Tuesday 13 September 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

Association of Ontario Physicians and Dentists in Public Service

Dr Martin Chisvin, board member

Dr Michael Kugelmass, board member

Dr Jansz Dukszta, president

Christian Labour Association of Canada

Ray Pennings, national representative

Hank Beekhuis, Ontario representative

Ontario Psychological Association

Dr Ruth Berman, executive director

Dr Mary Tierney, chair, task force on long-term care

Victorian Order of Nurses, Ontario division

Fay Booker, volunteer

Gale Murray, executive director

Regional Municipality of Waterloo

Ken Seiling, chair

Phil Johnston, commissioner, social services

Elizabeth Leeson

Kidney Foundation of Canada (Ontario); Canadian Association of Nephrology Social Workers (Ontario)

Janet Bick, provincial advocacy coordinator, Kidney Foundation

Lisa Bletcher, representative, CANSW

African Canadian Entrepreneurs

Delores Lawrence, president

Regional municipality of York

Eldred King, chair

Dr Helena Jaczek, medical officer of health

Peter Crichton, commissioner, community services

Multicultural Alliance for Seniors and Aging

Dr Dimitrios Oreopoulos, president

Dr Joseph Wong, vice-president

Canadian Mental Health Association, Ontario division

Carol Roup, senior director, policy research and branch services

Ruth Stoddart, executive officer

Lisa McDonald, community mental health consultant

Home Care Program for Metropolitan Toronto

Marian Walsh, president and chief executive officer

Dr Phil Daniels, board chair

Ontario Association of Optometrists

Dr Mira Acs, president

Barbara Wahl


*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:

Conway, Sean G. (Renfrew North/-Nord L) for Mrs O'Neill

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

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Tilson, David (Dufferin-Peel PC) for Mrs Cunningham

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Also taking part / Autres participants et participantes:

Ministry of Health:

Czukar, Gail, legal counsel

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

Wessenger, Paul, parliamentary assistant to the minister

Clerk / Greffier: Arnott, Doug

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

The committee met at 1006 in committee room 1.


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

The Acting Chair (Mr Dalton McGuinty): Good morning, ladies and gentlemen. I want to draw to committee members' attention that we have been provided with a second draft summary of recommendations for our perusal.


The Acting Chair: The first presentation this morning will be made on behalf of the Association of Ontario Physicians and Dentists in Public Service.

Dr Martin Chisvin: I'm Martin Chisvin. I'm a geriatric psychiatrist at the Queen Street Mental Health Centre here in Toronto. Michael Kugelmass is also a geriatric psychiatrist at Queen Street. Jansz Dukszta is a rehabilitation psychiatrist at Queen Street and president of our association. Debra Eklove is the executive director of our association.

The Association of Ontario Physicians and Dentists in Public Service was formed in 1974. Membership includes 400 full- and part-time salaried psychiatrists, general practitioners and dentists. Most of our members work in Ontario's 10 provincial psychiatric hospitals and nine Ministry of Community and Social Services regional centres for the developmentally challenged.

The aim of the association is to provide quality care in Ontario's psychiatric facilities and the community for patients and their families. We do this by providing leadership, information and support to the front-line staff in the delivery of mental health care and advocating on behalf of our patients.

We are here today to represent a group of people most of whom cannot represent themselves. To society they are somehow invisible as they sleep in doorways, over subway gratings or stagger through public parks gesturing and talking to themselves. For the members of our group and thousands of our coworkers in the provincial hospital system, they are the people with whom we share our working lives.

To us, they are ill with schizophrenia, manic-depressive illness, dementia and other organic brain diseases. To us, they are people, but people with chronic mental illnesses. So far, these illnesses are only controllable. Cures are rare and prevention very difficult. In the case of schizophrenia, for example, the illness strikes people very early in life, in the late teens or early adulthood, and if they don't die by suicide or misadventure, they can live to be 65, 70, even 80 years or more. If this isn't a long-term care problem, we don't know what is.

It's true that many psychiatric patients fall through the cracks in the present system. Why? Three reasons: (1) the move to deinstitutionalization that started in the 1960s; (2) the shortage of specialized long-term treatment for them in the community, and driving both of these issues, (3) simply a lack of funding. With the financial cutbacks to the mental health system, those cracks are getting wider.

We're here today to plead strongly on behalf of these people, because despite the focus on long-term care, Bill 173 completely ignores this frail and vulnerable group. Why? Because nowhere in Bill 173 is there any reference to them. It's as if they don't exist.

As many as 40% of the homeless and disfranchised we pass on the street every day have been our patients at one time or another. Like many Canadians who walk by these people every day without really seeing them, it appears that Bill 173 is dealing with them in a similar way: Just ignore them; maybe they'll go away. That's our impression of Bill 173. Nothing in the legislation so far has convinced us we're wrong. I hope we are.

With that background, we begin our comments with a question for the committee's consideration. In the framework statement of the bill, we note there is reference to age, over 65, and to people with physical disabilities. Why are there no provisions for many young adults and adults in midlife who also need long-term care due to their mental illnesses? Some of these illnesses require lifelong or periodic long-term care. We believe these patients should be considered under the bill in much the same way as adults with physical challenges.

Right now, our association's members play a pivotal role in the mental health care of the elderly and others who have severe mental illness. Today, what we would like to do is provide our views on several aspects of Bill 173.

We'd like to start by commenting on the lack of integration between two important reform programs: long-term care and mental health care. Currently there's an important implementation committee working on mental health care called the Mental Health/Long-Term Care Interface Working Group. This working group has recently presented a progress report to the Association of District Health Councils of Ontario. We don't have time today to present all the issues and questions raised in this report. However, we have attached a copy to this brief and we urge those committee members who haven't had the opportunity to review this document to take a few minutes to look it over.

Generally, the mandate of this working group is to recommend policies and guidelines for the regional and district levels on how to coordinate two service systems for the elderly: long-term care and mental health care. Clearly the work of this group is important for the future, yet the long-term care reforms embodied here in Bill 173 are already going ahead before completion of the mental health reform process, a process which may take five to 10 years to complete.

It may be fair to say that Bill 173 binds all of us working on mental health reform by limiting the possible long-term care solutions in mental health. If Bill 173 goes ahead as drafted, it effectively ties the hands of the interface working group in addressing the long-term care issues of the severely mentally ill and the elderly mentally ill.

As it currently stands, Bill 173 ignores three critical issues: the need for long-term care of the severely mentally ill who are not elderly, the needs of a large percentage of elderly who suffer from mental illness and the need for flexibility during the mental health reform process. We need this flexibility to address the long-term care issues of those with concurrent medical and severe mental illnesses.

Especially in times of economic constraint, no legislation can be successful unless it deals realistically with funding issues. Like many other groups you've heard from, we wonder where the funds are going to come from to support the creation of multiservice agencies and other long-term care initiatives. Even as we speak, funding for health care is already being drastically reduced.

Looking specifically at mental health, funding is going to be cut in three ways:

First, there are expenditure control cuts. At Queen Street Mental Health Centre where I work, a $7.5-million cut was announced recently. That's about 10% of the hospital's budget. That's 120 patients; 120 patients who won't have a bed if they need readmission. In total, all psychiatric hospitals in the province will have their budgets cut by $40 million or more. The community mental health sector will see cuts of $6 million in the next two to three fiscal years.

Second, there are funding cuts coming as a result of mental health care reform. It's been estimated that, over 10 years, the mental health care reforms are expected to reduce the number of psychiatric hospital beds by a further 50%. These are supposed to be reallocations within the mental health envelope, but our experience has been that if the money is cut, we never see it again.

Third, we anticipate reallocations within the mental health budget resulting from these reforms now under way in long-term care. We expect that community geriatric psychiatry services are going to have to be funded out of the present, much reduced, mental health care budget.

In its document Putting People First, the government states that no new money will be made available to support mental health care reform. Changes will be made by reallocating resources -- money and people -- within the existing mental health budget. In other words, will MSAs and long-term care facilities be receiving part of that reallocated money at the expense of the provincial psychiatric system? Yet, according to the present wording of Bill 173, the mandate of these organizations does not include the severely mentally ill. However, at present, it is clear that people with severe mental illness cannot be managed in the long-term care system. This is often why they end up in provincial hospitals in the first place.

Who does have the responsibility for them, and what are the consequences for them and their families with all these current funding cutbacks and future reallocations?

Well, as most of you know, these people may be invisible but they don't just disappear. They go to hostels that bar them after a while because of their agitated or psychotic behaviour. Then they go to the street. Or they end up in nursing homes, where sometimes they have to be isolated or restrained because of their behaviour.

Let me give you an example. Recently, at Queen Street Mental Health Centre, an elderly woman was brought to us from a nursing home. She was very agitated and had assaulted two of the residents of the home. We admitted this woman to the geriatric psychiatry unit. She quickly settled down and her behaviour remained calm. This is not an uncommon occurrence in our psychiatric hospitals. Why? Well, people respond very much to their surroundings. Our hospitals give them a less crowded environment with more personal space. Our staff are trained to deal with agitated or aggressive behaviour. Higher staff ratios mean that patients can be monitored more frequently.

In this environment patients can settle down, but become agitated again if returned to a less supportive environment. This problem can only be resolved by close working relationships between long-term care providers in both the physical and mental health areas. In our view, Bill 173 perpetuates and exaggerates the separation between physical and mental health care. It actually makes close liaison much more difficult.

The Ontario population is aging at a rapid rate; that is clear to all of us. What may not be so obvious is that mental and behaviour disorders are much more common in people with declining health and advancing years. We can expect an exponential increase in these problems in the next 20 years.

The Canadian Study of Health and Aging, a document which is well known to this committee, indicates that 8% of all Canadians over the age of 65 currently suffer from progressive dementia -- just one of the mental illnesses associated with aging. The same study estimates that the actual number of dementia cases will more than double by the year 2021 and triple by 2031. In some provincial hospital schizophrenia clinics today, the average age of our patients is between 50 and 60.

Clearly, the stakes are high for long-term care reform for the elderly with mental disorders.

Without dwelling too long on statistics, an appreciation of the impact of elderly mental health is important in the larger picture of health care reform in Ontario, of which long-term care is a part. Ministry of Health studies have shown that as many as 50% of all hospitalized elderly have at least one psychiatric problem.

The numbers are even more striking in long-term care facilities. As many as 70% of their elderly residents exhibit personality or behaviour problems which may be psychiatric in nature. And as many as 80% have a diagnosed psychiatric disorder.

Our association members are on the front lines of these new, and at times alarming, mental health care needs of the elderly. As these people with mental disorders live longer, we've also had to grapple with the issues of their long-term care. It seems to us that now, when the problem is increasing and placing strains on existing systems, is not the time to radically shift the burden of this responsibility. Nor do we believe it's the time to diminish the role of the trained professional in the assessment, treatment and ongoing care of these elderly patients. That's what appears to have happened by not considering mental health needs in Bill 173.

There have been profound changes in the last 20 years as Ontario's psychiatric facilities have taken a more integrated approach with community-based programs and care. Ontario's institutions have progressively adopted more outpatient and home care approaches, becoming an integral part of the community-based services in their regions.


Over the past 20 years, many of Ontario's psychiatric hospitals have implemented community-based service programs for the elderly. One example is a program at Queen Street Mental Health Centre called PACE, Psychogeriatric Assessment, Consultation and Education. Six other of the provincial hospitals -- namely, Brockville, Kingston, North Bay, Penetanguishene, Thunder Bay and Whitby -- have similar community geriatric psychiatry programs. In other centres, the psychiatric hospitals collaborate with community-based programs.

Essentially, these programs are geriatric outpatient programs run by the psychiatric hospitals, offering a quick-response multidisciplinary team made up of psychiatrists, GPs, nurses, social workers and occupational therapists. Working with family members, this team quickly assesses the elderly patient's mental health and recommends treatment or, if necessary, long-term care. These programs are accessed by public health nurses, family, friends, family doctors and psychiatrists. Where possible, the geriatric psychiatry team carries out the consultation, assessment, treatment and follow-up in the patient's home or on an outpatient basis.

These special teams are often also involved in assisting the family or patient in accessing other service providers in the areas of housekeeping, housing and specialized professionals. In essence, the community geriatric psychiatry programs have been operation in a multiservice agency fashion for the last 20 years. The PACE program at Queen Street, for example, carries out thousands of in-home visits a year.

These community geriatric psychiatry programs are highly successful and well received by families and groups representing the interests of the elderly. We believe that community geriatric psychiatry programs are the most important building blocks available today in the reform of long-term geriatric mental health care. They have been developed, tested and implemented successfully by highly trained and experienced specialists in mental health care for the elderly. They are based on the principles of family and patient involvement, appropriate treatment and non-institutional care whenever possible.

With that general background on the role of psychiatric hospitals in elderly and long-term mental health care, we'd like now to provide some specific comments on Bill 173.

Our members would welcome the chance to become more involved in the implementation of the reforms proposed. However, to do this in a meaningful way, we feel that the role of psychiatry and the psychiatric system currently in Ontario should be recognized in the bill as a partner and stakeholder in the reform process.

Another general comment on Bill 173 is that we feel it is too restrictive and not flexible enough, especially when it comes to the effects on mental health care reform over the next 10 years.

If this bill is to take us into the next century, then it needs to be more accommodating for change. If you look back 30 years, it's easy to see how wrong we can be in designing mental or general health care for the future. In looking at the objectives set out in the bill, we have some suggestions as to the way in which the mental health aspects can be strengthened.

As explained earlier, seven of the 10 psychiatric hospitals in the province have adopted community geriatric psychiatry programs. Building upon these existing successful programs should be pivotal to the long-term care reform process. Our community geriatric psychiatry programs have treated thousands of elderly with mental disorders, the majority of whom have eventually returned to their homes and families or long-term care facilities.

When we look at the mandate of MSAs, as outlined in the draft bill, we note that mental health and psychiatric care are not even mentioned in the four types of mandatory services to be provided. Yet, the statistics on elderly mental illnesses, provided earlier, clearly indicate that mental health is a major concern with long-term care givers. Indeed, psychiatric disorders are so prevalent that we don't see how this bill can talk about long-term care without talking about psychiatric considerations.

Our association would like to see a clear definition of responsibilities for mental health and how they are to be met. Are psychiatric services to be part of the 20% of purchased services? Are important psychiatric services going to have to fight with other necessary services such as the Red Cross, the VON etc for part of the 20%? Is that what we want to happen? The way the bill reads now, that's the scenario that's painted.

Regarding the bill's objective of improved community-based service system, we have been actively working in this regard for 20 years through our community-based geriatric programming. However, these programs are not the complete answer.

We believe there must be an understanding and recognition of the role of institutions in long-term care where elderly patients are a threat to themselves or to their families or their community. In these cases the types of treatment, ratio of staff to patients and specialized training needed can only be found in the established psychiatric system.

For many of these patients, the institution is a first resort to long-term treatment and care and not a last resort. For many of the patients I described earlier, the psychiatric hospital is their community, since they are among people specifically trained to look after their needs, and they are with others like themselves.

We need to recognize that for people with severe mental illnesses, the long-term care solutions must involve both the institution and the community, each having its specific role to play, each serving its purpose in a coordinated and balanced way. We wonder how this balance is going to be improved under Bill 173.

In particular, we think our expertise could be invaluable to other long-term care providers in managing mental disorders or behaviour problems. Instead, we feel that Bill 173 will only increase the tendency to dump people with complex problems from one system to the other.

We'd now like to present you some views on how Bill 173 might be improved in order to be relevant to the severely mentally ill community:

(1) That the legislation be amended to include specific references to those with dementia and chronic psychotic illnesses;

(2) That the legislation be amended to allow each community sufficient flexibility to develop and implement a multiservice system to meet its unique needs;

(3) That the legislation be amended to eliminate the four-year deadline so that each community will have the flexibility to develop and implement the best system possible for its long-term care needs.

In closing, we hope that we have offered some insights, raised some vital questions and presented some solutions. We thank you for your attention to this presentation and remain available at any time to this committee for further information or elaboration.

Mrs Barbara Sullivan (Halton Centre): I think that this is an extremely important brief and I'm pleased that you've come forward with it.

During the latter part of your brief I've been looking at the progress report to the district health councils on the mental health long-term care interface. What is clearly evident here is that there isn't a structural integration of the two systems, nor of the reform process.

I'm going to ask the parliamentary assistant first of all if, given in the mental health system the reduction in funding for psychiatric hospitals and the reduction that we know from the estimates in community-based mental health funding, and no new money for mental health reform, long-term care is getting some of the reallocated dollars to pick up the slack that will clearly be evident in the mental health system.

Secondly, how do you intend, through this long-term care bill, Bill 173, to deal with the very serious problems of the dually diagnosed, the psychogeriatric population, and not only of those individuals but of the young adults and the adults in middle age who need long-term care because of mental illness?

Mr Paul Wessenger (Simcoe Centre): I think what we have to accept is the fact that we are establishing a somewhat integrated system for long-term care dealing in particular with the aged and the physically disabled. I think that's clear. We have many other components of our health care system. We have the acute care system, which again is a separate system. It's not integrated with the long-term care, and the same with mental health, which is also a separate system and has its own reform process being carried out.

That doesn't mean you don't have to have interfaces between the systems. Of course you have to have interfaces between the systems. But, for instance, to suggest integrating the mental health reform into the long-term care reform -- let's say it would be a tremendous challenge. We may eventually, in the way our health system evolves, have a total integration, but I think at this stage we have to accept the fact that we're integrating within certain limited services and long-term care is one of these integration areas. At this stage we're not considering any additional integration of specific services.

I certainly acknowledge and understand the concern of the presenters that yes, there has to be an interface between the two systems. But I would suggest that the whole approach on mental health is a separate reform process.


Mrs Sullivan: I think that it's very hard to justify that argument when you know the level of population proportions that has dual diagnoses, particularly with an aging population to which the long-term care reform is ultimately geared. Furthermore, when you have eliminated the clinician even on the physical side of the problems, what are you going to do on the psychiatric side of illness?

Mr Wessenger: I would suggest to you that probably there's as much interface of the long-term care system with the acute care system among people in the long-term care, perhaps more interface than there would be with that and the mental health system. We haven't integrated the acute care system with the long-term care system. To reform a system I think is a basic challenge itself without -- and you have to reform a system, I would suggest, before you move to any further integration.

Dr Jansz Dukszta: I would like to comment. I believe that in fact there is no integration between the mental health system and the proposed changes, the ones that we're now discussing. Not only that, but while we are proceeding with the cuts, which are not related to the reform in the mental health system, we're taking an incredible risk with what will happen to the people who are under 65 and over 65 in terms of their future admission. It's very easy to discharge someone when the system is not integrated because we expect that someone else will take care of that individual. If that's not happening they will end up either on the street or with the police.

Unless the two systems are integrated and unless the cuts are actually now stopped, we are asking for an enormous problem. Almost every jurisdiction so far has said there is a minimum of beds which are necessary for psychiatric patients and for the mental health and for the elderly patients, and we have moved towards the cuts which are related to this bill at the moment. That one bill would provide all sorts of services while on the other hand cutting off our ability to provide care both for the mentally ill and for the psychogeriatrics.

Mr Tilson: Mr Wessenger simply disagrees. He simply says that mental health is a separate issue. I'm interested in your comments. Just recently you've talked about how right now there are already cuts that are going on. You talk about that $7.5 million in cuts were announced, about 10% of the hospital budget. My question is, what other social problems, and you're reiterated some of them, are going to be the result of this bill when we know that cuts are going on to the other agencies? In your paper you say that, "Oh well, they'll be sent off to other agencies," but there are cuts going on there. So my question is directly: What other social problems do you anticipate as a result of these cuts?

Dr Michael Kugelmass: Already we've seen, because of cracks in the system with current legislation and changes that have occurred over the last number of years -- I can give you two anecdotes of things that happened to me yesterday, in fact.

When I was getting on the subway coming to work yesterday morning, a lady got on. With my experience, 25 years of working in mental illness, I think she had a chronic mental illness. She was obviously on the streets because there was nobody to look after her. I've seen her several times, getting on the subway. She was very loud. She was obviously responding to voices, talking about Communist China, Masonic and Jewish plots against her. Of course, she emptied the subway all around her. There's nothing that anybody could do for her and everyone was terrified of her.

The second case was a call I had yesterday afternoon from a daughter of an elderly patient who had been referred to me in one of my other positions as a psychogeriatrician at Wellesley Hospital. The waiting list for her to see me is two months, and she was pleading on behalf of her mother to be seen earlier. I couldn't see her earlier at the Wellesley but I suggested that our PACE program, that you now know about, could see her in her home if she lived in eastern Toronto. Well, she was in Cobourg.

I believe there's another crack in the system in the fact that although we may be somewhat well organized in Toronto, when one gets to the outskirts there's very little help for people. I believe the changes in legislation are not only going to widen and deepen the cracks that exist but they're going to create more cracks.

Mr Tilson: You've commented about different programs. You're talking about the PACE program. Do you anticipate that there will be changes to these types of programs as a result of this legislation and as a result of the cuts?

Dr Kugelmass: We don't know how the legislation will affect the PACE program. As a result of --

Dr Dukszta: There are two parallel tracks.

Mr Larry O'Connor (Durham-York): You can turn around and ask the minister a question --

Mr Tilson: Mr Chairman --

Dr Kugelmass: If I may respond to the rest of the question.

The Acting: Order. Mr Tilson has the floor.

Mr Tilson: I'm directing my comments to you, not to the government members and I suppose --

Mr O'Connor: They might like to respond to them.

Mr Tilson: You must have philosophized looking at these cuts that are going on along with this bill and what affect they will have on these types of programs.

Dr Kugelmass: I can answer the second part of your question, which is the cuts in the budget in the hospital. As far as we can determine, it will obviously create more work for our PACE program. If the budget cuts the PACE program as well, we just don't know the response. We haven't been told that.

Mr Tilson: The issue with respect to Mr Wessenger's comments, have you had an opportunity to consult with the government on the views that have been put forward in this paper, any members of your --

Dr Dukszta: On this bill, no. On the mental health reform, we were included at the provincial advisory committee after pressure on the social contract negotiations. But this is a committee which is extremely large and it's very difficult to get a point across.

In summary, I would say that the professionals who work in the system have been consulted in the most minimal fashion, and these are the people who actually do know what work is done. The consultation has been done generally with a number of other people but not, interestingly -- and I will give you an anecdote.

I believe when the provincial advisory committee was discussing questions of retraining and a presentation was made about what kind of training should be done for the professionals who are being let go, which they will be, the committee had no representation from unions or from us and was presented by other people. Yet, it's the people like ourselves, the nurses and OPSEU, who should be directly involved. If we accept the concept of working in the community, they should be directly involved in what kinds of jobs they're going to do and how they're going to be trained to do them. This has not been done.

