understand why the government would initiate changes to the system which, in an attempt to centralize services, would simply establish a system that would stifle our deliverance of satisfactory long-term care.

The Red Cross homemaker service wants to continue giving long-term care to the residents of Muskoka district. If you look at Muskoka carefully, you will see a service already achieving many principles on which Bill 173 was based: accessibility, decreased fragmentation, consumer orientation and cost-effectiveness.

The Canadian Red Cross program has had in place for the past four years a 1-800 number for easy accessibility from all points in the Muskoka region. When receiving a call from a consumer requesting our services, our supervisors work very closely with that person to make sure that we can best meet the needs of that client for the least cost to them, for example, reviewing the number of hours of services needed, piggybacking this service on to another activity or directing the client to a cleaning service, if that is more appropriate and if that service is indicated.

We are in a very unique position in Muskoka, because there is only one homemaking agency -- the Red Cross. Nursing and professional services are delivered by the home care program and, due to areas of the municipality not receiving services, only two home support programs exist in localized settings. Services are not fragmented and the few service providers coordinate services --

An emergency alarm sounded.

The Chair: It's okay; that's "advised." It's my office, I think.

Please go ahead. There may be another bulletin as we go along, but we won't leave you and you won't have to leave us unless there's the demand that we get out of here. So please go ahead.

Ms Moore: Services are not fragmented and the few service providers coordinate services very well. The Muskoka-East Parry Sound home care program case managers work very hard to provide services to all clients. For those not currently covered under their program mandates, calls are often made to appropriate agencies for assistance on behalf of the client, rather than the client themselves having to hunt around, getting lost in the cracks or giving up hope.

To become more cost-effective and also ensure that the consumer gets quality care, the agencies throughout our area have developed joint level 2 and level 3 home support training programs for homemakers under the leadership of the Red Cross homemaker program.

An emergency alarm sounded.

The Chair: I apologize for this, but at least we know that here we're safe. Please go ahead, and if we have to leave, we will do as directed. Please continue with your presentation.

Ms Moore: Red Cross is recognized by clients, home care and other providers for its high calibre of service provision. This is because the agency has been proactive provincially in setting standards of service delivery, and this is the agency which is recognized by other service agencies as having a meaningful quality management program. We are definitely consumer-responsive because this will ensure that all consumers receive the same high-quality standard of care. Customer satisfaction surveys conducted by home care attest to the high level of satisfaction of consumers.

An emergency alarm sounded.

The Chair: Again, my apologies. Please go ahead. My only concern is that's where my office is. I don't know what I've got left.

Ms Moore: I must say, I can't help but wonder, since this is the eighth time the Red Cross has presented, if there's not a message here.

The Chair: Please don't take it personally.

Mr Jackson: There's nobody I'd rather be with in the middle of a fire. I want you to know that.

Ms Moore: I haven't had my first aid training yet.

As a result of long-term care reform, other positive steps are being taken to improve service and to reduce costs in our area. A cooperative purchasing consortium of agencies was developed to increase volume purchases and therefore to decrease the cost of office supplies. Equipment and training resources are shared between agencies in order to reach the largest number of people at the least cost to the agency. Therefore, in Muskoka we are accomplishing much already that other areas are still struggling towards, which, I must add, is not reflected in the Price Waterhouse report.

The legislation must be flexible enough to meet the rapid changes in long-term care. This would allow the service providers to meet the changing needs of their diverse communities. It must encourage all people in providing community-based long-term care to strive for fair and genuine collaboration to efficiently provide this service to the community. We are insistent that the system must not fail the vulnerable who depend on these services. We are proud of the steps we have taken to meet these service demands.

I would just like to add that as someone who has worked in long-term care for many years, I think the role of voluntarism is essential to our system. Staff may be very caring, but they are paid staff. Volunteers are there because they care and they want to be there.

Ms Gibbs: As I said, I am Barbara Gibbs and I manage the homemaker program in Muskoka branch. We provide services to Muskoka and we are beginning to provide home support services in the Honey Harbour-Port Severn area, where it was recognized that gaps in service existed.

Where other agencies provide homemaking and home support services, we work very closely to ensure coordination for clients. As you have heard, there are actually few service providers in our area, so we do not have the problem of fragmentation.

To give you an idea of the size of our homemaker operation in Muskoka, we will provide 144,000 hours of service to 1,600 clients this year. More than 61,000 home visits will be made by well-trained, uniformed Red Cross homemakers to citizens of our communities. These visits will enable clients to recover at home, to live with dignity in their homes and communities or, if they choose, to die at home within familiar surroundings and with the support of loved ones.


