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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 20 - Evidence


VANCOUVER, Wednesday, June 8, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 9 a.m. to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the chair.

[English]

The Chairman: Let me begin by thanking our witnesses for coming today. We would like to pick your brains on the key things we ought to recommend in our report, which is why the letter to you talked about the fact that we are interested in focusing on actions that can be taken and things that we ought to recommend with respect to the mental health of seniors.

The Senate social affairs committee has been conducting hearings across the country, but we are doing four special one-day pieces, of which this is one. We held one special hearing already on children's mental health. We will do this one on seniors' mental health. It is not that we have not had other comments on seniors' mental health, but we wanted to concentrate on a single topic. In addition, we will do one on addiction and one on mental health in the workplace. Each of those four one-day topics will be a separate chapter in the report. We are running a little late in terms of when we will actually issue the report. Realistically, it is more likely to be the first week of January rather than the last week of November. That general time-frame is still our target, assuming that at some point the government does not fall and we are temporarily put out of existence. If there is an election, the committee cannot hold hearings, but committee members can have meetings informally among themselves. One reason we have rushed to get all the public hearings done is that if the House of Commons makes our life complicated, we will continue to work in any event.

We appreciate all of you taking the time to today to talk to us about mental health for seniors. I suggest first we go round the table and everybody say a sentence as to who they are so we have in our mind people's connections. Then I will ask each of our outside guests to take four or five minutes and tell us what they think our top two, three or four recommendations should be. Then we will simply have a discussion.

I will start off. I am Mike Kirby, chair of the committee.

Senator Pépin: I am Lucie Pépin, a senator from Shawinigan. My background is nursing.

Ms. Robena Sirett, Manager, Older Persons Adult Mental Health Services, Vancouver Coastal Health Association: I am Robena Sirett, the manager of Older Adult Mental Health Services for the Vancouver community.

Senator Cook: I am Senator Joan Cook from the other side of the country, Newfoundland.

Ms. Jennifer Barr, Education and Publishing Consultant, Centre for Addiction and Mental Health: I am Jennifer Barr from the Centre for Addiction and Mental Health in Ontario.

Senator St. Germain: Hello, I am Senator St. Germain. I am a senator here from British Columbia, former Vancouver City policeman, and fighter pilot in the air force, but I now work with these great people. They are all from the East, I see. We have even our Montreal cowboy over here, my good friend, Senator Gill.

Mr. Ken Moselle, Manager, Performance Standards and Monitoring, Mental Health and Addictions Services, Vancouver Island Health Authority: Good morning. I am Dr. Ken Moselle, Manager, Performance Monitoring and Standards Mental Health and Addictions, Vancouver Island Health Authority. I am a clinical psychologist by background and training, the "numbers guy.''

Ms. Charmaine Spencer, Gerontology Research Centre and Department of Gerontology, Simon Fraser University: Good morning, I am Charmaine Spencer with the Gerontology Research Centre at Simon Fraser University. I am a gerontologist working with vulnerable populations.

Ms. Faith Malach, Executive Director, Canadian Coalition for Seniors' Mental Health: Good morning. My name is Faith Malach, and I am the Executive Director of the Canadian Coalition for Seniors' Mental Health. My background is social work and health administration.

Dr. Martha Donnelly, Head, Division of Community Geriatrics, Vancouver General Hospital: Good morning. My name isDr. Martha Donnelly. I am an academic at UBC. I am Director of the Division of Community Geriatrics for Family Practice at UBC, as well as the Director of the Division of Geriatric Psychiatry at UBC. I am also a geriatric psychiatrist, and work clinically on an interdisciplinary team at Vancouver General Hospital in geriatric psychiatry.

Ms. Penny MacCourt, British Columbia Psychogeriatric Association: Hi, I am Penny MacCourt. I am here representing the British Columbia Psychogeriatric Association and the Seniors Psychosocial Interest Group, which is a national organization. I am also representing the Centre on Aging at the University of Victoria, where I am a research affiliate and have a post doctoral fellowship. My area of interest is seniors mental health, and has been for years. I am really excited to be here and look forward to being able to contribute.

Senator Gill: Aurélien Gill from Quebec, Lac St. Jean, Saguenay, north of Quebec City 200 kilometres, not very far from Montreal and Shawinigan, and very far from Vancouver, B.C. I used to be involved in the Aboriginal world. They call me sometimes Indian with blue eyes. All my life I have been involved in the Aboriginal world, so I am part of the problem. I am trying to be part of the solution.

The Chairman: Senator Gill understates it. He lives on a reserve, and he was at one point chief of his band.

Senator Trenholme Counsell: My name is Marilyn Trenholme Counsell. I started out in life as a nutritionist and became a family physician.

The Chairman: She is also a former lieutenant-governor of New Brunswick.

Ms. Margaret Flower, Clinical Counsellor, Centre for Addiction and Mental Health: My name is Margaret Flower. I am a clinical coordinator in the field of geriatrics at the Centre for Addiction and Mental Health in Toronto. My background is nursing and social work.

Senator Callbeck: I am Catherine Callbeck from that beautiful province of Prince Edward Island. My background is in business, teaching and government.

Ms. Suzanne Crawford, Program Manager, Older Persons Mental Health and Addictions Network of Ontario: Good morning. My name is Suzanne Crawford, and I am here representing the Older Persons Mental Health and Addictions Network of Ontario, plus Leap of Faith Together, LOFT, Community Services. LOFT Community Services provides housing, outreach and support to older adults and seniors in Toronto suffering from mental illness and addictions. It is our passion in regards to supportive housing for those that are the most marginalized within our community.

The Chairman: Thank you very much.

Ms. Sirett, let us begin with you and we will go around the table. Take four or five minutes and tell us, if you could write our recommendations on seniors mental health, what would you tell us to do.

Ms. Sirett: Thank you very much. I have given you a handout to speak to my three big points. I hope everybody has one. It is a two-page document with Vancouver Coastal Health in the top left.

Basically my key points follow. First, is recognition that seniors who have mental illness and/or addictions often have multiple complex social and medical problems. I know that is obvious to us here. I think the key point that comes from that is that when we do our planning, whether it be for an individual, a systems level, or for a program that we need to work across the silos of mental health — addiction, medicine, and geriatric medicine — I think we can break down the silos if we are all in the same room talking together; that is a major point. I have listed some small examples of things that I think can come from that.

One thing that we need is research benchmarks and planning tools that include seniors with these multiple complex problems. As I try to research best practice, as I try to research benchmarks, it is easy to find ones for seniors; it is easier to find ones for people with addictions and mental health needs. The people that I serve, probably most of us serve here, are by definition the complex individual, and it is harder to get the information that we need there. I need help in that area. Translation of research into the best practices for the Canadian context is really important. Lots of work has been done in the United States, the UK, Australia and New Zealand that is very valuable. I need some help translating that into our context here.

In terms of practical things, a national home care strategy is something that I have certainly heard about. One of the key things about any home care strategy is that we need to acknowledge that the social isolation and mental health issues impact people in their day-to-day functioning. If a home care strategy does not take that into account, we are not serving our population. One of the challenges in British Columbia over the past few years as our home care program has tightened up, is that it has been harder to get services for people that need a companion — someone to go with them to the store, not because they physically need the help, but because of their mental illness, they are not able to do that, or to access other services. There needs to be a lot of flexibility in whatever programs we come up with. I support the initiatives around the primary health care system. We need to look at physician payment models that allow primary-care physicians to spend adequate time with people.

A second primary-care area that I would like us to look at is strategies for eliminating the stigma of the double- whammy of a mental illness and aging. Both are very powerful stigmas, and together they influence the care that people seek and receive. There are suggestions in here, particularly for help in strategies for early detection of depression, dementia and substance use. I think that takes a public awareness campaign. I think that takes help for the primary-care system.

One thing I think is important that I know you have heard about when you speak to the younger adult population with mental illness in their families is their vision of recovery for people with mental illness. That is harder to define when people have severe dementia. I know people here can describe it in different ways. However, it really is having a system that allows people to get into as normal activities as possible for whatever is age appropriate; living out roles that are meaningful for them.

The report talked about support for the elderly parents of people that are caring for people with mental illness. I have a lot of concerns for the baby boomers that have had a life-long illness and probably have been institutionalized. Our medications were not as good for them in their early years, and there will be a crisis in housing and programs for that group.

Finally, and I do not have a lot of information here, but support is important for the caregivers and looking at innovative ways for caring for the elderly, whether it be in the workplace or in the support networks. The work of the Alzheimer Society of Canada, for example, is very good, and we need to be able to support that. We need involvement of families and friends in systems planning for the elderly as well, and recognition of the costs of caring for seniors in their home. I know there is a large movement in the younger adult group.

My three big themes are: the complex needs of the population we are trying to serve; the stigma of working with people with mental illness or the stigma for people that have a mental illness and who are aging; and then solutions for families and other caregivers.

The Chairman: Before we move on, I would ask Dr. Drance to introduce herself.

Dr. Elizabeth J. Drance, Geriatric Psychiatrist; Physician Program Director for Elder Care, Providence Health Care: Good morning. My name is Elizabeth Drance. I am a geriatric psychiatrist at Providence Health Care, and the Physician Program Director for Elder Care at Providence Health Care.

Ms. Barr: I would like to begin first by complimenting you, Senator Kirby, and the committee for the work that they have done to date. I have found the reports to be very comprehensive, while at the same time recognizing and acknowledging that you are only skimming the surface of this topic. It is gratifying to be here and to know that you are willing to look at seniors as a special population. I have four points I would like to make.

One is that I come from the Centre for Addiction and Mental Health. Ms. Flower and I are both here from Ontario. Ms. Flower works in the clinical area and she will speak to that. I work in a community department. Our focus is on knowledge exchange. I have worked in the field for many years now, and I am going to speak to that. My first over- arching comment is that addictions are easily lost as a subset to mental health, which is not to say that we should keep it separate. We absolutely have to integrate these two fields. You have recognized that in some of your recommendations, and there are many overlaps. A lot of what we will say today applies to both fields. There is a great deal of congruence. However, discrete areas, and areas in the addiction area need to be served with specialty services, which, of course, I am sure you have heard hundreds of times, is lacking in terms of support across the country.

The second point is that seniors are a distinct group.They deserve strategies, programs and policies that address their particular issues, as other groups need idiosyncratic programming across the lifespan. We cannot paint everybody with the same brush. Older adults are notoriously under-diagnosed in terms of addiction problems. They are under- recognized. They areunder-identified. They are under-reported. They areunder-referred. When it comes to the addiction system in Ontario — and I understand that mental health system — they are under-represented in that system. This is not to say that older adults do not have addiction problems. They very much do. We know some of the reasons for this under-recognition that has been called the hidden problem. One reason is that some of the symptoms can be confused with other symptoms sometimes called typical symptoms of aging. Another is that there is a generational stigma; a greater sense of shame for older people if they have personal problems such as addiction or mental health as well. The other is this: the why-bother attitude. If a person drinks too much, you hear family, friends, or service providers say, "They have earned that right and it is okay.'' We, as a society are not making the connection to their quality of life and their deserving a better quality of life, and how misuse can impede that. When it comes to programming, if a senior manages to be referred to an addiction treatment program, they are unfortunately, more than likely, to be ill-served in that program. All of that to say, we need specialized programs. In fact, we have had research over many years that shows what works best with this population, and we need to get that into the formalized system of care.

That brings me to my third point, which is what I call a failure of knowledge exchange. This is the job that I do in communities. We have a wonderful role. You might consider that role as far as knowledge exchange goes, or knowledge translation, as you refer to it in your material. My job literally is to bring evidence-based programs, products and services to communities across Ontario. I can say, and I almost take it personally, that we have failed in the area of older adults, and addictions, in particular. I expect it is the same in mental health. We have best practices. These were published by Health Canada in 2002, I think. These best practices in terms of providing addiction services for older adults, andMs. Flower will speak to the elements of this, have been evaluated over the last two decades. In your report, you refer to a 20-year time span for knowledge reaching the people that most need it. This is a perfect example. Programs have been shown to be successful with older adults in treating addictions, and yet it is widely unknown in the mental health and addiction system. We need to provide gerontology information to mental health and addiction providers. We need to provide mental health and addiction information to gerontology providers. That is putting it very simply. Of course, all this material has to be targeted to the individual setting. Again, it has to be particular to the individuals involved and their particular roles that they play. In terms of knowledge exchange, it has to be complemented by broad public awareness campaigns, and peer and consumer support.

That point leads to the next point, which is, I will say briefly, similar to your recommendation around school-based programming for young people where you want to provide programs that are easily accessible, for example, having an addiction counsellor or a mental health support group in a school setting. Similarly, because older adults are, for a number of reasons, not as likely to reach a treatment service, we need to provide the addiction and mental health services where older adults are found, in all that variety of settings.

All this information points to a need for the national strategy that you are working towards. I support your recommendation wholeheartedly to work from a national level to provide the kind of over-arching vision for all these needs that we will identify today.

The Chairman: Thank you very much, Jennifer Barr. Ken?

Mr. Moselle: Thank you for inviting me to the table. I had come today planning to observe and report back to my associates. I had not prepared anything formally. However, I am here this morning because I have given the matters at hand a fair amount of thought, and I expect I can find something to say. My presentation will be somewhat disjointed. I have a background in emergency response so I am supposed to be good in this kind of situation. We will see how it goes. I also have the advantage of being one of the first speakers, so I will not have to repeat what several other people have said. I do not want to get too involved in commenting on what other people have said. However, something to note first because I think it is so important, is the ad hoc arrangement of service silos within health care systems. So far as I can tell, it is purely historical artifact of the way smaller service units have come together into health authorities and other larger service delivery organizations. It has certainly not been rationalized around patient needs or the operational requirements of the services.

I can think of many situations where this ad hoc division between seniors' homes and community care, and mental health and addictions works against the interest of patients and also introduces serious inefficiencies into the delivery of care. We have talked about this in private conversations I have had with my associates in the Vancouver Island Health Authority. We had never used this language in any published documents. We talk about trying to break down those boundaries and create a program that we refer to quaintly as, people who cannot function in the community because they are messed up in their heads for some reason or another. It could be mental health and addictions; it could be a dementia; it could be an acquired brain injury; it could be some neurodegenerative illness; it could be they have been abusing substances for too long; or it could be a combination of all those factors. What this corresponds to operationally is more integrated planning and evaluation; more integrated processes to develop clinical informatic strategies to populate electronic health records with constructs that work across these program areas. I affirm the need to take a hard look at what these silos are. Typically, you have different programs organized together at the level of some senior executive. However, we need to turn that integration into something real and operational that translates down to the level at which care is delivered.

I want to talk a bit about evaluation and performance monitoring because that is my area. If we look at the performance monitoring frameworks within mental health and addictions right now, at least the ones that I have seen, these frameworks are largely populated by what I would call convenience indicators. It is information that has made its way into the performance monitoring framework, not because it provides us with a cunning understanding of how well we are doing around the care that we are providing, but because we can get our hands on the data. I acknowledge that there are severe challenges to getting our hands on information that would enable us to create performance monitoring evaluation frameworks that would enable us to answer basic questions such as: Is our care having an impact? If it is having an impact, is it the impact that we wanted to have? We do not always have a good impact, so we have to be able to answer both those questions with the data we collect. That is a daunting challenge. It is not a trivial matter to get the knowledge that lives in the heads of clinicians, and abstracted in a form that enables it to be put into electronic health records that can populate performance monitoring frameworks and generate powerful models that would drive the way we evolve our health care system. However, it can be done. I think it requires partnership. The partnership that I envision is one between the health authorities and the academic institutions. Every time I have ever seen reference to the notion of health service systems research in relationship to those organizations that are actually involved in the delivery of care, it always says there is severely limited capacity to do health service system research within those organizations that provide care.

I think that is a serious shortfall within those organizations. The health care service delivery organizations need to develop internal capacity to conduct that kind of research, because that research will only work if the data collection is fully integrated into the service delivery processes. It cannot be a one-off; lob an academic into the service delivery site, gather a bunch of information, and then go away for many years. There has to be ongoing collection of quality and pertinent information. You need that internal capacity, which anchors one end of a partnership with the academic institutions. Then I think you would have the capacity and the knowledge to create, analyze and report the knowledge that we need to better evaluate and manage our health care system. The capacity to generate that kind of knowledge would also enable the health authorities to operationalize and validate best practice standards that are being promoted. It would also help us to evaluate benchmarks against real data that paints a picture of what the actual service situation is to determine whether these benchmarks are viable and the impact of planning toward them.

Ms. Spencer: My observations are based in large part on when I was national coordinator on a project called, "Seeking Solutions: Canadian Community Action On Seniors And Alcohol Issues.'' The project ran between 2000 and 2003. It was a national project funded through Health Canada's National Population Health Fund, where we began the process of identifying emerging practices and approaches in prevention and treatment that showed considerable promise for older adults. One thing that we talk about in this area is emerging practices as opposed to best practices because it is not something that is set at any one point in time. The federal funding for initiatives such as Seeking Solutions has helped to begin the process of building knowledge in this area. However, these steps are just the beginning on a long journey.

I will try to avoid covering the same points that I know some of my colleagues will raise. I would like to speak primarily to the addictions issues affecting older adults, with again, passing reference to where they overlap with the mental health area. In effect, I would like to put some meat on the bones for the Senate committee issues and options report in terms of specific areas of action for research and education, continuum services and dealing with stigma and discrimination. Like Jennifer, I would also like to commend the committee for its foresight in recognizing older adults as a special population when it comes to mental health, mental illness and addictions. We know that older adults are often overlooked in discussions in this area, as well as in other policy areas, so this is a significant acknowledgment.

It would be helpful to give some background context in terms of addictions. There are currently about 4.1 million seniors in Canada, of whom about two thirds, or 2.7 million, drinkregularly or occasionally. Of this group, approximately169,000 to 282,000, or 6 per cent to 10 per cent experience significant problems in their lives as a result of alcohol use. That is approximately the same percentage that we see in the younger population. In later life, problematic use may develop as a result of changing bodies and changing circumstances, including the increased likelihood of needing medications in later life. We find that for older adults experiencing alcohol problems, there is an underlying depression or anxiety problem in about a quarter of the cases.

If I were to identify three or four priority areas, one of them would obviously be national information that is built on reliable information about older adults. Government priorities are often based in part on research and statistics about the prevalence of a particular problem. The available statistics we have are likely a significant under- representation of the true dimension of the problem for older adults and its impact on their lives, families and communities. The problem is that national surveys use subscales to indicate problematic use, which are based on negative social problems common among younger adults, but not necessarily the type of problems that older adults face. In other words, the young adult is considered the norm for all age groups.

We know from Canadian research, the little that there is in the areas, that the percentage of problems may be quite a bit higher in some health care settings. For example, up to 18 per cent of hospitalized seniors experience health problems from alcohol use. Recent research from Quebec and early work in British Columbia indicates drug use problems, particularly that dibenzodiazepine may be much more commonplace among older adults than we recognized to date. We have considerable knowledge gaps at this point.

National information needs to reflect that older adults in this area are an extremely heterogeneous group with diverse needs. They represent a 40-year age span. Although we know that alcohol consumption in general is higher in certain groups, for example, people who are well off or people who are poor, problem use is represented in all socioeconomic classes, all cultures, and all parts of the country among the senior population.