Mr Tilson: That says it all.

Ms Eklove: One of the programs of our association is a provincial outreach. Our members have felt so very strongly about the need for consultation and involvement in mental health reform that we have taken it upon ourselves to meet with other stakeholders: other professionals, other patient groups, other family groups that should know about mental health reform. We've met with people in housing, we've met with people in corrections and the police, we've met with people in education, many other professional groups, many of the groups that represent individuals with illnesses, and in all cases there are grave questions about the mental health care reform and how it will impact on their communities.


In some cases, some of the communities had not yet even looked at mental health care reform and how it will increase work or transfer work from the Ministry of Health to other ministries, so it is an issue which continues to astound us at times, that there is a wide range of people who will be affected by this bill who are only now starting to hear about it. We feel it's very important that information get out to them and that they participate with the government as fully as possible to ensure that what is put into place is not going to create more problems.

If I may also make just one point, how important the issue is to us; it happens that today is a board meeting for our association. My colleagues are all doctors in the psychiatric hospitals. For everyone sitting here, there is another colleague in the facility covering for them. They can't leave without the coverage, so what you see here is just a small show of our concern about this issue. In the gallery there are many, many members; in fact, if I could just ask the members of the association to stand up to get a sense of who is here representing facilities through the province.

Ms Jenny Carter (Peterborough): Could I have a question of information here, please? There's been a lot of talk about cuts. I was just wondering whether we could have some figures from the ministry as to what is actually happening here, certainly in the community section, and this does concern you when we're talking about the outreach from Queen Street and so on. I understand there's going to be much more funding than there has been.

Mrs Sullivan: That's incorrect. We dealt with this in the estimates and it is incorrect.

Mr Wessenger: We will undertake to get that information for you. While I just have the floor, I might indicate that the MSA will provide information, provide assessments and in addition the MSA will be able to get professional expertise in the psychiatric area.

Ms Carter: We're transferring the funding. It'll be there and there will be more of it, right?


Mr Wessenger: There's no connection between the two.


The Acting Chair: Representatives of the Christian labour association of Ontario, welcome to our committee. I'd ask you to please introduce yourselves and then begin.

Mr Ray Pennings: Thank you, Mr Chairman. First of all, a small correction: We are the Christian Labour Association of Canada. That's obviously a typo that's crept in. My name is Ray Pennings. I'm a national representative with CLAC. Hank Beekhuis is an Ontario representative who works out of our St Catharines office. Ed Grootenboer is our executive director.

As we've all learned over the past number of years, restructuring an entire long-term care system is no easy task. Ever since the release of a CLAC task force report in 1985 entitled Serving our Seniors, reforming and improving Ontario's system of long-term care has ranked among our priorities in representing our members working in the system. Since that time we've seen a steady growth in our membership so that today we are the third-largest union representing workers in the province's long-term care sector.

As a preliminary comment, CLAC supports the objectives of long-term care reform. Coordinating the various services and components of the system and equalizing the funding formulae in order to achieve a more equitable and effective outcome for both care receivers and care providers are worthwhile and, in our view, necessary goals. However, the manner in which one seeks to effect change is as important as defining the objectives, since the long-term care system, like health care in general, very much involves the lives of people, first of all those requiring care, but also those involved in the delivery of care and services.

Given that, our submission this morning will deal with the "how" of bringing about desired reform. In particular, we would like to express our reservations about the multiservice agencies as envisioned by Bill 173, as well as make some observations about the implementation process which followed the passage of the previous phase of long-term care reform, Bill 101, in the hope that the same mistakes are not repeated. We would argue that the structure and conditions proposed for MSAs in Bill 173 will negatively affect the working conditions and choices offered to care providers and will be an inefficient use of taxpayers' money, with resulting negative impacts on the quality of care provided.

At the heart of this bill rests the premise that new government agencies will be able to ensure more efficient and better quality care. This is a premise we would challenge and would like to discuss with the committee. In the creation of the multiservice agencies, we observed the introduction of various rules and rigidities which are likely to be counterproductive. Let us be clear: As we stated earlier, we fully support the objective of long-term care reform, including the creation of one-stop access for the consumer, coordinating the various services currently offered by hundreds of agencies and establishing a minimum basket of services available equally to all Ontarians.

Bill 173 does more than that. It provides not only a single access point for the public, but the MSA will be the only way to access long-term care services. No matter how much stock we put in the community representative boards and how much we legislate respect for linguistic, cultural or religious diversity, the MSAs will govern and direct where individuals will receive care. Agencies and institutions that were established to serve the needs of a particular linguistic or cultural community, a very important factor, particularly for the elderly, or that provide care on the basis of a certain philosophy, will inevitably change or disappear. There is no incentive or structure that will accommodate their continued existence and growth, and that is a loss for our health care system. No single agency, regardless of how community reflective or well-intentioned it is, will be able to provide the diversity of service which is part of the richness of our current system.

The elimination of the diverse services will occur because of the requirement that the MSA not only ensure access but also deliver at least 80% of the service. This reduces consumer choice. It also places the MSA in an inherent conflict-of-interest position. The MSA will have control over the funds, be responsible for ensuring that regulations are upheld and manage the delivery of service. At the end of the day, all of these functions will report to a single board of decision-makers, who inevitably will have to rely on the professionals who will run the MSA on a day-to-day basis.

By virtue of the provisions of this bill, MSAs are being placed in virtual monopoly positions, responsible for the total delivery of long-term care services. Whenever a monopoly position is afforded, questions of accountability are crucial. The bill before us deals with accountability by instituting an appeal process in part IX for persons who are denied services and by giving the minister revocation and takeover powers in part X. These measures, however, will only deal with extreme situations and, as we've witnessed in the recent crisis at Metro Housing, many people are victimized by a process that has to wait for extreme conditions before remedies can be decided on by Queen's Park.

In an era of fiscal constraint, our members worry that they will be pressured by management in the face of arbitrary fiscal limitations imposed by the MSA to compromise the quality of the service they provide and that there is no effective remedy against this, since the same board that's responsible for defending the quality of their service is also managing the fund and ultimately is their employer.

While Ministry of Health compliance officers may become involved, they have little leverage in dealing with the provider of an essential service who cannot easily be replaced. Today, in the community sector, there is more leverage as agencies depend on annual budget approvals and few are in that monopoly position in providing long-term care.

When our members ask us why the government is proposing to eliminate the various agencies that currently serve the community and replace them with a government agency, we've provided the government's stated rationale: This is supposed to eliminate the duplication of management and overhead costs and increase coordination by placing them within a single agency. The response usually runs something like this: "You mean the government actually thinks that one of its agencies is going to reduce overhead costs by creating a new bureaucracy? By the time they have the directors, communications persons, newsletters and consultants paid for, I doubt a penny will be saved." Call it cynicism if you like, but the reality is that government agencies do not have an inspiring track record in their ability to stretch scarce resources and manage efficiently.

One factor that enters into the government's rationale is its stated preference for the not-for-profit segment of the health industry. As a union, CLAC deals with community-based, charitable, municipal and commercial agencies. In our task of representing employees, the corporate structure represented on the employer side of the table makes little difference in the quality of care provided. There are those who argue it's inappropriate for health care dollars to end up as corporate profits. While we have sympathy for the argument that public dollars need to be spent efficiently, with value for money, our observation is that as much money is spent profiting management types in some of the so-called not-for-profit sector as it is in the commercial sector.

When, for example, a Revenue Canada taxation form indicates that a single executive officer of a home for the aged received remuneration of $136,000 in 1991, more than double the average for that position in the private sector, in addition to other perks and well-paid jobs for family members with dubious qualifications, we have little sympathy for the position that the not-for-profit sector is always to be preferred to the commercial sector.


We need to be aggressive in assuring that public funds are not benefiting certain individuals, whether they head up a private corporation or a public board. In our work on the long-term care funding committee, CLAC has worked hard for and supported measures that address these concerns. But the proposition that we need to target the elimination of commercial agencies in order to save the profits for our health system is a red herring argument. In many instances, for-profit institutions deliver as good if not better care in this sector for substantially fewer dollars than the better-funded not-for-profit institutions.

While the merging and amalgamation of various agencies into a multiservice agency will undoubtedly hasten the pace of unionization in the community sector, that does not mean workers automatically will be well served by such a model. Larger units of work organization have not proven to facilitate the choices of workers and the cultivation of a work community. The spectre of a large health care employer and large bargaining units to which all workers belong is a step backwards for plurality and democratic choice, not only for workers, but also for those in need of care. The ability for individuals to make choices and effect change in their local circumstances will be reduced and, in some cases, eliminated.

We submit that the public is better served when different facilities creatively work to solve problems in different ways. In the long term, diversity in labour and other kinds of structures makes us all stronger, as we learn from and build on each other's successes and failures. A single or unitarian system where everything ends up at the board of a multiservice agency concentrates power in too few hands and inevitably leads to unresponsive and bureaucratic isolation from the front-line situations and needs that must be addressed.

In summary, the requirement that multiservice agencies deliver, rather than just provide access to, services has consequences that are detrimental to the delivery of quality long-term care services. This requirement will have the effect of minimizing consumer choice and reducing the diversity of service available to Ontarians, creating a government bureaucracy that's unlikely to improve efficiency of the system, give rise to employment circumstances where all workers will become employees of large agencies, with the result that individual employees will be less able to make choices and meaningfully influence their work environment, and causing a conflict of interest within the MSA board, which will have to fund, regulate and manage the delivery of services. While mechanisms of appeal are established for those who are denied services, consumers and employees will have less recourse in dealing with quality of service concerns.

These negative consequences stem primarily from the requirement that MSAs deliver at least 80% of the services, as outlined in section 13. If this section were eliminated, there is nothing that would prevent an MSA from delivering the service itself, where that was locally decided to be best, but this should not be a uniform legislated requirement. An amendment to Bill 173 like this would allow for a smoother transition period, greater local flexibility and significantly mitigate some of the negative consequences we've outlined.

It is also important to observe that the accomplishment of long-term care reform needs to involve more than the passage of new legislation to create a new infrastructure; it needs to be matched by the necessary resources to make the changes work. Our members are increasingly becoming frustrated with processes and promises that do not result in real change.

To illustrate this point, we have only to review what's happened since proclamation of Bill 101 in July 1993. One of the major focuses of that bill is to establish a system of funding that would tie funding to the level of care required in long-term care facilities. Many of our members work in heavier care facilities and they looked forward to the passage of this bill, believing it would translate into the much needed increase in staffing levels.

Needless to say, we were disappointed when the first impact of Bill 101 was layoffs in many of the homes that were legitimately expecting increases. In developing the formulae for distributing funds, the previous minimum staffing requirement of 2.25 hours of care per resident per day was tied not to the provincial case mix index of 100, as we had assumed would happen, but to the nursing home average of 110.

The predictable result was substantial layoffs and reductions in hours, which translates into a reduction of care. Homes with higher CMIs, where we expected the hiring to occur, were reluctant to do so because of uncertainty surrounding the then ongoing social contract discussions and the fact that implementation announcements were being made by the minister at the last minute and, in some cases, retroactively. Since service agreements had not been signed designating staffing levels, there was no way to force employers to hire in order to match the funding they were now receiving.

Because of the extensive layoffs and service reduction that occurred, funding was again changed so a corridor was established with the floor CMI of 102 and a ceiling CMI of 116. When this didn't have the desired effect, another change was instituted in December whereby the minimum staffing regulation of 2.25 hours per resident per day was reintroduced and the floor was raised to 110. This was going to be in effect till March, when we hoped the uncertainty would be cleared up.

A funding working group made up of provider associations, labour representatives and ministry staff worked through the problems and come up with the unanimous recommendation for 1994 funding. Although we were all unhappy with aspects of the recommendation, it was a compromise we all indicated we could live with. The minister chose to disregard the unanimous recommendation which effectively would have bought us a year to deal with transition issues, and the funding work group was briefed on June 1 regarding her decision, which was to have been implemented on July 1.

Because that decision disregarded the careful compromises all sides had made in order to deal with transition issues, chaos ensued. Appeals were made by various groups on both labour and management sides of the table to the minister, the Premier and whoever else would listen. A few days later we learned the latest funding announcement was rescinded and funding was frozen for another year. Since that time, a further change in funding for non-red-circled homes for the aged had to be introduced in order to prevent layoffs.

We should make very clear in all of this that the dedication of the ministry staff who have had to carry this out is unquestioned. They have admirably sought to do a difficult job under very trying circumstances. Thus, in the implementation of Bill 173, the government should ensure that the reform is manageable and the resources adequate to get the job done.

We have experienced that the principal aim of Bill 101 to establish an equitable system of funding tied to the care requirements of residents today is still not a reality. When we explain to our members who ask why their staffing levels have not increased to match the heavier care requirements of their facilities, they only shake their heads in disbelief.

Each of these decisions can be explained and defended in the context of a crisis. An announcement is made. It takes a few weeks for the impacts to trickle down. We frantically look to shift a few dollars from one pocket to another in order to solve the problem. Of course, a few weeks later we find the other pocket short and we start the process again with a new crisis.

The moral? It's fine for the government to proceed with long-term care reform, but this involves more than passing legislation which deals with infrastructure. It requires providing the resources, financial and staffing, so that decisions can be implemented in a timely fashion without endless retroactive adjustments and crisis management decisions. In the context of Bill 173, we need to ensure that reasonable time lines are in place to see measures implemented smoothly. We've already seen confusion in the directions given to DHCs in planning for this phase of long-term care reform.

We need to answer some basic questions: What are the real costs associated with establishing MSAs? Where is this money going to come from? How will this be accomplished within the very ambitious time lines set out, considering we're talking about the amalgamation, coordination and takeover of hundreds of agencies, involving these agency boards, the DHCs, their long-term care committees and the ministry? Have steps been taken to ensure a smooth transition, or are we on the edge of another logistical nightmare that will make the confusion and uncertainty of Bill 101 look like a cakewalk?

These are not only matters of efficiency and wise spending of scarce dollars. Even more importantly, these matters impact very directly on the working environment for our members and the care that's provided to our seniors. In the midst of all of these discussions about infrastructure, guidelines and regulations, let's never lose sight of the front-line care givers who have the difficult task of providing quality care for those who need it.


Ms Carter: You're talking about government-run bureaucracies and saying that everything is going to get much more rigid and government-controlled. That doesn't seem to fit the facts, as I have seen them, because what is actually happening here is that administration of long-term care is being handed over by the government to local MSAs, which will have a funding envelope and will have flexibility to use that money for the benefit of the particular people they are serving. Also, MSAs are not necessarily going to be very large. In fact, apparently in Metro one home care program will be replaced by 15 to 20 MSAs, each with a volunteer elected local board.

I'm just wondering what you base this accusation of bureaucracy on. You have also said there will be no choice, and I know it is written into the act that when people are assessed when they are having this interview to find out what their needs are, their wishes will be taken into account, certainly their wishes as regards ethnic, linguistic or whatever characteristics of the institution or whatever that they might be going to. Could you comment on that?

Mr Pennings: Gladly. I understand the concern. When you look at the legislation on paper you see the creation of community representative boards with stakeholders and all of these things neatly defined. I guess our concern comes when you talk about -- and the point that we emphasize throughout our bill: Why then are the requirements placed in the legislation itself, for instance, that the agency must deliver 80%? If it is true community choice that's going to be made, why can't we leave those sorts of decisions for local boards to implement?

I think the bottom line of all of this, and one can look at the creation of various agencies that currently exist with community representative boards, the reality of the situation is in the field that decisions, even through those sorts of agencies, effectively are controlled by provincial guidelines. One can read the regular long-term care action facts that come from the ministry as well as the guidelines that are produced by the ministry, and one keeps seeing "upon approval of guidelines by the Minister of Health; upon approval" -- these things are throughout the whole process.

The point is that these structures will exist, no doubt about it, but the real effective decision-making locus of control is not going to happen at those community boards, and when we take a look at the track record of such boards and institutions around, I think the evidence bears it out.

Ms Carter: I see the provincial guidelines as being more a matter of maintaining standards because, as things are at the moment -- you talk about choice but there are a lot of areas in this province where facilities don't measure up to the standards that might be available somewhere else. I'd just like to put it to you that as things are at present, most consumers most of the time do not have choice. Just to take one random example where you might have different home care organizations supplying home care workers for people, I think normally somebody is allocated and I understand that, in one region at least, it depended on which day of the week your application went in where that particular home care giver came from. If you wanted to get the same person a second time, you had to make sure you made the application on the right day of the week.

In the market realm where people are paying for services, then obviously in that sense they have a choice, but I don't think that has been the case otherwise.

Mr Pennings: Certainly in this era of scarce resources you're quite right. The choices one wishes were available are not always there because of the funding crunch that a lot of people see, a lot of agencies see. The waiting lists that do exist throughout the province for various services -- that is a very valid concern, but the answer to that is to not structurally create a single-access system that is going to control the entire system.

Mrs Sullivan: I'm interested in two issues that you've raised, and I'm pleased actually that you raised the questions with respect to worker choice and the units of work organization. Certainly, current theory is that productivity and creativity are increased in a smaller multi-disciplinary environment and it was the first time that point has been raised in our hearings and I appreciated that.

I also want to go back to the issue that you raised with respect to the planning for the transition, and particularly with respect to funding. You have certainly delineated the funding mess that followed Bill 101, and which still continues. I suspect that there will be a funding mess following Bill 173, since first of all, as you pointed out, no one knows the real costs of this implementation.

There are many issues that haven't even been identified beyond identifying the words, and I think one of them is the adjustment issues, the issues of severances and wage parity and pensions for staff people from existing positions who will have to transfer to an MSA, the question of capital assets for existing organizations that may or may not be transferred, any liabilities that the government may face putting businesses out of business, questions of requirements for purchase of either non-mandatory services that are needed to meet a patient's requirements or those services which might be provided by facilities. None of these questions are answered, and in fact they're very much in the dream stages at this point.

I wonder if your organization has looked at various efforts of the district health councils to see if they are coming up with any responses to these kinds of questions.

Mr Hank Beekhuis: I think it's sort of interesting that you raise that, partly because of the fact that if you read through the whole Windsor-Essex win-win document, it's very neatly sidestepped in terms of the whole issue of MSAs. They deal very much with the hospital sector.

Once they started the process, they to their horror discovered that instead of the 30 or 40 agencies they thought might be involved in this, in the MSA, that they were up to 230 by the time they were done. I think the logistics of it are scaring everybody off.

For example, you will financially probably use up a tremendous amount of funds just to try to equalize things. Currently there are people out there, and wrongly so in our view, who are being paid minimum wage for the same job that other people are getting paid $16, $17 an hour for. How are you going to put that together? There's such a wide disparity out there now that I think we need to take a step back and see what we're doing.

Mr Jim Wilson (Simcoe West): Mr Chairman, I know you've indicated you didn't want me to ask a question, but perhaps I could just thank the group for an excellent presentation. I want to say that from the bottom of my heart on behalf of my caucus too, in terms of we've had some submissions from other unions that I don't think, to be very frank about it, they put as much common sense into their submissions as we see here. I think you've given us a very forthright and honest approach.

I want to ask you, just very quickly, if we can't get the government to change its mind about the 80-20 rule and the rigidity in the system and those other things that may make life or continue to make life difficult for the people you represent, should we, on balance, vote in favour of this legislation or not?

I can tell you my experience has been, after three and a half years as Health critic that bills come in and you can tell by the questions from the NDP -- we were talking among members last night and we can't remember a time -- the people who have been here a long time tell us they can't remember a time when well over 90% of the groups that appeared before this committee in the past few weeks have been opposed to the major technical components and indeed thrust of this legislation. I'd just like your comments on that.

Mr Pennings: I'm not going to venture outright and say how you ought to vote, I suppose. But I will say that if the chaos that's going to come out, as I indeed think it is, of the implementation of Bill 173 is anything close to what we've seen in Bill 101, the immediate effects that are going to be felt both by care givers and care receivers are going to be negative, and I think that's a problem.

I think when we look at the overall scheme, we need to address some of the real concerns that Bill 173 is seeking to address, some of the duplication that exists, lack of coordination, lack of single access. Those are very valid objectives, and we can't be silent on that either, and we can't throw out the baby with the bath water. I guess that's where the decision you're going to have to make, as everyone has to struggle in terms of the end, where are the compromises to be decided. But I will say that the 80-20 rule and the process envisioned here, the timetables, are a recipe for chaos.



The Acting Chair: The next presentation will be made on behalf of the Ontario Psychological Association. Welcome to our committee.

Dr Ruth Berman: I'm Dr Ruth Berman, executive director of the Ontario Psychological Association, and with me is Dr Mary Tierney, chair of our task force on long-term care. As well Dr Tierney is a geriatric psychologist and senior scientist at the Sunnybrook Health Science Centre. We're pleased to have the opportunity today to share our views on Bill 173.

The Ontario Psychological Association is the voluntary organization representing the profession of psychology in Ontario. Our membership of approximately 1,400 includes psychologists, psychometrists and graduate students in psychology.

The Ontario Psychological Association has been an active participant in long-term care reform since 1990, at which time we were invited to have a representative on the long-term care program design advisory group. We have submitted three briefs outlining our perspectives on the care of the elderly and disabled in the province. We also presented our views at another public hearing last March on Bill 101, An Act to amend certain Acts concerning Long-Term Care. The impetus for OPA's involvement has come from our members who work with the elderly and disabled. These members see the need for reform and believe that psychologists can contribute to the health and wellbeing of these potentially vulnerable people.

We acknowledge that the legislation is in place at this time. We understand that the government is attempting to deal with resource problems. As a result, the citizens of Ontario will not be entitled to full coverage of all services available to them. The services of psychologists are among those not included in Bill 173.

The OPA sees merit in long-term care redirection. There is a read need to organize, develop and coordinate services for the burgeoning aging population and the physically disabled. We also agree that there is a need to develop community-based alternatives to institutions and provide support to informal care givers. We see the changes proposed under Bill 173 as an attempt to provide more fair and more equitable distribution of community and long-term care resources.

However, there are some areas within the legislation that require clarification. The compendium to the Long-Term Care Act, 1994, states that the act concerns "elderly persons, adults with physical disabilities and persons who require health services at home." We understand that this would exclude people with developmental disabilities and are uncertain about the inclusion of those with acquired head injuries. Why are these individuals excluded under this legislation and how will they receive services? We believe that these individuals appropriately meet the terms and conditions of the act and their exclusion is most regrettable.

Although we recognize that psychological services have not been designated as a core service in the multiservice agencies, we believe that psychologists can make significant contributions to long-term care given our knowledge and skill.