In the last three years, our service has expanded by 110%, with an increase in the number of consumers, complex care clients and the introduction of the integrated homemaker program. I believe this growth would have been extremely difficult, if not impossible, to cope with without the experience and support of the volunteer committee members and the huge, province-wide infrastructure that exists with Red Cross.

As a manager and a lifelong citizen of the Muskoka region, I take great pride in providing quality service which does respond to individual client needs. Our customer satisfaction surveys, sent to all clients after service completion, which can be anonymous if the client chooses, indicate a high level of satisfaction, and I might add that our local home care program, independent from Red Cross, conducted its own client satisfaction surveys on our service which confirmed that high level of satisfaction.

As a manager, I know how important it is to provide services at a price that taxpayers can afford --

An emergency alarm sounded.

The Chair: Good. We're safe, so we can continue.

Ms Gibbs: This is working under stress -- and I have to tell you that I was greatly dismayed when I read the Price Waterhouse study, which says our administrative costs are almost 30%. In actual fact, our administrative costs are just under 11%, and this is the norm for Red Cross programs throughout Ontario.

Even with this low overhead, we have been able to develop many programs which have moved the entire homemaker industry forward; for example, our quality management program, our Homemaker Handbook, which is a policy procedure guide given to each of the almost 6,000 homemakers --

An emergency alarm sounded.

Ms Gibbs: -- and an automated accounting and scheduling system, to name a few. We in Muskoka now provide service with professional backup 24 hours a day, seven days a week, as do all Red Cross branches across Ontario.

I challenge some of the comments in the recent report of the senior citizens' alliance which appeals to ordinary citizens, consumers and taxpayers to prevent the short-term interests of providers and politicians from undermining the viability of our publicly funded, long-term care systems. This report suggests we are self-serving and are fighting to retain the current system because we fear change.

We, like members of the alliance, want seamless, coordinated care, to have easier access to the system. We have not resisted change -- in fact have advocated for change for years. We have seen inefficiencies in the system and have worked very hard to correct them. While the system has benefited from our initiatives over the past years, much still needs to be done and we are actively participating in making the system even better. Remember, providers are taxpayers too and many of our volunteers and staff have spouses, parents or other loved ones who have been clients or they themselves have been clients.

Our interest is the present and future wellbeing of the clients we were and the communities in which we live and work. I know my community well and I know that organizations like Red Cross, with a long history of service to the community, have earned the trust of the citizens and have become a part of the fabric of the community. I believe it would be careless to assume that a new agency would attract the same number of volunteers and the same level of donations. Despite the negative press we have all heard and seen lately, our organization attracts dedicated volunteers and staff who are greatly loyal to the Red Cross.

For example, homemakers and management staff fund-raised on their own time to send dollars to places in the world where citizens are not so fortunate. That money is also used for additional training to build on their already excellent skills. I must say, that fund-raising is running bingos from 10:30 on a Saturday night till 1:30 on a Sunday morning, and that's done by the homemakers and staff, so it isn't that they're doing it easily.

We also have taken money and donated to other organizations to provide respite for family care givers. We are very proud of this kind of commitment. I believe it stems from a belief in the basic principles and mission statement that this humanitarian, volunteer-based organization is built on an identity to a caring organization firmly established in the community. I am not convinced that the new system as is presently described will be more cost-effective; in fact, quite the contrary. I think it will eventually offer less service and will be less able to respond to the changing needs of the client.

I hope that in some ways I have presented a good news story. In Muskoka we do not have fragmented service. We have already instituted efficiencies and there is a will to develop a model which builds on the strength of the current system. I urge you to amend the legislation to allow this to happen.

The Chair: Thank you very much. I'm sure this has been the most dramatic presentation that we've had before the committee, and I want to commend you both on being able to get through it with all the racket that's going on. I'm not quite sure why the siren is still going, but presumably it will end at some point.

Mr Jackson: Only the fire department can turn it off.

The Chair: Okay, that's why. We'll move then to Mrs O'Neill, who is ready with her questions.

Mrs O'Neill: Thank you so much for coming. I think I have heard almost all of the presentations from Red Cross and I've certainly met with Red Cross groups as well.