The second point I would like to emphasize for today isagain desperate need for resource services that are targeted to older adults. No matter what figures we use to indicate the alcohol or drug use problem, I would like to point out the magnitude of the gap between the need and the resources in this area throughout Canada. Through all of Canada, there are specialized programs for older adults experiencing alcohol or drug problems in only 12 communities, five of which are here in British Columbia. Most of these programs, actually all of them, use what is referred to as a harm reduction approach, which is awell-established and effective approach for working with, and helping, older adults. In total, these 12 programs serve approximately 1,250 seniors in a given year. In other words, that is less than four-tenths of 1 per cent of older adults who are experiencing problems. The specialized services for seniors with substance use problems are noticeably absent from all of Atlantic Canada, Saskatchewan, and the Territories. In the remaining provinces where there are specialized services, these services are community based programs, and they usually serve a large urban area. Even though some of the programs have been aroundfor 20 or 25 years — one of our local programs is celebrating its twenty-fifth anniversary — their funding from year to year tends to be precarious.

The other thing that is important in understanding the services and resources is recognizing that not all older adults who experience use problems in this area need treatment. However, they need appropriate support and assistance, whether they live in the community or in a congregate setting such as a nursing home. A small proportion of the remaining older adults may be helped by physicians, counsellors, or psychiatrists, only some of whom may have background in either gerontology or geriatrics. It is commonplace in the community for programs to say that, "We serve people aged 9 to 99,'' but in reality they may not have experience in working with older adults. That particular service gap represents under-recognition of the issue at the policy level, plus overall low-level funding in terms of addiction and mental health services in all the provinces, in combination with marginalization of older adults.

There is also a significant degree of fatalism and ageism. In other words, what is the use — they are old and it is their last pleasure? Basically, older adults are treated as a drain on society. Most people are unaware that older adults do as well as, and in many cases better than, younger adults when they receive appropriate assistance and support for their alcohol or other drug problem.

The third key area that I would suggest for emphasis is what the issues and options report has talked to, and that is stigma and discrimination for older adults with substance use or mental health problems. Again, building on the comments of Robena who talked in terms of that duality of age and mental health, and that intersection of those two key points, it actually magnifies the stigma that much more. Stigma affects older adults' perspectives of their own condition. It becomes a "master status.'' It means that they are shunned by their friends. Their problem is often hidden by families. Because of the lack of understanding of the nature of alcohol or drug dependence, particularly if it is characterized as a lifestyle problem, its effects on older adults means that older adults are often denied basic health and home care services in this area. Again, building on what others have mentioned, older adults have complex needs, and because of the lack of the appropriate services in the community, they are unfairly characterized by health care providers as bed blockers; as using up the health care resources that people with "real problems'' need. At every turn, they are ostracized and marginalized. Practitioners who work with older adults in this area point out that practitioners seem to spend half their time advocating for older adults simply to remove some of the existing barriers and to get the basic services that older adults take for granted.

In the Seeking Solutions project, seniors pointed out that in their lifetime they have seen other matters that were previously stigmatized, hidden and never talked about, such as cancer, divorce, pregnancy, and developmental disabilities, become normalized through information, education, and social change. They ask why that is not possible here too. It is not just stigma, but stigma with ageism.

The committee, in its issues and options report, talked about the potential for housing discrimination for a person who has a mental health, alcohol use or drug use problem. I would like to put that in a broader context in terms of the federal policies on housing throughout the 1990s that effectively reduced the availability of housing for that group. Providers, given the choice between somebody who has minimal needs and somebody who has complex needs, will choose tenants who have minimal needs, effectively shutting out older adults, as well as other people who may have substance use or mental health problems. This problem is consistent across the country. Scarcity of affordable, appropriate housing, in combination with lack of information, education, training and availability of resources, leave people with complex needs highly vulnerable to discrimination. Although some housing money is becoming available, most of the benefits are downstream, so they may not be available or realized during the life of older adults in need. It is important to realize that this does not have to be the case.

I am really happy that Suzanne Crawford is here. We know from other regions that if you have a few additional services for building managers, if you have well-balanced information along with education and knowledge of community resources, that older adults manage quite well in the community for extended periods of time, and do not need to risk institutional placement. We have the examples of remarkable and diverse housing models for seniors such as LOFT in Toronto, to meet the needs of older adults who are experiencing discrimination. With increasing government emphasis on evidence-based policy, there is a need for research on these models to help demonstrate their efficacy, and where appropriate, use them as housing models to help meet the needs of older adults who have either substance use problems or mental health problems. We need to understand the house model, along with the policies and regulations that can support or undermine our ability to meet older adults' needs. I am thinking particularly in terms of housing regulations and housing policies in that area.

Ms. Malach: My role today is to offer you the national perspective, and there are different groups of people here today who represent specific programs within local communities, and within the provinces. The Canadian coalition has the role to pull it all together and create a strategy, or attempt to collaborate with everybody across the country and bring things together.

I would say in six brief points that, number one, we need a national strategy for mental health, which is outlined in your third report. Number two, we need to identify in a final report that seniors' mental health is a distinct issue from other groups, and you will hear that today. Number three, we need an action plan for awareness, stigma reduction and education. Number four, we need an action plan on research, data collection and a surveillance system so we know what is actually going on. Number five, we need an action plan for collaboration across all stakeholder groups, whether the plan is for actual groups that are working within the community, or long term care facilities, as well as federal, provincial and territorial levels of government. Number six, we need an action plan that addresses care delivery and policy.

Those are my six overarching and quick pieces of information. I have a formal submission, but those are the six points in summary.

The Chairman: Did your sixth point deal with the policy on delivering care? I did not understand the term.

Ms. Malach: It is a policy that looks at service delivery access issues; a number of the different issues that I think you will hear today, but specifically a policy that looks at delivery of services for seniors.

Dr. Donnelly: I will mention three things that I think are important for seniors' mental health right now. The first is the need to integrate the work of clinicians, academics, and administrators. Ken has already mentioned this to a certain degree.

Working in this field for 20 years, I feel badly seeing clinicians not supported when they have good questions and there is nobody to help answer their questions. I see academics doingone-shot programs that have no ability to be followed up later. I see administrators who see the larger picture, but are really blind to the clinical problems, or the problems that the academics see because of structure of dollars. I would like to see somehow that we bring these people together and actually go forward. That is my first point.

My second point is that we need to work on increasing the depth and the breadth of education about geriatric mental health. I think that is true in four different areas. First of all, interdisciplinary education: In geriatric mental health we have to work in a team, and yet we get little education at the undergraduate level about working in a team. Nurses are taught in nursing silos, physicians in physician silos. They seldom learn to work together. We need to work on that, not only at the undergraduate level, but when we get out there and work in teams; we need the time to be able to discuss team work. Yet administrators are constantly saying, "How many patients are you seeing?'' They are not saying, "Are you sitting down and discussing things?'' That really needs to be emphasized.

Continuing education needs to be emphasized. I find thatwhen teaching undergraduates about dementia and frailty, they are too unsophisticated to understand the issues when theyare 19-year-old medical students or nurses. When they get out into practice and they understand the issues, then I think we need to educate them more. However, when dollars are cut, the first thing that is cut is evaluation dollars.

The second thing that is cut is education dollars. Then they say, go out and do the service. It is not right, and it is not right that the poorest paid worker gets no education. I am not worried about doctors. They make enough money that they can be educated on their private time. However, the care aids need that, and seldom do we put that into programs. I think there is an inequity between the rural and urban education systems. We should not have that. With our modern technology we can achieve something. I have taught from Vancouver to Smithers in telehealth. We can do a lot if we pair the urban areas that have all the resources with rural areas. We could do a lot with the same resources in the system; not even more resources.

Finally, with respect to education, I am sick of projects that are educational. I want programs. I want things that are sustainable and that look at what the education program does and how it changes people in their practice. I think we need to work towards that. Again, that is a funding issue and a policy issue, because so often education is not considered part of the job; either doing it or getting it.

My third issue is, we need to work more on collaborative care. The silos of family practice and mental health do not work. I am privileged to work with Canadian Collaborative Mental Health. We are trying to get family physicians, front line staff and mental health people working more closely together. We are creating a geriatric tool kit to try to help more programs like this across the country. It is my firm belief that we need to take those programs, especially mental health programs, and put them at thatprimary-care level connecting them. Unless we connect mental health reform with primary-care reform, we will not make that happen. That is my third point; we need to work on that collaboration.

Ms. MacCourt: You have covered a lot, and I am hard pressed to know where to start.

I represent the B.C. Psychogeriatric Association and the Seniors Pyschosocial Interest Group, which is a national group. I would like to start where we come from, which is a broader perspective on mental health than mental health as lack of mental illness. We see mental health as being many of the things that you talked about. The relationships between people is affected positively or negatively by the social environments in which people live; the availability of supportive resources, as someone mentioned, housing. There are also other things such as transportation that enable people; they support people's strengths and resilience if they are there. If they are not there, people can become isolated, depressed and so on. We begin from the place that mental health is broad. Unfortunately, though, we also say that the system is set up around mental illness. Services and organizations are structured utilizing a biopsychosocial model with an emphasis on a biomedical model. That is in service delivery, but also in how policy is developed, what services are funded and even what research is funded. It also goes across ministries, as someone already mentioned — the stovepiping amongst ministries — and also between the provinces and the federal government.

Our first point, then, is the desire to see mental health as a subject area include mental health promotion and support for mental health, where all people fall on a continuum of mental health, if you like. In other words, you can be mentally ill, but you can still have better or worse mental health, and your mental health while you are mentally ill can be supported by friendly visiting, transportation to a day program, and by the milieu in which you live, et cetera.

The other aspect is, we think that through mental health promotion, it is possible to prevent some mental health problems, and even some mental health disorders. That is the first place we come from.

Membership of both the B.C. Psychogeriatric Association and the Seniors Psychosocial Interest Group is basically clinical. We have educators, researchers, an ethicist or two and a policy analyst or two. However, by and large, the membership comes from people who are working in the field. People who are working in the field can see from whatever place they are working that it is much bigger than the services they can offer. As a clinician myself, I cannot even access services such as home support for someone who has a mental health problem but is functionally able to do things, for example. Clinicians can see the various issues, but we do not have access to resources, nor are those resources necessarily out there and available to people.

The other place we are coming from is the idea of psychosocial approaches. The biopsychosocial model is the one that is prevalent and the biomedical piece is important, and we are not going to talk about the co-morbidity and so forth because other people will do that, but other psychosocial factors can affect people. We mean everything that is not biomedical. Community development projects, social supports, cognitive behavioural therapies and all those kinds of things are psychosocial. That is where we come from. We had the good fortune of getting a national grant, the Population Health Fund, to look at psychosocial approaches to the mental health challenges of late life, which let us go across the country interviewing seniors and focus groups, service providers in other provinces, and policy makers right across Canada, including the Northwest Territories.

What we found out was the way seniors talk about and think about mental health is in a broad sense — I spoke of it. Things that support mental health are things such as housing, access to medications that you can afford and a decent culture of caring in the places where they live and within the services they use. Out of this we developed this brochure, which is a seniors-to-seniors brochure, which I will leave with you, that quotes from seniors about preparing for the mental health challenges of aging. They do not talk in medical terms. Unfortunately, the entire system with which we have to help them seems to be couched in terms more of mental illness. We talk of services. We think about it all within the health care system. This makes it frustrating for people in receipt of services, as well as people trying to provide them. I think everybody has touched on that point already.

Our recommendations come from those places. We support the anti-ageism and stigma. We support the national framework on aging, or the national strategy. We are sick to death in this province of reorganizations, of moving the deck chairs on the Titanic, that waste resources that are already confined into tighter and tighter roles that allow less and less flexibility or innovation, and that eventually gets reorganized anyway. We have had seven in my region; we have had seven directors in five years. There is something really wrong with that picture.

With the national framework or national strategy, it would be helpful to create equal access for all Canadians to mental health services, including mental health promotion, prevention, and supports. It is not equal across Canada. It is not even equal in cities and different places in British Columbia, as Martha Donnelly says. We would like to see that value based and principle based. The guidelines of the B.C. Psychogeriatric Association for best practices for mental health go across the continuum. They apply to people in the community right through to acute care. The guidelines are a set of principles, a set of values, to direct services delivery. They are based on areas that we looked at in the environmental milieu, which includes housing, the psychosocial rehabilitation model, care giving and supports needed for care providers.

We are now doing a little bit of research to evaluate the implementation of the model. However, let me say it is as usual; this is one of those situations where we did the guidelines in response to the adult mental health guidelines, which did not mention seniors; we got to do the guidelines but there was no funding to actually implement them. It is interesting that they are being picked up in other parts of Canada. We think that the values within the guidelines could create a great framework, a great basis and foundation, for any kind of national framework, which would then filter down to services.

The other thing we developed out of our project was a seniors' mental health policy lens. This lens is somewhat like a gender lens, but it takes into account sub-populations amongst seniors and population health determinants, which would be poverty, housing and so forth, that we think are important principles for healthy aging policy and mental health promotion. The lens is an analytical lens to look at the unintended negative effects that occur when policy is made at the program level or at the legislative level that has a negative impact, or can have a negative impact, on seniors. It is not that anybody intends it. It is just that it is thoughtless because of the ageism, the way most of the expertise is confined to the health care system and various other things.

We recommend that the seniors' mental health policy lens be used as a bottom line on everything that goes to finance committees at the province and at the federal level saying, "Has this been screened with the seniors mental health policy lens?'' We are seeking funding with the Population Health Fund to implement and evaluate. Again, here is a tremendous project that is in the field, with huge input for seniors and everybody else across the country, and yet it is a dead-end unless we can get funding. There is so much of that.

Another little piece that ties into this is the whole area of research, which several people have spoken about. Because of the way services are organized, et cetera, we have a devaluing or lack of value and under-funding for psychosocial approaches of the non-biomedical approaches. The reason for that, in part, is a prioritization that is created. Secondly, it is because they are not researched. They are not researched because nobody is interested in providing the funding for them. I think, privately, there is a greater interest in other areas. This pattern leads to a vicious circle where we do not have evidence, we do not even know what is going on and yet we think we are doing good work. It is innovative, but off the corner of your desk there is only so much you can do. All our membership works off the corner of their desk. We would be interested in supporting an initiative that does good data collection, that has meaning, and that looks at the broader field of health if it moves the field forward. We created a psychosocial research agenda, which we presented to the Canadian Institutes of Health Research, CIHR. It is a known fact — we did some research on this — that they fund fewer psychosocial approaches, that they fund less qualitative research, far, far less, the aging and the mental health divisions both, compared to psychosocial research. We created this agenda and it is in our report here. We are asking for this report to support psychosocial research, which includes health research and systems research, and to support funding it. A national framework that rests on the guidelines, a seniors' mental health policy that is promoted for use by government, and programs, could make a huge difference to the system as we know it today. The national framework could expand that definition. It also could be based on values of seniors and values of people who want to help seniors with mental health issues.

Frankly, the way things work right now, it seems like that is the last thing that comes into play when you cut education, when you cut services and when you cut supports. It seems like the whole system at the moment, in this province anyway, is driven by economics. Not that economics are unimportant, but as Charmaine Spencer said, bed blockers are the word of the day, and things are acute-care driven. Acute care is not a whole system. We urge the broader understanding of mental health, and the support and funding that would lead to better care and preventing things from happening.

We have several other recommendations, but those are the key ones I wanted to mention.

Ms. Flower: I thank all of you for being here, particularly Senate members. It is heartening for me to hear people that I have known in the field for a long time speak about the importance of our older adults. I would like to address several points quickly.

First of all, we have heard about the unique needs of older adults this morning. I would like to speak about current options. Alternative or preferred treatment models have been referred to, but I would like to expand on them because they exist. Charmaine spoke about the small number. We have only 12 in the whole country, and I think we have four in Ontario. I would like to talk about the existing resources, because we do have some resources, and a possible strategy to apply to the immediate situations and the longer term approach. I might leave these a little toward the end.

On statistics, finances, and other challenges, I am not going to speak to those. I respectfully defer to my colleagues in the room. When we look at best practices, there is a new phraseology that has come up, and it is called the three Ds; dementia, depression and delirium. These illnesses all have similar presentation. It is hard for clinicians to identify exactly what we are seeing. Then, when we see it, what do we do about it? An over-arching factor is substance use. When I speak about substance use, I am speaking about alcohol, prescription drugs, over the counter drugs and holistic preparations. I am not speaking so much about street drugs. However, these you will see come out with the greying baby boomers. There are designer drugs out there.

When you can imagine that dementia, depression and delirium can be mimicked by substance use, and also in the reverse, this makes for a very complex picture. One complication of substance misuse is that there is a physical impact, emotional impact, psychological impact, legal impact, and the list is quite long.

We also have to look at some of the other older adults. We have older adults who have concurrent disorders. We have older adults who have dual diagnosis, and this is not a phrasing that I hear too often. As we all age in better health, then we have to prepare our systems to speak to those particular areas. We need to ask questions. Who has the knowledge base? Who will be the service providers? Are there differences in mental illness and illnesses that are age related? What is the impact on our complete system? Where does the knowledge transfer happen?

I maintain that there is a fair amount of adequate knowledge out there. There is certainly a lot of knowledge in the field of mental health in older adults. There is little knowledge out there in the field of substance use in older adults. I particularly talk about substance use because addictions have a different connotation. There is a medical description of addiction.

We cannot limit ourselves when we work with older adults to speaking about addiction. It sends us off on the wrong field. We have to look at substance misuse as well as abuse. For substance misuse, as a clinician, I would often see that older adults often misuse their medications inadvertently, or they may be social drinkers. A couple of glasses of wine in an older person, particularly older women, as we change, can be devastating. What is the outcome of that? We see greater falls, as an example. We see a much higher use of hospitalized beds and the difficulty to get people seen. Falls alone take up a big percentage of our time and monies in hospitals. When you have this complex problem with dementias, depressions, delusions and substance misuse, we do indeed need extraordinary help in looking at what we can do.

What are possible strategies for the immediate situation?There are exemplary publications addressing older adults and health-related illness. In Ontario, PIECES is one of the areas that provide specific information on working with older adults and mental health. Suzanne Crawford will speak about the Older Persons Mental Health and Addictions Network of Ontario, OPMHAN, who is also working in this field. There needs to be training that combines the models for mental health and substance misuse, to remove them from the silos. We are doing a grave injustice to our population. We are straining our health care system when we look at either/or. We have to look at both. I think we would see a cost reduction in the medical field if we had this ability to look at both. We do have resources. It has been said already at this table. We do have expertise in geriatrics. We have expertise in geriatric psychiatry. We have expertise in substance misuse. How do we collect this across Canada, because we need all this information? Will one- size-fits-all work for all the peoples? No, it will not. However, if we have a good base, then we can extrapolate what we need for specifics.

There are geographic challenges; urban and rural, to say nothing about the breadth and width of the country. What influences the content, and who are we trying to reach?As Dr. Donnelly said, we are trying to reach everyone. Doctors receive a lot of education. As a clinician, and as I see the lesser education for people who provide greater input and support for older adults, I have to look at the personal care support workers; people who do amazing work, who are often in the older person's home and who are in all the support institutions, if you will.