Psychologists are regulated by the College of Psychologists of Ontario under the Regulated Health Professions Act. The RHPA recognizes the expertise of psychologists by granting them the authority to perform the controlled act of diagnosis in relation to psychological and neuropsychological disorders. The minimum training required for psychologists includes a doctoral degree, typically requiring four years of study after the master's degree.

Dr Mary Tierney: Psychologists can assist long-term care patients both through direct and indirect services. In terms of direct services, there are three primary ways in which psychologists can assist the elderly and disabled in Ontario.

First is diagnosis and treatment of mental health problems. It is well documented that senior citizens and the physically disabled, as well as their care givers, suffer from psychological problems more frequently than the general population. These psychological problems arise primarily because of the stress of having to cope with the physical and mental challenges of being disabled or elderly. This stress can affect the individual's health and wellbeing, causing problems such as alcoholism, depression, anxiety, suicide, malnutrition or improper use of medications, any of which can lead to expensive hospitalization.

Even if the physical problems do not lead to hospitalization, the psychological burden on the care givers may impair their ability to cope, leading them to seek hospitalization or institutionalization for their dependent. Moreover, a family member who receives little more than informal support in caring for an older or disabled person is at risk for personal health problems that may in turn result in the care provider becoming the next consumer of formal health care services.

These preventable and treatable psychological problems are often not identified or are misdiagnosed. It has been found that from 40% to 70% of elderly patients' mental health needs are misdiagnosed by the general physician. When they are identified, they often are treated with psychoactive drugs that can have harmful side-effects. Although there is a place for such medication, we know that medication does not provide people with the necessary skills to cope with their problems. Research has consistently shown that coping skills, self-esteem and the ability to exert control over one's life are important factors in illness prevention and in better recovery from illness.

Psychologists are recognized as experts at diagnosing and treating mental health problems. Psychological services will reduce the reliance on psychoactive drugs. These drugs can cause cognitive impairment and can increase the likelihood of confusion, disorientation and, hence, dangerous falls. Both cognitive impairment and falls can increase the risk of hospitalization. The cost of psychological services becomes very reasonable when compared to the cost of acute care hospitalization, placement in long-term care facilities and the direct and indirect costs of medication.

The second area is the diagnosis of cognitive impairment. The elderly are more likely than younger people to show dementia. Unfortunately, many treatable conditions, such as delirium, severe sensory deprivation, anxiety, depression and drug overdose, can be confused with dementia and, if misdiagnosed, can lead to institutionalization and failure to provide appropriate treatment. Accurate and early diagnosis can prevent premature and/or unnecessary institutionalization and enable the best treatment to be provided before the problem escalates. The human tragedy of being misdiagnosed with Alzheimer's disease and placed in a nursing home is a challenge not being directly addressed by long-term care redirection.

The internationally accepted criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association state that the diagnosis of dementia must be confirmed with a neuropsychological assessment. However, rarely are these psychological services available to the citizens of Ontario unless they are admitted to a chronic care, acute care or rehabilitation hospital that has these specialized services.

Unfortunately, with the downsizing of services in Ontario hospitals, psychological services are becoming even less available to the public. The only other means of accessing such services is on a private fee-for-service basis. The cost of accurate diagnoses of cognitive impairments and dementia must be measured against the cost of misdiagnosis, inappropriate treatment and institutionalization.

The third area is care giver support, and first I'd like to talk about family care givers. Improved support for family care givers is a major goal of long-term care redirection. This change is based on the recognition that families may become overwhelmed and feel their only alternative is to institutionalize their dependent family member.

Research has shown that families institutionalize their dependent member when that individual begins to show dangerous and/or other socially unacceptable behaviour such as physical and verbal aggression, repetitive calling out, wandering, sexual disinhibition and resistance to care. The most frequent manner of controlling these behaviours at home or in institutions is with psychoactive medications, especially neuroleptic or antipsychotic medications.

Besides having to cope with the serious side-effects of these medications, care givers are not typically taught the necessary skills to handle these behaviours in a nonpharmaceutical way. This can lead to a vicious cycle whereby care givers can seek increasingly high doses of medication for the dependent member and thus increase the risk of complications.

Many of these behaviours can be effectively controlled through behavioural management programs. In this regard, psychologists can assist family members by assessing cognitive, emotional and personality functions. Based on these findings, a profile of strengths and deficits can be provided. Once this is done, the psychologists can then develop a behavioural management plan that considers the profile of the individual and the care givers' abilities and resources. This plan should integrate and coordinate the efforts of all care givers, make specific recommendations for intervention, address recruitment of additional resources and respond to the training needs of the care givers involved.

Next, professional care givers, aides and attendants. Psychologists can help other professionals through the development of behavioural intervention programs to deal with behavioural disturbances associated with dementia and brain damage. Understanding the behavioural implications of neurological damage can help the care giver in anticipating and interpreting many actions of the ones for whom they are caring. Psychologists can train professional care givers and the attendants of the physically disabled in the community to work more effectively with their clients.


As you can see, the services of psychologists can be both directly and indirectly provided to the recipients of long-term care redirection. Under the system provided in the present legislation, psychologists can also be valuable assets in consultation on long-term care issues.

First, the bill states, subsection 20(1), that when an individual applies to an approved agency, the agency shall assess the person's requirements, determine eligibility for services, and for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person. The bill also states that a multiservice agency shall refer a person to other services that may meet the person's requirements more appropriately than the services that the agency provides or arranges.

The assessment of applicants will obviously be an important undertaking for approved agencies. Sometimes the problems and their solutions may be obvious and direct. However, there'll be many applicants whose problems are subtle and difficult to assess before a care plan can be developed. Psychologists, given their expertise in the design of objective behavioural measures, can be of service to the applicants indirectly by working with the MSAs and other approved agencies in developing valid and reliable assessment instruments.

This will assist placement coordinators and agency assessors in accurately identifying problems. It should also improve their ability to develop treatment plans, make appropriate referrals and provide the best placement options. Also, psychologists can help the MSAs in providing guidelines as to when a referral for direct psychological assistance would be appropriate.

In this regard, psychologists could be of assistance to the Ministry of Health in helping to develop criteria for the expenditure of funds on professional services, both psychological and otherwise, when the MSAs cannot meet the needs of the client.

Dr Berman: In summary, the OPA continues to support the efforts made and the need for better coordination of services and resources for our long-term care population. We very much regret the ministry's decision to exclude psychological care as an essential service under Bill 173 in spite of the ministry's repeated acknowledgement of its value and for the needs of long-term care patients for these types of services.

Bill 173 provides for some, albeit limited, access to the services of psychologists. As such, the establishment of clear and specific guidelines for how, when and for whom such services are to be utilized becomes critical. We would thus strongly encourage this committee to support our recommendation for the establishment of criteria with respect to referral to and utilization of the professional services of both psychologists and other health care providers.

We suggest that this committee consider including in Bill 173 a statutory requirement that the Ministry of Health seek consultation with the professions concerned in order that the necessary and appropriate guidelines might be developed. We thank you for your attention and we'd be pleased to answer any questions you have.

Mr O'Connor: I appreciate your presentation today. One of the things that we have heard has been the assessment of the consumer coming into the process. You have mentioned that you are on the design advisory committee, and the questions that I have are, currently today, what is the access point for the consumers that you have; has your association had any involvement with any of the local planning processes through the district health councils; and what has been your feedback to the association from any part of your organization or members that may have been involved in that process in trying to recognize the need for assessment of the consumer group you represent?

Dr Tierney: In terms of present access, as we mentioned, the major access is when a person's admitted to a hospital, whether acute, extended care or rehabilitation hospital. Other than that, in the community, really the only way is through pay-for-service. That is done, but obviously that is at a cost to the individual.

In terms of the second question, the district health council?

Mr O'Connor: Yes, have any of your associate members been involved with that process?

Dr Tierney: A number have tried, including myself, but we've not been invited to be part of the process.

Mr O'Connor: In being involved in an assessment, then, at the hospital, which is then the access point, the information that you would gain through the assessment process that you do, would you have a recommendation to people from the ministry that would be taking a look at -- I don't know whether you are part of the working group on assessment, but the knowledge that you gain could then be used, if appropriate, for furthering the service of the consumer when they are sent back or returned to the community.

Dr Tierney: We aren't part of the working group. We were told that we could be consultants to it, but we aren't part of that working group on assessment.

Mr O'Connor: Is there some part of the assessment that you do, then, that would be useful to -- what we've heard in our consultation is the case managers saying, "We're the best person to assess the case and to manage and help to direct appropriate care where necessary." How do you fit into that process? How do you see yourselves?

Dr Tierney: We're not saying we should be assessing everyone as they come in the door; what we're saying is that we could assist those who do that assessment in developing a tool that would be useful for them and also having guidelines for when the person should go through a more detailed screen and a more complete assessment. So it's really two-pronged.

Mr O'Connor: Is there a follow-up mechanism there that would allow the case manager to have some of that information from the assessment that you've done already so that the appropriate aftercare that may be necessary would kick in, so that the consumer is going to be serviced in the best possible fashion?

Dr Tierney: That would be dependent on whether the consumer went to an acute care hospital that had a psychologist who had expertise in the area. At Sunnybrook -- and I can only speak for Sunnybrook directly -- often the assessments that we do are used, definitely, for placement decisions.

Mr O'Connor: So there is a relationship in Sunnybrook with case managers, then?

Dr Berman: Oh, absolutely.

Dr Tierney: Oh, yes, and in those hospitals where there are psychologists, but that's what we mentioned, that hospitals are being downsized, psychology departments are being hit. It's often said, "Well, go to a hospital, and that's where you'll get that resource," but that resource is just not there any more. So it just won't be available to the public.


The Acting Chair: The next presentation, please, is to be made on behalf of the Victorian Order of Nurses, Ontario division. Welcome to the committee.

Ms Fay Booker: Making this presentation this morning on behalf of VON in Ontario is our provincial executive director, Gale Murray, and myself, Fay Booker, a volunteer in the organization.

VON has been serving the citizens of Ontario since 1897. During this time, VON services have evolved in response to the needs of our communities and have included cottage hospitals, community services such as Meals on Wheels and visiting nursing. At the invitation of the government, VON was the first administrator of the home care program. Over the years, VON has been in the forefront of change in community health. It is from this base of experience that we offer the following recommendations and comments on Bill 173:

(1) 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 requirements for accountability;

(2) The legislation be amended to remove the four-year interim arrangement such that federation or coalition models should be allowed to continue if they are proven to be cost-effective, delivering quality care and giving consumer satisfaction;

(3) The multiservice agencies should be required to provide data on the unit cost of service, quality indicators and consumer satisfaction;

(4) The legislation be amended to allow for consumers to choose the MSA from which they wish to receive services where it is economically feasible to have multiple MSAs;

(5) Evaluations of initial collaborative MSAs be carried out to assess their cost-effectiveness, service quality and degree of consumer satisfaction before requiring all communities to adopt this form of long-term care service delivery.


In regard to flexibility and accountability, Ontario is a large, geographically and culturally diverse province with a complex health care system, including one of the most fully developed long-term community care systems in the country. Such a complex environment requires that the service delivery system reflects the needs of the community it serves and that any major structural change can be proven to be a change for the better. This implies that the legislation directing long-term care reform be flexible enough to allow for this diversity of population and communities.

Bill 173 appears to allow flexibility for the MSA: The MSA must be not-for-profit; the governing body must be composed of consumers and experts in health and social services; the MSA is to be accountable to the community as well as to the minister. VON supports these requirements. Our concern is that while the legislation appears to allow for many different models of governance and service delivery, the comments of the Minister of Health and the ministry staff to the media have implied that just the opposite is true: Only one model for the MSA is acceptable, the one that amalgamates all current service deliverers into one agency. This is not in the best interests of communities which are diverse, and this is not what the communities want or expect, in the view of VON.

This committee has heard from the representatives of many organizations across the province saying there must be flexibility; VON is saying it also, based on our long experience in community health in Ontario. Each of the VON branches offers a variety of services, differing from community to community. Why? Because the needs and priorities of the communities vary.

Our first recommendation is that the legislation 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. All governments require accountability, given the size of dollars spent on the health care system and the importance of this system to the people of Ontario. The question is how this accountability can be best achieved. The legislation proposes to establish independently incorporated, not-for-profit agencies accountable to the community served and the minister. VON supports this approach.

It has been voluntary, charitable, not-for-profit agencies that have developed the long-term care community health care system that is currently in Ontario and which is one of the finest in Canada. Specifically in the areas of palliative care in the home, the utilization of intravenous therapy in the home and innovation in the use of appropriate health workers, such as the homemaker, attendant care worker and the registered practical nurse and registered nurse, the Ontario agencies have shown leadership in continuously improving services and the delivery system.

These agencies have done this under the direction of independent boards made up of community representatives. If there is to be continued accountability for service development at the community level, then Bill 173 must allow the MSA and its board to be accountable to make the decisions with regard to the best structure and service delivery model to meet the community need. If these boards cannot make these decisions, what, then, is the point of setting up a requirement for independent agencies from government?

All governments of Ontario have had a long association with independent, not-for-profit, charitable organizations. The government has on many occasions praised these organizations for their contributions. They have shown accountability by improving the system, as shown by the successful shift of acute care to the community from the hospital, resulting in cost savings to the system and clients more satisfied because their care is at home.

Given the track record of the long-term care community agencies and the current initiatives they have spearheaded to meet the important outcomes of long-term care reform through improved access, better integration of service delivery, development of a chart in the home that all providers can use and a commitment to work on a standard assessment format, VON believes that the legislation should allow this voluntary incremental integration of services that achieves the ends of reform. Thus, the arbitrary requirement that anything less than a full amalgamation of agencies is required for MSA designation and that all interim initiatives have to result in an amalgamated MSA within four years should be withdrawn from the legislation. Rather, the legislation should be enabling, allowing the minister to support new forms of service delivery that meet the goals of reform.

The recommendation is that the legislation be amended to remove the four-year interim arrangement such that federation or coalition models could be allowed to continue if they are proven to be cost-effective, delivering quality care and giving customer satisfaction.

VON has debated internally the proposal for capping the long-term community care budget by de-insuring in-home services. This means that the citizens of Ontario would no longer be entitled under OHIP to such things as visiting nursing. However, the government would be assured of the projected cost of services because of the budget cap.

VON is prepared to support the move from an open-ended health care system to a planned and affordable system. However, we are concerned that this not result in the waiting lists already forecast by the legislation. To avoid this unacceptable feature of a capped system, VON believes that it is imperative that the reformed system must be adequately funded.

Cost-effective service in turn will come by the government requiring fiscal and quality accountability by developing in partnership with the agencies standards for service cost, quality and consumer satisfaction. These standards should be based on experience and utilize a quality management approach. Agency performance on these indicators should be published both for consumer information and as an incentive for agencies to learn from each other's experience and continuously improve.

We recommend that multiservice agencies be required to provide data on quality management indicators: cost of unit of service, quality indicators and consumer satisfaction.

Given that MSAs will not all offer the same type or level of service outside the core basket of services, in urban areas where it is economically feasible to have more than one MSA, giving consumers the choice of MSA can improve MSA accountability and reduce the occurrence of waiting lists. If agencies know that consumers can compare them based on published data and that consumers can choose to leave one MSA for another, then there is more incentive for the multiservice agency to be cost-effective and avoid the creation of waiting lists. Where it's economically feasible to have multiple MSAs, the legislation should allow for consumers to choose the MSA from which they wish to receive services.

The preferred VON model is a federated MSA. As referenced earlier, the health system in Ontario is one of the best, if not the best, in Canada. The provincial long-term community care system is more fully developed than most provinces, thanks to government and the current agencies' efforts. At this time, there are a number of agencies like VON who have historically been improving the quality, cost-effectiveness and range of services provided. These initiatives were based on community needs and often supported initially by fund-raised dollars. In VON, these initiatives have included palliative care, foot care, volunteer visiting and continence rehabilitation, to name only a few. Our sister agencies have also initiated and financially supported new initiatives.

Today, the long-term care community agencies have been working together to address the long-term care redirection through new proposals to improve consumer access and promote continuity of care. This committee has heard about these efforts in all parts of the province. The common theme in discussions across the province with consumers, communities and planners has been the need to improve the system while building on its current strengths. Let us not throw out all this experience and knowledge gained over the years.

The desired model for the MSA for the most part is a partnership model. The effectiveness of a partnership model can be ensured by having an automated information system allowing comparability of data, having staff on-line to use computers to avoid repetitive data collection and having a common client record system province-wide to promote the exchange of information between MSA workers.

VON is proposing a partnership model because we believe it will allow the outcomes of long-term care redirection to be achieved without destroying the existing long-term care community system. By piloting and evaluating this model as well as others that communities may develop, the government will be ensuring that the citizens of Ontario are actually going to have an improved system at the end of the day.

As was noted in the Hamilton-Wentworth DHC presentation, much research needs to be done in terms of cost-effectiveness, quality and consumer satisfaction. We recommend that evaluation of initial collaborative models of the MSA be carried out to assess their cost-effectiveness, service quality and degree of consumer satisfaction before requiring all communities to adopt a form of long-term care service delivery.

Maintaining volunteer involvement: This committee has heard from many, many agencies across the province that currently have volunteers in service delivery and governance roles that they fear the MSA will result in a loss of volunteers to long-term community care. The minister and ministry staff have gone on at great length to reassure that volunteers are not at risk. However, when the experience of Quebec in setting up similar agencies was reviewed in their task force report on health promotion, that is what was found: "Furthermore the government has often been reproached for killing the volunteer movement by systematically paying people in the community to do the work they formerly did without pay."


Whether the minister believes it or not, volunteers -- and I am one myself, and you have heard from others -- are not going to give the commitment of their time and energy and charitable donations to an agency that is perceived to be quasi-governmental.

The minister speaks as if having 1,200 agencies involved today in long-term care is bad. This would only be wrong if it could be shown to be wasteful of the taxpayers' dollars or offering substandard care. There has been no data presented to suggest that this is the case. Rather, in the planning documents and in the government's statements there is acknowledgement of the contribution of these agencies.

This is not to say there is not room for improvement in the system to make it more easily accessible, more comprehensive and continuously improving, both in terms of cost and quality. VON believes that cost-effectiveness can be achieved through better planning between agencies and through the development of common management information systems allowing comparisons between different services. In some cases there can be economy of scale by joint purchasing arrangements and other arrangements. VON itself has used these techniques to improve its outcomes.

After careful review, all of our 33 branches across the province are now meeting with and planning with our partners in the community to achieve the outcomes of the long-term care redirection by building on our shared experience. Some of these interim models are already in place, for example in Windsor. These innovative models are supported by VON boards across the province, but we are careful to pilot first to ensure that they are achieving their goals. I say this to illustrate that the current volunteers in the system are committed to improving it. Their commitment should be fostered by recognition and respect for an independent but accountable governing structure based on community requirements and preferences.

Consumer education: Bill 173 does not directly address the need for well-informed consumers who are able to take responsibility for decisions related to their health and the services required to promote their health and independence, and to use these services wisely. The sections on assessment imply that the consumer will be assessed by a health worker, his or her needs identified and appropriate services provided. This implies a passive role for the consumer.

VON's philosophy of care states that individuals have a primary responsibility for their own health. A primary role of the MSA should be to educate consumers such that they can take up that responsibility. The legislation's paternalistic approach should be amended to one promoting consumer independence and accountability. Promoting healthy consumer behaviour will be as important to the success of long-term care redirection as the restructuring of the system.

Just in conclusion, this presentation has highlighted some of the key issues in Bill 173 from the perspective of VON volunteers and staff across the province. It also reflects what VON has heard from its partners in the long-term care system.

In summary:

-- There is a need for flexibility and accountability in the MSA structure and service delivery models in a complex province like Ontario if we are to achieve the goals of redirection;

-- New mechanisms must be developed to promote cost-effectiveness in the integrated service delivery model replacing brokerage;

-- The partnership model utilizing a federated board and geographically based teams should be tested and, if effective, permitted to continue;

-- Volunteer involvement requires respect and support for independent, not-for-profit, charitable agencies as MSA partners;

-- Consumer education to promote independence and accountability is crucial to the success of the redirection.

VON is requesting amendment to the legislation such that the above issues are addressed. We will be submitting specific suggestions for these amendments to the committee prior to the committee's line-by-line review of the legislation.

In conclusion, we thank you for the opportunity to present these recommendations and to assure you that VON is committed to working with all our partners in the communities across the province as well as government to promote the objectives of the long-term care redirection.

The Acting Chair: We have time for one question only. Mr Conway.

Mr Sean G. Conway (Renfrew North): I really don't have a question so much as just an observation, and that is that -- let me put it in an interrogative form -- there's no doubt, then, in your mind, speaking for your organization, that if the bill were to be implemented as now written it would have a very negative effect on the level of volunteer commitment to the long-term care programs that are currently in place?

Ms Booker: That's correct. That's our view as the legislation currently stands.


The Acting Chair: Our next presenters are appearing on behalf of the regional municipality of Waterloo. Welcome to the committee, gentlemen.

Mr Ken Seiling: My name is Ken Seiling. I'm the regional chair of the regional municipality of Waterloo. With me is Phil Johnston, who's commissioner of social services, and Kevin Mercer, who's the director of long-term care services. I have provided copies, and I'm sorry I didn't get them to you in advance of today. I've heard many of the comments just in the few minutes I've sat here already, so you're going to be hearing a few things over again.

We feel there's little doubt that reform is needed in this area. In fact our region was one of the areas chosen to pilot the one-stop-access pilots that were attempted and then got lost in the shuffle when governments changed hands and the program passed by the wayside, so we have a long history of involvement in this area.

My comments today are going to focus around the need for continued local flexibility in service management and delivery, the dangers of forcing us to abandon a brokerage model and the inherent difficulties of special-purpose bodies as an administrative structure.

The regional municipality of Waterloo has and continues to demonstrate its commitment and capacity to provide accessible, accountable, quality services that meet the needs of residents. Our extensive history in the planning, management, provision and funding of long-term care services is founded on collaborative, cooperative partnerships with the community which we have been elected to represent. The Social Resources Council of Kitchener-Waterloo, a pioneer in social planning funded by the region and the province, has long been a model for community-based planning. Its joint efforts in many areas with the district health council have proved invaluable in developing community consensus and planning on many fronts.

We are in touch with our community, much more so than the provincial planners in Toronto, and have attempted to bring that knowledge to the table on many occasions. To date, I must admit, much to our dismay, we've had very little success.

The acute home care program was pioneered in Waterloo region by the Victorian Order of Nurses in 1967. With the advent of regional government in 1973 and with the encouragement of the Ministry of Health, administrative responsibility for the program was transferred to the health and social services department of the region. In 1983, the Minister of Health introduced a chronic home care program to the region as a means of addressing the changing health care requirements of elderly residents. Shortly thereafter, the school health program was added to the health and social services department mandate. Finally, in 1986 the region of Waterloo was selected as the site for the integrated homemaker program. By 1993-94, the region of Waterloo's home care/integrated homemaker/school health budget was approximately $21 million and provided service to some 3,600 clients monthly.