I am very pleased that you have shown that you do want to coordinate and you've proved that in your brief, your 1-800 number and the other things that you have mentioned in your own area. I guess my first question to you is, could you ever have envisaged that this would happen, that Red Cross and homemaking would be threatened through a government bill?

Ms Gibbs: No, I did not. Actually, I joined the Red Cross three and a half years ago. I worked as a nursing supervisor in the hospital at that time and my husband urged me not to change jobs, and I said: "But the Red Cross will be here for ever. It's a safe organization and they have provided care for so long that there's no threat leaving a hospital and going to the Red Cross." So no, I did not envision something like this would happen.

Mrs O'Neill: I don't think anybody did. I think you're seeing, as am I, that many people are joining with you now that they realize the jeopardy you're in and indeed maybe they are in.

I'm very pleased that you brought your administrative costs forward. We have had one other group bring theirs forward, and I think theirs was somewhere in the neighbourhood of 7%. It may be a smaller organization than yours, I'm not sure. You say this is characteristic of most of the Red Cross units across the province. Would you be able to provide that in writing to this committee? I think that would be very helpful if you have that data available.

Ms Moore: I certainly would be pleased to do that. As you may be aware, there is a press conference tomorrow at which the three organizations named in the study are going to be addressing the misinformation contained in the report.

I must just express my concern that the numbers themselves can be presented very misleadingly. In the report, part of what they classified as administrative cost that could be shared when we move into an MSA structure was the cost of vacation pay to the homemakers, and I would just like to report that I was speaking to 140 homemakers on Saturday, and they clarified with me that no, they would not be willing to give up 70% of their vacation pay to move to an MSA.

Mrs O'Neill: I think those are the kind of details that we need.

Ms Moore: I'll get that to you.

Mrs O'Neill: Certainly the Red Cross has been very helpful in describing why it can't be a member of an MSA. I don't think anybody could have ever believed that could happen.

Ms Moore: I joined the Red Cross on the day that the legislation received first reading. I was surprised.

The Chair: The sirens continue, but we remain safe here. I want to wish you a quieter, calmer return to Muskoka this evening than the welcome we've had for you here at this committee, but thank you both again for coming and for your presentation.



The Chair: I call on our final presenter for today, Miss Sharon Gillespie. We welcome you to the committee and we want to thank you for your presentation. I was just interested in flipping through, and committee members may be as well. This morning for the first time, certainly for me and I think for everyone, we learned about the On Lok Senior Health Services, and then I see you have quite a section on that. So some of these things are beginning to fall into place. In any event, welcome to the committee and please go ahead with your presentation.

Ms Sharon Gillespie: Thank you. I may be a little different in that I prefer to work in the private sector retirement industry in medium to small facilities in the hope that they will be prepared for some sort of role in serving seniors in the long-term care system. In this presentation I'd merely like to read the cover sheet, but initially explain the contents of this presentation.

Behind the blue page entitled "The Present?" there is a chart outlining the progress that the retirement industry will probably take to develop ultimately a support services model. I prepared this chart. Only retirement home developers that understand me do it. I don't want you to believe that they (a) understand it or (b) are performing it in any large scale at this present time, but the desire is there.

In the second section, the reason I've put "The Past?" with question mark is that there are three abstracts there: one discussing the On Lok model as it originated; a replication in a rural setting, which is the Wyoming project; and replication in an urban setting, which is in Colorado. I think many of the things that have been discussed today are reflected there when you speak of consolidated case management.

The reason I put a question mark is that in a geometrically growing problem and without discussion of the exponential function, I just don't know how that model can fully be expressed.

In "The Future?" there are two abstracts from Sweden which, if you look at the stats -- and I have put a little excerpt there on how to translate the currency to American dollars -- much of what has been discussed in backgrounder information to district health councils and other agencies reveals what is already happening in Sweden, and in many respects they are our future.

So, based on a discussion of that content, I'd just like to return to the first page and read this to you.

In this presentation, my goal is to present my views on the content and intent of Bill 173.

Content: darts and laurels.

Laurels: The service to client is well protected and designed to deliver a professional standard. This can only result in better personal service planning and the prevention of abuse through ignorance and lack of training.

Darts: Client access to services could be misunderstood. What is meant by "assisting" a person or "training" a person? Will clients ask to be assessed for services that may or may not exist according to their definitions or current practice? Will clients make life-changing decisions on insufficient/incomplete information, eg, their habitat?