As we look across Ontario, it is a little scary because we have people who are good-hearted, who do good work, but have no knowledge of dementias, depressions and substance misuse.This is important because we do not have to train everyone to know all these things but we have to train people, I suggest respectfully, to recognize behaviours and to respond to behaviours of the older adult in a way that is respectful and that will set up a good therapeutic union. Therapeutic unions are researched to be 40 per cent of helping older adults, of helping any of us, to maintain better mental health.

What do we know? I think we have available materials that have been proven in the field. There has been education to service providers across Ontario that has proved successful. We cannot keep up with the demand. There needs to be training that combines the models of mental health and substance misuse, and that removes the silos. I know I have repeated that, but it is so key for me.

What are some of the models? In Ontario, we have the Community Outreach Programs in Addictions, COPA in Toronto, which was started 22 years ago. Then there is Older Persons Unique Solutions 55, OPUS 55. I used that model at the Centre for Addiction and Mental Health. There is Sister Margaret Smith Centre in Thunder Bay, Lifestyle Enrichment for Senior Adults, LESA, in Ottawa, and the Peel Addiction Assessment and Referral Centre, PAARC, in Mississauga. We have a dense population, and our peoples are older adults that are expected to travel far afield for services.

There are some main tenets in this. Why does it differ? These programs accept people that are still using, which in the addiction field is an amazing concept; why would you let someone come who is still using? That becomes a barrier.

Where we can, we do home visits. I work from a hospital. Home visits are not available to me. They are simply too expensive. People have to come to me. We work in a harm reduction model that has been indicated and is certainly supported by the World Health Organization.

We work where the client is at. This is really important because when we talk about being client-centered, not all of us have the same understanding of what we mean by client-centered. When you are client-centered in an addiction field, there is an agreement already happening between the counsellor and the individual in the room. That agreement is, the problem is substance misuse. When you are truly client-centered in working with older adults, one of the so important pieces is that the client, the older adult, identifies what the problem is for them, and you help them work on it. That problem is seldom substance misuse, so a lot of work has to be done. I think we have a lot of possibilities. I am positive that we can make steps; that we can introduce short-term resolution. I think, of course, the longer term recommendations, what we have to look at in curriculums right across the board, are important, and these have already been brought up to the table.

Ms. Crawford: As I said earlier, I represent two different hats. One is the Older Persons Mental Health and Addictions Network of Ontario, OPMHAN. In the submission there is a whole background in terms of how the network started, our key objectives, and what we are working on right now, et cetera, so I will not go over all that. It is nice to go almost last because I can then summarize what everybody else has said in regards to some of the network suggestions also.

The network totally supports the need for research so that we can fully understand the extent of older adults and seniors with mental health and addictions issues. We definitely recommend a national campaign to fight stigma and raise awareness. We definitely agree in regards to education and training, especially for those doing the hands-on practical support in the seniors home, day after day. We need the clinical component, but we also need that hands-on practical daily support. That is what really fills the gap.

Now I will throw on my housing hat and talk a little bit in regards to LOFT Community Services and supportive housing. OPMHAN recognizes that we need to study existing successful initiatives, and we need to invest in supportive housing and other housing models created to meet the needs of older persons with mental health and addictions issues. As the program director of a large supportive housing program in Toronto, I get calls daily, and I do not get calls asking me, what are the statistics, where are the research? I get calls saying, "My mother will be evicted at the end of the month because she has a mental illness. Where is she going to live?'' Those are the calls I get daily.

St. Anne's Place is one of our newest programs. It has been in existence for only three years. After six months we were full, and we have 200 people sitting on the wait list right now. These are the people we serve: those living on the margins, the homeless, the victims of elder abuse, the poorest of the poor, the frail and those that do not have any family support. Many of them are living with serious and chronic mental illness.

When we talk about serious and chronic mental illness, we are not talking about Alzheimer's and dementia, which everybody automatically assumes. We are talking about the older adult and senior who have lived their life with schizophrenia, bipolar disorder, or a personality disorder. Because people are aging, obviously we are going to see that more often. These people are probably the most difficult, the most vulnerable and the most forgotten people that we serve.

Why does supportive housing work? We think it works because we promote recovery and independence. We have heard this over and over. We focus on safety. We focus on the physical space. We focus on the 24-hour hands-on support.

As I said, we need our psychiatrists. We need our clinicians, but you know what? They come into the home. They are there for an hour and they leave. Who is there for 24 hours a day? It is the supportive housing, and it is the supportive housing in a psychosocial model. It offers security. It offers peace of mind. It offers flexibility. It offers creativity where these individuals, the older adults and seniors with mental health and addictions issues, can live in the community. I am talking again about in the community, living with the respect and the dignity they so deserve. In fact, supportive housing may be one of the few alternatives there are for older adults and seniors with mental illness and addictions.

We have attached a number of vignettes in our submission, and I want to tell one story. This is one story out of thousands. It is about a doctor of psychiatry who became mentally ill in his late thirties and has lived with a mental illness for his adult life. He is now 76 years old, and he also has some serious addiction issues to prescribed pain medication. He was in a large general hospital in downtown Toronto where he had been for six months. They needed respite from him. They could not deal with him any more so he was sent to the large psychiatric facility, the Centre For Addiction And Mental Health.

They did not know where to put him and what to do with him. They did not even know what field he should be on in the hospital. While he was in CAMH they tried to house him in two separate long-term-care facilities, nursing homes. He wasevicted from both in less than two weeks by the police. Here is this 76-year-old gentleman with terrible mental illness and addictions issues: Where is he going to go? There is no place for him to go. St. Anne's Place took a huge leap of faith, which is what LOFT stands for, and we thought, with our flexibility, with our creativity, with the 24-hour hands-on support, we could probably provide a great housing situation for him.

Needless to say, he moved in three years ago. He was probably one of our first tenants, and he is still with us today. He has been able to re-connect with his family. He is now off his OxyContin, which he was addicted to. Has it been easy? No, it has not been easy.

In terms of supportive housing and where it can fill that gap, this gentleman now has his own one-bedroom apartment in the community with the proper supports and assistance, and did not need to be placed inappropriately in a long-term-care facility. I could go on and on forever about the housing part.

Back to the Older Persons Mental Health and Addictions Network, we feel that a national coalition of provincial older persons mental health and addiction networks, in collaboration with the Canadian Coalition for Seniors Mental Health, and other national partners, should be started in each province and territory within Canada. The network in Ontario, which was started over two years ago, now has over 60-plus members of it. The network works together to bring all the issues and concerns of not only the clinicians and staff that are working with older persons with mental health and addictions, but also the families, the caregivers, and the consumers themselves. The network brings them together to work towards building all the information that we need to support them.

Dr. Drance: I can add one element to this conversation that is perhaps more specific, and that is talking about the population of people, of frail elders who live with us in residential care environments, the step past the supportive housing environments. One thing that we need to talk about in terms of developing strategies nationally is that the people who live with us now are incredibly complex in terms of their mental health and addiction needs. Of the people who come to live with us now,80 per cent to 90 per cent have significant cognitive impairment or dementia and would previously have lived in the provincial mental hospitals. Our model of keeping people close to home, close to their communities, close to their families is an absolutely ideal scenario. However, to do that in a way that honours the individuals, we must therefore increase our staffing levels commensurate with the complexity. Education is a wonderful thing, but you can educate until the cows come home, andif you have only 2.2 hours of care, you can only deliver so much person-centered care.

I would like to commend the committee for its focus onperson-centered care. One issue I would like to raise is: How do we define person-centered care? Margaret Flower raised that issue: How do we define the care that we deliver to people so that we honour their values and their needs within the system of care that we have? I think we have done a fair amount of education with hands-on staff and the interdisciplinary team as a whole, with respect to the biomedical issues of delirium, dementia and depression.

I do not think we have gone past that, as Penny MacCourt says, to discuss the biopsychosocial issues, and the well- being issues. Our long-term care environments have been hammered away in terms of cuts to the point that we are providing people with custodial care. We need to be clear on that. Despite the fact that we want to provide vibrant communities where people will thrive until the day they die, that is not what we are currently able to do. Our model of care is an institutional model. It is based on an acute-care model, and that is fine if you have an acute illness. However, if you live in a care home, you need to live in an environment that is a community and not a hospital or an institution. Our physical environments mimic that. Currently, we have these large institutions that look like a hospital. If it looks like a hospital, people behave as if it is a hospital.

We need to redesign our physical environments so they are much more in keeping with the supportive housing, the smaller groupings of people, so they can actually thrive and they are at home.

My other comment on that is that we do not have the research. We say that we have best practices, and we all say that we know what we need to do. As Penny says, our research funding agencies do not fund us to say that yes, when we change the environment, we can prevent more rapid cognitive decline for people with dementia, or we can prevent depression. While there has been an emphasis and a correct emphasis on making sure we have mental health services for people in residential care, I think with the whole notion of prevention and health promotion, we may not need as many mental health resources if we have environments where people naturally thrive.

I think that sums it up. I want to be concise in my comments. It was interesting to hear all the people around the room comment from their various perspectives and see the common threads that run through all our desires and hopes for seniors in the future.

The Chairman: May I thank all of you.

I have been making notes, and I think that as Elizabeth said, there are about four themes that cross what everybody said. We will try to organize a discussion around those four themes. We can talk about one for a while, and then move on. Those of us on the committee will chime in with questions and comments as we go. It will be a round-table format.

Let me put three of four themes that emerged on the table, and then we will let people take them one at a time. One theme that appeared in a number of your statements was the question of the linkage between primary care and mental health in general, and seniors mental health in particular. In other words, I think it was Martha Donnelly who made the observation that we clearly need to find, as we do in primary-care reform, a way of making new multi-disciplinary primary-care group practices able to deal with mental health issues and seniors mental health issues in particular. The question is: How can we do that? How do we get from where we are to there? That is, in part, an organizational question. The other organizational question has to do with the housing issue, whether they are nursing homes or supportive housing. As Elizabeth said, places that look like hospitals will behave like hospitals, et cetera. What are the specific things that need to be done on the housing question?

The third issue that is clearly out there is: How do we know if we are making any progress? I think Ken Moselle suggested that we collect data on things that people are able to collect data on, whether the data is what you really want to know about the system or not. It reminds me of that old cartoon about the guy who drops his money and looks for it under the light post because that is the only place that he can see. Again, it would help us to understand what are the outcomes that we ought to push for in terms of actually getting them measured, which ties into the broader question: what is the research plan that needs to be done?

Then, there were three other issues that people may want to comment on. One, I was struck by the training question forfront-line workers. My gut tells me that is a big gap. I do not know if it is. My instinct says, whenever we think of training we think of professionals, and when we think of front-line workers, they are the last people who are trained. In some sense partly related to that is the issue of both training and support for family caregivers: the training because they often do not understand it, and the support because they need respite and a variety of other things.

We only had one brief comment from someone on the cultural diversity issue, which I would include in the Aboriginal issue. I was struck by Margaret's comment in her document. It is not something she said, but I will read you the sentence.

Margaret, at some point you can explain why you said this. You said, "Providing language interpreters who are culturally competent seems the current option with respect to multicultural cases.'' However, you then say, "but this is not necessarily the most client-centered'' approach, which blows my mind since we had always understood that the client-centered approach simply meant finding someone who understands the culture and the language and you solve the problem. I would like you to expand on that at some point.

I suggest that we organize the rest of the day around those themes and any other additional ones that come up.

With that background, I would ask my colleagues if they have any other specific issues we ought to raise.

Senator Pépin: I was happy to hear you bring us all your expertise and for us, it is really wonderful. It will help us draft a much better report.

The discussion was about the elderly in general. Canada these days, and B.C. in particular, comprises many people from multicultural communities. How do we respond to the needs of the elderly who come from different multicultural societies? How do they have access to service delivery in their own languages? Also, are the nurses, doctors, and people who give the service trained with the dimensions of the different cultural society?

We heard representations in Toronto and were told that it is difficult to have access to, and to find, doctors who can understand where different cultures are coming from. These people often cannot find good housing and good services. Many of them do not speak English correctly. What can we do to help them? What services are available right now, and what can we do to improve delivery? I am speaking about the Chinese, Sikh and Hindu communities.

I will leave it to my colleague, Senator Gill, to discuss the Aboriginal situation. To my mind, however, it is important that we address that question, because Canada is becoming increasingly a multicultural society, and it is important to deliver services to people in their own cultural context.

Senator St. Germain: My question relates to Aboriginal issues, because as you know, Mr. Chairman, I have been sitting on that committee for I think 100 years. I have sat with Senator Gill on it.

I would like to know from the experts and the professionals in the field whether there is going to be special consideration for Aboriginals. The normal structures may not necessarily apply, or work, in the situation of our Aboriginal communities, especially with our elders because many of them live on reserves. A lot of them are moving into the urban areas of our major cities now, so it has to be a concern.

I am also an Aboriginal under section 35. I am Metis, and we have tremendous problems with our people regarding addiction. It is moving from alcohol into various other areas. Will the committee's report reflect this? I am sure it will, Mr. Chairman, but it would be nice to get some input from the Metis. I can assure you that it is a challenging committee to sit on, the Standing Senate Committee on Aboriginal Affairs. We have a complexity of social issues to deal with, with our people. I would like feedback from the experts here this morning. If we do not get it by way of delivery at the table here, possibly we could get something sent to us by way of a written report.

Senator Trenholme Counsell: I want to thank you all for being here. This is a remarkable group of experts and people with passion and dedication to seniors.

We are speaking to seniors here today, and we are sensitive about this. First, I agree with what has been said. I am worried about the lack of reference to rural people. Rural Canada was mentioned once, I think, with respect to immigrants and Aboriginals in all this discussion, but especially the immigrant population.

Suzanne Crawford really touched me because from my experience, a long while of practising medicine, when she talked about elder abuse, the frail and the poorest of the poor, I really felt she was coming to the heart of the matter. To me, that is the most painful and most challenging part of it. I want to put this out for our discussion, Senator Kirby, and we have to have the experts.

We have to have the experts in every part of health: orthopaedics, dermatology, gerontology and so on. Most of us here today are seniors. Where do you draw lines? This week, mandatory retirement is going out the door, and so on. I listened carefully and I heard very little discussion about family. Every one of us knows that not everyone is so fortunate as to be in a family, so we are a family of Canadians. We talk about breaking down the silos, but we are almost creating another one in the sense of the life cycle. When you talk about a senior who is alone in a room, depressed and maybe abusing drugs, many of the factors are the same as a young person who is in that situation, or a depressed mother. There is so much overlapping in all this.

Yes, two glasses of wine will have a much worse impact on a senior than it would on someone who is 40. Of course, in the whole life spectrum there are all these differences.

Senator Kirby mentioned the link with primary care, and I think that is really important. I would like us to talk about that link with primary care, family health and community health centres. I do not know whether it is wise or whether we can afford to create a specialization, so to speak, out of seniors mental health, because someone who is 65 or 80 can have the same problems as someone who is 35. Of course, the age is different.

I throw that out for discussion because we need to think about individuals no matter what age they are. We need you specialists bringing your expertise, your study and your experience to the table.

The Chairman: That is a question we need to think about: To what extent does focusing on seniors, children, or whatever, effectively create a separate ghetto, in a way? It is not really a ghetto, but a separate enclave. How do you deal with that question?

Senator Cook: I want to say quite seriously that getting old is not for wimps. I come from a simpler part of the country, in a way. I come from Newfoundland. Our stresses are different. They are not the stresses that Senator Pépin talks about: multiculturalism, language, and whatever. However, we have the stresses of distance: of people who have lived all their lives in outport communities, and through circumstance, board up the family home and go into a nursing home in town. With all the mix, the expertise and the studies everywhere, is there a place for them to stay where they are as long as possible?

Looking for probably a simplistic solution, is there a community health setting, I refer to it in other meetings asone- stop shopping. It takes a community to rear a child. The community looks after its elderly through shopping, dropping in, or whatever.

However, there are certain supports, such as lifelines and these kinds of things that allow people to stay where they are. I look at the personal caregiver, who for me is an essential person, and you have all articulated it very well. Training is essential, as is continuing education.

I went looking for a solution as I normally do. We train caregivers to look after the little ones: early childhood development, or whatever you want to call it. In my province, those caregivers are paid the minimum wage and we expect a lot of them, or a lot from them. However, could we haveprograms like those in our community colleges, a two- year program, one that looked at the academic pieces, and one that was on-the-job training to see if you had a feel for that? I know when we closed out the school of nursing at home and went to the university-based models, the students did not see the floors of the hospital until day two in year two or something or other. Some of them found out that the practical things, such as bed pans and the like, were not really what they thought nursing was all about. If we are going to put a program in, we should have some kind of anon-the-job training for it, and I would like your opinions on it.

Aging is natural; it is an old evolution of our society and we cannot isolate it from who we are as a society. My granny knit dolls clothes and had a big white apron, and the apron was a place where I crawled to when I hurt. My mom, my children's granny, became a world traveller. This granny, so far, puts on her shoes and goes for a run. You look at the evolution of how we age and where we age. Yes, we need a program that moves and meets the needs of people where they are. In my province, there is a program where a supermarket comes around, you pay a dollar or two, and you go on the bus to get your groceries. It is all geared to people living in their home.

I have not heard anyone mention that which gives life its meaning; a pet such as a dog or a cat. In our nursing homes we have programs, pet therapists. My grandson came home a little while ago and said, "Nan, I met a woman who knew your mother.'' She has been dead for 20 years. I said, "Where were you?'' He said, "We went to Glenbrook,'' which was the nursing home.

His school has a program where children go into the nursing home. These are the kinds of things too that give a quality of life to seniors that I hope I can be part of. I know there is a need for all the bits and pieces such as the clinicians and the professionals. Somehow or another, we have to maintain some level of normality, if you like, for the person that we care so much about, and which is our elderly. You talked about research and I spoke to the chair. Sometimes more money is not the answer; a reallocation of services is. We had a little conversation about Canadian Institutes of Health Research, CIHR. I am sure you have all heard of it. I am not sure how their program is delivered, or if there is a place for this table in it. However, there are opportunities within the system where we can insist on getting our fair share.

There is a need to work collaboratively. We have to do that in a province the size of mine. Where resources are not there we become more innovative; we create things where they meet the needs of our population. For us, the thing is to allow people to stay where they have spent their lives, for most part. We saw that in the downturn of the fishery where 30,000 people leftbecause of a cod moratorium. They were the people between 30, 45 and 50. In the outports, there are only the elderly and the frail elderly. To ask those same people to go to Fort McMurray, Tumbler Ridge, or wherever, where their people are gainfully employed, does not sit well. I think a lot of people, especially throughout your community, Senator Gill, suffer from isolation and they do not want to go to a strange place.

I think we need to keep those people within the spectrum of care. The idea of the creation of a national coalition of provincial older persons, given the fact that we work in the federal system, and this delivery of care is done on a provincial basis with different standards from province to province, that is the reality. In terms of a national mental health strategy, we are talking about what we think is best, and then we have to rely on the goodwill of the provinces because of our structure to implement it. It is awesome. I am sure you people find those stresses on a regular basis.

The other reality is that there are not enough professionals out there. How do we encourage our young people to be part of this piece, from psychiatrists to nurses, doctors, therapists, psychologists and all the rest? I see that as a challenge. However, more than anything, I would like to hear about training caregivers within this national strategy that we are about. Also, on the need to work collaboratively, why would we work any other way?