With the creation of the region in 1973, ownership of Sunnyside Home for the aged was assumed by the region from the county of Waterloo. Over the past 20 years, the role of Sunnyside has evolved to the point where our case mix measure, the measure which addresses level-of-care requirements, continues to increase. Almost 50% of our 265 residents require a significant amount of heavy extended care. Sunnyside has also expanded its services to address the needs of individuals residing in the community through the introduction of the Alzheimer day program and several outreach programs.

Under the authority of the Homemakers and Nurses Services Act, the region purchases homemaking and nursing services for those residents of the region in financial need of such services. While the services under this program declined somewhat as the result of the introduction of the integrated homemaker program, the need for the program continues to be evident both to augment the services available under the integrated homemakers program and to meet needs not eligible for subsidy under the IHP guidelines. In 1994, expenditures for the homemakers and nurses services program are expected to be $309,000, representing a monthly case load of 100 individuals and families.

Despite the fact that the current government has not included rest and retirement homes in the reform agenda, these homes are viewed by regional council as an important service in the long-term care network. Through 18 purchase-of-service agreements, approximately $800,000 will be expended in 1994 to provide service to some 200 domiciliary hostel residents.

The region has also contributed for many years towards the cost of home support services for the elderly and physically disabled. In 1994, 10 agencies received $164,000 in funding towards the cost of meal provision, counselling, transportation, friendly visiting, home maintenance and repairs, to name but a few, and that doesn't include the money donated by the lower-tier municipalities.

Lastly, the region staff and elected officials have worked towards greater coordination and integration of health and social services, greater responsibility for local government to plan, prioritize and manage services and increased communication and cooperation between institutional and community-based services. Specifically, the region has worked closely with the district health council and the social resources council to plan services that meet the needs of local residents. By way of example, the region collaborated with these planning bodies to develop one of the four pilot projects for the government's 1987 one-stop-access initiative. While the government abandoned the initiative, the work of the steering committee remains valuable today, and there's considerable documentation on how that would work.


Municipalities are a level of government entrusted with the role of ensuring and improving the economic, environmental, social and public health of the communities municipal councils represent. It is critical, therefore, that the government recognize municipalities as such and not just as another service provider or transfer payment agency. To continue to fulfil its legislated role in the future, the regional municipality believes that the authority and scope of municipal governments should be expanded and not fragmented amongst new local governing structures. This is consistent and supportive of the position taken by AMO in its presentation to you on another day.

Municipal councils must have input into key decisions that determine the quality of life and the economic prosperity of their communities. This belief forms the foundation of the region's mission statement, which states our commitment to advancing the wellbeing of a community in which people want to live and work. Further, we are dedicated to providing quality municipal services delivered with care and accountability. This philosophy is also affirmed in the region's vision for the new official policy plan, which states that citizens will be provided with "...safe, comfortable livelihoods through economic, social and physical development and growth."

Innovations and program planning, management and delivery speak to municipal strengths, such as accountability, responsiveness, flexibility, consultation, collaboration and coordination. Notwithstanding these positive characteristics, we recognize that there are areas that need to be cleared up, particularly as related to unclear provincial mandates and insufficient human and financial resources.

As stated in the 1987 Canadian Council on Social Development report entitled The Role of Local Government in the Provision of Health and Social Services in Canada, "...local governments are more likely to provide a quantity and quality of service consistent with the preferences and needs of local residents." The authors also felt that local responsibility for the provision of services has also resulted in greater efficiency in allocating resources because a local electorate is more aware of the benefits and costs of services.

County and regional government structures are also experienced in serving a large and often diverse geographic area. There appears little rationale, therefore, for a proliferation of multiservice agencies within local government boundaries. Numerous examples of the competent and professional administration and delivery of human services such as police services, community health services and social services are evident across the province. Accessible services can be ensured through the establishment of branch offices rather than the creation of several MSAs, each with its own board of directors and catchment areas.

The regional municipality of Waterloo is adamantly opposed to the creation of special-purpose bodies to assume planning and management roles for health and social services. As stated in the 1970 Waterloo area local government review, the Fyfe report, special-purpose bodies and commissions complicate representation and accountability and cannot be held responsive to or representative of the public as can be a municipal council. That statement is as true today as it was 24 years ago.

There appears little reason, for instance, why the multiservice agency could not be made the responsibility of a committee of council. The regional municipality of Waterloo has a history of utilizing committee structures to advise staff and council on health and social service matters. By way of example, advisory committees have been established to provide advice to staff on the administration and delivery of the home care program at Sunnyside Home. Similarly, the child care advisory committee and a community coordinating committee for Jobs Ontario provides advice to the health and social services committee of regional council on matters pertaining to their respective mandates.

I might add that the Premier himself goes around the province telling how the region of Waterloo is probably the most successful Jobs Ontario delivery program in the province for our success rate, and that is done as an agent of the regional council, not a special-purpose body. So I believe there is ample evidence to show it can work.

One must also question the wisdom of establishing upwards of 40 special-purpose bodies across the province given the associated one-time and ongoing operating costs. Not only will accommodation costs such as furniture and communications networks be required, but support services such as financial systems, human resources expertise and legal services must be provided. There can be little doubt that such costs would far exceed the costs of modifying existing structures. Municipalities, particularly those 30 municipalities currently involved in the administration and delivery of long-term care services, already possess the requisite management resources. Why would we go about recreating them again?

The government has stated that not only will the MSA be a single point of entry for consumers accessing long-term care services, but it will also be a major provider of services required by consumers. Given the fact that the local design of the MSAs is to be based on the notion of flexibility and on meeting the individualistic needs of the communities they serve, the region of Waterloo contends that the government should be willing to consider a brokerage model should this be the community's model of choice. The brokerage model currently utilized by the region's home care/integrated homemakers program is extremely effective from both an administrative and a client service perspective.

From an administrative perspective, the brokerage model allows for the delivery of services by one or more agencies depending on the community need. Accountability of the community is enhanced in such a model through the tendering or purchase-of-service process. Such a process ensures that providers compete for contracts on the basis of price and quality. The inclusion of service standards based on outcomes also permits monitoring and evaluation of effectiveness and efficiency. Client choice is therefore also safeguarded, a critical factor that service monopoly cannot guarantee.

The vital role of the voluntary sector as delivery agents is also preserved by a brokerage model. And lest you think I'm concerned with the turf war of who's operating, I think here is the crux of where I think it is in our community. Volunteers contribute substantially, both in time and money, many valuable services that form part of the long-term care portfolio. Of particular importance during this time of government constraint are the significant dollars raised through annual fund-raising activities. It is unlikely that this source of program revenue will continue if all services are directly delivered by the MSA. As a result, the government should expect to contribute additional dollars to make up shortfalls in operating costs. A service monopoly model would therefore have a devastating impact on the existing volunteer network and on the cost-effectiveness of many services.

Lastly, a brokerage model spares the expense and effort involved in addressing labour relations matters, an exercise that could become quite cumbersome given the presence of several unions and numerous bargaining units and collective agreements, not to mention the need to integrate unorganized labour into existing staff complements. Volunteers will be lost and wages and salaries driven up needlessly.

In addition to the work of volunteer groups and agencies, I don't believe that the government recognizes or appreciates the amount of non-mandatory, discretionary funding covered by both the region and the lower-tier municipalities. Once the role is taken over by some non-governmental special-purpose body, I don't believe that the optional money and program support now being contributed will continue and it will disappear, together with the work and money of the volunteer sector. As one local health care planer has said, "An avoidance of the municipal contribution appears to be politically unwise and foolhardy."

Let me say it one more time. The regional municipality of Waterloo, in planning partnership with the Waterloo Region District Health Council and social resources council, have cultivated and developed an outstanding capacity in formal and informal long-term care services for the residents of our region. Both lower-tier and upper-tier municipalities, public and private sector providers and an array of consumer-driven advisory committees participate and direct an impressive array of long-term care services which is second to none in Ontario. The MSA concept as currently espoused fails to recognize these involvements and contributions. These thoughtful and sensitive and accessible service delivery arrangements in the region of Waterloo will be placed in peril by the MSA.

To give you some sense of the strength of the feelings in our community, let me reflect on two conversations I had recently with two individuals with responsible roles in the care system of our region. These are both very senior people in the health and social services field, and they described the current proposals and the bill as a form of violence: Violence against the delivery model, which works well in our region; violence against the groups and agencies which deliver services, whether paid or unpaid; and violence against a community which has worked for many years to build a care infrastructure. The second conversation, which just happened two nights ago, was with a long-time volunteer who stopped me at a reception and pleaded with me to do everything possible to stop the destruction of a system and of the local groups which were so important to the community.

While the regional municipality of Waterloo commends the government for identifying a list of mandatory services to improve accessibility across the province, we are concerned that a commitment to fund these services appears to be lacking. As we have already seen, the introduction of new funding formulas in municipal homes for the aged has had a significant direct and indirect impact upon residents. Specifically, many municipalities have had to increase their levels of funding as a result of red-circling. At a time when the government is seeking higher standards of care, it is failing to provide the necessary financial commitment to achieve the new standards. In addition, staff reductions have occurred and in some instances beds have been permanently closed.

Concern is also raised by the fact that the Ministry of Health is imposing fiscal restraint in the home care/IHP programs for 1994-1995. As a result, it will be extremely difficult for home care programs to meet service demands with funding frozen at the 1993-1994 levels. The waiting list for integrated homemaker programs in the region of Waterloo has already increased from 50 clients a year ago to 114 today. This situation will only deteriorate unless funding levels are restored.

It also goes without saying that if programs are mandated, expensive new bureaucracies established, salaries and wages driven up and the volunteer and municipal contributions undermined without the province being able to fund the results, the new act will see exactly the opposite of that which it was intended to do. It will see the decline of services and the further rationing of existing support. Is the ideological drive for a separate, centralized, controlling agency worth the loss of service and commitment which communities such as ours will experience?

My plea to you today is simple. Please amend this legislation so that it does not destroy the hard work, planning, love, and commitment that so many people in our community have given to the building of a long-term care system. There is dismay and anger within our long-term care community today from those who believe that the government refuses to be flexible and ultimately will drive them from the fields they have chosen to serve. They see themselves and their roles as being altered and destroyed by the direction of the legislation. Please do not allow this to happen. Amend the legislation so that it provides the flexibility for true local planning and delivery.


If the decision-making authority is to be at the community level, accountability to the residents of the community must be ensured. Bill 173 as currently written does not enable this to occur. For this reason, the region believes that the bill must be recast so that it recognizes and builds on existing local government structures. It also believes that the government must recognize that different operational models must be allowed where they will provide for more cost-effective and locally supported services.

In summary, it is our contention:

-- That the authority and scope of municipal governments should be expanded and not fragmented amongst new local governing structures.

-- That we oppose the creation of special-purpose bodies to assume the planning and management roles for health and social services;

-- That the government should be prepared to commit to adequate funding of any service it deems mandatory;

-- That legislation should be flexible enough to allow consideration for the continuation of a brokerage model of service delivery;

-- Finally, that the government must not allow the destruction of the volunteer and agency components of the current system, which provide much-needed support.

Mr Tilson: Your brief is indeed an excellent brief. I have one question and it has to do with funding, which I'm sure you probably anticipate. The government doesn't seem to have any idea what this is all going to mean, notwithstanding it's making major cuts. We've had volunteers come forward and say that they're just not going to exist any more. Fund-raising is going to be down, if not eliminated, notwithstanding the fact the system needs these groups, not only the volunteers but the money, the fund-raising dollars that are raised. Have you put even in general terms the effect this legislation will have financially on Waterloo?

Mr Phil Johnston: I'm afraid the answer is no, because it's pretty fuzzy at this point in time. I think all that we have, speaking in an administrative role, is a genuine level of concern. All the signs seem to be danger signs. There are cutbacks occurring already. The chairman has indicated there have been expressions of concerns about the loss of the voluntary sector, which will have to be taken up, I guess, by governmental spending, yet the indications are that such governmental spending will not occur. I think the bottom line for us, and I think it's nicely summarized in the brief, is that the exact opposite of what is intended is likely to occur, that in fact the service levels will drop, not increase.


The Acting Chair: Our next presenter is Ms Elizabeth Leeson. Welcome to our committee.

Mrs Elizabeth Leeson: Thank you so much. I think I can pretty well represent the age group to keep us out of the old people's home. My name is Elizabeth Leeson, and I thank you for the opportunity to speak. I may say that I do not presume to represent the feelings of people who are terminally ill.

During my working life I was involved with elderly persons. However, not until I became one in that age bracket was I aware of the frailties of the aging process.

In order to become more representative, I have spoken to several older people, ranging in age from 75 to 92 years of age. Married couples to whom I spoke each had been together for more than half a century. They are frail, some with progressive illnesses, but very attached to each other. They manage by just the closeness and caring developed over their lifetime.

One lady wrote to me to say that both she and her husband were diabetic and they tire easily. She has suffered several strokes, and her husband has a form of Parkinson's. They would like to have help with shopping and cleaning the home, including windows and kitchen cupboards. They would be prepared to make reasonable payment for the service. Their greatest wish, however, is to be together.

Single persons living alone in their homes or apartments, when asked about continuing their lifestyle, replied in the same way: house cleaning. They all said they require a little bit of help.

The comprehensive list of assistance listed on page 6 of the bill is excellent. If implemented, it ought to be possible for us to remain in our homes. Our independence and element of dignity is so important.

With the aging process, walking generally becomes slow and muscle power appears to be non-existent. Moving furniture, carrying groceries etc become difficult, if not impossible. Cleaning windows, which involves climbing, is not only dangerous but unwise. If we have always cared for our homes, we continue to do the best we can. It takes much longer, but creature comfort gives us a feeling of contentment. When the task becomes impossible, there is the danger of losing hope. When hope has gone, death is not far behind.

Life must have purpose in order to survive.

In a previous presentation by the Medical Officer of Health for East York, she spoke about the late Muriel Smith. This type of tragedy, unfortunately, is all too common.

Many of us, and I am one, are completely alone. My only child died 13 years ago. Many older persons are alone, not only by death, but are abandoned by their own children. This appalling situation appears to have manifested during the period of the nuclear family.

Dying alone holds much fear for the elderly. At one time, this was unheard of. It is a sad reflection upon society that so many instances of death are not discovered for days or even weeks after life has expired.

I suggest that persons alone in the world or without a support system have a central telephone number. In case of illness, this could be used in order that a home help could be dispatched. The duties of the provider would be to prepare a meal, shopping for necessities or just change the sheets on the bed.

A little bit of tenderness could go a long way in the recovery of the patient. To be sick and alone, not belonging to anyone in this world, is a very frightening experience. There is not much incentive to make the effort to recover.

Furthermore, I suggest a doctor on call could visit the home. The same telephone number could be used for both doctor and help provider.

I do not live in a building solely for senior citizens, but on one day each week our local Eaton's store provides, free of charge, a transhelp bus to take any elderly persons to the local shopping centre. We do appreciate this service when carrying our groceries. Perhaps other corporate sponsors would be willing to provide this kindness to elderly patrons.

In conclusion, each person to whom I spoke, and I agree, says we ought to pay for whatever service is provided. We wish to maintain our independence for as long as possible. To avoid any abuse of the system and to discourage a further drain on the public purse, payment ought to be mandatory.


Mr Tony Martin (Sault Ste Marie): Thank you very much for coming before us today. We've been on the road for a bit now with this piece of legislation, and I personally always find it refreshing, with somebody like yourself, who is obviously a person in a position to make use of some of the services that will be coordinated and provided through this particular exercise of the government, to hear of your thoughts, your concerns and your hopes.

I just celebrated my own mother's birthday on Saturday night in Sault Ste Marie. She turned 79. She and my dad still live together and take advantage of some of the home care service that is available. It allows them to stay in their own apartment unit and, with the help of family, they're able to have a healthy and happy time in their old age.

I guess that's what we're trying to do with this piece of legislation: make sure that everybody across Ontario, in every corner, has access to the kinds of services they need to live a wholesome and happy later period of their lives.

You mentioned one piece where we listed the services re this piece of legislation. Is there anything else in it that you see as helpful re your continuing to live where you do and some of the others like you across the province continuing to stay at home?

Mrs Leeson: Well, I've only spoken to people who want to stay in their homes and try to be independent, but we do need a little bit of help. You mentioned your father and mother. That makes all the difference. My only child is dead. My husband is dead. My little grandson is dead. I have two other grandchildren I can't see. I wouldn't know them if I saw them. Apart from that, I'm like the CN Tower: I'm a lone-standing structure without anybody in the world. So we're in an entirely different situation. I just feel that so many people are invisible.

You see, the lady who wrote and told me about her husband and her own situation, they are struggling, because I don't think they know where to go for help. This is why I suggest a central number. I remember Muriel Smith. I didn't know her personally, but I remember the impact, and this is exactly how I feel personally that I shall be found. That's why I ask for a central number; perhaps just someone having flu and you just feel you can't lift your head off the pillow. Phone.

Mr Gary Malkowski (York East): Thank you very much for your presentation. Your words are important to us and your consumer perspective is one that we value.

Talking about the East York community care and some of the services that are provided there, we hope East York will become a bit of a model. If you have any familiarization with what's happening there, could you talk to us a little bit about your own experience as a consumer and what kinds of services you've used?

Mrs Leeson: I don't feel that I want any service in particular except that central telephone number and someone to help with the housecleaning.

Mr Malkowski: Okay. We hear that loud and clear. That's important to us. Thank you for your feedback.

Mr Tilson: Thank you very much for coming.

Mrs Leeson: My pleasure, Mr Tilson.

Mr Tilson: It's always difficult to come down to these things, I can imagine, and make presentations. You obviously have put a great deal of thought into your presentation and I thank you for that.

My question is that we in our party are opposed to the legislation, if anything because it's going to do away with volunteers; it's going to do away with volunteer fund-raising. In your position, will you be able to manage alone?

Mrs Leeson: I don't know for how long I shall be able to manage alone, for the simple reason I have nobody. I have no support system whatsoever. But I know definitely I do not intend to enter a senior citizen home, not while I am compos mentis. So the only thing that comes when you can't manage is just give up. But each day I live in the hope, and this is the one thing that does keep me alive, that my grandchildren will realize they do have a grandmother and I shall see them before the end. That's the only thing that keeps me going.

Mr Tilson: Thank you very much. We need personal stories such as yours to come and assist and hope that the government will listen to some of your --

Mrs Leeson: Well, I've tried for many years to get the government to listen, but if Bill 124 had been proclaimed and if they had had three parties agree on that bill, if it had been proclaimed, it would have made all the difference in the world to a great many people, and I am one.

Mr Tilson: That's Mr O'Connor's bill.

Mrs Leeson: No, that was not. That was Mr Scott's bill, when he was the Attorney General.

Much more emphasis must be given to the people who want to be independent and need that little bit of help, because you see, we go back a very long way, when we did our washing, our cleaning and everything with an element of speed. There weren't the material things that we have now. We want to keep that standard and it's very, very difficult.

Furthermore, if you put on housecleaning and different other services for the community of older people, it could provide a great many jobs, because everyone does not want to be professional. Lots of women and men like to do housecleaning, and if properly trained, it could create a great many jobs. But just give us our independence and a little bit of encouragement. That's all we want.

Mr Tilson: Mrs Leeson, thank you very much for coming. Your comments are greatly appreciated.

Mr Conway: Mrs Leeson, I want to join my colleagues in thanking you very much for a very good presentation and a very strong defence of your point of view.

Mrs Leeson: I'm in the age bracket that I know what it feels like.

Mr Conway: I hear you loudly when you say you do not want to go to a home if at all possible. Just one of the things I'm interested in, from your experience personally and with any of your friends -- I think members of the Legislature of all sides are really concerned about elderly persons who are alone and don't have the kind of support system that I think we would all like to see in place. In your case, you've got grandchildren. You live in Metropolitan Toronto.

Mrs Leeson: I wouldn't know my grandchildren if I saw them. When my daughter died, I was shut out, like thousands of other grandparents in the same position.

Mr Conway: That was my question: the role of family in a situation like that. In your personal case, your relationship with your grandchildren is not --

Mrs Leeson: I fought for 12 years through every aspect of the law to see them, and eventually in Newmarket court on March 15, 1993, I was treated like a criminal and forbidden to make any further effort to even communicate or send them a Christmas card.

Mr Conway: Thank you very much.

The Acting Chair: Mrs Leeson, a very special thank you for taking the time and making the effort to come down and speak with us here today.

Mrs Leeson: Thank you so much.

The committee recessed from 1218 to 1408.


The Chair (Mr Charles Beer): We'll get under way and we will call our first witnesses, from the Kidney Foundation of Canada (Ontario), if they'd be good enough to come forward. Welcome to the committee.

Ms Janet Bick: My name is Janet Bick and I'm the provincial advocacy coordinator with the Kidney Foundation of Canada (Ontario).

Ms Lisa Bletcher: My name is Lisa Bletcher. I'm a renal social worker at Credit Valley Hospital in Mississauga and I'm here representing the Canadian Association of Nephrology Social Workers (Ontario).

Ms Bick: Good afternoon. We appreciate the opportunity to present our views on Bill 173 today. As I think a lot of the members of this committee are quite well aware, at present there are over 6,000 Ontarians being treated for end stage renal disease in the province. The greatest increase in that renal failure population is among the elderly, who make up the bulk of those individuals who are using long-term care services. The members of this committee will be quite familiar with a lot of the other issues regarding renal care as a result of the study that was undertaken by this committee last April.

The Canadian Association of Nephrology Social Workers and the Kidney Foundation support the goals and objectives of the long-term care reform. Like most health care recipients, individuals with kidney failure would almost always choose to remain in their own homes with appropriate support services rather than be in an institutional setting. Renal patients have always been at a disadvantage with regard to long-term care services. Often their needs cannot be met in either a community or institutional setting due to a lack of appropriate services, restrictive eligibility criteria and a lack of understanding of their particular needs.

Of course, the reasons for this situation lie somewhat within the scope of long-term care reform, while others of those difficulties will require changes in the way health care is delivered to these people.

The objectives of Bill 173 are admirable and we certainly would be pleased to support a well-funded, well-managed system that would allow people who require health care and support services to stay in their own homes for as long as possible. We certainly recognize that that's really the most cost-effective way of meeting their needs, and that certainly is true of the renal failure population.

We've identified a number of areas in the legislation which we believe require more detail to ensure that the goals of the act are met. I would like to pass the microphone to Lisa, and she will provide you with an overview of those recommendations.