Just to explain that, clients in the private sector now who may be experiencing -- we've just listened to the ladies from Muskoka -- a room rate of $48 per day plus services plus food cannot duplicate that in a hotel or anywhere else for that amount. Just the meals and the room alone would cost much more than $48 a day. Currently, Bill 120 has opened the door for us to duplicate the care delivery practices of the public sector through case management, formal and informal, which could bring down care to merely a visitation experience and leave many people with only a room and only food. The door has been opened for this event to occur, although I hope no one walks through it.

When people are asked to be assessed by patient coordination services and they're told, "Yes, you can have X hours of home care," will it be explained to them how this will be delivered? Will it be explained to them how this is expressed over a 24-hour period? Will it be explained to them how a life-changing decision regarding buying or selling a property when they cannot recover those funds will affect the rest of their lives?

Intent: darts and laurels.

Laurels: Management by results has met management by objectives head-on. Management by results, of course, is how the provincial government functions, and the Ministry of Health and its providers tend to be dealing with management by objectives. The focus on ability, where quality management must be more than a quality assurance program; accountability, where cost-effective fund transfer patterns will open public-private liaisons for service provision; accessibility, where MSAs streamline service delivery. Nothing could be more excellent than this event.

After-care safe homes -- very creative private-public sector partnerings have occurred in Sweden and are outlined in those abstracts.

Darts: With rehabilitation, prevention, respite omitted from the list of services you end up with a lean, mean medical model. It does not encourage progress into the vision of a support services model. Where is community development? Where is the empowered client? Apart from any discussions or current theories on long-term care, when you look at the content of this bill, it screams, "We are going to do the medical model the cheapest way possible." It doesn't talk about any progress into what you might term as the psychosocial model or the social programs model; it merely looks like a very efficient budget-saving measure.

Just as an addendum to that, I'd like to speak to you as politicians. The most powerful person you know at this present time in Ontario is a female 60 years old. By the time she's 70, for a five-year period she'll be the voting strength in this country. By the time she's 75, the health care crisis will be upon you. If I was a female 60 years old at this present time, I'd be very encouraged by special pension programs related to an early retirement in this hectic world, I'm sure. It's just a thought for you to consider.

The remainder of this document is meant for you to review, food for thought as you finalize this bill.

Mr Jackson: I appreciate very much your brief, and you've shared with the committee a considerable amount of external resources for us to consider. However, I want to go to your main thesis that you laid out very carefully for us. First of all, let me ask you if you're aware of those provinces which have undertaken reform of their long-term care and used more of a support services model.

Generally, it's come through moving medical services into the Community and Social Services panel and Comsoc being the lead ministry. Ontario has chosen, for whatever reason, to bring it through the medical or Health ministry models. I've been receiving some feedback about the distinctive look, or the potential outcomes would be different when it's taken one track over the other. I think that's part of the point you're making here.

Ms Gillespie: It's pretty hard to have a shotgun wedding of two groups of people, one that makes $17 an hour and the other that makes $17,000 a year. That can only end in annulment, which it has.

Mr Jackson: So what you're suggesting here is that the resources of the two ministries are configured differently and are approached differently, or what am I to interpret from that statement?

Ms Gillespie: Too much for them to realistically get along.

Mr Jackson: True, and across Canada we've seen lead ministries, but depending on which ministry takes the lead, you get a differing approach. One of the concerns I had was that although we're told the ministry responsible for disability issues, the Ministry of Transportation and the ministry of Comsoc are supposed to be involved in this process, we're seeing precious little of their ministries' influences in the development of this legislation and in fact responses to these public hearings when we raise questions. It has been predominantly a medical model.

Ms Gillespie: With transportation discussions being slated for 1995 and somewhat on hold, I can see why you wouldn't perhaps have a lot of input, because there hasn't been a lot of inclusion. But I have great respect for the Ministry of Community and Social Services. I have great respect for all the meetings I've had, many of them spearheaded by Mr Beer, on 24-hour, residential, on-site, off-site, caring for the elderly, services, and when you look at the thread of thought which is followed regardless of who entitles it, it's a social services incentive and thrust.

Perhaps the sophistication of the Ministry of Health is through long-term administrative excellence, whereas in the social services field even learning about administration is only about 30 years old. So I think the sophisticates, certainly in this project, are the Ministry of Health.

The Chair: Thank you again. I notice the peace and quiet that has descended on the building since you began your presentation, but we appreciate your coming here and for the material you've provided us with today.

The committee now stands adjourned until 9 o'clock tomorrow morning.

The committee adjourned at 1752.