Senator Callbeck: Like Senator Cook, I come from a small island on the East Coast. We are approximately 140,000 people so the challenge is there, or the situation in some ways is a lot different than in downtown Vancouver , Toronto, or the larger centres.

I have specific questions and explanations, but they can be covered under the categories that you announced, Mr. Chair.

Senator Gill: Many points have been raised this morning. People have tried to explain their feelings about a national strategy. Everyone would like to have services so they can feel secure and then be able to help others. I think that is the purpose of the exercise.

There seem to be a lot of services in Winnipeg, but there also seems to be some overlap. That is my impression. Maybe it is not the case.

We are talking about specialized services for mental health, but as human beings, the physical and the mental go together. If something is wrong somewhere, the body does not work. With regard to a new strategy, instead of talking about new services, perhaps we should talk about the physical side of things. When we have something wrong with us, we go to the hospital. We see doctors and specialists, and we try to get the treatment we need. It seems to me that lots of specialized services are there. We want better services and we want to pump more money into this field, but perhaps we should treat the person as a whole, old and young, instead of always making distinctions. In doing that, we marginalize some groups. We put some groups in the corner and we do not serve them. We try to do things in good faith, but sometimes we miss the boat. In solving one problem, we often create other problems.

I have been discussing this point with my colleagues in the Senate, saying that we try to be good for all Canadians. By adopting a national policy to cope with the situation, we may hurt some Canadians.

I agree with Senator Cook that an isolated area and an urban setting are not the same thing. The people in my area tried to bring in a specialist, but it was too far. No one wanted to go there because they are working in the big cities such as Toronto, Montreal and Vancouver. In addition, the universities are typically in the big centres. We do not have the services that people usually have in urban centres.

I say that we should have a national strategy, but it should be flexible enough to apply to different needs. Instead of creating problems, we should solve something for all the people in this country.

When we look at people we evaluate them, and sometimes they may not seem to be in line with the majority of us. This does not mean they are mentally ill. It may be that they are from a different culture. There are cultural differences among people.

The Aboriginal and immigrant populations are growing. Different nationalities are coming to this country. Any national strategy will have to be flexible to take into account these various cultures. That is an important issue. If we find a way to deal with these different cultures, maybe in the future we will not see so many Aboriginals in jail, for example.

Of course, education is also important. In an organized society like Canada, when people are afraid, they do not learn and they become ignorant.

As we try to organize ourselves, sometimes we create problems. Maybe it is better to know more about what is surrounding us, about these different cultures and different people, so thatwe can better cope as a society, but we should not try to be super-organized all the time.

The Chairman: Thank you, senators, for your comments.

Two main issues have been put on the table. One relates to how the primary-care reform or multidisciplinary primary-care groups handle mental health. Are there specific recommendations that need to be made to ensure that mental health is included in the primary-care reform package? The second issue is housing. Two or three of my colleagues made an interesting observation. We have had a lot of comments on supportive housing. We have had comments on long-term-care homes and so on. The reality is that the best housing is probably housing in a family home, or with a family member. Certainly, it is probably the cheapest. It is probably best for the patient. Right now, unfortunately, government takes the view, by and large, that if you are in the home of a family member, you are on your own, which is really kind of silly. If the alternative is supportive housing, the reality is, it would be a lot cheaper to give the person living in their home some additional services, to avoid them having to go into an institutional setting at some time. However, trying to get that kind of logic into government is difficult. I would love to have comments on both those questions.

Let me make one other comment so you understand where the committee has always come from. We have always taken the view that money is the means to an end, and so the first thing to do is to figure out what you would use the money for. Simply saying, as the research community in particular is inclined to do, "Just give us more money as opposed to telling us to re-allocate,'' is not enough. We understand more money will be required. We want to figure out what we would do with the money, and then we will figure out how much is needed.

The second thing is to recognize that Utopia is not achievable. The definition that we have always set is, we try to get recommendations that we would define as being just inside the outer edge of political feasibility. In other words, push the system as far as you can, but not so far that you do not get anywhere. We would rather try for 75 per cent of an optimal solution and get it, than try for 100 per cent and not get anything. To that extent I ask you, in giving us specific suggestions, to temper your comments, keeping in mind that we are happy to push the system hard, but not happy to be so ideal that it cannot happen.

We will begin with Martha. She raised some organizational issues.

Dr. Donnelly: I am going to speak about the Canadian Collaborative Mental Health Initiative, which I am also scheduled to speak about at the National Shared Care Conference in Ottawa this weekend. Scott Dudgeon and Nick Kates are in charge of that. I think this committee has heard from them before, but they are trying to develop a charter. We are developing tool kits to help people figure out how they can integrate mental health into the primary health care system.I think it is important because this is an issue that is not awhole-lot-more-money issue. It is working in a different way by having that collaboration. I appreciate when people talk about whether we should totally segregate mental health, but this issue brings the mental health workers to the primary-care system when needed. I think that is good. We are looking at several tool kits. One of them is on multicultural issues; how you deal with that. One is on Aboriginal issues; how you deal with that. One is on geriatrics. We have to look at some of those things. I think they are important.

I am a firm believer in this collaborative care kind of model because I think it is better and less expensive, quite frankly. When we do not have enough health professionals, we have to use them correctly. We cannot use the high- powered specialists to do the primary work.

We have to get away from that. I still think the high-powered specialists are necessary. They need to do the research, they need to do the education, and they need to be organized for the sicker patients. However, I think that collaborative model is something that connects with primary care, because in those community health centres you have family physicians, nurses, and so on. You just might have a mental health member as well. Then, you might have a psychiatrist coming in for part of the time. I think that is a potential solution.

I wanted to mention one issue about the rural things too. We should do more collaborative care between the larger centres and the rural centres. I see no reason why we cannot have larger communities supporting smaller communities, through telehealth and outreach visits so that I, in Vancouver, can support Smithers through a telehealth connection. They can have their team in Smithers. We can talk about cases. They can interview a patient in Smithers. I can observe and I can teach them. I do not want to do the work myself. I want to transfer my skills to them so the local community can keep them. In the Newfoundland outports, if you can have that telehealth connection, you could have a lot of high specialist help right at the centre. I think blending telehealth kinds of things and collaborative care could be helpful.

Senator Callbeck: We have used telehealth since 1972 but only selectively, so I think this is the time now to be inclusive with all aspects of it.

Senator Gill: I agree with this connection between the centres and the isolated and rural areas of the country, but many people living in isolated areas want to decide for themselves. We can give them a formula, but let them decide for their own people.

Senator Callbeck: Doctor, you are involved with telehealth and you speak positively about it. Anyone I have heard talk about it speaks that way. Why are we not using it more?

Dr. Donnelly: There are two or three things that I can think of. There have been funding barriers that are now beginning to be overcome. There are potential medical and legal concerns. Some physicians worry if they have not seen the patient within the same room that there may be less of an opportunity to be clear about what is going on, so they might be sued. There are those problems.

There are problems setting up the ports. Telehealth is not without cost in the sense of creating the ports and transmission. However, I think these things can be overcome.

Ms. Sirett: I wanted to comment a little more on ideas in primary-care reform. I agree with Martha Donnelly, there is absolutely a need for specialists. However, I think we all recognize that the family physician is probably the front door to care for most people. There are problems for those that do not have physicians, and that is certainly an issue in B.C. I think ways that we can find to support the family physicians to do the initial work is an really important part of it: initial screening for depression, substance use, and early dementia, and how we can work with the strengths in the community, whatever community that be, whether it be a specific ethnocultural community, a rural community or a neighbourhood. We need to work on strengths in that community to help do that screening, and to help provide outreach to the seniors using some of the prevention and promotion models that Penny's group would be looking at. Working to support those communities is a whole subject unto and of itself but I think we should use whatever models we can use for community development.

I am lucky in that within Vancouver Coastal Health we have a community developer department that will work with communities of seniors or ethnocultural communities and with the service providers.

The Chairman: What does community development mean precisely?

Ms. Sirett: Community development is the process of bringing all the stakeholders together. For example, I was thinking of a Chinese ethnocultural group. We could bring together people that are involved in providing charitable works and social services already within a certain community such as a Chinese community to work with the care providers in that area as well. We could find where the commonalities are in that group of stakeholders, and then move forward on what little projects can be done that can make little differences on a day-to-day basis to people, and build on that.

The Chairman: Is this like a facilitator role?

Ms. Sirett: Yes.

I am looking for other people around the table to help here.

Ms. MacCourt: It is somewhat like a facility role, and it has been used in different places. One area in Calgary has a healthy community model, which is a community development model where they bring together stakeholders and so forth. They look at programs that look as though they overlap. They help people navigate between systems. They also support people where they are at. They use the strengths of the community. They build community capacity. The unfortunate thing is when this has been funded, it has usually been short term, for three years, and then the community developer leaves. In some communities, such as in Newfoundland, there are not the people to pick it up and take it because, as you said, they are frail and elderly or they are very young. A community development model is in keeping with mental health promotion, prevention, and supporting people, and there are good models out there.

As we become more acute-care driven and more mental-illness driven, these positions have disappeared. There used to be roles; psychogeriatric outreach programs used to have community development as a piece of what they did. It was going out into the community and creating the resources to support people so they did not have to come into the mental health system. However, as resources become scarce, what you get now is strictly case-driven. You take in the clients. They have to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, DSM-IV, whatever it is these days. Then you treat them and put them back out. You still may not have services out there that would support them. It is part of that shrinking. It is where education has gone. It is where research has gone. It is all focused on one end of this continuum.

Senator Cook: We are hearing that we need programs and not projects. We need what is sustainable

Ms. MacCourt: That is right, and we need the whole continuum considered. What does it say? Going upstream or downstream, I never remember which, we keep dropping people into the water and catching them at the bottom. Instead, somebody needs to go up to the top and put a barrier up, or do something that prevents people from sliding down.

Senator Cook: We need programs that are sustainable and ongoing, not a project that has a finite beginning and end. We have suffered from that in Newfoundland.

Senator St. Germain: My question or comment relates to what Senator Cook brought up in regards to the implementation of whatever recommendation comes across, because the provinces are responsible for implementing whatever. That to me has always stood out, whether it is Aboriginal issues, health issues, or what have you. I am sure there is no simple solution. It is a complex scenario. Possibly during this course of the next few minutes somebody could comment on that.

Senator Cook: To bring it clearer to you, Mr. Chair, Heart Health was a wonderful program; a federal initiative delivered with federal funds at a provincial level. After it was over, it was over. It did not go anywhere. The province did not continue. It was not a program. It was a project. We have to be careful with that.

Ms. MacCourt: Many wonderful projects have been funded for short periods of time, and then they end. When that happens, it is a disservice to the entire community, to the service providers and to the people that receive services.

Dr. Drance: When you talk about community development, we are talking about the ideal place for people to live out their later years, which is obviously in their own homes with adequate supports. As was mentioned earlier, the health care system will not do this, and social work will not do this. It is about creating community capacity so you have volunteers, family members, caregivers and professionals who are supported to provide that kind of community. I think you do the community development piece at a local level. It is exactly as you were talking about where solutions are not imposed from somewhere else.

What do we need? What services do we need? What kinds of resources do we need to provide that in our environments? Even when you look at that small percentage of frail seniors who need to live within a residential care environment, they need to be seen as communities also. We need to use that same community development model certainly in providing the medical care and the mental health care, but creating also the capacity of families there. Our institutional models have always said, "You bring your loved one and we will take over from here.''

The bottom line is that families do not want that; or if they want it, they want to be able to come and go, as works for them. We need to say to families, "We cannot do it all. You are part of a community here.'' This is how we can create those vibrant places where people will thrive. It does not matter whether you are at home or whether you are in a residential setting. It is that community that will create the mental health and the well-being.

Ms. Spencer: I would like to offer an observation in terms of primary-care reform, and it will not surprise anybody at this table. First, there are an increasing number of seniors who do not have a physician, period, particularly in rural areas, and particularly in terms of loss of physicians within rural areas. Second, when they have a physician of some sort, they are being limited to things such as a 10-minute visit, or what seniors organizations are continuing to report are things such as one visit, one complaint. They see signs that say that. That is not conducive to good mental health service at any level or to any kind of health service for older adults. For older adults in these circumstances, focusing on one issue at a time leads to a crisis-type of approach in terms of providing health services, and providing services to the older adult. That is one thing we need to be mindful of in this area.

The Chairman: What happens in a rural area where somebody is a senior and someone does not have a doctor? What do they do? Do they go to the local emergency room?

Ms. Sirett: Yes, they go to emergency.

Ms. Spencer: Except that the hospitals have been closing in some of the communities, so they do not even have that.

Senator Cook: They do not have money for an ambulance, and maybe there is no neighbour to take them, and the family is in Tumbler Ridge.

Ms. Spencer: Yes, and that is an important reality.

Senator Trenholme Counsell: Regarding the isolated seniors, this is where telehealth can come in. Telehealth, of course, is largely specially trained nurses. We need a lot more telehealth, as well as telemedicine. I think those are both excellent new trends.

In terms of seniors coming to a physician's office with more than one complaint, it is challenging. I think both sides are at fault here. In the future, as we hopefully get community health centres where we have nurse practitioners, and where we have group practices, shared practices, this issue will be dealt with much better.

It can easily take a long while to listen to the stories. They are all important. However, I think we need shared practices and working with other professionals. This is a perfect example where nurse practitioners can really help the physician, and, more especially, help the patient.

Mr. Moselle: To follow up on this discussion aroundprimary-care reform and shared care, we are involved in a shared-care initiative right now. I am concerned with rural remote service delivery for —

The Chairman: Can you define what you mean by shared care? For some people across the country, certain terms mean different things in different places.

Mr. Moselle: That is exactly what I want to define. There is the traditional model of shared care where the knowledge that resides within a medical specialist is transferred to a primary-care provider, typically a physician. That is the old model where you have, for example, a psychiatrist helping a primary-care physician learn how to better assess and treat depression, for example.

However, within the context of this shared care, telehealth is one way of getting that knowledge from the specialist to thefront-line primary-care physician. In the project we are working on, physicians are saying they do not want a psychiatrist to tell them how much Paxil to prescribe to a person who is depressed because they have had to learn how to do that because they are dealing with everything in their practice. The issue is that a complex array of providers out there are looking after people with complex problems, particularly complex chronic problems. Physicians are just some of those provider specialists or some of those providers but there is a whole array of organizations and service delivery units that collectively are looking after people with complex needs.

Some of them are delivered by the health authority; some of them are delivered by non-profit societies. They collectively provide the basis for looking after people with complex chronic problems. An important part of shared care is not simply putting expert knowledge in the hands of physicians. It is putting direct access to all those services in the hands of primary-care physicians. They cannot spend all day trying to set it up for one person. When we talk about shared care, we need to be clear on that. The cost lives within the world of shared care around the notion of a navigator as an in-between person whose position is between a primary-care provider in that whole network of other collateral supports.

I would like to emphasize the importance of scoping out shared care properly to include the notion of putting an array of providers directly at the disposal of primary-care physicians, to enable them to look after complex clients, both in urban, and particularly, in rural remote settings.

Dr. Donnelly: Shared care in Canada between family practice and psychiatry was originally between family physicians and psychiatrists, but it has moved now to collaborative care involving all the disciplines.

The Chairman: Does it include non-medical or non-health-care disciplines? For example, is supportive housing included, or a psychologist, nurse practitioner or whatever?

Dr. Donnelly: It includes nurse practitioners, psychologists, pharmacists, occupational therapists with liaisons to housing, and so on. It does not necessarily mean having them there, but having liaisons. It is predicated on primary health care reform working because at the moment, on a fee-service basis, a family physician cannot do this kind of work. There is no way.

With primary health care reform, if we create these community centres where there is a physician, a nurse practitioner, a nurse, social worker and physiotherapist, then the appropriate person could do the work. Then a psychiatrist might come and give them advice. Maybe they do not need to know the Paxil amount, but maybe they know something else, and then they can walk in and walk out, but the primary-care people can do the work. Also, they may need a mental health counsellor to do some of the counselling, and that would not necessarily be a psychiatrist. It might be a nurse or a social worker. That is the kind of model I am talking about with these collaborative care models.

The Chairman: However, it is predicated on primary-care reform working. Yet, if you look at the evidence across the country, is progress being made? Absolutely. Is it being made unbelievably slowly? Absolutely. The resistance among the medical fraternity, is big, particularly in Quebec and Ontario. It is much less true in Atlantic Canada and much less true on the Prairies. At this point, there is no way to overcome it. Am I right? Is that a fair reading of the state of the land?

Dr. Donnelly: I think that is a fair reading if you look at the whole in perspective. However, there are a lot of places where resistance occurs. That is where we talk about the early adaptors in collaborative care. If we can get in to those people who are interested, let us work with them. That is what is happening. We need to wait until it is further embraced to make it right across the system. However, we can work with the early adaptors.

The Chairman: I am being unduly pessimistic, is that right? I think I am realistic.

Dr. Drance: Ken raises that issue of access, and the ease of access. There are many services out there, but right now for a frail senior or their loved one to figure out who to call, where to call, that navigator role is a key one. Family physicians need to be able to navigate the system as well. We have not done a good job of gathering all these services together and helping people access them relatively straightforwardly. It is an incredibly complex system. With other issues around interdisciplinary teams in general within care for older adults, I think we truly lead the way in terms of our comfort in working in interdisciplinary models. I am not saying it is ideal, but it is good relative to the rest of the medical system.

The Chairman: Who is "we''?

Dr. Donnelly: We are the people who work in geriatrics or who work with older adults in seniors' care. All of us realize that the needs and the complexity of the physical, psychological, mental and spiritual are all so complicated. We cannot do health care independently so we have learned, I think, to work effectively together. Can we do better? Of course we can. Again, the notion of working between nurse practitioners as they increasingly come on line, and the rest of the team, is an ideal model in terms of things such as residential care where physicians currently are not allowed in certain provinces to visit somebody any more than once every two weeks by virtue of the medical plan, unless they are called.

The Chairman: Sorry, not allowed by whom?

Dr. Drance: They are not allowed by the medical plan, thefee-for-service model, so there is no ability to come more often.

As part of primary-care reform, we are looking at creating a residential-care physicians network. What will that take for the physicians finally to be part of the interdisciplinary team within a residential environment? We are having some interesting success in terms of working with physicians with an interest, because they want to be there, but they cannot do it if they are not compensated to do it.

The Chairman: If you have a couple of illustrative examples, scenarios or whatever, and you could send them to us, that would be great.

Dr. Drance: Certainly.

Ms. Malach: I am hearing what everybody is saying. I am a bit concerned that we have skipped over an issue of assessment and screening, and where primary-care fits into that. What the coalition has heard is that primary-care physicians want to be involved, but they do not have the assessment tools necessary to make accurate diagnoses, and there is real concern that cases are being missed. There are suicides — Charmaine would know the numbers — where literature shows that seniors who kill themselves have usually seen their primary-care physicians within two weeks or a month before their suicide. It is a real concern.

One thing that the coalition is working on with Health Canada is the creation of national guidelines in the areas of treatment and assessment for depression, delirium, suicide prevention, and behaviour and mood issues within long- term care facilities.