Ms Bletcher: As you will see in our written submission, the CANSW and the Kidney Foundation have offered six recommendations. I will refer to each one, but I'll focus mainly on recommendations 2 to 5 because I feel they need more explanation.

Recommendation 1, which refers to the bill of rights: Bill 173 should be amended to include a specific requirement that all information must be provided to clients in plain language and in accessible formats.

We support the bill of rights, as it affirms the rights of the client to receive information on community services, information on laws, rules and policies and information on the complaints process. However, because many renal patients are visually impaired due to the fact that many of them are diabetics, and because the renal population is multicultural, with many patients unable to speak or read English, the information must be available in an accessible format; for example, if we could provide the written information in various languages or provide audiotapes, or even if interpreters could be available when we pass this information on.

Recommendation 2, access to services: Qualifications and staffing levels appropriate to the services the MSAs are required to provide should be clearly specified in the regulations, as well as a clear set of guidelines for the sharing of the assessment and resource education roles between the MSA and hospital social workers who are already providing service to the clients.

Currently, renal social workers are providing many of the services outlined for the MSAs. Actually, we sort of referred to ourselves after we read this as the mini-MSAs. The services that we provide already are assessment of patient needs, provision of information to patients and families regarding what community resources are out there, sharing the information regarding what the eligibility criteria are, referral to these resources and services and follow-up.

Linking renal patients up to available community services actually works quite well at present because these patients have access to renal social workers and we are attached to the hospital renal program. The renal social workers' understanding of the needs of their patients, their knowledge of the community resources and their easy access to other members of the health care team make for a quick referral process. The question is, what will happen when the MSA staff becomes involved?

The legislation does not address the procedural aspects of these functions of the MSAs, nor the qualifications of the MSA staff providing assessments and information. A number of concerns arise from that: the duplication of service; increased paperwork that may cause delays in timely access to services -- actually we're already experiencing that with the passage of the Long-Term Care Statute Law Amendment Act of 1993, where the placement coordination service is taking on more tasks, so they have many, many forms to be filled out now; third, the creation of another level of bureaucracy; fourth, the ability of the MSA staff to make a valid assessment based on a one-hour hospital or home visit; and fifth, possible delays between referral and initiation of service that will lead to delays in hospital discharge.

Recommendation 3, mandatory services: The mandatory services provided by the MSA should be clearly defined in the legislation if the goal of bringing consistency to service delivery across the province is to be met. The definition should specify which services will be subject to charges.

Providing the MSAs with a list of mandatory services is important, but if the services are not described in more detail, each MSA may define them differently. It's not clear, for example, whether assistance for peritoneal dialysis exchanges would be considered a professional service or a personal support service. Will a nurse have to provide this service or could an attendant care or homemaker provide this service?

In terms of transportation -- this is also an example -- will MSAs actually work with a client to set up a regular transportation schedule for treatment in clinics and will they also follow through with making sure the transportation will continue?

These are the kinds of questions that need to be answered.

Recommendation 4, eligibility for services: The legislation and regulations have to provide MSAs with the flexibility to do creative problem-solving to meet the needs of renal patients, who do not always fit neatly into prescribed eligibility criteria. Under the current system, many renal patients fall between the cracks due to eligibility criteria that are not sufficiently flexible to accommodate a particular situation.

For example, the integrated homemaking program, which actually has been very beneficial, requires that the client needs help with personal care, whereas many renal patients only feel comfortable with a family member providing this personal care. But then they do need assistance with housekeeping tasks, as the family member cannot do it all. Another example is the renal patient who is not eligible for the regional respite program, as it is only for the memory impaired. So of particular concern are those patients who do not fit into a single category like seniors, the developmentally handicapped or the one that I've already mentioned.

Recommendation 5, availability of services/waiting lists: The legislation and the regulations should establish a system of priorities for waiting lists and priorities for services which are provided to individuals who depend on life-sustaining treatment such as dialysis.

The legislation requires that services be delivered in as timely a fashion as possible but does acknowledge that services may not be available. This results in waiting lists. There's nothing in the legislation that permits the prioritization of individuals on the waiting list or between services provided.

For example, if the amount allocated for community nursing services for dialysis patients is reached and a waiting list is created, money cannot be shifted from another area to provide additional services. The individuals on the waiting list would be forced to continue to occupy expensive acute care beds in the hospital or switch to haemodialysis, which is a more costly type of treatment.

The last recommendation, 6, regarding the regulations: Key regulations such as those governing assessments, determination of eligibility criteria, definition of the nature and amounts of services that may be provided should be drafted prior to third reading and available for public input.

Due to the broad regulation-making power that the legislation permits, it's very difficult at this point to determine whether or not the MSA system will really mean improved availability and access to appropriate long-term care services for the renal population. We feel that the public needs more input prior to the third reading so that the interests of the current and future clients of long-term care services will be taken into account.


I'd just like to make reference to a couple of case examples in appendix C. I don't think I will read them out, but I just was hoping that people would refer to them. These are two of many I could have come with, but both of these cases serve to illustrate the difficulties renal patients have in attempting to remain in their own homes. There's no question that they choose to remain in their own homes in most cases, but too often they're forced to switch to a more expensive form of treatment or be admitted to acute care beds in order to be able to receive treatment. They point to the need to make eligibility criteria more flexible and to provide adequate funding to community services to provide the assistance that these individuals require.

Thank you for giving me this opportunity. It's hoped that you'll consider these recommendations when you proceed to examine the legislation.

Mr Jim Wilson: Thank you very much for your presentation, Janet. It's good to see you again. You're becoming a regular contributor to the social development committee. Lisa, we certainly appreciate the input from renal social workers. We've had no one from that profession to date appear before the committee specifically with renal care in mind.

I agree with a number of things. I should say, I guess, from the work this committee's done and the work members have done, that I certainly agree with your latter comments, Lisa, in terms of the general feeling I find with dialysis patients, particularly haemodialysis patients in my own area. They would just like the service as close to home as possible, not necessarily in their homes, although we're having great success in my local area in getting a number of machines in homes. We'd frankly like a satellite so we could share those resources with those who haven't been fortunate enough to get a machine in home, but that is a subject for another day. Hopefully soon the Central East Study Committee will be reporting back to the Legislature and we'll have some more progress on the dialysis situation.

Specifically, I know it's your last recommendation, but I think it's quite key, and that is with respect to regulations so that we know what we're talking about in this bill. You started off the presentation saying what a number of us would agree with, and that is that the principles seem great, the bill of rights seems great. However, I'm not convinced, after over two weeks of public hearings and dozens of meetings, that the legislation as drafted meets those principles and meets the government's own tests for an effective piece of legislation that would indeed enhance long-term care services in the province.

When asked yesterday about regulations, the parliamentary assistant indicated they hadn't written any yet, which I found pretty astounding, that they would want us to vote on third reading without knowing what the recommendations are. In fact, I don't think that was a complete answer from the government.

My question that I'm going to direct to the parliamentary assistant is one that you ask, and that is, how are waiting lists to be handled? Waiting lists are a growing problem in the province and will be more so, I think, because we're going to spend millions of dollars in administration with MSAs. During the next four years, I think, there's going to be less money for front-line services and more money for bureaucracy.

Will there be rules, Parliamentary Assistant, or guidelines, or what is the current thinking of the government with respect to how MSAs will be directed to deal with the waiting lists which I believe are inevitable with this legislation?

Mr Wessenger: The legislation clearly sets out the ability to make regulations with respect to prescribing rules for waiting lists, including ranking them in terms of their priority. So in reality, that will continue to be a needs-based situation with respect to setting priorities. That will continue to be so.

While I have the floor, there's one other item that was raised that I don't know whether you'd like to deal with at this time --

Mr Jim Wilson: Could I just touch that point --

Mr Wessenger: -- the other question on the transportation issue.

Mr Jim Wilson: Just with respect to that, though, if you're going to be making regulations after this thing leaves Parliament and leaves this public forum, what input would groups like the Kidney Foundation and renal social workers have into that? Is there some committee they should be on now to advise you on that?

Mr Wessenger: I'll ask Mr Quirt to indicate the process with respect to regulations.

Mr Geoff Quirt: At this point there are about 11 working groups with representatives from various consumer and provider interests that are helping us in the program design stages to develop a program manual for multiservice agencies that will address the issue of who's eligible for how much service and how best to manage those services within a defined budget.

As you know, there are waiting lists now. The only solution to eliminating waiting lists would be to have an unending supply of funding, and home care programs do a good job now of managing their resources and making sure that emergencies are taken care of and that resources are used appropriately.

We want to make sure there's a capacity to deal with emergency situations as they come up, and the prioritization of clients is one of the topics for discussion at that working group level. If you're not involved in those working groups, we'd certainly like to talk to you about your interest in them and find out the most appropriate way for you to make input specifically with respect to the issues you've raised in your brief.

Mr Jim Wilson: Is that a commitment that you'd like followed up with, Mr Quirt?

The Chair: There's an offer there.

Ms Bletcher: Definitely.

Mr Jim Wilson: I'd like to make sure the offer's followed through. I take Mr Quirt at his word.

The Chair: I think a lot of us heard it, so we've got --

Mr Jim Wilson: We've heard a lot of things, Mr Chairman, in the last four years.

The Chair: The parliamentary assistant had a comment on one of the other issues that you raised.

Mr Wessenger: The other comment you made is you said that the legislation does not specify what transportation services are to be provided. It does, and I'll ask legal counsel perhaps to indicate the details of that.

Ms Gail Czukar: I just wanted to point out that transportation services are defined in the bill. They include both assisting people to use existing transportation where that's the need or to use alternate transportation where they're not able to use existing transportation. So I think the answer to the question in the brief about working with the client to set up regular transportation schedules and so on is yes.


The Chair: I call on our next witness, from the African Canadian Entrepreneurs, Ms Delores Lawrence, president. Welcome to the committee.

Ms Delores Lawrence: Thank you very much for allowing my organization to do a presentation to the committee this afternoon. You all have in front of you a copy of my talk which you could follow with me or you could ask me questions after. I'll certainly leave ample time for that.

Just a little background on the African Canadian Entrepreneurs, otherwise known as ACE. We were incorporated in 1993. We're a not-for-profit organization, and our goal was to support the economic and political empowerment of African Canadians. Our membership includes all African Canadians who are currently entrepreneurs in Canada and those who support the goals and objectives of ACE. By African Canadians, it encompasses those who are born in Africa, the Caribbean, Europe, North and South America. ACE is governed by a president and a nine-member board of directors who are elected for two-year terms.

The issues that are before us that bring us here today are that the Minister of Health has released Bill 173, the second bill related to reforms of the long-term care system. This follows Bill 101, introduced in November 1992 and passed in June 1993. The long-term care system in Ontario is a system providing health and personal support services to seniors and people with disabilities. The main components of the bill are the introduction of the bill of rights and the tool of multiservice implementation agencies, otherwise known as MSAs.

Whereas Bill 101 focused primarily on institutional care in nursing homes and homes for the aged, Bill 173 deals mainly with services that are provided by community agencies. This will ensure that people remain at home or in their home communities for as long as possible. In other words, institutional care is being delayed.


Currently, there are several providers of different types of services such as nursing care, physiotherapy, speech therapy and personal support services; for example, assistance with activities of daily living, which includes bathing, dressing, cleaning, shopping, laundry, and bill payments, to name just a few. These are available to seniors and to the disabled in Ontario.

Over the past few months, as president of the African Canadian Entrepreneurs, I have attended seminars, workshops and information sessions sponsored by the Metropolitan Toronto District Health Council, which established a committee in April 1993 to look at MSAs in Metropolitan Toronto. Several factors should be taken into consideration.

The size and the diversity of the population of Metropolitan Toronto are unique in North America. One of the concerns is, how do we ensure fair and equitable access to services by all ethnoracial communities? There is no doubt that all the MSAs should be reflective of the population in Metropolitan Toronto and equitable.

How do we ensure that the large number of volunteers who have historically played a significant role in planning and funding continue to do so? Millions of dollars have been generated by agencies and community-based fund-raising projects. How do you ensure that this will continue?

The Ministry of Health has decided to impose restrictions on agencies that do not become part of MSAs. This no doubt will mean the loss of thousands of jobs both in the private and non-profit sector. Section 13 of Bill 173 limits the amount of service an MSA can purchase from any agency, private sector or otherwise: no more than 20% of all the home care services being provided by the MSA. The government had planned to limit only the commercial sector to 10% or less. However, when the legislation was introduced, the government extended the ceiling to include all providers who are not part of the MSA.

Private sector companies face a crisis situation. More than half the commercial home care agencies in Ontario account for almost 50% of the services provided in Ontario.

What does the future look like?

There is no doubt that if the commercial agencies go out of business, the employees will also be unemployed. This is not encouraging news.

Many home care workers are minorities and women. How can these laid-off workers be guaranteed jobs when the government made commitments during the social contract negotiations to fill new jobs in the health care system with unionized hospital workers who were laid off? This means squeezing out this disadvantaged group.

What about the severance packages? Does this then mean that they are sent back to the social welfare system?

This bill is a bill about not just long-term care reform, but killing entrepreneurship in health care and killing jobs. Home care workers no doubt await the same fate as their colleagues in day care, whom the NDP government cast aside without any support or any bridging of benefits for seniority.

In conclusion:

It is encouraging to see the introduction of the bill of rights and we support its inclusion in Bill 173.

MSAs should be the coordinators of services rather than the coordinators and deliverers of services.

The bill should not eliminate individual charitable structures currently in place. The uniqueness of ethnoracial communities definitely is a plus when it comes to fund-raising. Will the government make up the difference in lost fund-raising dollars?

It is important that consumers have a choice. By limiting private sector to 20%, there will be no choice.

With the government running MSAs, it does not mean that efficiency will be increased or delivery of care will be more cost-effective. In fact, competition keeps costs down and is reason enough not to limit private sector to 20%. Do not create a monopoly, but provide the most cost-effective approach to health care to the people of Ontario.

The Chair: Thank you very much for the presentation. Just before going to questions, I remind committee members and also those who are with us that because of the number of individuals and groups that have asked to appear before the committee, in trying to ensure that we hear from everybody who has asked to come, we have to limit our questions to one with each presenter. The fact that there is only one question does not mean there isn't a lot more interest, but I'm afraid we had to make the choice between ensuring that we heard the views of those who wanted to come before us or listening to ourselves, and we get to do that so often in the Legislature that we thought this was perhaps the fair compromise. With that in mind, on the rotation the question is with the NDP and Ms Carter.

Ms Carter: Under your heading "The Future" you say that under Bill 173 there's going to be a lot of unemployment of people who are presently employed in home care and so on. I just want to challenge that, because I think actually what we're looking at is a big expansion of services. Although many areas in Ontario have had very good services, there have been other places that haven't been so fortunate. There have been gaps, and what we're trying to do is to spread those services all over the province so that everybody will have the essentials. Actually, there is a large increase in jobs available, and I believe there have already been thousands of extra workers employed in home care. Maybe we could have some figures on that.

Mr Wessenger: I'll ask Mr Quirt to provide that.

Mr Quirt: We can estimate that with the investment of $441 million in new programs and services throughout the entire length of the redirection budget -- we're about halfway through now; we've invested about $250 million and there's another roughly $190 million to go -- thousands of jobs will be created. Our estimate, for example, with the implementation of the integrated homemaker program, based on the number of workers and their wages and the number of full- and part-time jobs in the system now, is that 5,000 jobs were created with the introduction of the integrated homemaker program alone. We hope that as a result of the redirection there will be many, many more jobs added, and as has been noted earlier, mostly in the direct service area as opposed to administration.

The Chair: Did you wish to comment?

Ms Lawrence: Yes, I would like to comment on that. When the government had made the social contract commitment, I'm sure many of you are aware that there are many hospitals that were doing things as simple as laundry, and the laundry department has been eliminated. A lot of displaced workers are out there at this time. If the current home care situation in Ontario is you have about 50% of the market now with the private sector, how can you -- I'd like to see some research that would show that those jobs would in fact be re-created. What would be happening is that there would be an awful lot of people out there without jobs if the displaced workers in the institutions are used first.

The Chair: Ms Lawrence, thank you for coming before the committee and raising the issues that you have.



The Chair: I call on our next presenters, from the regional municipality of York. The committee is always thoroughly delighted to have representation from the region of York.

Mr Eldred King: It certainly is our pleasure to appear before you on this very important issue. I will introduce the members representing the region of York: Mr Bob Scott, a regional councillor from the town of Newmarket who chairs our health and community services committee; Dr Helena Jaczek, medical officer of health, region of York; and Mr Peter Crichton, the commissioner of community services.

Charles, I'm delighted to hear you say that you are delighted that you have guests from York.

The Chair: We have both quantity and quality when York comes forward.

Mr King: We'll agree with you.

Mr Tilson: Let's not overdo this.

Mr King: No, let's not overdo it. Let's not forget about Peel.

We are here today to express to you our very grave concern with Bill 173, An Act Respecting Long-term Care in Ontario. We have in York region been a partner in providing health, social and support services to senior citizens and people of all ages in our community for more than 20 years. We are completely mystified by a provincial government that proposes legislation such as Bill 173, an act that ignores the existence of regional government, a tier of government which was originally created by the province of Ontario, and that minimizes the value of long-standing community-based volunteer organizations and creates a whole new bureaucracy for the taxpayer to support.

We have a presentation to make today on what we specifically object to in this act. We shared this presentation with our planning and service delivery partners in the community on August 17 at a special meeting, and although you will hear or have already heard from groups in York region who support our position, there has not been sufficient time for us to fully consult within our region. I would add that I don't believe there is sufficient time for anyone with the responsibility that has been placed on the district health council to fully respond to the impact and implementation of the intent of the act.

We would very much like to have the time to explore a regional management model and to reasonably discuss the appropriate governance of a multiservice agency with all stakeholders in York region. The question of governance is very much in the forefront in these days when the cost of supplying services and the duplication of supplying those services is so very evident.

I will ask Mr Crichton now to present our position, and Dr Jaczek will also assist.

Mr Peter Crichton: We are here today to express the regional municipality of York's concerns regarding the establishment of a new non-profit agency to provide long-term care services in the community, and to request a change to section 13 of Bill 173. This section limits purchase of service outside the multiservice agency to 20%. We believe a change is necessary in order to preserve an individual's choice of preferred service provider, as well as to provide communities with greater flexibility in designing the multiservice agencies. We are also here to request a change to subsection 11(3) of the legislation to give municipalities the first option to be designated as an approved multiservice agency.

We urge the government to delay the implementation of Bill 173 while a thorough review of the issues is undertaken. We note that these issues and others have been raised consistently during these hearings.

We are in full agreement that access to long-term care services for senior citizens and the physically disabled in the community had to be simplified. We recognize that previous provincial governments have made attempts to consolidate program delivery and funding rationale. We recognize the effort made by this government in continuing to reform the entire system of long-term care services in Ontario to ensure that coordinated and integrated care is accessible to all. We also acknowledge that the task has been made more difficult by financial constraints that have impacted our communities and our families in unprecedented and drastic ways.

As public service providers, we are increasingly aware of the transformation that has already taken place in moving from facility or hospital care to community-based home support systems. We wish to emphasize to you the responsibility that municipalities have towards the provision of community support services. Municipalities view these programs as major public services. We support the continuing trend towards community-based long-term care services and we also believe that such services should be viewed as a major public utility.

Dr Helena Jaczek: For these reasons, we suggest to you that the model of a multiservice agency, as proposed in Bill 173, has a number of flaws. We have two major concerns.

First, consolidation into a single provider agency: The requirement that 80% of long-term care services in the community must be provided directly by MSAs creates a single service provider that has a virtual monopoly on the delivery of a major public service. While perhaps appropriate in small rural communities, this will not necessarily improve service in more urbanized areas with many existing agencies and a diversified population.

We are very concerned that detailed cost-benefit analyses have not been done. While savings may be achieved in the short term by consolidating administrative functions, the long-range cost-benefit is questionable, given the magnitude of program delivery, the areas of specialization that will have to be developed and the size of the supporting organization that will be created. Further information on base budgets and ongoing funding proposals for MSAs should be released by the government and included as part of both the communities' and the provincial review processes.

We have a great deal of concern about the future of many community-based agencies, about preserving the character and expertise of these existing agencies. We are also concerned about the continued commitment of volunteers and the loss of charitable contributions to a service provider that is viewed as a large bureaucracy.

Our second problem with the bill as it stands relates to definition of governance models that do not recognize the role of regional government.

The MSA will become the provider of a major public service, but will be accountable only to its board and the provincial government. The guidelines speak in vague terms about accountability to the MSA's "membership, consumers and ultimately the community," and a "board that will be representative of its community and include a diversity of interests."

Regional government is accountable to the people through the municipal election process. Furthermore, regional council is constituted of member municipalities, somewhat on a proportional basis, and surely this is truly representative of the community in its broadest meaning.

When regional governments were established in the 1970s they were also given a mandate to serve the human and social needs of residents in the more densely urbanized areas of Ontario. They are accountable to the public through an open, democratic, electoral process and have established mechanisms for review and appeal of decision-makers' performance.

It does not make sense to us to create a new model of governance for essential public services when regional municipalities are prepared, qualified and legally entitled to provide such service. You have already heard this position from the Ontario Association of Municipalities in its continuing support for the role of municipalities as providers of human and social services.

Mr Crichton: There are a number of reasons why the region of York should have a strong leadership role.

First, the region has a long history of human service delivery. Since 1970 the region has, under the Regional Municipality of York Act, been responsible for the provision of a range of both mandatory and discretionary health and social services. In 1978, the regional municipality was also incorporated as the board of health. The region has a local focus and a proven ability to balance the needs of urban and rural residents.

Secondly, regional councillors are directly elected by the public. As we said earlier, regional councillors, by their electoral mandate, are directly accountable to the public. The existing electoral process ensures accountability to the public and, if there is a future commitment to reform of the electoral system in York region based on direct elections, then accountability to the public will only be enhanced.

Third, regional government has a sound administrative structure and experience with transfer payments from the province. The region already has an administrative infrastructure in place -- for example, human resources, finance and legal services -- so that the existing network of professional staff and support services could easily be applied to the provision of a fully integrated system of long-term care in the community.

In addition, the region administers numerous transfer payments from the province under many different acts, having a diverse range of funding formulas and subsidy agreements. It already has extensive experience in managing transfer payments or service agreements for service mix, service level, quality, quantity and economy in such program areas as home care, hostels, child care and employment programs.

It is our contention that a regional management model would achieve the goal of one-stop shopping for community-based long-term care services by bringing together the existing expertise and organizational structures of the region of York with participating service providers in a mutually beneficial and ultimately more efficient, cost-effective and accountable way.