We have brought together people, and there are people in this room who are part of these groups. We have brought together all disciplines — primary care, psychiatry, psychology, social work, nursing, pharmacy, caregivers groups, and different cultural groups — to create guidelines for assessment and treatment. Once these collaborative groups are together, they actually have something in front of them to help guide the care they are providing. I wanted to emphasize the point that we also need to look at the assessment tools, the treatment tools, and the training that will be necessary once these guidelines are created to actually implement them.

Senator Gill: Improving services does not mean adding services. Sometimes we have to adapt the services that have been there for quite some time. Personally, I have been treated by my mother and my grandmother, and I am still alive. Do you know what I mean? I lived in an isolated area and I am still alive.

We have big problems with our hospitals right now, and cannot afford the services that we are being given. What have we been doing as a solution? We are trying to add other services.

We should not start from one extreme and go to the other. If we want to improve our services, we should improve the existing services. I am not saying that we should do only that, but we should consider it. In the smaller communities, lots of people can help themselves. Aboriginals were independent. We were self-sufficient. Many treatments that were used in our communities years ago are still used in different forms. The same thing applies to small non-native communities.

I am talking about better coordination of existing services. Right now, when a person has a problem in an isolated community, a plane takes them to the hospital and it costs a lot money. We are currently sending the people to the services instead of bringing the services to the people.

Ms. Flower: I would like to add to what Faith was saying about assessments, because without a good assessment, we have no information. The experts on assessments are not the clinicians. The experts on assessments are the persons themselves; hearing their stories. We have to take the time to hear their stories. There are certainly tools that are useful, and I think are used fairly regularly across the board. The Folstein Mini Mental State Examination and the clock drawing are things that give us information quickly. However, in the field of substance misuse, there is no tool that is specific to older adults that is sensitive enough to meet the needs of older adults. At the program I am working with we are hoping to be in some partnerships. We do have a tool that we have started on.

However, the reality is that the majority of people who are go into the field to the individual's home to do assessments do not ask specifically about alcohol use. We get a lot of information on the drugs that people are using, which is very helpful. However, that other little piece so often slips away.

Ms. Barr: I would like to bring the discussion back to the addiction issue. We have talked about opportunities and problems with a more formalized and funded system of care. I am not suggesting that we add a whole new raft of services or a whole new layer of funding. Charmaine pointed out that in terms of addiction, or more correctly, substance use problems for older adults, the services right now in the country are serving, I think she said, 0.4 of 1 per cent of people that are experiencing alcohol and other drug problems.

The Chairman: Half of 1 per cent?

Ms. Spencer: Half of 1 per cent.

Ms. Barr: Less than half of 1 per cent.

Ms. Spencer: One half of 1 per cent of older adults who have substance use problems receive specialized services in Canada, specifically senior-specific addiction services. That is not to say that they do not have access sometimes to mental health services, or they may have access to a private counsellor and other kinds of services.

That access is to specifically specialized senior services for substance use problems. These programs are very scarce across the country. Realistically, not everybody needs that though.

That is really important to emphasize. It indicates this significant gap between needs and resources. With the Seeking Solutions project, one thing we focused on is emphasizing that there is a role, both in prevention and in terms of support and assistance, for many different people, partners within the community, to help older adults on the prevention side. In terms of being able to deal with issues at an early stage and then recognizing that for some individuals, there is that need for more ongoing kinds of supports and services for them. Again, we need to recognize that a continuum is needed for older adults.

Ms. Barr: The other point I wanted to make around that is because an older person can be served so successfully by following a number of principles that are based on evidence, based on evaluated programs, we know there are tremendous savings. Say, for example, a typical addiction service provider in a small community in Ontario. I worked in Peterborough, Ontario for many years. They had four or five staff that served the general population; aged 0 to 99, I think, is how they put it. However, for them to take the time to go into a senior's home and work with them individually was a luxury that they could not afford.

We did a community development model, and we brought a committee together to look at older adult issues and why they were not referred to the treatment service. In fact, we put in a proposal to the Change Foundation to try to get funding to measure what we felt could be shown. That was, had there been some intervention, they could be prevented from going to the emergency department on a revolving-door basis for constant episodes of moving from one facility to another, or moving from being close to eviction and ending up at emergency.What is considered a luxury or an expensive service from the addiction-treatment-provider point of view, which they could not afford to do, probably could be shown to have tremendous savings within the system itself. In any given community some of these individuals are well-known to many of the care providers. There is that feeling of, "What do we do?''

The Chairman: This gets back to my data question: Has anybody done a study of any of these issues to show the potential savings? We know that governments are dollar oriented. The reason I want to come back subsequently to the research on the service side is it is critical not to rely on governments' willingness to do something because it is the right thing, however nice that would be, but in fact to get them to do it because it will save money.

Ms. Barr: I know that one small piece of research that was done in Winnipeg years ago — and Dr. Jasik is hoping that somebody will replicate it — did look at older adult admissions to emergency, and there was a startling figure on the prevalence of chemical dependency.

The Chairman: Do you have that reference somewhere?

Ms. Barr: Yes, I do. I can give it to you.

The Chairman: If you could, that would be great.

Senator Pépin: To come back to what Senator Cook and Senator Gill were speaking about, people who live in rural areas or outside the city have a problem with access to services and caregivers. If there were some access to those services in the rural areas, those people would not be obliged to move into a special home in the city. One of the solutions would be to find a way to provide access to those services in different areas.

I am always reminded of the Brandon example. They had to close the hospital and had only one doctor, but they were able to organize and offer access to a caregiver, a nurse practitioner and a doctor. They organized access to those services and it appears to be working quite well.

I was listening to the news this morning. The Minister of Health in Quebec is saying that building homes in which to put the elderly is not the solution. They have to find a way to stay at home or live in their neighbourhood. If we can find a way to provide access to services and caregivers, that would help a lot.

Senator Gill: Is there a study indicating where the people who live on the street in big cities like Vancouver, Toronto and Montreal come from?

Ms. Barr: Some of them have been evicted from their homes.

Mr. Moselle: We just took a look at all of the homeless people in the Lower Vancouver Island back in January when we did our homeless count, and a grossly disproportionate number come from Aboriginal communities. We know that a grossly disproportionate number of those people are psychiatrically disabled. I think a fair amount is known about homeless people, where they are coming from, and that is the pattern that will keep coming up in those studies.

The Chairman: Lucie's comment gave us a natural transition from talking about the primary care issue to the housing issue. I would like us to move into the housing question, but with a particular focus on the point that a number of my colleagues have raised, which is what do we do to keep them in their own homes and provide the services in the community, as opposed to, I hate to say it, warehousing them in either supported housing or big institutions of some kind?

Ms. Crawford: I just wanted to comment on access to service and the difference between rural and urban areas. Yes, obviously there are more services in an urban community. We provide supportive housing in two large public buildings in the city of Toronto, but we found that though the services are there, the people were not going. Why were they not going? One reason was transportation, one was a language barrier; another was poverty. We cannot forget about people who are paying over 75 per cent of their income in rent; they do not have the money to hop on the streetcar, even though it is $1.20. They just do not have that money. Or due to their mental illness, they were delusional or paranoid or whatever. People were not going in the first place to see even their primary care physician. Therefore, when we look at a practical approach to supportive housing and how we can help fill the gap, basically, you get a staff member to go along with them.

If you have to, you pay for a cab to get them to their physician.

Talking about cultural barriers, one of our programs is in a large public housing building and one third of the population there is elderly Chinese. We have obviously put together a culturally diverse staff to ensure that we have people onduty 24 hours a day who speak Cantonese or Mandarin. That has been hugely important in breaking down not only the barriers within the building itself, but the barriers in regards to talking to the physicians. You talk about social isolation. Of course, when an older adult or senior gets to their doctor, many of them are so isolated they want to spend three hours there. It is their contact person. When we look at supportive housing, we can become the eyes and ears for those people who have real difficulty in expressing themselves.

I do take a little offence at the term "warehousing'' in regard to supportive housing.

Mr. Chairman: I thought it might get a rise.

Ms. Crawford: Again, maybe this is an area where there are so many different terms and definitions, and misunderstandings of the term "supportive housing.'' It is in the people's communities. It is where they live. It is where they have lived for 40 years and have aged. We bring the services to them. It is not that we are asking them to move somewhere else where the supports are. We bring the services in to them. It is their homes. It is their communities.

In regard to cost effectiveness, we have found — even though we do not have lots of statistics because of lack of resources — in our own basic research that in the first year of a supportive housing program starting up in a public housing building, we were able to reduce 9-1-1 calls and use of emergency byabout 75 per cent.

Dr. Donnelly: I want to make a comment on housing. Clearly, most seniors I meet want to stay in their own home, and that is a good place as long as you can get support services in. The problem is there are sometimes policies that do not allow you to bring in the appropriate support services for mental health clients. For instance, in B.C. right now we can get homemaking help for people who need help to take a bath. However, if people are suspicious and isolating themselves, we cannot get the homemaking services in. Their physical health is considered important, but not their mental health to the same degree. You have to look at the policies.

The Chairman: If you can give us illustrative examples of that it would help us, because the answer obviously — and you agree with this — if we cannot supply the services, is to change the policy.

Dr. Donnelly: Absolutely.

The Chairman: Illustrative examples of that would help put the meat on the bones of the description.

Dr. Donnelly: I can send them in later.

Another good example is that in assisted living, which we are moving towards in B.C., you have to be able to direct your own care. Therefore, if you are suffering from dementia to the point where you lose the capacity to direct your own care, you cannot have somebody else direct the care for you, so you cannot be sent to an assisted living facility. I can send you that note.

There are certain policies in supportive housing in B.C. that mean you cannot accommodate a certain level of dementia because you cannot have that kind of support going in. We really do have to look at a lot of those policies, but I will send you those examples.

Mr. Moselle: Following up on some examples of policies that are responsible for the situation that Martha was talking about, in our health authority they were planning to pull home support from 173 psychiatrically disabled adults.

However, some senior executive was concerned that maybe something bad would happen. We did an in-depth, methodologically rigorous projected risk analysis of what might happen to those people. We came up with some interesting findings, such as 43 per cent of these 173 adults were living in squalor, despite the fact that they were receiving some home support; 53 per cent or more were actively psychotic at the time the assessment was done. Depending on how you projected risk — and you could do it using a variety of means with a greatdeal of information that we had collected — we estimated that two-thirds of those individuals would be booted onto the street anywhere within 72 hours to six months of home support being pulled. I can send you the executive summary of that study, but it turned that policy right around.

That home support is still in place.

Senator Callbeck: Suzanne, in your opening remarks you mentioned St. Anne's Place, and I have been reading about it here in your brief. Certainly I commend you for this initiative. I am wondering about the financing. How was this financed initially? What about operating costs? Who pays for the expenses?

Ms. Crawford: We receive funding from the Ministry of Health and Long Term Care of the Ontario provincial government for the supportive housing aspect only. We employ personal support workers.

It is a non-medical model. Presently the building has 110 units but we only receive funding to serve 35 of those. We have had a request in to the government for the last four years to expand and enhance the services there.

In Ontario there has been no new funding for expansion of supportive housing services in the last five years.

St. Anne's is extremely affordable because we have formal rent-geared-to-income units, which came from the City of Toronto. It was operated by the province for many years and we wereactually one of the last groups to be downloaded to the city; 85 of the 110 units are rent geared to income. People pay a portion of their income towards the rent.

Senator Callbeck: What portion is that?

Ms. Crawford: Thirty per cent.

Ms. MacCourt: I hope our discussion about housing will also be in terms of long-term care facilities. It gets back to the idea that every place can be a community, but there need to be resources in place to do that. The rhetoric about people remaining close to home, at home and so forth has sometimes been to the detriment of family caregivers and care aides who have not been given the resources, the education or the training — which we will go into later — to be able to do a job beyond providing custodial care. I am interested in housing as an environmental milieu, as a tool for mental health, for or against mental health, if you like. I am hoping we can discuss it in that framework too.

Ms. Spencer: A lot of my comments have already been covered by Suzanne and by Martha Donnelly.

I too was quite surprised by the use of the word "warehousing'' in terms of supportive housing. I am wondering if it might be beneficial if Suzanne and I were to put together a glossary of terms as they are used across the country so that there is a common understanding of the different kinds of housing approaches. I think that might help to correct some of the assumptions that people may have about what supportive housing is, what assisted living is, what a care facility is.

The Chairman: That would be really helpful. We have already concluded that we will have to put a glossary in our report. Simple example: "Peer support'' is used in some places. It is called"self-help groups'' in others. Some people like the term "consumer,'' some like "patient,'' some like "consumer/survivor,'' and so on. In the end we will choose a word, but we will put in a definition so everyone will know what it means. If you two would not mind doing that, that would be great.

Ms. Spencer: Following up on Martha Donnelly's comments, I would be very happy to offer examples of policies and regulations in the housing area that work to the detriment of older adults with mental or substance use problems. I am thinking specifically of things like the exit criteria within what we call in our province "assisted living,'' and some of the challenges there. I would be able to use that to provide both vignettes and a brief explanation.

The Chairman: That would be great.

Ms. Malach: I have two points to make. The first is when we are talking about support for people in the community, I want to emphasize that the supports need to be not only for the individual with the mental illness, but also the caregiver. At a home care forum that I attended we heard a lot about the fact that the individual with the mental health problem is at home and being cared for, but it is the respite that the caregiver, the wife, the spouse needs to keep the person at home that is critical. Often, they have to transfer somebody to a long-term care facility because they simply cannot handle it, and when we are talking about caregivers in the case of seniors, we are often talking about a spouse — an 86-year-old taking care of an 88-year-old.

The second issue that I want to pick up on is Penny's point that when we are talking about the housing continuum, we are also talking about long-term care facilities, retirement homes, assisted living facilities. One of the recent problems is the integration of the services in the community versus the services when people are admitted to long-term care facilities. For example, we know of the case in Ontario where a man was living in the community and had had all kinds of assessments, but within the first few hours of being admitted to a nursing home, he killed two other residents. All kinds of questions were raised as to why mental health and illness were not assessed prior to his admission. Why was it not assessed again when he was admitted? Where is the gap between what is going on in the community and what is going on when people are admitted?

The Chairman: Your comment on the assistance at home reminds me of my 90-year-old grandmother, who looked after my 92-year-old grandfather until he passed away, and she thought she was fine.

Mr. Moselle: Just to give you a little cross-cultural information here, I lived and worked for many years in Malaysia and Singapore. In Malaysia the solution to all of these problems was quite simple — provide more or less no services. However, the reason that worked was the extended family network was largely intact, and that is a very resilient unit for dealing with complex problems.

In Singapore the solution was quite different. The Government of the Republic of Singapore will lend you money to purchase an apartment if you purchase one within three kilometres of where either your parents or your spouse's parents live. If you want to live further away than three kilometres from either set of parents, of course you can do that, but you have to purchase your own apartment. That was the Singaporean solution. I am not advocating that, but it is an interesting concept.

Of all the discussions today, I am most focused on this discussion of supportive housing. If I had some money and a magic wand that I could wave once to overcome organizational inertia, I would spend the money on supportive housing and use the magic wand to help promote a paradigm shift in the delivery of care within mental health and addictions. Despite the fact that mental health and addictions have been marginalized on a legislative, policy and funding level, when you look at the paradigms that govern care, it is still more or less an extension of acute care. That is still the dog that wags the tail of all the services in the community. We have to be clear on what is the dog and what is the tail in this situation.

When you move into the community, the paradigm shift is away from the notion that health care for people with chronic mental health and addictions problems, and seniors, is prescriptions to treat illnesses within that population. The treatment is supported housing, with somebody there every day to help look after people whose problems come up constantly for the duration that they have what is typically a chronic condition. We did take a look at a supported cluster care model within our health authority, at the characteristics of the clients who are being maintained within that facility. It is a very complex but very viable model of care, with a per diem cost that was probably one-half to one-third of that to put a person in a more traditional licensed residential care facility.

Therefore, I think supported housing is the real improvement opportunity, and exploring a viable model for supported cluster care or assisted living for people who may be elderly, but most of whom are actually not frail — au contraire. However, they cannot direct their care and they need a different kind of support. I think there is a tremendous improvement opportunity there.

Senator Gill: Since we have a lot of experienced people around the table and we will have to make recommendations, I would like to know what recommendation you would make concerning more and more First Nations people moving downtown and more Aboriginals being jailed.

Could we say that the services for the general public are at the same level as those for Aboriginal people? I would like to hear comments on that if we have time.

The Chairman: I will come back to that in a second.

Dr. Drance: Just to go back to the housing issue, perhaps we cannot completely manage the more complex needs at home, regardless of how much respite there is, but I think we can do much more than warehouse people. I would love to say we do not do that necessarily in long-term care. However, some people do. For some people, that is the quality that can be delivered. I also agree with Ken that we are looking at significant paradigm shifts to actually see the care- home world as a community focused on people's well-being.

Getting back to Senator Cook's comments about animals and children, and natural elements being part of people's homes, pet therapy is a very nice concept. It also means, however, that the animal comes but then goes. It constantly reminds people who like to be with animals of what they have lost.

The same applies to being able to care for a garden or your own home. We assume that when people are very frail they just need to be recipients of constant care, but in fact they need opportunities to give back, otherwise they lose their raison d'être.

I would like to suggest that there are different models than we traditionally use within our long-term care settings regardless of the physical environments. We mentioned that those buildings look like hospitals. However, if you work hard enough, you can create community even in those lousy architectural developments. To do that there has to be a profound attitudinal shift, from the directors to the front line staff, to families, to people who live there, and a change in philosophy of care. I have mentioned in my brief a number of options for creating that kind of environment.

I also wanted to mention the situation that Faith talked about, the Casa Verde inquest. The coroner's report was superb with respect to recommendations that came out of that scenario. If we followed those recommendations, we would be creating environments that were, first, much safer, and second, provided a much better quality of life for people living in residential care.

The Chairman: Do you want to send us those recommendations?

Dr. Drance: They are actually in my brief.

The Chairman: Good, because I have not had time to read it.

Ms. Sirett: We will probably need to speak more about this when we talk about multicultural and diversity issues. However, when you ask what is being done for the Aboriginal population, in an environment like Vancouver we are starting to look at models of working on the different strengths within a community and developing services that work for the Aboriginal community. It is a limited program and it is not enough, but we have a native liaison program worker who runs traditional sweat lodges for clients with mental illness. With his experience of working with people with mental health problems, he has an understanding, acceptance and tolerance of their behaviour. There are small examples of things that are happening. Again, it is not enough, and I cannot speak to all of them, though I should be able to.

Ms. Flower: I would just like to reflect on what Elizabeth was saying. I had an opportunity to be in Hong Kong and look at the care provided in an institutional setting for older adults who had physical, mental and developmental difficulties. I saw simple things such as flooring that was really important in reducing falls, upholstery that was washable but not plastic. Yes, it is a bigger cost, but not a huge one. I will send you some information about it. As you are aware, I work in a hospital, and when behaviours get too severe, people will be isolated. Our method of isolating someone is in a room with a bed that is bolted to the floor. In Hong Kong they used a room that was made to look like a living room. Yes, everything was bolted down, but there were comfortable chairs. There was a television set. There were knickknacks on the bookcase. What is the difference?The difference is that when you are in a place where there is just a bed, your anxiety rises enormously, and we are trying tode-escalate the behaviours. I did see an older person being taken into this room, and that person's attitude changed, because it was recognizably a room in a home. It might be someone else's home. However, that impacts the behaviour. People could go back to the behaviours that were more familiar to them, and they were certainly calmed down much faster and in a much safer, more respectful way.

Ms. Crawford: I just wanted to make a comment about family and caregiver support. Yes, it is extremely important, but we cannot forget that there is a group of older adults and seniors out there who have nobody. Whether it is because, due to their mental illness, they unfortunately did not develop a relationship, have a family, or through again unfortunate circumstances with mental illness and addictions, the family support just is not there any more. We need to be looking at a supportive environment for them where they can live with dignity and respect. They do not have to be warehoused in a deplorable boarding home, sharing a room with three other older men and having to urinate in a bucket under the bed because they cannot get into the bathroom.

When we opened St. Anne's we worked closely with the women's shelters and moved in 50 older adult and senior women who were homeless and living in the shelter system. Why were they homeless and living in the shelter system? Through mental illness or whatever, they were evicted from their apartment and have nobody. They have nobody. There is an entire group out there who do not have that kind of family caregiver support, and we cannot forget about them.

Ms. Spencer: I would like to build on some of the comments that Suzanne made about having family. Another part of that is recognizing that not all family relationships are necessarily supportive, and that in different kinds of circumstances they can become strained. One of the areas that I work in is abuse and neglect issues for older adults, and particularly the dimensions of physical, psychological and financial abuse.

One of the most common risk factors in the area of elder abuse — I do not like that term — is substance use and mental health issues. Sometimes it is the older adult who has the problem. Sometimes it is the other person, usually another family member, who has the problem. Typically, we are talking about people in their forties with mental health and substance use problems and who are unable to find affordable housing, obtain appropriate services or have adequate financial resources, either through employment or social assistance. They tend to move back with aging parents. If all of their different needs, including their mental health or substance dependence needs, are not being appropriately met within the community, then they suffer and their parents suffer. Therefore, when we are thinking of issues for seniors around mental health, we also need to be cognizant of the intergenerational issues in this area.

The Chairman: One of the items we have left to deal with is what do we measure? How do we know if we are doing better? You may want to call it measurement or data. You may want to say "Here is the service-related research that needs to be done,'' because we fully recognize we will have to kick start CIHR to start doing some that is actually useful for our purposes. However, we are happy to do that.

The second issue will be what is the appropriate training, particularly for front-line workers? That is critical. What do we do to offer support to family caregivers, and maybe even training for family caregivers?

Finally, I want to talk a little about cultural diversity, not only in the Aboriginal area, but particularly in the Aboriginal area, where anyone who has looked at any of the data will recognize that on the mental health and addictions front, Canada is a third world country at best, if not worse.

It is very clear that, in the end, one of the big gaps, not just in mental health but throughout the health care system — although it is worse in mental health than elsewhere — is a complete lack of output measurement data to know whether or not what we are doing is working, whether it is making anything better. I think some of the material Faith gave us has a research agenda to back it. Others of you had documents in which I noticed an appendix with additional research information. Clearly, we will have to argue for additional money to be spent on research. Whether it is a reallocation or new money is a different issue. That is up to us to decide, but we will clearly need to ask a number of research questions. The pivotal issue in that sense will be to know exactly what we need to measure and what we need research on.

I would like to have a brief discussion of that to give us a flavour of what you think needs to be done, but could I prevail upon all of you to run that around your minds for a few days, and even if you just say, "Look, here is at least one question,'' we will compile a list. I think we have to really push the research community to start doing something useful as opposed to what they want to do.

Dr. Drance: I agree with that. I think one of the challenges is that we need to create strong partnerships among the care providers, families, the Alzheimer's society and formal researchers, because even if we tell the more academic groups the questions that need to be answered, since their experience is not with applied research, many times we do not get the answers that we need. When we are looking at creating a research agenda, we must focus on making sure that there is a partnership between the people delivering the services and the people conducting the research, so that it is not just "You ask this question, here is our solution, and now can we come and measure it in your place.'' No. It has to be something much more integrated than that.

The Chairman: That is important, but we need to find a way to get research done by academics, which is fine, because that is what the research community is, in a way that is actually useful

Ms. Malach: I would strongly encourage everyone to take a look at this report on the workshop that the Canadian coalition put on. I included it in the blue package. We broughttogether 47 key researchers from across Canada in different disciplines to talk about exactly this issue: What do we need within the seniors mental health community? What are our themes? What are our barriers? What are our enablers? This report sets all of that out very clearly. We heard not only that we need a lot more research, but that we need research by various levels, not just academics, but people in the community who are doing the work, rather than in laboratories and in isolation.

We also heard that researchers within Canada who are working in seniors' mental health have no idea who the others are, and it is a very small group so it is disturbing. They wanted a network for them to clearly know what research is being done, who is doing it, how to get in touch with those people, what the outcomes are, and then how we can transfer the knowledge to clinicians. The coalition agreed at that meeting to at least take a stab at creating this seniors' mental health research network. Of course, our problem is the funding for it, but in reality it is not that much money. We are talking about setting up something electronically.

The Chairman: We are bound to have to recommend some form of a knowledge exchange centre that would be funded in some capacity or other and which would include not just those questions, but best practices and all kinds of other information.

Ms. MacCourt: We had a similar process. The B.C. Psychogeriatric Association and the Seniors Psychosocial Interest Group brought together not just researchers, but practitioners in the field of seniors' mental health, advocates, seniors themselves and seniors' organizations, and that is where the psychosocial research agenda at the back of our submissions came from. The reason for focusing on psychosocial research was the emphasis on the biomedical and the greater funding for that in general.

We did approach CIHR. We examined their material — and this is not news to them — and they fund very little psychosocial research in the neurosciences of mental health and aging. A very small proportion of their money goes to psychosocial research. Part of the reason for that is they do not have the right kind of people there to review qualitative research, for instance, which sometimes is the case here, or non-biomedical research. That becomes a detriment. They do not have as many submissions, never mind as many people who are successful proportionately. That is why we in particular are pushing the psychosocial research agenda.

I am an academic and a clinician, a researcher. I am all those things. I have a foot in each of those camps, which is helpful. I was very struck by the centres of excellence in Quebec, and CLSC is one of them, but it is a research centre for building capacity. They have their own researcher attached to the geriatric mental health outreach program, and so they are able to do exactly the kind of applied research, Elizabeth, that you are talking about. It is a funded position, so they can transfer the knowledge too.

The Chairman: It is community based too, I presume.

Ms. MacCourt: It is, and when I last spoke to them, they were doing a major reorganization of the way each CLSC looked at its own community and identified the populations. In their particular community they have seniors as their population, seniors' mental health and also multiculturalism, and they said they have translated different kinds of information about mental health into about 30 languages. That is a model whereby you could do research that has meaning

The Chairman: Lucie, can you find this information? Just as a matter of curiosity, in Quebec, and take the Montreal regional health authority as an example, are the CLSCs part of that or are they separate? Do you know?

Senator Pépin: They are part of it.

Ms. MacCourt: It seems to be a quite different way of doing things. It seems to be much more community-based, from my understanding, than in the rest of Canada, and perhaps more locally responsive too. As I say, I do believe they are changing. The only other thing I would mention is that the network of researchers is a really good idea, as there are people in small cells and different universities. There are various centres on aging. I belong to the centre on aging at the University of Victoria, and there is one at Simon Fraser. There is now a Centre for Research on Personhood in Dementia here in B.C. too. There is a variety of centres, and even linking them together in your own province is an issue.

We suggested at our research forum that while people could put their ideas out there, they were not well received because the funding is minimal and short term, and we all compete. It is set up so you have to compete for the money through academic procedures that make it difficult for people to collaborate, especially in academic settings. They are not rewarded for collaborating with clinicians, and if you put clinical people on your research team you actually get marked down by CIHR. You are less likely to get funding. Issues like that also impinge on what we do.

Ms. Spencer: This is a follow-up to the comments that Elizabeth Drance was making and recognizing the fact that we are talking about outcomes or outputs in terms of research. We are talking about material that is very "soft'' and difficult to pin down, to select out. From a research perspective, that is challenging, and if I were a community program operator, for example, I would be quite cautious about the outcomes of that research. Does it catch the nuances of what we are doing here, and will it actually undermine our work in the long term?

I also wanted to mention that maybe we need to be thinking beyond the CIHR in terms of where the research can be done and what needs to be done. For example, Canada Mortgage and Housing has an external grants program. It is quite small, though. That is the problem. It is $25,000 per year, but they also have an internal program. Maybe there are ways we can promote mental health and substance use issues in some of that housing research. It is a challenge to get them to think of that area, but sometimes, a gentle prod from somebody other than the researchers can help to influence that.

The Chairman: I get the message. Let me give you an interesting example.

I had a private conversation with Ivan Fellegi. Statistics Canada did a study about a year and a half ago on the state of health care of Canadians, but also they did a small part on mental health. They are planning to do that every three years, and I said to him that he has to sit down with us and we will tell him the questions we want on the mental health portion. They will agree to do that, and it does not cost anybody anything. It is part of Statistics Canada's regular program. I think we can get a lot of cooperation, a lot of people helping us, but thank you for drawing my attention to a program that I did not know about.

Ms Sirett: I know a lot of work is done on what outcomes and indicators are necessary. I think a key point to keep in mind with mental health and the older adult population is how people manage day-to-day life. People can have Parkinson's, diabetes, dementia, and still be managing in their own home. That is a good outcome. Someone can have schizophrenia and be practising as a physician. The burden or cost to society and health is minimal. The same illnesses, the same diagnoses, can also be terribly disabling, and it is people's daily functioning that we need to be capturing because those are the outcomes that we are working towards as clinicians.

The other thing that we need to be able to measure is risk. We do a lot of work in our system on risk for the elderly population, for our mental health population in terms of how long can we leave people living by themselves, and then whose measure of risk it is. Is it mine as a clinician and my tolerance for risk on that day because I am thinking about my own grandmother? Is it the senior's sense of risk and, "Yes, let me fall down my own stairs.'' Is it our risk, our concern for someone driving, even though we know that taking their licence away will be a big problem? Is it the risk for the hospital systems? If we send somebody home, we should put them in care because they will be better off, even though the risk for falling is as high as it is for people in their own home. Those are important issues that we need to be looking at.

One of the things that I need help with as a manager of a clinical system is looking at research. Jennifer, the best practices document is very good and I use that. I use the B.C. psychogeriatric guidelines for health authorities. However, in terms of numbers and data for the complex group that we see, it is difficult to do research when someone is demented, has a physical illness, functional impairment, and some kind of psychotic illness on top. Elizabeth, you might be able to speak to this more, but you mentioned yesterday people with dementia being able to give consent to being involved in research, that we need to ask their families for that consent and to honour it, because if we do not, we are always guessing. It works for people on this medication if they do not have heart failure, but everybody I know has heart failure. How do I prescribe?

Senator Callbeck: This is a question to Charmaine. This morning you were talking about the importance of collecting information built on correct statistics. You mentioned one of the problems is the national surveys. Did you want to say that they are mostly based on young people?

Ms. Spencer: Good question. Yes, there are problems with the questions that are included in the General Social Survey and some of the health surveys in terms of how they identify the percentage of individuals who have substance use problems, for example. Some of them are provincial surveys. Some of them will include questions from what is called AUDIT, alcohol use disorders identification test. You have to score eight or above before you are identified as having a substance use problem. If you actually look at the questions, they are asking about effects in terms of work, in terms of driving. Questions like that will effectively exclude many older adults, although not all, and do not capture the parameters in which problems might pop up for older adults. That is one of the ongoing challenges in this area.

I was looking at one of the most recent surveys that talked about the percentage of older adults drinking five or more drinks a day more than once a month and I think the figure was something like 6.7 overall. It is actually more like 11 per cent if you are talking about men aged 65 to 69. It is 27 per cent for older women. We have a lot of problems in using that kind of cut-off when indicating a problem for an older adult. Quite frankly, if you are drinking at that level, you are probably in a hospital or you are at substantial risk, particularly if other medications and things along that line are involved. We are only capturing one end of the spectrum of substance use problems for older adults using the current criteria.

The Chairman: Faith, did want to make a comment?

Let me remind you, by the way, your last recommendation says that you would be happy to work with us to identify statistics that are needed and gaps. I am taking you up on that, okay?

Ms. Malach: Absolutely. Our pleasure.

I have just a couple of comments on issues that are going through my head as we are talking about research. A couple of other barriers that we face: When we talk about "seniors,'' I am not sure whether there is an assumption that we are talking about a large range of people, so although the coalition generallysays 65 is the minimum age, some groups go down to 55, others start at 60. However, we are also talking about people wholive to over the age of 100. There are vast differencesbetween 65-year-olds and 95-year-olds, and when we are collecting indicators and looking at statistics, we need to remember that even within the seniors' population, there is a huge range.

The other point is that there is a great challenge in measuring in long-term care facilities when there are no reporting requirements for mental illness. The problem is that people are not assessing it because of some of the stigma within the institutions, so they are not identifying it as a mental illness. They are looking at some of the common symptoms of depression and figuring it is a normal part of aging. There is not the recognition even within our institutions, so when the questions are asked, there is difficulty in knowing the accuracy of the answers.

Ms. Barr: One more quick comment about research so that it could perhaps be included. When you look at health promotion and prevention efforts, one of your recommendations, which I think we are all completely in favour of, is about raising public awareness to decrease stigma. It is so needed. That is the kind of population-based research that is very costly and difficult to do, and the measures are best made over the long term.

The Chairman: Australia is now in its twelfth year of a national anti-stigma campaign. They track the data at the end of every year, and it is absolutely dramatic how they have changed public attitudes. Look what we did with drunk driving in this country. Look what we did with anti-smoking in this country. Look at what we did with Participaction, until we stopped funding it. The reality is that it is possible to change attitudes if you make a sustained, long-term investment. It should be a 10-year run. It is not; we run it for 18 months and then get out.

Ms. MacCourt: The notion of long term applies to research as well.

The Chairman: Absolutely.

Ms. MacCourt: One recommendation our organization would really like to see is talking to funding agencies about the length of time that they are willing to put money out for. Things like mental health promotion, determinants of health and how they affect seniors are long-term projects, as you say. We want to push the psychosocial research agenda because it is definitely the poor cousin, and for the same reason. You cannot conceptualize it neatly and put it in little boxes, but it is an important step. It is a big step. If we cannot do the research, apparently we cannot get the money to do the work. If we cannot do the work, we cannot do the research. It is like a catch-22, in that we are caught in a system that is definitely organized around biomedical thinking and is hierarchical. We want your support for this.

The Chairman: Let me turn to the question of training, particularly for what all of you called earlier today "front- line workers.'' I would like to know first if anybody knows of any that is going on. We know, for instance, if I remember correctly, that there is a two-year mental health support worker program at Brandon Community College. One of the Maritime provinces also had a similar program. Should we be advocating strongly for a two-year program to train people, a community college program? Maybe it does not have to be two years. I am not pushing two years What do we do? How do we describe the training and what is required to meet, as you said, the needs of the people who actually deal with patients all the time? Who wants to take a stab at that?

Ms. Barr: I think that you will remember Christine Bois and Dr. Brian Rush from CAMH, who made a submission to the committee about concurrent disorders, mental health issues combined with addiction problems or substance use or misuse problems. Christine has been heading up a project looking at a training strategy in Ontario around concurrent disorders. They are working with community colleges and it turns out that the personal support worker program — it is a diploma program or maybe a certificate program — was very short, a number of weeks. Now they are changing it to a number of months, perhaps one or two full semesters. I apologize for not knowing the details, but they were very glad to hear from Christine's project team about interjecting mental health and addiction issues into their program, and they will be working to incorporate that into their curriculum. That is an example.

The Chairman: Do you know offhand which community college?

Ms. Barr: There are a number of them around the province. They were all contacted through our network of consultants and a number of them have come forward.

The Chairman: You might ask Christine to send us a note of that.

Ms. Barr: I will.

Ms. Crawford: I find this training, especially for the front-line workers, very interesting. As Jennifer said, it is usually personal support workers, who used to be the old health care aides. They had the health care aide course. They have done away with that now. It is strictly called a "personal support worker.''

The Chairman: Where do they get this course?

Ms. Crawford: There are private learning-enrichment foundations that do it. Local colleges do it. There is no standardization in regards to getting a personal support worker diploma. George Brown College in Toronto is one of the bigger ones, and it is actually an 18-month program. People can go to this place called Integra, which has an 18- week program, and they both offer a personal support worker diploma. There needs to be some standardization in training for personal support workers. It also needs to include the issue of aging and mental illness. It is a basic training program right now that looks at how to give a bath, how to make a nutritious meal, how to clean the toilet. It is very task-oriented, but it needs to get a little more into philosophical issues that are related to aging and mental health. I come back to our organization, and that is one of the things that I think we probably do a little differently, in that we do training, training and more training for our staff.

The Chairman: Which you run yourself?

Ms. Crawford: Which we run ourselves, but it is very important to us. I obviously totally agree there needs to be some kind of standardization in regards to the personal support worker training program throughout the country. I do not know what it is like in other provinces, but in Ontario, it is all over the map.

The Chairman: It is an interesting observation that it is all over the map in Ontario and none of you know what is going on across the country when presumably it is the same skill set. What do you do in your home care program?

Ms. Crawford: The other thing we have to look at is who is taking the personal support worker training program. In urban areas, typically it is new immigrants. It is young women. English is not their first language. It is a quick course and does not cost a lot of money. They can go out there and get a job. I think there are some systemic issues there in terms of looking at attracting other individuals and who is taking that training, especially in urban areas.

The Chairman: As a matter of curiosity, what do you pay? Minimum wage?

Ms. Crawford: No. We recently did a comparison, and we actually pay close to $2 an hour more than the average. The average right now is around $12.50 an hour in Ontario.

The Chairman: What does Providence do? You are a big institutional setting as opposed to supportive housing. Are you using licensed practical nurses, LPNs?

Dr. Drance: We are embarking on a completely different model that is focused more on what we were talking about earlier, that it is the personal care aides who really know the people the best. We are working towards consistency, creating small groupings of people who have a relationship with the care aide and decreasing the number of people they have to provide care for so that they can develop a relationship with people more easily, rather than having this emphasis on tasks. Whether it is a home care worker or a person working in a care home, the focus has being on getting your tasks completed and then your job is done, whereas we are saying a lot of the work is the relationship with clients and helping them to do things that they like to do, as opposed to just helping them to get dressed and eat. Our organization has decided not to go with licensed practical nurses, but to keep our RN numbers as high as possible at the same time as increasing the numbers of care aide staff.

The Chairman: What is a care aide?

Dr. Drance: A care aide is the same as a personal health worker. It is the non-professionally trained group. We also have them deliver the regular medications to people who are living in our care homes, just as they would do if they were looking after people in their own home. That allows the RN staff to function at a much higher professional level and do more direct care and assessments. As Faith said, if the nurses are constantly handing out medications, they do not have the time to do the assessments that are needed. That is why we have gone this route.

The Chairman: Effectively, you are using nurses for things that really only nurses or someone above that training can do, and you have pushed the other tasks down a level. Are you training these people yourself?