We propose that the region take the lead role as the manager of the MSA, while existing community-based agencies retain their separate identity and program delivery systems. Regional resources would be directed towards coordinated administrative and case management functions, purchase-of-service activities and audit for quality control. In addition to the accountability requirements of the province, accountability to consumers and residents would be assumed as part of the existing relationship between the public and regional council.

Dr Jaczek: It is for these reasons we are suggesting in the strongest possible terms that the province remove the 20% limit on purchase of service by repealing section 13. We are also suggesting a change to subsection 11(3) to state the preferred designation of municipalities as approved multiservice agencies in areas where municipal interest has been expressed.

We do not believe that a multiservice agency as prescribed by Bill 173 will provide cost-effective or improved service to the many rural and urban residents of York region. Due to the haste with which this legislation has been drafted, there has been insufficient time to study its cost-effectiveness, its fundamental flaws or its impact for consumers. This bill should be delayed while additional study of other governance models and a complete review of the financial implications are undertaken.

Mr King: In closing, I would like to say we totally agree that there's no question that it's time the service to our residents should be reviewed. I think at the regional level -- and I only speak for the region of York -- we do have the administrative infrastructure. We also have a long history of serving our residents and meeting their needs. Again, I plead with you to make certain amendments to this bill which would provide the opportunity for us to further examine exactly how it should be done and hopefully it will be done in a way that will serve the residents of this province most effectively and efficiently. I thank you for hearing our position.

Mrs Sullivan: Thank you for your brief. We have heard from a number of other municipalities and I think one of the things that strikes us is that their impression is that people were, through the consultative process, looking for a mechanism to improve single access to a coordinated series of services. They were looking for a multiservice system, not a multiservice agency. In many communities such as your own -- Waterloo was here earlier today -- what we have found is that the municipalities themselves were taken aback when this legislation came forward in this form.

I particularly appreciate your appeal for a delay while study of other governance models which would provide the flexibility to meet needs in each community are available, or at least an adjustment to the bill that would provide that flexibility, and a complete review of the financial implications are undertaken. We have been appalled to learn that there has been no feasibility study done, no cost-benefit analysis of this proposal and no pilot is anticipated.

I'm going to ask the parliamentary assistant once again if the government would undertake a pilot project with a review in order to conduct a complete review of the financial implications of this MSA model in comparison to a model such as that which is presented by the region of York where, in the past, a municipal system has worked and served the people in that community.

Mr Wessenger: No, we do not intend to proceed with a pilot project, but I might point out that this legislation is very flexible and permits a differing time frame for different areas for developing the proposals. I think there's a great deal of flexibility in the legislation as it is and we undoubtedly will see some multiservice agencies develop at an earlier stage in some areas than in others. Undoubtedly, those will be studied and looked at as examples for other areas.

Mrs Sullivan: There's not much flexibility when you have a four-year time line that's statutory.

Mr King: I think there are certain areas that we have outlined to you that need further examination. I think it would be folly to move into a process that has not been totally examined, whereby it may appear that it can be done better than it is at the present time. I think you should always look at all options. In my conversation yesterday with the chair of the district health council, whose responsibility it is to indicate the appropriate model for the delivery of this service -- and we will be working closely with the district health council -- they have not concluded yet what it should be or who it should be. All I stress again is that I think we cannot accept any additional cost for providing services and it would only appear in the best interests of all that we choose the best method.

The Chair: We have just a minute. I'm going to allow the other member from York to put one question.

Mr O'Connor: I appreciate you coming before us. I guess we have heard this type of brief presented to us before. We haven't heard a lot of people come and say, "Please create the MSA, not from the government but to another level of government." There hasn't been anyone saying, "Please shift it from one arm of government, because we don't agree with it, to another."

I guess another thing we hear is, what about the volunteer element? If government is running it, then you're not going to get volunteers out. If government is running it, then as to the fund-raising that does take place out there in the community today, how will that happen? I just wondered if you might want to comment on your ability to bring in volunteers that might be different than if another level of government was to run it, or fund-raising. I know you're well aware of the process and the district health council isn't about to sanction one model over another, because they're going through a process still, and you'll be part of that.

Mr King: Let me respond to that this way and then I'm going to ask Mr Crichton to respond. I have not worked at the provincial level, but I certainly have at the local level for many, many years and it is very evident to me that it is much easier to get volunteers to work for local groups than it is any provincially organized body.

Mr Crichton: Our proposal would retain some of the positive features of the present system, many of the positive features of the present system. In fact, the hands-on delivery at the local level, the line people who go out and provide the home support services, the homemaker services, the nursing services, those kinds of services would be provided by existing agencies in the community that have a long association with the community, understand the community values, represent the diversity of the community and have established a volunteer base that has its roots in the establishment of the community, particularly a community like York that is young and growing. We think the model we propose retains that feature.

Make no mistake about it: We are advocating a brokerage model, but we're advocating a model that streamlines the current system, that brings more efficiency, brings more economy and brings more effectiveness to what you have now. You'll get more for your dollar than you will under a system that creates a new agency and that will increase the cost. Yes, you will save a few dollars on administrative costs by collapsing certain administrative costs under certain agencies, but in the long haul your costs will rise significantly and we think that money will only come out of the new funds allocated or existing funds, and therefore diminish the present level of service overall.

The Chair: I'm sorry that time is our enemy and I'm sure we could follow up on these and other questions quite profitably. May I again thank you for the presentation, the proposal and also the document which was passed at regional council.



The Chair: I call on the representatives from the Multicultural Alliance for Seniors and Aging. Welcome to the committee. It is good to see you both again before the committee.

Dr Dimitrios Oreopoulos: I am Dr Oreopoulos. I am a busy kidney specialist at the Toronto Hospital, and Dr Joseph Wong is a busy family physician downtown. One common thing between both of us is that, in addition to being busy practising physicians, we are both very active in our corresponding communities.

I think for the last 10 to 15 years we both have witnessed some terrible stories involving members of our ethnic groups in trying to have access to the health care system. We can spend time to tell you various personal experiences but, instead of doing that, we both decided to be founding members of the multicultural alliance for seniors. I would like to start by introducing a little bit of the association that we started in 1989 and then I'll let Dr Wong present.

The Multicultural Alliance for Seniors and Aging -- MASA -- was established in 1989 to represent the interests of the multicultural communities with respect to the needs of ethnic, older adults and their families.

The goals of MASA include: to provide mutual support to member organizations; to serve as a resource to multicultural communities in Ontario who wish to develop services for their seniors and to mainstream seniors' agencies who wish to provide services to multicultural communities; and to provide advice to government and planning bodies regarding the needs of multicultural communities for long-term care facilities and community-based services.

MASA has more than 40 member organizations in Metropolitan Toronto and Hamilton, representing over 25 different ethnocultural communities. I would like to draw your attention to this little brochure with the names of the organizations that are represented in MASA. Some of these have well-established services, some are in the process of developing services, while a number of communities are in the planning process. In total, I think we represent more than 40% of the ethnocultural groups in our city. It is our view that, through mutual support and collaboration, we will better serve the needs of our respective communities and the residents of Ontario.

Dr Joseph Wong: On behalf of the members of MASA, we wish to express our support for the ongoing efforts of all members of the Legislature to develop a system of long-term care which will effectively meet the needs of Ontario's seniors and disabled.

We believe MSAs are an essential component in reforming the delivery system of long-term care services. At the same time, our purpose in addressing you today is to place before you certain recommendations, which we believe will strengthen the ability of these agencies to serve the needs of ethnic seniors and their families.

Our members strongly support the third right of the proposed bill of rights for persons receiving community services, which states: "A person receiving community services has the right to be treated in a manner that recognizes his or her individuality and that respects cultural, ethnic, spiritual, linguistic and regional differences."

However, in order to ensure that this right is protected, it is essential that services be planned and organized in such a way as to empower ethnic seniors through their various communities.

In her letter to Metropolitan Toronto District Health Council, the Minister of Health emphasized that the planning process for MSA implementation must take into account the needs of different ethnocultural communities. She further indicated that some planning consortia will identify themselves as leads for various ethnocultural communities. We believe this makes good sense, because it will allow for the concentration of resources in order to maximize quality and efficiency. We further believe that Bill 173 should reflect this commitment.

MASA therefore recommends the addition of the following subsection to paragraph 11: "The minister may designate a multiservice agency as a lead agency for an ethnocultural community."

This will ensure consumers' choice with regard to appropriate linguistic and cultural services anywhere within a planning district. This will also maximize the efficiency and cost-effectiveness of available resources. However, the establishment of lead MSAs for different ethnocultural communities should not reduce the effort and commitment of other MSAs in providing appropriate cultural services to their constituents within their own catchment areas.

Dr Oreopoulos: MASA members endorse the requirements for board composition of MSAs described in Bill 173. However, we believe that the legislation should outline a process for ensuring that ethnocultural communities are appropriately represented. Specifically, MSAs should be required to solicit nominations from ethnic community organizations in their geographic areas. In addition, there should be a formal appeals process for groups which feel that their communities have not been adequately represented.

Bill 173 envisions a system in which ethnic seniors will receive services which are culturally, linguistically and spiritually appropriate. However, it establishes no framework for ensuring that such services would actually be delivered. MASA therefore recommends that subsection 20(1), which deals with service plans, be amended by adding clause (d) as follows: "for each person who is determined to be eligible, develop a plan of service which takes account of the person's preferences based on ethnic, spiritual, linguistic, familial and cultural factors." This language is consistent with the language of Bill 101, dealing with care provided in long-term care facilities.

It is the view of MASA members that the legislation should also require MSAs to develop training programs for their employees and volunteers in order to sensitize them to the special needs of ethnic seniors. We therefore recommend the addition of the following to section 20: "An approved agency shall develop training programs to sensitize their staff and volunteers to the ethnic, spiritual, linguistic, familial and cultural needs of persons receiving services."

Finally, MASA members welcome the proposed amendment to the Ministry of Health Act concerning the selection of persons to be appointed to the district health councils. We endorse the need to ensure that the membership of these councils reflects the diversity of the communities for which they are planning. However, based on our experience with planning for MSAs, both in Metropolitan Toronto and other districts in the province, we believe that the provisions of the legislation are inadequate. In many cases, we and our colleagues throughout the province found extreme insensitivity to the needs of ethnocultural communities and a profound ignorance about the problems faced by ethnic seniors and their families in assessing services.

It is essential, in our view, that district health councils be required to establish multicultural service committees with specific responsibility for planning health and social services for the members of ethnocultural communities. Thank you for the opportunity to address the standing committee on these matters.


Mr Tilson: Sir, I was interested specifically in your comments about the number of your member organizations. I think you mentioned there are 40 in Metropolitan Toronto and Hamilton. The major concern of many private sector groups that have come forward to the committee appears to be the impact of the 80-20 rule; in other words, that MSAs are only allowed to purchase 20% of the services from outside the MSA. They feel that the private groups, the small groups, the service groups such as VON and Saint Elizabeth Visiting Nurses, will simply disappear.

I guess my question is whether you've addressed your concerns with that. I'm looking at your existing services. I appreciate the amendments that you're recommending to enable the people in the various communities that you represent to have these services. Does MASA -- the 40-odd member organizations, and there may be others -- fear that these groups, these existing organizations, will disappear as a result of this legislation?

Dr Oreopoulos: I don't think we should be the right persons to address this, Mr Tilson, but the concern is that we already have problems with these organizations. If you call home care and you tell them that there is a person who doesn't speak a word of English, they will have difficulty sending a person. What we're in front of you here to say is that, in the development of the MSAs, we can make sure that we eliminate these problems that we already have so many of.

Mr Tilson: I understand what you're saying. I guess the problem with the legislation is that we're supposedly all the same; the difficulty is that we're quite obviously not all the same. There are many different cultures all over the province that have different individual problems and need individual attention. I think that's the concern, that we've got this Big Brother attitude that in effect is going to cause more problems. I think you would agree with that.

My question is directly to the existing organizations. If you get the funding, you're okay. But obviously on an 80-20 formula, those groups aren't going to get the funding; they're gone.

Dr Wong: We did address this problem, this particular issue and concern, in MASA meetings. As a matter of fact, the overwhelming majority of the members of MASA are not very satisfied at all with the present system. The present system does not pay any attention to differences in culture, to differences in language.

I'm using my practice as an example, and I'm quite sure it generalizes to people from other ethnocultural communities. Seniors of Chinese origin are not able to receive services in their language, in their culture, so every time the seniors came in and complained that although there are some visiting personnel, health or social services going to their home, nevertheless they were not receiving the appropriate help. It is very difficult for us to request VON, home care or other organizations to send somebody there who knows the language and the culture.

We can't understand why this cannot be done, because there is no lack of people, professionals or other workers, of Chinese origin who can speak both languages, English and Chinese, who could serve these seniors as well and at the same cost as other people. But this problem has long been ignored.

Mr Jim Wilson: But does that mean we just get rid of the VON and the Red Cross? That's what this bill does, make no mistake about it. Who says the MSA, even if you get all this representation -- because it's a government-run thing basically -- is going to correct those historic problems?

Dr Wong: I'm not quite sure MSAs are government-run things. It is government-funded, but it would be composed of agencies from a planning consortium, from a planning district, a planning region, which come together. For example, in the region where I am coming from, from northwest Scarborough, about 10 different agencies are coming together to plan MSAs to serve northwest Scarborough. Yee Hong Community Wellness Foundation, St Paul's L'Amoreaux, VON, home care, Red Cross -- including Red Cross -- and a number of other smaller organizations which serve the district will come together to plan the MSA serving that particular area. So we do have input from the existing organizations as well.

If the MSA is an idea whose time has come, if it means abolishing some established organizations in order to build a better system, I would say, so be it, because the present system cannot persist. I could bring out so many seniors in my own practice, and I'm quite sure Dr Oreopoulos and other people would be able to tell you that the linguistic and the cultural aspects of care, which are very important, have long been ignored by the system, and I think we have to do something drastic to change it.


The Chair: I call on the representatives from the Canadian Mental Health Association. Good afternoon.

Ms Carol Roup: We from the Canadian Mental Health Association very much appreciate this opportunity. My name is Carol Roup. I'm the senior director of policy research and branch services with the provincial organization of CMHA. Ruth Stoddart is our executive officer, and Lisa McDonald is a community mental health consultant with our organization; one of her special areas is long-term care. We are members of staff of the CMHA, and in that capacity we're representing the views of our board.

Although this presentation and our submission were, by necessity, done in quite a rush, I do want to say that we did extensive consultation within our organization, and it's based on this consultation that our board arrived at its views and at the submission that you have before you.

For the purposes of the record, the CMHA, Ontario division, is an incorporated, registered, non-profit charitable organization which was chartered in 1952. Over 4,000 volunteers are active in direct board, committee and direct service provision in a network of 36 branches located in communities across the province. Ontario division and branch services and programs receive funding from government grants, local United Way branches and supplementary fund-raising activities.

The Canadian Mental Health Association is primarily concerned with the impact of reform of the long-term care system on people with serious mental health problems and their family members. So our response to the Long-Term Care Act highlights issues of particular concern for these individuals and their families; however, some general concerns have been raised.

We realize that our time is really short. We have no intention of reviewing our submission word-for-word. I'm going to ask Ruth Stoddart to deal directly with the importance that we place on its impact on people with serious mental illness, and Lisa McDonald will deal specifically with issues of concern around multiservice agencies. However, I really would urge you to read it because we do make some points about district health councils and the role of volunteers, which we also think is really important, but we're going to deal with our two major issues.


Ms Ruth Stoddart: Our first concern has been stated as primarily with the needs of people with serious mental illnesses. We're aware that clause 1(c) of the legislation implies that the receipt of community-based long-term care services will be based on need. We have noticed, however, that the compendium that was put out as a companion piece to the legislation seems to emphasize throughout that community-based long-term care and support services are to be provided to the elderly and people with physical disabilities. There is no direct mention anywhere in this companion piece to the legislation about people with mental illnesses or mental health problems. We're very concerned about this because, as is understandable, we feel that a lot of people will read the compendium rather than attempt to read the entire piece of legislation, and it may have a direct effect on service delivery.

There are several groups in particular that we're concerned about, the first being elderly persons with mental illnesses who require psychogeriatric and other long-term care and support services; that is, those people who are already in the long-term care system but also require some sort of mental health services. In addition to this, there are also the elderly who had some form of mental illness prior to becoming 65 years old or becoming a person eligible for services for the elderly.

The second group of people that we are concerned about are individuals who have both physical and mental disabilities. These people may already be in the long-term care system but certainly also require care for their mental disabilities.

Third, there are many people with serious mental health problems who require community services and supports in order to live in the community. These people often require long-term care services and supports although they may not be elderly or have physical disabilities.

Finally, the families of people with mental illnesses often are the care providers for these people and certainly do need services and supports. The Canadian Mental Health Association, Ontario division, would like to recommend that all individuals who require long-term care and support services in order to remain in the community should be eligible for those services. We would urge that the reason that supports are given to these people should be considered only in developing the service plan under the legislation, not with respect to whether or not services should be provided to people.

Finally, with respect to people with mental health problems, paragraph 56(1)16 of the legislation allows for regulations to be developed to determine eligibility criteria for people who will receive long-term care and support services. We would urge that these regulations, when they are developed, not exclude anyone who requires long-term care services.

The second thing I'd like to talk about is the coordination of the mental health reform initiative of the Ministry of Health and the long-term care reform. Coordination of these two reform initiatives is necessary because, as I've stated, there's a strong interrelationship between physical and mental illnesses, especially among the elderly, and there is a need for both systems to provide appropriate and effective services in a coordinated manner.

We would recommend that the definition of "professional services" in subsection 2(7) of the act include psychogeriatric services to ensure that there is a coordination between the two systems.

Additionally, we would urge that MSA staff be trained in doing psychiatric or psychological assessments as well as knowing about mental health services which are available and also the reverse, that people in mental health service agencies certainly be trained to know about long-term care services and supports.

We feel that age or disability should not determine which system, that is the long-term care system or the mental health system, should provide services for people in need. Access to appropriate services should be based solely on need, with the least possible disruption to the person receiving the services.

Finally, we would also like to talk about the coordination of the long-term care reform with services currently being offered by other ministries in the province of Ontario. The CMHA, Ontario division, is concerned that the original long-term care legislation came from three different ministries in collaboration. The most recent version of the legislation is solely the province and the Ministry of Health. Several problems could arise with this. For example, the Ministry of Health bases its services on district health council boundaries. Unfortunately, a lot of long-term care services are provided through the Ministry of Community and Social Services as well as other ministries, such as Housing, which don't have the same regional boundaries within the province. We would like to see coordination and cooperation among all the ministries in providing services, primarily because the most important thing is providing services to people in need.

Ms Lisa McDonald: I'm going to talk specifically about multiservice agencies. CMHC, Ontario division, supports the concept of simplifying access to the complex system of available long-term care and support services. Within the Long-Term Care Act, the proposed solution to simplifying access to the system is the establishment of multiservice agencies.

The primary concern of CMHA, Ontario division, is improving access to long-term care services for those who require them. We'd like to point out, however, that the establishment of MSAs may or may not be the best way to achieve this, and it's certainly not the only approach. It's not been demonstrated, for example, that structural and governance reorganization necessarily lead to better service provision. There must be recognition that there's no guarantee that MSAs will in fact improve the current system. The approach being taken in the mental health system is to improve access to services through the enhancement of case management services, which doesn't necessarily involve a structural reorganization of service agencies.

Given the key role to be played by MSAs, however, CMHA is concerned about specific areas of the legislation that deal with accountability, approval of MSAs and board composition.

First, with respect to accountability, Ontario division recommends that the following areas be reviewed.

The minister retains sole decision-making power with respect to the approval of an agency to provide a community service, and under section 9 "may impose terms and conditions" of approval. These terms and conditions require further clarification within Bill 173, and the circumstances under which they can be changed or removed should also be described.

Section 56, paragraphs 34 to 36, also specifies that regulations may be made governing the membership, selection of the board, management and operation of approved agencies. Also included are takeover powers by the minister, which include the power to remove MSA directors and appoint others and the power to take control of, operate and manage MSAs. We're concerned that community ownership and accountability for service providing agencies to their local communities could be reduced by these regulation-making powers. Of primary importance to CMHA, Ontario division, is the assurance that MSAs are governed, managed and operated in such a way that identifying and responding to the specific needs of local communities are given very high priority. This ability to be sensitive and responsive to local needs must not be hindered by regulations developed in the future.

Also, according to the legislation, service providers will be required to provide reports and information to the minister. This seems to be more clearly explained in the legislation: For example, what kind of information will be required and for what purposes, and how will this information be collected when services are contracted out?

Regarding approval of MSAs, subsection 11(3) of the legislation states that a municipality or a board of health may be designated as an MSA provided that the suitability of all other approved agencies in the geographic area has first been considered. With many of its 36 branches across the province located in rural and northern communities, CMHA, Ontario division, is very aware that many areas of the province have very few agencies that provide mental health and other support services. We're concerned that it is within these rural and northern municipalities that a municipality or a board of health will become the multiservice agency simply due to a lack of options.

When a municipality or board of health is designated a multiservice agency, it must provide the same services and adhere to the same requirements of other MSAs. For example, presently it's unclear how a municipality or a board of health would meet board composition requirements. If municipalities and boards of health are not bound by the same rules and procedures outlined for MSAs, we're concerned that access to a range of services will not be consistently ensured across the province.

With respect to board composition, we'd also like to make some recommendations. One of the factors to be considered in determining the designation of an approved agency as an MSA is whether its board of directors "reflects the diversity of the persons to be served by the agency in terms of gender, age, disability, place of residence...and cultural, ethnic, linguistic and spiritual factors."

CHMA, Ontario division, would like to see this section of the legislation strengthened so that it's not only one of the factors considered but a requirement. This is especially important if ethnoracial communities are to be appropriately served by MSAs. Family and other care givers should also be specifically included on the board.


I'd like to make some comments now on the provision of services by MSAs.

The four kinds of community services that will be provided by MSAs include community support, homemaking, personal support and professional services. Limitations on purchasing services from independent service providers rather than providing service directly are placed at 20% of the approved budget in each of the four categories. In order to allow for MSAs to be phased in, the legislation allows for MSAs to be exempted for up to four years from the requirement to provide access to the mandatory services in the four areas and from the 20% limit on contracting out services.

Safeguards need to be built in to ensure that MSAs are allowed exemptions only if consumers and care givers have other options for accessing services or supports that they need. Although we recognize the need for a transitional period for the development of MSAs, the ability to ensure provision of long-term care services and continuity of these services during this time is critical.

We're also concerned that MSAs will not be required to limit the purchase of services from individual providers to 20%. This would allow for a situation in which an MSA provides only information and referral, and purchases all other services and supports from individuals. This would certainly not be consistent with the mandate of MSAs to provide one-stop access to the full range of community services.