Dr. Drance: Yes. Education is such a key issue, because there is the initial education that people receive in college or school training, and then, as Suzanne mentioned, there is ongoing continuing education. In many ways, education is power, so that the more people understand about the issues that they are dealing with, the better they feel able to do that. On the other hand, as I said, you can provide tons of education, but if people then go back to a setting that does not reinforce what they have learned, they just go back to doing the tasks.

The Chairman: It is a culture change.

Dr. Drance: It is a culture change, exactly.

The Chairman: Are you finding, as Suzanne said, that in Vancouver the workers are largely immigrants, non-English speaking, et cetera?

Dr. Drance: I would say probably 70 per cent of our care aide staff are from other cultures, and I think that many of them come to the work with a real desire to form relationships with people. They come out of their training with that same desire, and then they enter the workforce and it is nine baths to give and ten people to feed and they do not have the opportunity to do the work that they have been trained to do and want to do.

The Chairman: They focus on the aid, not the care.

Dr. Drance: Exactly. Only by virtue of the fact that the system has pushed them to do that, not because of anything that they might want to do.

Ms. Spencer: I wanted to comment that if you are looking at what is happening across the country in the public colleges, through Seeking Solutions, our cross-Canada project on seniors and alcohol issues, we did a survey of colleges in every province and territory on anything to do with seniors' mental health or addictions issues. That will be current to about late 2003, early 2004, so we do have that available.

The Chairman: Good. That would be helpful.

Ms. Spencer: There is also an issue with public colleges in terms of curriculum development, and that is driven by economics. If they think that they cannot sell the program to the students, it will not be offered. We find that some of the community colleges in different parts of British Columbia cannot get sufficient enrolment in courses for services for older adults because it is not seen as sexy and likely to provide stable employment. It is a big challenge in parts of the province for a community college to offer a residential care aide course generally, let alone on the mental health aspects and things along those lines. Again, this speaks in part to the ageism issue and our way of looking at working with older adults.

Ms. MacCourt: Just picking up on that, there are distance education programs too. Home support workers are the ones who go into the homes, and the care aides go into the facilities. I thought that in the public system, at any rate, people now have to have training to be employed in a long-term care facility or as a home support worker. They have to have training in geriatric care. The degree of emphasis on mental health or addiction really varies. In my experience, it is usually picked up by the psychogeriatric outreach programs that provide that mental health component as part of a training course, or there might be a psychogeriatric educator in the community to provide the extra training. They might speak to someone at Malaspina University-College, where I am, but ongoing education is a hit and miss affair. In B.C. right now — and we can pass this information on to you — there is a project under the chronic care model looking at dementia care, education for caregivers and care providers, trying to establish a provincial program. Initially, it was to be built on the Ontario model, but I think that has changed.

The Chairman: A provincial program to be delivered through community colleges?

Ms. MacCourt: A variety of methods, but one standard curriculum with components that need to be addressed for people entering the system and those in the system. However, there is no money, so everybody came together to create it and now they are going to the provincial government asking for money to fund the network they are building and the delivery of these modules. It will be in a module format. Martha is also doing case-based modules in geriatric mental health for multidisciplinary teams, including care aides. That can be quite effective. There again, there was funding for the creation but not for the implementation. There is a lot of material around, but it is not being implemented. We also have the private college system, and frequently people on social assistance are directed there as a short-term method of getting some education to get out into the workforce and get paid. It is necessarily by their choice, but also it does not mean there are necessarily jobs.

One of the issues we have faced is the "de-skilling,'' where you keep pushing down the level needed to do any particular task, but not necessarily with the support or the education for that. Another issue is lots of casual employees are being used inlong-term care facilities and home support in spite of the emphasis on continuity of care and the mission statements of various places. They bring people in for half-shifts. This creates problems with morale. It creates problems with the motivation to get the knowledge.

The Registered Nurses Association of B.C. looked at thefull-scope RN and the full-scope LPN in long-term care. They have just done a report, and we could get that for you, if you like. It would give you a sense of what those roles could be. There is also a group from the community colleges in B.C. that could likely provide curriculum information if you are interested. However, unless it is made mandatory for the private as well as the public operators to hire trained people, and unless there is more about mental health in the curriculum than there is currently, it is not as useful as it could be. It is better, but not as useful.

I would just like to touch on the issue of culture, what we train people to do, and the focus has been on the bathing and so forth. I have just done 15 focus groups on long-term care around psychiatric behavioural problems of dementia, education and that kind of thing. What comes across is there are very different cultures and facilities, and there is inadequate research in this area, but you wonder what is it that causes a culture to be the way it is? In some places that have the same number of staff as others, they do pay attention to the residents as individual persons. They are focused on relationships and are supported by management in that. The morale is usually quite high. In other facilities that is not the case, and people are actually quite cynical. They have begun to feel over the last couple of years that our resources keep shrinking in this province for long-term care, for staffing and so on. We try to do more with less, in many ways without addressing culture, team work and the area of relational care. We set up our front-line caregivers for what we call "moral distress,'' that is the catchword these days, but where they are caught between. As Elizabeth said, they come out of training keen. They came to the work because they wanted to and because they care, and then it is bang, bang, bang, bang, just keep moving on those nine baths. We set them up to experience a lot of angst about the work they are doing, never feeling they do it adequately.

Quite often, we will throw education at them. I do it myself. You talk about individualized care, you talk about behavioural recordings so that you can follow behaviour, and you talk about care planning meetings, but in many facilities those things are not happening. In home support there is even less because they are not in one spot. You have people who are not well trained, whose real asset is themselves, not being well supported and trying to provide care out there. I do not know how you want to talk about that, but it is more than training. It is supporting those cultures and providing the incentives. It is not at issue of more people necessarily, although there is a point at which you do need more people. It is more a question of support for the people who do that work

Senator Trenholme Counsell: The situation in institutions, where workers have to give ten baths and feed eight people, is very real, and I do not know that that will change because of the time allowances for so many hours per patient of nursing time and so many patients to look after. It is terrible for the people who work there, and I do not really see it improving because the level of need of the patients is increasing. You do not get into many of these institutions unless you have great needs. I am just wondering if we have in Canada any kind of brochure in praise of caregivers for seniors that could be distributed to home care workers who work in individual homes for one hour, two hours, four hours a day, whatever it is, or in nursing homes to the people who are not registered nurses or registered nursing assistants — or even to them — that would, first of all, empower them and congratulate them on what they have become. I think it is a very discouraging situation. They probably have little feeling of being valued in our society, and they should be valued.

You could have also publications with brief but valuable information on what to look out for. Many times today I have thought about the seniors coming to me — not only seniors, sometimes other people who have problems with confusion and delirium — with bags of bottles of pills. You have to sort through that now. This is what a nurse practitioner would do so well, but that is just one thing that people who work in the homes should look out for. It is not a problem in the institutions. I do not know whether the mental health association or the federal government could make that happen, but maybe it would be empowering.

Ms. Flower: Thank you for those words, senator, because there is tons of written information out there. Certainly at CAMH we look at language that is not above a grade 5 reading level because we need information that is clear, that is precise. There are two problems: To give the definition of the illness, the depression, for example, is one thing, but to let people know what steps they should take is something else. The pamphlet that you would like to see, and which I think is easy to produce and would be very worthwhile, would offer support there, but there is a hierarchy. The registered nurses would look at it, and that does not apply to them. It is not for them. However, certainly the Registered Nurses Association of Ontario has fact sheets on best practices and we have an excellent module for long- term care in Ontario. We ourselves at CAMH have a number of these one-page information sheets. I think it would be very inexpensive and would raise the persons' sense of feeling valued. I would also like to talk about how the personal support workers have to provide 10 baths in a certain time. I think we have to look at what we are doing. Who says everyone has to be bathed every day? It is once a week, if you are lucky.

Senator Pépin: As nurses, we have to give 10 baths a day.

Ms. Flower: I think we have to note the value of the personal conversations that go on and make that a higher priority. It is a better mental health approach than the other route of "we must.'' If I could just tell one story — we were told this by personal support workers — Mr. X was such a dreadful person. He would not get into the shower; it took four staff to get him into the shower. We asked, "What do you know about Mr. X?'' They had some ideas. They knew his family and so on. What they had not understood was that Mr. X was Jewish. He had been in a concentration camp as a child. As he aged and his mental ability shifted, the fear of getting into a shower just devastated him, and we were sending four people to force him in. That is not healing and it is not capturing the stories, because the stories are the essence of the individual

Ms. Malach: My thought is that we have to put a lot of emphasis on training needs; the coalition would agree that training is essential. We also talk at the coalition about raising the accountability beyond the providers, the people already committed to being there and caring for people, the caregivers already committed to being there and caring for their loved ones, to make the hospitals in the provinces also accountable It is often a challenge for us when we hear that service delivery numbers or staffing numbers will not change because of resources, but yet we still expect people, whether trained or not, to show certain behaviours. We often talk about what would happen if we made training in mental health issues part of an education accreditation within all hospitals and long-term care facilities. The idea would be to make sure that within provincially legislated long-term care facilities, it is specifically identified that nurses have to provide a certain number of hours of mental health care, just as they have to provide one or ten baths a week, whatever it is, and actually have it written down. We have looked at the legislation in Ontario with Monique Smith and realized that the terminology does not fit within mental health. "Medical care'' means physical care. "Training'' means medical training or how to give baths or showers. We want mental health explicitly defined as part of care, and we want it specifically defined that training should not just focus on falls prevention and restraints issues, but also on mental health issues.

The Chairman: In effect, you are telling me that the legislation is strictly oriented towards physical care. That is it?

Ms. Malach: Yes

The Chairman: Mental health is not a negative. It is just ignored?

Ms. Malach: Yes.

The Chairman: Is that true in other provinces? You are giving the Ontario example. Anyone know about B.C.?

Ms. MacCourt: The facilities have changed tremendously in the last few years. In Manitoba and B.C., historically, they were for people who could still walk and did not have dementia, an entirely different population. That is why our facilities are so poorly adapted for the people we are trying to care for now, and the staffing levels have not changed. They may have even gone down, and yet, as Elizabeth has said, the complexity has increased tremendously. It is all physical care. The other issue is the multidisciplinary team we talk about. That has been decimated too in long-term care, so you basically have your front-line workers and a nurse, and you might only have one for 50 people on nights, when everybody is tucked away in bed, hopefully. That is the historical situation and it has not changed. You could recommend changes.

Ms. Spencer: Senator Counsell was asking about ways to recognize the formal caregivers, and actually in Quebec there is a Roses d'Or program run by FADOQ, which is basically a federation of seniors' organizations. Roses d'Or is a recognition of facilities that are doing things well. It is a very positive approach. I think words of praise are extremely important, but I also think a pay raise for service providers and caregivers would be nice, as would a full-time job.

Senator Trenholme Counsell: I would like to think of a broad way in which we could possibly do something like this, maybe a booklet saying "Thank you for caring,'' because in every institution now you will have people who are 25 years old and people who are 95. Of course, the majority are in the older age range, but you have people with severe cerebral palsy or accident victims with brain injuries, and so on and so forth. These same caregivers in our communities are going into homes where they may spend two hours a day caring for someone who is 95 and the next two hours with somebody who is five years old, because many of them are employed by organizations that provide care. While government does legislate so many hours, I do not think you could ever get them to think in terms of a budget of so many hours for physical care. It is the attitude that has to change. You cannot legislate that, and you cannot say, "There will be a half an hour a day for mental health.''

The Chairman: That is what I meant by "culture.''

Senator Trenholme Counsell: That is right, but we can raise this, if we are going to talk about caregiving in this mental health report, which obviously we are. It is a caring society, if you will, and it is looking beyond the bath. When you are giving a bath, whether it is to a baby or someone who is like a baby and is 95, it is the same thing. You are not just washing the skin. You are caring for the person, and I think we can talk about this philosophy of caring.

Ms. Barr: CAMH, the Centre for Addiction and Mental Health, is in fact coming out with a booklet. It will not be called "In Praise of Caregivers'' unfortunately, although that is a great title, but it is "Responding to Older Adults with Mental Health and Addiction Challenges,'' or substance use challenges, I cannot remember. Anyway, it is a booklet and should be comingout in the next six months. It will be very inexpensive, maybe between $5 and $10, or possibly free, depending on what funding we can find, at least throughout Ontario, and there are other educational materials that we are working on.

Charmaine is busily writing some material for us that can be disseminated as a beginning. You are talking about something else. I just wanted people to know that was in the works.

Ms. Sirett: I hope my comment does not seem too frivolous, but there is just a slight irony. This is an excellent booklet. I just want to point out the disclaimer at the back, that the views expressed herein do not necessarily represent the official policies of Health Canada. I just found that a little ironic.

Ms. MacCourt: That is my booklet. That is produced by the Seniors Psychosocial Interest Group. I did not know that you had to put this statement on everything, so I had to have a stamp made and stamp it on about 10,000 copies by hand, even though they paid for everything.

The Chairman: That is your caring federal government for you. That is a joke we will have to find a way to include somewhere, a good note of levity.

Dr. Drance: In reference to the issue of nursing hours and how we are not likely to see an increase for the people living in care homes, that is quite distressing, because I do not think that would be the case if we had developed a new technology in an acute care setting that required more nursing hours for a good outcome. We would not even question it. It would be how and in what way we would reallocate those resources. I would also like to point out that nursing hours across the country are completely inequitable, so that places in Saskatchewan provide over three hours of nursing care for the same kinds of people to whom, say, B.C. provides 2.8 hours. Looking at this inequity is perhaps something that we could encourage.

The Chairman: You mean nursing home regulations?

Dr. Drance: Yes. The numbers of hours that we are funded for is very different across the provinces.

I also wanted to mention the labour environment. We have wonderful workers who do provide excellent care and who, at least in British Columbia, were fairly well compensated, but there was a rollback and unfortunately they lost wages, which was just unbelievable in the context of increasing complexity. One of the other challenges within that labour environment is that you do not always have the right people doing the right job. People with the most seniority are promoted and hired into ongoing positions, which it makes it very difficult, because many of the younger people or the people who have taken the training have the interest, have the gerontological experience, but we cannot hire them for those positions because of our labour situation. That makes it a little complicated.

One final story that I have not mentioned, but which I think is important, is that things can change even when the resources are extremely limited. Our health care organization, in which we have 700 elders living with us in very traditional care settings, has adopted a philosophy of care known as Eden, an alternative philosophy that has traditionally been thought of as bringing in pets and plants and children, and that is nice, but it is much more than that. It is a set of 10 principles that helps us to move towards truly person-centred relational care. It is, as you mentioned, Mr. Chair, a labour of culture change, and culture change does not happen in a year or six months. It happens over a decade. People are frustrated. They want to see the changes happen quickly, but we are in the midst of a revolution in looking at the way we can deliver care differently and getting back to thepre-1960s when people longed for the small communities of care. There are good things happening.

The Chairman: Could I then turn to the cultural question, not just in the sense that Suzanne mentioned, and I think you used the example of Chinese workers and so on. I am also curious to have Margaret comment on the question I raised earlier. Your document says it is not necessarily the best thing from the patient's point of view to have someone trained in a particular culture and a particular language. I would like people's comments on that, but with a particular focus on the Aboriginal community, not because Senator Gill is on the committee, but because we have been appalled as we travelled across the country by the quality of service for Aboriginal Canadians, whether they are on reserve or, in cases like Vancouver and Toronto, off reserve. Does anybody have any thoughts on what we can do, what we ought to recommend on the multicultural question, but more specifically on the Aboriginal question, in terms of providing service? Is anyone doing it well?

Ms. MacCourt: I did some mental health promotion work across Canada not too long ago, and there are some good models. There are some ways in which services are being delivered. For instance, I think it is in the Northwest Territories, or it could be the Yukon, people living in very isolated communities have to fly down quite frequently, and of course there are tons of complex medical problems. The band owns a house in town where they serve traditional food. They are accompanied to the house, they have a cultural broker who goes with them to all the appointments, and whatever customs are appropriate for that particular group of people are followed within that house. The spiritual aspect is there too, so that is available in the city.

The Chairman: Where is that?

Ms. MacCourt: The house is in Vancouver, and I think the program comes out of the Yukon, but I can get you that information.

The Chairman: I know, for instance, what they do not do in Ottawa. People often come to Ottawa out of Nunavut. When people come from Nunavut for treatment at the Ottawa Hospital, they do bring an interpreter with them, but the purpose of the interpreter is not a cultural one. It is because the individual actually cannot communicate with the doctor. I would love to see that. Does anybody else have good news, bad news?

Ms. Sirett: I do not have anything specific to add about the Aboriginal population other than what I mentioned earlier.

There are some models of cross-cultural care, and that is one way that we are looking at things. Everybody involved in health care should have some competence to learn from the people they are working with, the clients, about their culture, and be able to help interpret what I am doing as a clinician to their culture and vice versa. We are looking at it more from a cross-cultural perspective. For example, it is important to have language interpretation, but it might not necessarily mean that a Chinese doctor has to see a Chinese family. A Vietnamese doctor could easily see a Chinese family, for example. However, we must all have that understanding and cultural competence. We actually have a cross- cultural clinic for mental health where there are a number of psychiatrists, most of whom do speak more than one language, but they do not just see people from their own ethnic or language group. They all have an understanding ofpost-traumatic stress disorder. It is important in a city like ours, where we have lots of refugees. That is a particular competence.

I do not know if we know enough about the elderly who come to Canada as refugees and have been victims of trauma or torture. We are trying to develop programs that can be more responsive and flexible, depending on the refugees that are coming to our city. We have specific programs for our largest groups, like the Chinese, the Sikh population, but, for example, in the last decade we have had a large number of people come from EasternEurope, the former Yugoslavia. Were we adaptive enoughfor that group? Probably not, because we only had Chinese-, Sikh-, Vietnamese- and Spanish-speaking workers, but we did not have that cross-cultural competence where we could go in and work with them.

The Chairman: What do you do with all the Aboriginal street people in Vancouver? It is in your territory.

Ms. Sirett: It is.

The Chairman: What happens?

Ms. Sirett: Penny, maybe you can speak to it.

We do have specific services within Vancouver Community Mental Health. There is a native health liaison program within Vancouver Coastal. I am just not as well versed in it.

The Chairman: You understand why I am asking, because it is a huge percentage of your street people.

Ms. Spencer: I do not have a lot of information on health issues of older Aboriginal people with me today, but these are some of the things I do know. I know, for example, going back to an intergenerational perspective, that within some of the communities on Vancouver Island, older Aboriginal people are actually the supports to younger persons with substance use problems. They are the role model and the support around the mental health and addiction issues there. One of the best-practices sheets that we developed out of the Seeking Solutions project is on working with people who are identified as hard to house, hard to help, people, for example, who are living in the Downtown Eastside, some of whom are older Aboriginal people, and looking at what works well with them and what does not.

We have that kind of information from a counsellor who works with them one on one as well, looking at things more broadly in terms of the variety of different cultures. I think it comes back to looking at the impact of different kinds of federal policies on the well-being of older adults. It is important to understand the connection between cultural position and poverty, particularly in terms of immigration. That includes things such as old age security policy and the 10-year rules that leave a lot of older immigrants in very poor circumstances throughout their senior years, and understanding the effect that has on their mental health.

We have some cross-Canada research looking at rates of depression in Chinese communities. It varies among older Chinese people in different Canadian communities and varies quite significantly from community to community. For example, in Vancouver, the rates are actually higher than in some of the other communities. Older members of the Chinese community have been here a long time, but they can be quite isolated both by the language and by changing family roles. That is negatively affecting their mental health.

We need to understand the different ways in which signs of depression show up within different cultures, and it may not necessarily be the typical signs. More often, it can be somatic symptoms instead — changes in sleeping, changes in eating, things along that line. We have bits and pieces of information that apply within different cultures. It has only been popping up within the last couple of years. This is quite new research. Again, it is in isolated pockets, and we do not have a way of bringing that information together and being able to share it across the country.

Senator Trenholme Counsell: As I was listening, I remembered going to a First Nations community, to their new health centre. The minute I walked in the door, I realized that there was a sense of spirituality there. It was apparent throughout the place. I think that this concept of bringing the mind, the body and the spirit together is one that we should learn from our First Nations peoples. Of course, it is the essence of the World Health Organization's definition of health, and we should talk about that a lot more. It is very relevant to what we have been talking about today, the mind, the body, and the spirit. Those are not the exact the words of the World Health Organization, but we know what they are. I think that if we can move away from medical clinics to health clinics, community health clinics, community health centres or whatever, we can make these places more embracing and more inclusive. We can talk about healing centres, the concept of healing rather than medicine. I think that we have a lot to learn from the First Nations in this way and a lot to learn from around the world. I would like to see this kind of philosophy perhaps mentioned in the report.

Ms. MacCourt: As a member of a multidisciplinary community outreach program in mental health, how we handled the native population in our community was, basically, we did not. They were down there on a reserve, and we actually have a reserve in town. We just did not make visits there. It was not part of our mandate because it was a federal jurisdiction. There was a liaison person who came to the hospital to advocate for people and try to help them get placed back home, and that was part of the band office administration. When it came to substance abuse and First Nations people, we definitely did not take them because we did not take anybody who had a substance abuse problem. That was not very long ago. Now we have integrated substance abuse and mental health problems, at a theoretical level at any rate. However, there are still areas of federal jurisdiction that apparently prevent us from providing services to that reserve. That is my community.

When I was working on the Seniors Mental Health Policy Lens, which I told you about in my presentation, two of the organizations that came up were the National Indian and Inuit Community Health Representatives Organization, NIICHRO, and the Canadian Ethnocultural Coalition, CEC. I will provide you with information about both those organizations in a letter, because they brought people together from several communities, including First Nations, to identify the challenges that these seniors face to their well being and their mental health within our society. They talked about cultural disruption, ageism, sexism, and so on. There is some print material that came out of these meetings about the needs of people from their perspective that I can supply to you, as well as the contact information.

The Chairman: Who stops you from providing service to people on the reserve? Is it your policy?

Ms. MacCourt: Our policy. It is our provincial mental health department.

The Chairman: It says "Leave it alone, it is not our problem''?

Ms. MacCourt: That is right.

The Chairman: I do not mean to be critical, but the result is that it just does not get done. God knows, the feds will not do it. They may have the legal responsibility, but they will not do it.

Ms. MacCourt: That is true, and it is right in the middle of our community. The other thing I will send to you: I was thinking about your questions about First Nations. When I was doing the mental health promotion work, I talked to people in Nunavut, Yukon and Northwest Territories. I heard some interesting stories about seniors' mental health, because that is what it was about, seniors' mental health promotion, and we were looking at a broad definition of "mental health.'' There are some neat stories there and contact information. That was contract work I did for the federal government. I was telling the researchers at lunch, "You do not own it any more,'' but they will not give it out to anybody. However, I will ask them for it and say you want it, because it is quite bulky. It is full of information from all over the country about what is happening in seniors' mental health, and they are using it as a resource, I understand, but not releasing it.

The Chairman: I know I should not ask this question because it is really stupid, but why are they not releasing it?

Ms. MacCourt: Because they are using it as a resource for their own department. I think there is also maybe the aspect that they do not want to be responsible for doing things. It had lots of suggestions about what they could do, which is part of what they asked for, but they did not perhaps want to be put on the spot and have to do them at that time. I will get that for you.

The policy lens that I mentioned to you is an analytic lens. It looks at policies that affect seniors, like waiting list policies, the policies that Faith was talking about that create barriers for people, those First Nations issues. It looks at policy and programs in terms of accessibility, also in terms of subpopulations. One of the questions it asked was did the policy or program avoid negative impacts for gays and lesbians, ethnocultural minorities, women and so on, the idea being that it is educative too, so if policy-makers were to use this, they would have to consider First Nations. I think the mentally ill are actually one of the groups. They would have to consider the impact of policy on caregivers, and other issues such as accessibility, seniors' sense of security, dignity and so forth. It is based on population health, mental health promotion, healthy aging policy and seniors' values as expressed across the country.

Ms. Flower: To go back to the earlier question on what do we know is happening with Aboriginals, I can only speak for the City of Toronto, and for the Centre for Addiction and Mental Health in particular. At CAMH we have a huge push for diversity. We have been doing this for quite a number of years now. We have diversity champions. We have all sorts of posters in our halls. We really try to monitor it and make sure that we are doing our best on diversity. It was the choice of the Aboriginal community not to be included because they felt that their needs were better met by their own people through the sweat lodges, the healing circles and so on. It even came to the point that, and I think this also speaks to diversity, they recognized that as Aboriginal peoples, going to the Centre for Addiction and Mental Health was not an attractive option; and so they have moved off site, supported by CAMH, to an area that is much more in keeping with their values, beliefs and culture.

The Chairman: But you people provide the service?

Ms. Flower: Not strictly. The program manager makes sure that he hires only Aboriginal people in all the necessary disciplines, so there is a psychiatrist, there are a number of nurses, a number of social workers. The criterion is that they themselves can be seen as part of the process.

The Chairman: Do you have a description of this?

Ms. Flower: I will get you one.

Senator Pépin: My question has to do not with Aboriginals, but with immigrants. I was wondering if it would be reasonable to have doctors from different communities immigrate to Canada. In Quebec, and this is new, many taxi drivers are medical doctors. The proposal is that they be paid to train for a year or two, but that they have to wait to "recycle.'' I do not know if that is the right word in English. They will get their degree in Quebec, following which they will have to look after people from the community.

Do you think that idea is reasonable? How can we go about getting medical doctors to immigrate here? I know they will have to go through maybe a year or two of training, but they can be given bursaries, as we do for students. Perhaps they should have to reimburse that money later. It is an idea.

Ms. Flower: If we are providing, say, two years of training, which would be phenomenal, perhaps we could ask people once they are trained to stay in the area and give back the two years to the community.

Senator Pépin: I think we could do that, because I know that in Quebec right now, if you are a medical student who received a bursary, after you graduate, they will send you to a remote area for so many years and you have to practise there.

The Chairman: There are precedents for that. When I was a student, all kinds of people who were being educated as doctors were actually being paid by the military. The deal was the military would pay for your medical education, and I think you owed them one year of service for every year they paid for, or something like that. For dentists and doctors that was a very common way to get an education. I do not think that is an unreasonable condition.

Senator Cook: I may forget this if I do not say it now, Mr. Chair, but remember when we did the health study, the main one? We had as a witness either a psychiatrist or a psychologist from the Brantford area. She was native and had gone back to work with her people. Do you remember? I think she talked about children. I do remember that she had gone back to whatever the First Nation is in the Brantford area.

The Chairman: Yes. It was during the hearings that ultimately led to our previous report. She was a very early witness. I do not remember her name. We will get you that material. I believe at the time she was the only native woman psychiatrist in the country.

Senator Cook: I do not remember, but we can go back and check.

Ms. Spencer: I was just thinking back to people from different parts of the country who kindly served on our steering committee for the Seeking Solutions project. In Kahnawake, the approach to substance use issues for older adults was to integrate it into the community health clinic, focusing not on ""You must stop drinking'' and things like that, but on building people's level of knowledge on health conditions such as diabetes and gently integrating the drinking information into that. That is one of the approaches that is being used. I know that in Calgary, where we do not necessarily think about an Aboriginal population in the downtown area, but actually it is a poor area of the city, they work very much one on one through the clinic, trying to build the community support and some knowledge of the health connections, again not necessarily focusing on saying "You must stop drinking.''

The other thing that crosses my mind, and this is from a couple years ago when I was asked to give a workshop for the Pacific addictions institute on older adults, most of the people who attended were native care aides. They spoke of the special challenges in and their concern about working with older members of their own community on substance use problems. That was a personal challenge, because they were saying, "I know that I am supposed to respect my elders, but I look at the problem and I wonder why it is like this.'' They are facing a big struggle in understanding the nature of the problem among older members of the urban Aboriginal community.

Our steering committee member from Kahnawake talked about how we need to be cognizant of the cultural changes within Aboriginal communities and recognize the diversity of those communities. Models that work in one area — let's say Quebec — do not necessarily work in Nunavut, Alberta, British Columbia or Prince Edward Island. It is not one size fits all. Figuring out the approach that makes the most sense within a particular community seems to be part of what is working.

Ms. Sirett: I can certainly try to get you some information about what B.C. is doing in Vancouver. One thought that occurred to me while people were talking is my experience of living in New Zealand, the work done there and the mental health system for the Maori; it has actually developed. I believe the Maori developed their own independent system, and it seemed like a very successful model when I was there.

The Chairman: They are 40 per cent of the population, and the constitution gives them a significant role in terms of seats in Parliament and everything else.

I would like to move on to my last topic. What do we do with respect to either training or assistance for family caregivers, because there is a huge burnout problem? I think there is alack-of-education problem. None of us is trained to be parents, but somehow we muddle through. Should we be thinking about a way in which, if spouses or children have to deal with a mentally ill senior, they can acquire some skill sets? I do not even know if anybody is doing that.

Ms. Barr: I would like to promote the idea of awareness strategies, because these problems are so stigmatized. Part of the family's dilemma is that they sometimes face the burden of care, if they can hang in there. The stories in your report spoke poignantly of that very thing. They are isolated, they are pushed away, they are shunned, and so there is no question in my mind that we have to look at ways to support families. The broader approach of raising general awareness to de-stigmatize both mental health and substance use problems will go a long way toward bridging that gap.

The Chairman: Is training an issue?

Ms. MacCourt: We do train family caregivers in my community, and have done for a long time.

The Chairman: Which "we''? You wear a lot of hats. Which "we'' are you talking about?

Ms. MacCourt: From a seniors' mental health perspective, as clinicians, we have done training for caregivers for quite some time. We also do support groups and outreach to caregivers to provide support in the home, and there are respite programs and so forth. The point I would like to make about training, especially for adult children, is they want information. They want lots of information, because that is what our generation has been trained to do, to search for information, so we feel we can cope better. The group that I see as special are the senior spouses, who are usually providing care. I do not know how you feel, but I am already so old that I cannot stay up all night any more. I cannot stay up even half the night and still feel fresh the next day, and very often these older spouses are getting up because somebody is wandering, they are not sleeping because of their own problems and so on, so we set them a very challenging task. I am concerned about that particular group, and training is useful, because I think people like to know what is going on. They like to know about medications, about approaches even, and what dementia really means. That is one of the issues we go into.

I think whenever we have these kinds of discussions and do that kind of work, we have to keep clear in our minds that that wife is experiencing this entirely differently from the objective way that I am providing the information. She is lying to her husband for the first time in her life; she has to because he has dementia. She is dealing with legal systems and power of attorney. She cannot even sell the car because it is listed in his name. There is lots of information you can put out there. I am doing research with spouses right now on long-term care and their own experience of the system, on letting go, and their role as a daughter or as a wife or whatever. We often do not honour that or give it attention. I think education is important, but in my experience it has to be coupled with sensitivity. Also, we do not have enough services to support caregivers. You can get a couple of weeks' respite every six weeks.

The Chairman: A couple of weeks every six weeks?

Ms. MacCourt: You could possibly get two weeks of respite in a facility, go six weeks, and then get maybe two weeks again. That is the maximum. That is only if you are waiting for a bed. More likely you will get it twice a year. For a lot of people, especially older spouses, it is not worth their while. It is too hard to get the person ready. The adjustment process is such it is too hard to take them back. The other issue in home support, and someone has already alluded to this, is when the person dies or goes into a facility, that is it for the caregiver, and yet they are still going through a lot. They do not stop caregiving when the person goes into a facility.

We have caregiver support groups, but people have to come out to them. There is an innovative program that provides outreach to caregivers whereby somebody goes to the home. They are actually other caregivers, people who have had caregiving experience, their peers, and they provide support in the home. Having said all that, with the complexity involved, no matter how much training and support you give, it is unrealistic to expect people to be maintained at home by 86-year-old frail spouses forever. When the time is up, in my experience, it is really up. People go, go, go, and then all of the sudden that is it, and there is frequently no place for the partners. Then they become very ill and suffer from depression themselves. They do suffer from illness themselves as a result of caregiving, so there is a second victim.

Ms. Sirett: I am aware of a couple of programs, including the one that you just spoke about, where a volunteer peer goes to the home. That is a program that I believe the Alzheimer's Society of B.C. and the national society are looking at adopting, and I think it shows a lot of promise as a model.

One of the programs we tried in Vancouver — again, it gets cut as money gets tighter — is the Caring and Learning Program. It brought family caregivers and paid caregivers together — home support or facility caregivers — in the same room to talk about their experiences. They can learn from each other about what to do for individuals. They may say, "This is what works for me with your dad,'' or "This is what works for me with my dad.'' There is a sharing and an understanding of both points of view so that a family coming into a facility can understand why something does not happen when they hear from the caregivers about the pressures of all the other things that they have to do in the day. I think that has been useful. It is not so much related to training as it is to sharing, learning, and listening to each other's stories.

You talked about the information that our generation is looking for. I think it is important to be good consumers for our family members. It is hard enough as a trained person who knows how to navigate the system to help parents and older people do the same, or write down questions for my parents to take to their GP. How do we help other people be good consumers? There are campaigns out there that basically say, "Go and ask your doctor about this drug,'' and those models may be useful.

Senator Cook: Yes, I think that really needs to be addressed.

I will share with you two personal experiences regarding friends of mine. One has a husband who is suffering from early dementia, but I have lost her as a friend. His illness has consumed her totally, mind, body and soul, and she has allowed it to happen. It would have helped if there had been some support for her at the beginning of this process.

My other friend has a sister. Mom and Dad were very special to her. Mom died. Dad moved in, which was a big mistake. You cannot talk to her, so she goes through that process alone. The time comes when he has to go into a long- term care facility. It would have been nice if there had been a pamphlet or something for her the day that she put Dad away. It is about letting go. She felt for two or three months like a gerbil on a wheel, going every day, bringing home the wash and all the rest of it. She said, "I have to go for counselling.'' Then she felt that there was something wrong with her. I think if she had been given a little pamphlet about letting go, or if someone had been able to talk to both of these individuals as part of an assessment, they would not have found themselves in their current state. I think that is an issue that we need to address in some way. I am the counsellor for both of them.

The Chairman: Is Joan's story very unusual or very common?

Ms. MacCourt: It is a common story — here again, I make a plug for mental health — if you keep shrinking the system into mental illness. We used to do that. Our psychogeriatric outreach team used to be able to provide that service. Long-term care facilities used to be able to visit people before they moved in. Now you are lucky if you get 24 hours' notice. Quite often, you do not get information about people when they arrive at the facility because they come straight from the hospital. No records are passed on, nobody is prepared, and also the existing brochures in a lot of facilities right now are out of date, so they are creating unrealistic expectations. It is not as good as it was. You need to re-create that, but you will not get it in a straight mental illness system.

Senator Cook: It has to happen somewhere along the continuum, or we will have another one or two people in the same state.

This facility said to her, "Go away. You are here too often. We do not want to see you.'' Having said that, he is a diabetic, his medications got mixed up, and she went in one afternoon at the regular time and he was out of it. That is not an easy situation for the people who love their family members and have to care for them. He has become more remote now, so it is easier for her to adjust, but when he was reasonably aware of his surroundings, there should have been some form of help.

Ms. Spencer: About five years ago, COPA, an outreach program in Toronto for seniors with substance use problems, actually received funding through Veterans Affairs to look at a program to provide information for caregivers. They found it extremely challenging to do that and to really engage families around some of those issues. As people have been saying, when you are up to your neck in alligators, you forget that the idea is to drain the swamp. That is a major challenge. It is beneficial to be able to offer to family members, particularly in terms of the substance use problems, information regarding issues such as cognitive impairment, frontal lobe damage and brain damage, so that they can differentiate between "Dad is lying to me'' and the damage caused by the chronic problem.

I have very good connections with the various Alzheimer's societies and adult care groups. Personally, it has been challenging, not in terms of the mental health issues, but in getting people to feel comfortable talking about substance use issues. For example, an outreach program in Vancouver called the Seniors Well Aware Program, or SWAP, wanted to look at family caregivers and their substance use — alcohol, tobacco, tea and coffee — and their use of prescription medications. When some of the adult care services were approached, their response was, "We cannot ask that of the people who come here. We have nice people. They do not have those problems.'' Getting people to talk with family members and engage them about what is happening in their lives is an issue.

Again, this is a very stigmatized issue. Interestingly, SWAP did a small study in shopping malls and places like that. In reviewing some of the responses from family members, they found that even where people have home support and other services, they are experiencing significant stress within the family unit. Being able to do that work is really challenging. As Jennifer and others have been saying, it is important to build it into our broaderde-stigmatization strategies, and that may be the most productive approach over the long term.

I want to mention a side-door approach to dealing with the issues that people are concerned about. Several years ago, our centre produced a residents' booklet explaining the rights of residents living in long-term care facilities and their family members. It is amazing how often social workers in hospitals and care facilities use it as a means of helping to reduce the level of stress and concern the residents and the family members are feeling. It was not a tool geared to mental health, but it certainly had a positive effect on the mental health of family members and the residents of the facilities.

Ms. Crawford: In regard to education and training for family members and caregivers, the Older Persons Mental Health and Addictions Network includes family members in all of their training, and we will be doing so in the future. In May and June of this year, OPMHAN did 13 workshops in 9 different communities across Ontario. It was called "Raising Awareness for Older Adult Problematic Substance Use.'' I know that Margaret attended some of those workshops. The network held two different sessions. One was for older adults, obviously, and the other was for caregivers. I think it is a very important part of the whole effort. OPMHAN is a provincial network, but other provinces and territories could take on that role. The network in Ontario has already developed tools and training that could be used for family and caregivers.

Ms. MacCourt: One of the recommendations in our report was about integrating policy and practice, and also funding the national framework. Charmaine was talking about her book, and just like these, I bet you cannot get it anywhere, because the funding is short term, the work is voluntary or project managed, and it dies. Much of the good work here is being done outside of systems, and I hope that this committee can think of a way to link the provinces and the federal government, such as a seniors' secretariat.

The Chairman: It goes back to the point Joan raised. We need programs, not projects.

On behalf of all members of the committee, let me thank all of you for taking a day to spend with us. We really appreciate it. Between the briefs we received from you, your comments today and the material that you will be forwarding to us, I do not think we will have trouble writing a comprehensive chapter on services for seniors. This discussion has really pushed the envelope, and we thank you all for your help. It is been terrific.

The committee adjourned.