Again, this may be more likely to happen in the rural and northern communities which have a shortage of community services. It's not clear how the mandatory community services outlined in the legislation will be provided in these areas. There's also a need to make allowances for the transportation requirements of individuals living in rural communities. While services and supports may exist to serve consumers and care givers, access to them is denied if distance, a lack of suitable transportation or the resources to pay for it are not considered.

This is a particular concern, given that the act specifies that some fees will be charged for services that incorporate transportation expenses. There is the potential to create a system in which those for whom transportation is not an issue, due to proximity to services or the ability to pay, receive one kind of service and those who live in rural areas and can't afford transportation receive only those services that are provided without cost. That's assuming that there are free services in the area.

In addition to the services an MSA "must" provide, the minister "may" authorize provision of additional services. We recommend that decisions to provide such services should be driven by demonstrated community need. As well, the focus in developing services within MSAs must remain on serving those people whom long-term care and support services are intended to serve.

With severe cutbacks in the health care system, we're concerned that there will be insufficient resources to implement long-term care reform in the way that it has been envisioned. This is particularly an issue within rural areas. This concern is heightened by reductions in hospital beds in both the general and psychiatric hospitals. The Long-Term Care Act must guarantee access to services that are currently provided under the Canada Health Act, for example, home care, without the threat of user fees being introduced.

Subsection 25(2) of the legislation should therefore be changed to rule out the possibility of the development of regulations allowing charges to be applied to certain services. With respect to assessing consumer need, the legislation also reserves the right to develop regulations to govern eligibility, amount of service provided, ability to pay and assessment. The criteria to be used to establish these regulations need to be included within the Long-Term Care Act.

The Long-Term Care Act has wide-ranging implications for those who require community-based long-term care and supports. This includes a great number of people who have mental health problems. Some individuals require long-term care and supports because of the serious and chronic nature of their psychiatric disability alone, whereas for others with mental health problems, the need for these supports is also related to the fact that they are elderly or that they have a physical disability or a physical health problem.

We have made a number of recommendations in our submission with a view to ensuring that those with mental health problems are appropriately served. In addition, we have commented on the proposed legislation in terms of how services are to be provided. With respect to this issue, CMHA, Ontario division, emphasizes the need for all agencies and structures that will be responsible for implementing long-term care reform to be governed by boards that are reflective of the community that requires long-term care and supports. This accountability to the local community must also be preserved in the development of MSAs and the designation of approved agencies.

The Chair: Let me interrupt you for a second, because I know you're about to say, "In conclusion." You've done extremely well with your time and I just wanted to say there is time if you want to just highlight, because I noticed you had to leave out three sections. If there are a couple things you wanted to say about those sections, there is time for that and also for a question.

Ms McDonald: Perhaps we'll just take a part out of where we talk about district health councils.

The amendment to the Ministry of Health Act will allow the government, through guidelines and regulations, to ensure that long-term care committees of DHCs are reflective of the communities they serve. CMHA, Ontario division, would urge that this be a requirement as well and that this be included within the legislation itself. Our organization recommends that requirements governing the composition of DHCs and their long-term care committees be similar to those recommended for governing the composition of MSA boards, that is, that they reflect "the diversity of the persons to be served by the agency in terms of gender, age, disability, place of residence...ethnic, linguistic and spiritual factors," and that additionally, family members and care givers be included.

We also point out that in order to fulfil the considerable mandate given to district health councils within the long-term care legislation, DHCs currently lack adequate resources to meet the current responsibilities they have, and that includes the implementation of mental health reform and all other health planning. CMHA, Ontario division, believes that inadequately funding DHCs will very likely lead to inappropriate and/or inconsistent implementation of long-term care reform across the province.

Do we still have time for another highlight from another section?

The Chair: Probably one quick one and then, "In conclusion." I know you've taken a lot of time to prepare this and you've hit a lot of the key issues that we've been addressing. I just thought this way you can get some of those comments on the public record.

Ms McDonald: I think we'll talk a little bit about our concerns around voluntary agencies. One of the concerns of our organization is that funding is currently provided by agencies such as the United Way as well as donations from individuals, and that these won't necessarily continue to be provided to the MSA. It must be recognized that many agencies currently providing long-term care and support services rely on these kinds of contributions to maintain their service, and every effort must be taken to ensure that these very valuable resources are not lost to the system.

In conclusion then, CMHA, Ontario division, would like to emphasize that both the mental health and the long-term care systems have a responsibility to provide services to those with mental health problems. What must not happen is that those with mental health problems experience difficulty in receiving service within the mental health system because they're elderly, and/or they're excluded from services within the long-term care system because they have a psychiatric disability.

The need for long-term care and support services should be the only criterion which determines eligibility for service covered by the Long-Term Care Act. Extreme caution must be exercised in further defining the eligibility for services to be provided through MSAs to ensure that exclusionary criteria are not developed. A great deal of care must also be taken to ensure that individuals providing mental health services are adequately knowledgeable about long-term care issues, and similarly that those providing long-term care and supports are knowledgeable about mental health. Placing a high importance on consumer choice and the ability to provide services in a flexible way are essential considerations in the development of this legislation if those with mental health problems are to be appropriately served.

The Chair: Thank you very much for that presentation. I can assure you that members have lots of material to read, but we do read it.

Mr Martin: Thank you very much. You've certainly put a lot in front of us in a short period of time, a lot of good material, I think valuable recommendations, some of unique feature to your own concern, the mental health field, and some certainly that reflect concerns that others have brought forward.

Overall, I think I heard you saying that you supported an initiative that would deliver services of a long-term care quality to communities that give a high degree of local control over what happens, and I heard you saying that it was important that there be equity of access across the province, that no matter what little hamlet you get into, people should have services to deal with their particular need, and you talked a bit about the need to make sure we weren't shortchanging the system either in terms of money, that there were resources needed if we were going to do this. That's what this legislation is built on, all of that plus the fact that we're right now in the middle of spending a fair chunk of money, about $450 million, in trying to enhance the services for people in need of long-term care in the province.


I wanted to zero in on something that was raised this morning by a group of psychiatrists and medical people in the field out there who have a concern about this as well. It's the issue of dealing with the reform of mental health care and the reform of long-term care at the same time, and do they fit together or do they not fit together? They're both big, big efforts. It took us 10 years to get to a point where we now have a piece of legislation in front of the government of Ontario that I don't think you want us to stop. We need to move forward with that. At the same time, we're reviewing the mental health area, which is a big piece as well.

My sense, from working with this over the last few weeks and hearing from people and trying to get my own head around it, is that this piece of legislation will put us in a position to be able to take in any reform to the Mental Health Act. I see consistencies. I see that we can build on this. I'm wondering if that is a feeling you share as well and if there are any thoughts there that might --

Ms Roup: I think that's the hope, and separately they both have enormous potential, and as so often happens when you read a piece of legislation or government policy, it has all that potential. I guess in highlighting some of our concerns, it certainly wasn't our intention to be negative about either. We've strongly supported reform to the mental health system and we've supported reform to the long-term care system. I think our concern is that they should be integrated and it's a serious concern.

In mental health reform, our organization continues to emphasize a continuum of services, both institutional and community, in which any given individuals could fluidly move in and out of different kinds of services they might need at different times in their lives or in different periods of their illness. So we'd want those two systems to interact in that way. We wouldn't want to see someone who happens to be in a psychiatric hospital now reach 65 but somehow get stuck there because that's the system he's stuck in. If these two systems are to jointly set up a continuum of services, it should be easy for people to flow from one to the other. They shouldn't be seen as blocks, but they should be part of an integrated system. So I think all the potential is there.

Mr Martin: If I might have one little supplementary, I hope --

The Chair: One little supplementary.

Mr Martin: Are you encouraging your people on the ground out there in the communities -- I know we have a chapter in Sault Ste Marie -- to be part of the local planning process for this?

Ms Roup: Very much so.

Mr Martin: You think that's really important?

Ms Roup: Very much so, but I think the point about district health councils and their capacity to conduct local consultation, both on mental health reform and long-term care, is that it's huge and we're not sure if it's a doable thing. Meaningful consultation from a district health council, which in some cases may have two or three staff and volunteers, is a huge mandate. But certainly, from our branches' perspective, we're encouraging them to assist DHCs to do that and to be involved in the consultation.

Mr Martin: I believe there are designated staff for this given to district health councils to carry this thing out.


The Chair: I call upon the representatives from the Home Care Program for Metropolitan Toronto, if you would come forward.

Mr Jim Wilson: On a point of information for the committee: Upon agreement with the Liberal caucus members here, if it's all right with you, Mr Chair, if I can have the next question, the Liberal Party then will take the optometrists. Unfortunately, I have to leave after this presentation.

The Chair: I'm sure it will be full of wit, pith and substance.

Ms Marian Walsh: My name is Marian Walsh. I'm the president and chief executive officer of the Home Care Program for Metropolitan Toronto.

Dr Phil Daniels: My name is Phil Daniels. I serve as the chair of the board of directors. First of all, thank you to the committee for the opportunity of coming to present to you today. You have a brief and, as you said before, you have lots of things to read. We'll try to hit some of the highlights and hopefully save some time for some interaction.

First of all, just briefly who we are. This is our 30th anniversary --

The Chair: Happy birthday.

Dr Daniels: It's a big year. Thirty years ago the home care program was strictly for those with acute care needs of a short-term nature. Over those years we've evolved into a comprehensive home care-home support organization now serving 14,500 residents on any given day and 42,000 over a period of a year.

We serve all age groups from infants to elderly, from those with physical care needs to those with mental health care needs, as I think might relate to the previous presenters, and certainly from those with complex, acute, chronic, rehabilitative and palliative needs to those with long-term care needs.

Our service delivery covers nursing, physiotherapy, speech therapy and all the other myriad of services that you see listed. The home care program also provides assessment and case management and case coordination services for all individuals referred for its care. The availability of this important part of our service delivery ensures a current, one-stop access and coordination system for those who require in-home services in the Metro area.

The program organizes its service delivery, offering a variety of programs that have been designed to meet the needs of a diverse population. The programs include acute care, chronic care, palliative care. We also have a school program for children, acquired brain injury program, complex care, a quick response program, which I think has worked rather well, and the integrated homemaker program, the IHP.

In carrying out our work, one of the areas of sensitivity is cultural sensitivity, and that's noted through contract arrangements with a wide range of service providers, which gives it access to an ethnically diverse workforce and also through translation arrangements that are provided within the home care program staff as well as through a contract with Access Alliance.

Beyond our commitment to efficient, effective in-home services delivery in Metro, the home care program's board and staff are committed to working in partnership with the community, the government and other providers of health and social services in Metro.

The commitment takes us beyond considering just our own role and our own future in terms of the evolution of long-term care as proposed in this legislation, and in fact we are talking about concerns and hopefully places that this act can be strengthened, not from home care's point of view but from the health care point of view in terms of all the residents certainly of Metro but all of the residents of Ontario. It's in this broader context that we pass along, hopefully, some thoughts that might be useful to you.


In terms of general observations there are three areas, and I'll comment on each of them.

The bill, as we read it, and we've highlighted this in our presentation, does not contain any vision for long-term care that specifies what long-term care is, who it is intended to serve, who is entitled to receive long-term care and how the various components of the long-term care system are intended to work together to ensure access to a coordinated continuum of care.

Second, we have some concern with what we perceive to be the deinsuring of home care services through this bill. At the present time home care regulations under the Health Insurance Act provide automatic entitlement to health care services to any insured resident of Ontario. By removing these provisions from the current legislation and not clearly stating entitlement and eligibility criteria in this legislation, it would appear as though it is the government's intention to deinsure home care. While such actions may be appropriate in terms of the long-term care component of the system, which historically has been available to individuals on a subsidized versus universal basis, we have some considerable concerns about the implications of deinsuring of home care for acute, chronic, rehabilitative and palliative care.

The third area where we have some concern is how prescriptive the act is as it is written; that is, that it is prescriptive to the point that it becomes operational in its direction. I think the legislation runs the danger of putting community boards, voluntary sector, in a position of wondering what they are they for. If they are there for local stewardship, then they must have some flexibility in terms of carrying out those mandates.

If indeed the legislation is to tell them point by point by point exactly what to do, then again, volunteers, whether they be volunteering their time in terms of services or volunteering their time in terms of leadership on boards and committees, will begin to question their real role in the whole system, and I think that would be a loss for the system.

Those are some general concerns, and I'm going to hand it over to Marian to look at some specific highlights of concerns and will finish off with some specific recommendations we would suggest.

Ms Walsh: While, as Dr Daniels has already indicated, the program does support the purposes of the Long-Term Care Act as set out in this bill, we have some concerns that the specific provisions of the act do not ensure, and in fact in certain instances actually work against, the stated purposes of the bill.

Our specific concerns about the provisions of the act in this regard include, first of all, the multiservice agency concept. It seemed to us, in examining the bill, that the cornerstone of the government's reformed long-term care system, and therefore the key component of the bill, was the establishment of the multiservice agency.

These agencies, according to the bill, will be required to provide access to and coordination of the long-term care services under their jurisdiction, but will also, under this bill, be required to be the primary direct service provider of those services by virtue of subsection 13(2) of the act.

This section limits the purchase of service in all categories by MSAs to 20%. Now essentially what this means in the Metro Toronto area, as one example, is that the current home care system, and thus the home care program for Metropolitan Toronto, may be divested to the 15 to 22 MSAs that are currently being contemplated for implementation in this area. At the same time, it may also mean the merger and/or the centralization of the approximately 250 community support agencies that have grown out of the voluntary sector in this area to meet the specific needs of local populations in their communities.

The implications of this change for the community support services system of the Metro area, and more importantly for the people who live here, and for the objectives of long-term care reform are, in our view, quite substantial, and we'd like to try to point out to you how they are substantial, first of all with respect to single access.

In terms of single access, the home care system currently provides a one-stop access for all insured home care services, which includes all services contemplated to be delivered by the MSAs in Metro Toronto, with the exception of community support services. That single point of access is currently available to all clients across the full spectrum of care needs, from acute care through to chronic, rehabilitative, palliative, school care and so on, on through to long-term care but not just limited to long-term care.

While we do acknowledge that improvements need to be made to better coordinate access to all services, including community support services, and to provide that access at more local levels and closer to the people that we serve, we simply don't understand how turning a single access point for what is essentially now 75% of the future care delivery system into 15 to 22 access points improves the system.

Another objective of long-term care reform is to ensure that individuals have access to a wider range, not a lesser range, of services in the community. We acknowledge that access to the approximately 250 community support agencies in the Metro area needs to be better coordinated, both among those agencies and between those agencies, in what is the current home care system.

However, what is contemplated in this legislation is not just the coordination but in fact the centralization and therefore the elimination of the voluntary sector through the integration of those agencies and their services, at least in the case of Toronto, into the 15 to 22 MSAs contemplated for this area. While this may improve the entry part of access by streamlining entry from 250 to 15 to 22 locations, it seems to us that what is sacrificed in the process is the range and diversity of services that these organizations provide.

Community support agencies in Metro Toronto have grown out of the need to provide services of a specialized nature to meet the needs of specific populations, whether these needs arise out of ethnic origin or out of special care need. Furthermore, these organizations carry out their work in a much more flexible manner than has been or is possible in a more formal, publicly funded environment. Thus, instead of broadening the range of services that people have access to, this legislation will result in our view in a considerable shrinking of the range and diversity of services available to the population that requires long-term care.

Beyond the home care and community support agencies that will be directly affected by this legislation if MSAs come into effect in Toronto in the way in which they're contemplated, there are also all of the other service provider organizations, both not-for-profit as well as proprietary, that have and continue to contribute a richness and diversity to the service delivery system available to the people of Ontario. In Metro Toronto the home care program currently purchases services from some 50 organizations which deliver everything from its nursing on through to its transportation services.

Having such a wide range of service delivery organizations available to the home care system has meant, first of all, that we have a wide range of special skills to draw on, as agencies have developed areas of special expertise.

Secondly, we have now developed the capacity, and only very recently given the economies of scale that we now have in Metro Toronto, to serve almost the full range of ethnic communities and groups that exist in Metro in an ethnoculturally sensitive manner.

The home care program and therefore the government through us as its agents have contributed to improved access to these now highly developed and specialized services for all of the people who require them in Metro Toronto, whether they are serviced through the publicly funded home care program or through private means. We would like to point out that estimates in our own field would indicate that essentially about 50% of the people who actually receive home care services in the Metro area on a daily basis are receiving those services through the publicly funded system.

We are also concerned that the funding that has been provided to these organizations through the home care program has enabled many of these organizations to develop other programs and services that are not part of home care but are nevertheless now available to the community as a result of home care.

Once MSAs come into effect, we have some concern about what we know will be the tension on the one hand between a system with a limited and fixed amount of resources and on the other hand a growing number of individuals, particularly elderly and disabled, who will be in need of care at higher and more complex levels.

Unfortunately, we would predict that the net effect of these tensions will inevitably be that if all services are put into the one basket, community support services that are now provided largely to the well elderly for preventive purposes will essentially be eliminated or traded off in order to ensure adequate provision of higher levels of service to those who will shortly need it.

We also believe that the mandatory move away from purchased service to direct service delivery has significant implications for consumer choice. With some 250 community support agencies available in the Metro area, plus the 50 agencies that the Metro Toronto home care program contracts with, the availability of choice for people in terms of who delivers their service is quite significant, whether you receive service from the public system or through some other third party or private means.

The elimination of these agencies either directly through centralizing them into MSAs or indirectly through the elimination of public funding for the purchase of these services and the threat that that would pose to the viability of these organizations will inevitably result in reduced choice for consumers and clients of in-home services.


What may emerge as a result of this restriction on the purchase of service is the development of a two-tier, in-home services system where those who can afford choice will purchase it and those who cannot will have no choice but to remain with the publicly funded provider of service. This, we believe, would be a tragedy for a community services system whose basic values revolve around consumer choice and where a major objective is the establishment of a more versus less equitable system.

Finally, we believe that the MSA concept has the potential to add significantly to the operating and delivery costs for in-home, long-term care services. As we see it, MSAs as they are currently conceptualized will become the primary providers of all in-home services and therefore will monopolize community service delivery. This will inevitably result in a significant reduction in the number of service provider agencies operating in Ontario and in Toronto and thus eliminate the current potential for competitiveness in the marketplace and the efficiencies that are achieved in such a competitive environment.

In the current system the voluntary sector contributes substantially towards the cost of service provision in the community in a number of ways: first of all, through the provision of direct services such as Meals on Wheels, transportation, friendly visitor and so on; secondly, through fund-raising and financial as well as in-kind operational support provided by sponsoring agencies at the local level.

Once these organizations are eliminated and folded into the publicly funded MSA system and have lost their community roots and identity, the people who volunteered their services to these organizations will no doubt cease to make those contributions. We would invite you, if you have any misgivings about that, to look at what happened in Quebec when the government introduced the CLSC system, which is not unlike what is being proposed here in terms of the MSA system in relation to its effect on the voluntary sector.

We also predict that the costs of centralizing, in the case of Toronto at least, the 250 community support agencies into a larger, more bureaucratic public system will far outweigh the combined operating and overhead costs of those agencies at the present time. Many community support agencies operate in non-union environments, in small, informal office premises that are frequently donated by churches or other sponsoring local organizations. Their overhead costs are generally at fairly minimal levels and as a consequence their operating and service delivery costs are relatively low.

The home care program achieves economies and efficiencies on the other hand through a centralized approach to administration and to the delivery of specialized services. The added cost of decentralizing the entire administration and specialized service delivery components of the home care program and the cost of replicating that in 15 to 20 different locations in Metro Toronto would we suggest be considerable.

Dr Daniels: I want to come back to a point that we heartily support: the aims and principles of long-term care reform. I want to make that quite clear. It's from that spirit that we offer some recommendations and suggestions in terms of the proposed legislation in ways that it might be strengthened:

-- That a section be added to this bill that defines long-term care and the population to be served by the long-term care system.

-- That a section be added to the bill which sets out the relationship between in-home and institutional long-term care services and between long-term care services and the rest of the health care system.

-- That a section be added to the bill which prescribes the eligibility for in-home services and ensures that such services are provided to individuals on an insured basis, at least for acute, chronic, rehabilitative, palliative and other hospital or otherwise insured replacement services.

-- That section 13 of the bill be amended to eliminate the restriction on purchase service and to redefine the mandate of MSAs as being to provide service coordination with the possibility of a variety of service delivery models to be determined at the local level.

-- Finally, that section 56 of the bill be amended to eliminate the level of prescriptiveness of the bill to allow for the kind of flexibility and community-board management of the system that is required if the objectives of long-term care reform and the purposes of this bill are to be achieved.

With that, we thank you for your time and hope we've been of some service to you.

The Chair: Thank you very much. I note as well for the record that this was a very full brief and there are other sections within it that you weren't able to read into the record, but we will certainly look at those.

Mr Jim Wilson: Thank you very much for a very comprehensive brief. I have just a couple of points before I ask a question. I certainly agree with your concern about the deinsuring of home care services. What I think people aren't aware of is that of course this is the 20th service we've seen taken out of medicare since this government came to office. Secondly, it's done for the purposes of allowing user fees to come into the system, because if the services you require don't form part of your plan of service under this act, of course then they are subject, or could be subject, to fees. The government can't get away with that under the Canada Health Act. Therefore it must deinsure those services -- sleight of hand, and certainly not something that we're prepared to tolerate in any way from my party.

The other thing is, with respect to the bill being overly prescriptive, I would agree, and think perhaps you agree, that that leads many people to believe MSAs are essentially fronts or window dressing for government policy, certainly, and for implementation of long-term care. I think you allude to that, although perhaps less strongly, when you say certainly people who become part of the MSAs may wonder what in the world they're doing there, because the job is essentially set out in legislation.

I comment on that because of course a previous group here had a couple of very strong words for me. It was Dr Joseph Wong and the Multicultural Alliance for Seniors and Aging. First of all they said no, there was no way MSAs were a government bureaucracy. I would ask him to re-read the bill if he were here.

But secondly, a very, very, very, very strong, I think, and worrisome almost accusation -- I don't want to put words in his mouth -- saying that one of the reasons -- and he was very clear in response to my question -- that MSAs must be implemented as envisioned in this bill and that current systems must be torn down is that people from minority groups aren't able to get home care services now that are culturally sensitive and all the things that are in the language of the bill of rights and that indeed are contained in Bill 101 as already an existing right in this province.

I note on page 4 you have a paragraph that says you're doing your darndest to ensure that your services are culturally sensitive. We're also told by Delores Lawrence, who, for example, was here earlier, that the vast majority of her workers are ethnic minorities and women. I want you to address that, because I don't come from a very ethnically diverse part of the province, so I'm trying to understand this, and I know and I respect Dr Joseph Wong. He's from an area where he's serving a diverse population, yet he's made I think a very strong statement of why there should be MSAs because the current system isn't working for a number of people.

Dr Daniels: I come from a highly ethnically diverse part of the province. I'm from Newmarket.

The Chair: Hear, hear.

Dr Daniels: The issue is to look at the problem first. If there is a problem, then try to analyse the problem and not solve it by a pre-determined solution, because sometimes the solution is worse than the problem was. Not for a moment could anyone suggest that every group in Metro Toronto is receiving services in the form that it wants in the best of all possible worlds. I wouldn't argue with that at all. To suggest, first of all, that proper efforts haven't been made, and in my view a lot of progress made, doesn't fit with the facts. Secondly, to look at the MSA introduction as it's looking at the moment and to feel some comfort that those concerns would be addressed I don't think fits with the facts as well. So I wouldn't for a moment question the concern, but I would question the solution that's being laid out at the moment.


The Chair: The parliamentary assistant wanted to just clarify one of the points that was made while everyone's here.

Mr Wessenger: Yes, I'd just like to make it clear with respect to Mr Wilson's comments, first of all, the services here are not required insured services under the Canada Health Act. Secondly, his comments about deinsuring so that we could charge for the services should be very clear. It's set out in the legislation there's no charge for personal services or home care under the act, and none contemplated.

I think the other thing we should be very much aware of, whatever we call the system of how we deal with the payment, it's the amount of money that goes into the system that's relevant, not the question of whether you call it insured or some other system. Even under the so-called insured system, we've always had a managed system.

Mr Jim Wilson: Could I just rebut that? Yes, you are taking an insured service which is guaranteed under the Health Insurance Act, excuse me. Secondly, you do not put a definition in the bill of exactly what you mean by home care. Therefore, it is quite correct to say that some of the services that some groups may now be delivering as home care and that may be covered could very well -- and are, as far as I can tell, but if you'd give us actually your financial figures, we'd know exactly what you're going to charge for this act. But I don't trust you. You told us in Bill 101 that -- you aren't very forthright with the fees. Yet at the end of the day $150 million worth of new user fees were introduced into the institutions.

Mr Wessenger: It's very clear right under the act what are the categories where regulations can be passed, and certainly there's no authority with respect to the areas with respect to personal care or home care.

Mr Jim Wilson: It's not clear to me, and I've been sitting here for weeks.

The Chair: I'm going to have to intervene here, because I think there is going to have to be an agreement to disagree, at least at this point, while we move forward. I regret that time is always our enemy and I want to thank you both. I'm delighted, Dr Daniels, to learn that we live in the same municipality. I want to thank you both again for coming before the committee and for your presentation today.


The Chair: I call upon the executive director of the Ontario Association of Optometrists. Actually, I don't think this is -- somehow --

Dr Mira Acs: Somehow you don't think so, right?

The Chair: The name just doesn't fit.

Dr Acs: No, it doesn't fit. Greetings.

The Chair: But you are none the less welcome. Every now and then the Chair has to decide, should I sort of indicate who it is before I ask them to introduce themselves, and I blow it every time.

Let me start over again. I now welcome the representatives from the Ontario Association of Optometrists. If you would be good enough to introduce yourselves, we have a copy of your presentation, and please then go ahead. I would just ask others if they could perhaps carry on their discussions outside, just so we can have a little peace and quiet. There. Please go ahead.

Dr Acs: Good afternoon. My name is Dr Mira Acs. I'm the president of the Ontario Association of Optometrists. With me today is Barbara Wattie Fuller, who is the director of policy and government relations.

The Ontario Association of Optometrists is a voluntary organization which represents the profession of optometry in this province. In our membership, we have more than 92% of those registered to practice our profession in this province.

The proposal by the Minister of Health, the Honourable Ruth Grier, to amend the means by which important core services are provided to certain clients of the ministry must in the first instance be recognized for its important attempt to simplify the access mechanism for those who qualify. This act, when implemented, will ease the burden presently facing some clients and their families as they try not only to find what services are available but also the steps required to establish eligibility for receiving those services. Members of the Legislature have all no doubt been frequently requested to assist constituents in need with respect to finding and obtaining these important services.

A second and equally important aspect of the legislation is the inclusion of a bill of rights for those who receive services under the provisions of the act. The provision of this section does no more and no less than state the absolute moral imperatives which must be inherent in the provision of any and all health and life care and services in Ontario. This progressive facet in this legislation is worthy of mention and praise.

Few are those occasions when legislation is so perfectly crafted that not even one individual group is able to think of even one amendment which they feel would enhance the bill. Others have presented their specific views, and we too find that there are two further specific areas which we suggest are worthy of reconsideration.

The first relates to the provision in paragraph 56(1)30 which gives the minister powers with respect to qualifications of providers under the legislation. It may well be that the drafters did not intend to infringe upon the powers of colleges under the Regulated Health Professions Act, the RHPA. However, we are concerned that without further consideration, a potential will indeed be created which will give rise to an infringement upon the powers granted under the RHPA, particularly with respect to the powers of individual colleges to regulate specialties and forms of registration.

To this end, we suggest that the present draft be amended so as to identify clearly and to confirm the role and power of the colleges under the RHPA with respect to the qualifications of their members or, alternatively, be amended to exempt members of the health professional colleges from this section or, and this may be the most efficacious option, to identify those individuals or groups of individuals whom it is intended to cover.

To some, an act to govern the provision of long-term care might seem a curious place to include significant amendments to the existing legislation governing district health councils. In particular, this point of view will be held by those for whom a comprehensive and fully consultative review of the concept and role of these councils is regarded as a more needed and more appropriate approach. Such an opportunity now being present, the inclusion of the present amendment provides the opportunity to comment on some specific areas with respect to the governance of the DHCs.

The amendments at hand speak to the composition of DHC membership as it relates to the specific diverse community which each represents. However, the principle of representative composition is dealt with in a very narrow way. There is still no requirement that council memberships represent a balance of providers and consumers. If changes are deemed to be needed to require participation in membership in the manner outlined in this bill, then this is the time to establish balance in other areas as well, including the need to ensure that councils are neither institutionally nor medically dominated or oriented in their composition.

There will be, no doubt, representations from those who have concerns about those services which are not specified under the legislation. These in part are services which may or may not be added by regulation. These include the addition of one or more groups of professional providers, specifically some regulated professionals.

There are two areas of concern here that are readily apparent. The first is that additions will be on an MSA-by-MSA basis. Either the type of care is required in this province or it is not. It is not somehow required in region A and superfluous in region B. Such a discrepancy strikes at the philosophical heart of any universal program in this province. The challenges to citizens in Ontario that arise from the optional provisions under local social assistance programs should clearly indicate to members of the Legislature why this is not a desirable mechanism in the present instance.

The second concern is that some key service provisions in the form of health care services have either been omitted in error or for reasons as yet unrevealed. Other groups must speak for themselves, but for optometry we say that consideration should be given as to how clients, especially those who are not easily able to leave their residences, will receive the diagnostic and therapeutic vision care that is so important to their continued optimum enjoyment of life.

The Ministry of Health includes optometric diagnostic services as part of the schedule of OHIP benefits. This does not, we trust, preclude future contractual arrangements under which a full range of services, both diagnostic and therapeutic, might be provided on other than a fee-for-service basis and we regard the MSA as a promising vehicle for developing alternative forms of payment mechanisms. Therefore, we suggest that the act must permit and indeed encourage MSAs to make arrangements which facilitate the inclusion of present fee-for-service providers either in traditional or in new forms of compensation so that they may thereby enhance the range of services rendered and the quality of life of those who are intended to benefit from the provisions of this new legislation.


The Chair: Thank you very much. I note for the record that you've summarized your recommendations at the end as well.

Mrs Sullivan: I have two questions, both of which I'm going to direct to the ministry, arising out of your presentation, which I think is an interesting one in that it's covered some areas that have not been talked about so far.

The first is with respect to the qualifications of providers under the legislation and the concern that is being raised, not only by the association of optometrists but by one or two other professionals, with respect to the RHPA and its role and the qualifications of providers under this legislation, in particular the qualifications of the new generic worker, whom, we understand, training courses are now being conducted for and so on. I'd like to know, first of all, what respect will be provided to the disciplines under the RHPA and, secondly, how a generic worker could perform some of the acts that are required to be performed by a professional.

The second issue that I wanted to raise is also raised here, and that's with respect to the fees of professionals when those professionals operate under a fee-for-service system. Under this act, would those fees then be part of the 20% that the MSA can purchase outside? Would there be then, if the 20% is used up, a situation that could occur where, for instance, there could be no eye tests done, whether they're needed or not, there could be no medical services purchased, whether they're needed or not, just because the organization has run out of the 20%?

Mr Wessenger: I will perhaps attempt to answer those questions, and then I probably will refer it to legal counsel on the first question, but my understanding is, for instance, the Regulated Health Professions Act will prevail, and obviously you couldn't prescribe any requirements contrary to that act.

Secondly, with respect to fees for professionals, obviously, if they're covered by OHIP, that would be the method that they would be covered in their compensation, for instance, in the situation of optometrists.

Mrs Sullivan: You see, that's where part of the problem is, because there is confusion -- I'm certainly confused about it, and the last exchange didn't alleviate that confusion -- about what OHIP will cover under the new act and what it won't cover under the new act, whether it's in terms of professional services or whether it's in terms of services that are now covered under the home care program that may or may not be covered under the long-term care bill.

Mr Wessenger: I think it's quite clear that if a service is not covered under OHIP, then it would have to come out of the purchase of services by the MSA. It should be noted, however, with the purchases from an individual it's not part of the 20% limit. In the case of most professionals, it would be a purchase of service from an individual.

The Chair: We'll go to legal counsel, and then if you have perhaps further questions arising out of that, I'll come back to the presenter.

Ms Czukar: With respect to the issue of qualifications of service providers, what the regulation-making power says is that we can make regulations requiring that service providers have certain qualifications or meet certain requirements and prescribing what those would be. The intention there would be clearly that, if optometric services were going to be provided, they be provided by an optometrist as qualified under the Regulated Health Professions Act.

In other words, this would refer to those acts, and clearly any acts that are required by those acts to be performed by qualified professionals and aren't delegable to others couldn't be performed by generic workers and wouldn't be performed by generic workers. The regulation-making power here is just to ensure that where service providers are going to be performing those services, they have the requisite qualifications under whatever the applicable statute is. In any case, you couldn't override whatever is required under the regulated health professions legislation by a regulation under this act, because statutes always prevail. So the intention here is to provide the vehicle for prescribing what qualifications people would need to properly do their jobs.

The Chair: Any comment on that?

Mrs Sullivan: Well, I suppose just on the 20%. Basically, what the parliamentary assistant is telling us is that services which are provided individually, if they are professional services, will be paid for over and above the 20% limit under this bill. If, however, you have a professional who is working in, let me see, say an HSO situation, which optometrists could be involved in in some cases, or in a joint practice or in a community health centre, would they be limited to the 20%? What's the rationale for the distinction?

Mr Wessenger: I think you're probably correct there, but I'm going to ask Mr Quirt to comment on this and perhaps also on the generic worker aspect.

Mr Quirt: First of all, if someone needed an eye exam they'd be referred to an optometrist and the optometrist would bill OHIP the way they do now -- whenever I get my eyes checked or you get your eyes checked -- so that's not going to change at all. The services that home care now delivers and the home care budget pays for, like nursing and physiotherapist services and so on, have been funded indirectly under the Ontario Health Insurance Act to date. There's no requirement that we provide those services as insured services, and there are two provinces left in the country that do consider them insured services.

Even though they're historically considered insured services, home care programs get a budget each year and try to manage within that budget, and as pressures exist for emergency services like hospital replacement services, the government responds accordingly.

When it comes to the 20% rule, the 20% rule is designed to limit the extent to which those programs and services that the MSA budget covers, services like nursing and homemaking, how big a contract they could have with a private provider or the Red Cross or the VON to buy homemaking and nurses' services. If, for example, a client of the MSA needed a service from a specialist that couldn't bill OHIP -- and I'll use a psychologist as an example -- then the MSA can go ahead and buy the services of that psychologist and that doesn't count towards the 20% limit in terms of their contracts with other service provider agencies.

I hope I've clarified it somewhat for you, but with respect to physician services or anybody else you can bill to OHIP, including optometrists, that doesn't change at all, and the role of the multiservice agency would be to identify if a client has a vision problem and make the appropriate referral to have that checked out, if in fact the family physician hadn't already done that.

The Chair: Did you have a query on that?

Dr Acs: I was just going to clarify that for the purposes of optometric services, the diagnostic component of optometric services is billable to OHIP, but the therapeutic component, whether it's the provision of glasses or low-vision aids or spectacles or contact lenses, is not. So of the full-scope optometric service, only the diagnostic component in fact is covered. The other components are not, so we do fall into both.

The Chair: As was noted earlier, you have raised some areas that we haven't looked at as closely and we appreciate it.


The Chair: I call upon our final presenter to come forward, Barbara Wahl. While you are the final presenter, we welcome you as much as we did the first presenter and also appreciate that you've come, I think, from Waterloo.

Ms Barbara Wahl: Yes, I have.

Ladies and gentlemen, I'm coming to you at the end of a long series of consultations. I'm sure you've heard more than you want to hear. As a registered nurse who's been involved in the community for over 20 years, I believe I have an accurate picture of the health needs of the community. I look at this from the perspective of a member of the district health council, as a consumer, as a provider for aging parents as well as a home care case manager.

I believe the principles of the MSA to be sound. Certainly there is a need for a central point of access. In some communities, this has existed for a long period of time through the Ministry of Health funded home care program. Integration of more services and responsiveness to individual needs are certainly excellent fundamentals. However, as this new vessel, the MSA, ventures into expanded territories, it becomes clear that direction for clients is required. This has been the role of case management in the community health area for over 25 years.

In order to help you understand the importance of case management, I'll ask you to join me in a day of visits with a case manager.

A case manager assesses and maintains services for approximately 120 people. This includes services, equipment and supplies and would include a multitude of services such as physio, nursing, occupational, health, social work, speech therapy, nutrition and homemaking and on and on. The degree of case management that's provided is directly proportional to the needs of the clients. Thus, an individual post-operative client might require only a little bit of service, while a senior who has reached a crisis situation might require extensive help.


If we go to visit Mr A, a new client referred by a physician, he lives alone in a rooming-house without cooking facilities. He walks five kilometres a day but appears unkempt and very thin. A case management assessment was made. He's satisfied with his level of care. His income is stretched and therefore the case manager, with his permission, registers him for meals at a senior program and much-needed foot care.

Most important, future plans and possible options are discussed. No further intervention is needed or planned at this time, but Mr A has a contact if he should require help later and background information is available for him.

Miss B, at 85, has Alzheimer's disease and her main care giver is her sister who is 87. These two ladies have had case management and home care support for two years. Initially, homemaking was set up to help with personal care, meal preparation, housekeeping, laundry and to provide support to the sister. Frequent, close monitoring has led to an increase of services, such as day away care for Miss B and a regular senior program for Miss C. At the current visit, case management increased homemaking to every morning to assist Miss B with morning activities and get her on the bus for day care. Future plans are discussed with Miss C as Miss B's confusion, wandering, incontinence and striking out are causing Miss C to consider placement. Much recognition was given to the sister for her incredible dedication and contact was made with placement coordination services.

Mrs D, at 82, has an acute, two-month history of repeated labyrinthitis, causing extreme dizziness. At this visit, she and the case manager agreed her state of health was much improved. Homemaking services were reduced, with the client's full support, from four to two times a week. Reassurance was given that the service would be increased if necessary. Of note is that her service provider had not volunteered that the level of service was more than the client needed and the savings that would be accrued to the system would be about $1,500 a year.

Mrs E, at 42, has a 10-year history of multiple sclerosis. She lives with her husband who works a 12-hour day. The home is being renovated. On discussion, the case manager finds out that the client has not been out of the home for months. She can no longer get her wheelchair over the stoop, but she does have an outside ramp. Planned renovations are not practical for someone in a wheelchair. Mrs E confesses her marriage is stressed. The case manager arranges to have occupational therapy to do an assessment of the renovations and her activities of daily living, to have a social worker provide counselling and to have a physiotherapist assess and treat a knee contracture which is developing. Homemaking is also increased slightly so that the homemaker can assist this client to get over the stoop and down the ramp and go for one walk a week. The client was encouraged to ask for help as needed. Frequent visits are planned due to her reluctance to ask for help and her currently acute problem.

Mr F is currently needing wound dressings three times a day in preparation for surgery. After assessment, it was decided that he would do dressings twice a day and the VON was arranged for once, including monitoring. Mrs F turned out to have cardiac problems and complained of stumbling and falling. Permission was given for the case manager to call her physician because she said she forgets everything when she goes to see him. Other services were not required at this time. Savings at the rate of two VON visits being saved each day would come to $23,000 a year.

Baby G, 18 months old, was born with a haemangioma of the throat, necessitating a tracheotomy. Medical treatment by a team of professionals is complex, but almost of it has been taught to the family. However, there are two other small children and the parents are very stressed. Support in the form of overnight nursing care was arranged. The family was also tied in with local peer supports.

Mrs H had been receiving homemaking services, but because her health had improved, she's now independent with personal care, was using the homemaking services as a cleaning service and did not meet the criteria of the home care program. Services were terminated and other alternatives were suggested. A time was arranged for the case manager to telephone to make sure she was managing. Savings, about $750 a year.

Mrs I, at 87, although blind, lives in her own home and is determined to stay there. She started with a half-day of homemaking and now has it twice a week. A VON nurse has been visiting weekly to pour medication, but even this has caused the client great difficulty because of her lack of vision and her arthritis which caused frequent spills of medication. Therefore, the case manager arranged with the pharmacy for weekly delivery of prepackaged blister packs for medication. VON services were discontinued until further needs arise. The savings would be over $2,000 a year.

Finally, Mrs J lives alone with two small dogs. She's frail and requires help with personal care, meals, laundry, housekeeping. She frequently calls police and a distant relative because she feels people are coming through the walls. Recently, she lost her budgie. A homemaker found it on a plate in the freezer. Homemakers are refusing to visit this client because she yells at them constantly and will not allow them to help her in any way. Mrs J is not eating. The case manager discussed the situation with the physician and the relative. Immediate placement was arranged through placement services and a home was found for the dogs.

These clients are typical of any given day. The situations speak for themselves. Even a simple case may require complex intervention if there are no supports. In each case, successful intervention was achieved because a team approach was used, with the case manager acting as a leader-facilitator. The case manager upheld the principles of client autonomy, matching the degree of intervention to the needs and wishes of the client and maintaining cost-efficiency for the province.

In all these cases, the service providers were not able to deal with the problems at hand in addition to carrying out their services. In many cases, the direct service providers did not have the education or experience to make appropriate decisions. This will be even more true as we see the proliferation of the generic worker who has little education in health care and only basic training. This worker will be on a one-to-one basis with the client, but without case management the client will not have access to the multitude of needed resources because the basic worker will not know about them. Cost of care will in fact escalate. In all cases, the service providers were in a conflict-of-interest situation as reducing the number of visits would have reduced their work and thus their income.

As a member of the DHC in Waterloo, I applaud the quality assurance and cost containment of case management. As a provider of care to elderly parents, I appreciate being able to speak to one well-informed and resourceful person about their case. I can depend on that person to assess the situation, make recommendations, implement the appropriate course of action and monitor the situation as appropriate. Finally, as a taxpayer I recognize that initiating the correct care at the time of need will in fact save dollars in the long run.

In Bill 173, case management is not even mentioned. I believe it to be an essential component of the MSA. In Ontario, case management has been an integral part of the home care program of community health for 25 years. There are 1,700 case managers currently providing the type of services which I have outlined. Other parts of the world are looking at our model as a model of excellence. I believe this government does have the insight to take advantage of the service of case management by building it into the MSA of long-term care.

The Chair: Thank you very much and particularly for all of the examples that you have provided to us.

Ms Carter: I think you've given us a very eloquent and personalized account of what case management is all about. I don't think you really needed to sell that to us; I think we understand that. I'm sure that case management is in fact an integral part of what we're planning. I'm just looking at section 20 of the act, which talks about how when a person applies to an agency for community service, the person shall be assessed.

Ms Wahl: Yes, it refers to case coordination.

Ms Carter: Yes.

Ms Wahl: But case coordination is not the same as case management. Case coordination is a very small part of case management. Case management has an ongoing monitoring role and ongoing assessment, recommendations and so on.

Ms Carter: So you're saying that that is not explicitly provided for.

Ms Wahl: That's right.

Ms Carter: I guess, when you have an act, not everything is in there and sometimes it can be counterproductive to put too much because sometimes, by adding words, you limit rather than allow freedom.

Ms Wahl: I think it's really important that the full component of management be built into this, rather than just coordination of services, because only if there is someone who is driving the boat are we going to be able to achieve savings and monitor situations, increase services as necessary and so on.

Ms Carter: Could I ask the experts whether they feel that case management is somehow embodied in what we're doing?

Mr Wessenger: I think if we look at section 20, it's certainly the opinion of legal counsel that everything is embodied in that because it sets out, for instance, the responsibility to assess the person's requirements; determine the person's eligibility for the services; develop a plan of service for each person determined to be eligible; review the person's requirements when appropriate, depending on the person's condition and circumstances; and revise the person's plan of service as necessary.

I'd certainly be interested in knowing what might be lacking from that. I know that legal counsel would -- since you've asked me the question, I might just throw out a question, if I might get away with it. Certainly, case management is an essential function of the services. But what about those situations where somebody perhaps just needs a meal; do you feel that you need such extensive assessment?

Ms Wahl: No.

Mr Wessenger: No, so it could be, as long as the case management is there for the --

Ms Wahl: Absolutely not. But, you know, it's very seldom that someone just needs a meal. I do that all the time; that kind of assessment is made on the telephone. But it's not as simple as just saying that he needs a meal or he doesn't, because why does he, and if he needs a meal, what else is wrong?

The Chair: Did you wish to comment on section 20?

Ms Wahl: I realize that that is there as such, but it's very important that it be identified as case management because it needs to be done as case management by someone other than the service provider, who has a vested interest in maintaining services, and by a case manager, who's a professional who has a broad-based knowledge of what's required.

The Chair: You've raised a number of questions, and while it is at the end of the afternoon, we appreciate you coming before the committee and, as I said before, particularly for the examples of what a case manager does.

Committee members, we stand adjourned until tomorrow morning at 9 o'clock in Kingston in the Ontario Room of the Ambassador Hotel.

The committee adjourned at 1643.