THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY

EVIDENCE


OTTAWA, Thursday, May 12, 2016

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:30 a.m., to continue its study on the issue of dementia in our society.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.

[Translation]

The Chair: Welcome to this meeting of the Standing Senate Committee on Social Affairs, Science and Technology.

 [English]

I'm Kelvin Ogilvie from Nova Scotia. I would like to start by asking my colleagues to introduce themselves.

Senator Seidman: Judith Seidman from Montreal, Quebec.

Senator Stewart Olsen: Carolyn Stewart Olsen from New Brunswick.

Senator Raine: Nancy Greene Raine from B.C.

Senator Merchant: Pana Merchant from Saskatchewan.

Senator Eggleton: Art Eggleton from Toronto, deputy chair of the committee.

The Chair: The committee is continuing its study on the issue of dementia in our society. We have two witnesses today.

I welcome back and invite Dr. Frank Molnar, Vice-President, Canadian Geriatrics Society, to present. He is appearing this time as an individual. Dr. Molnar, please.

Dr. Frank Molnar, Vice-President, Canadian Geriatrics Society, as an individual: As a practising specialist in geriatric medicine, I feel I can be of greatest help to you by sharing the harsh realities of dementia care. I have been reviewing the transcripts of previous witnesses and find they have done an excellent job in outlining the investments that have been made to date. Despite all the investments, acute care hospitals are being overwhelmed by the care of persons with dementia. We do not have the resources to meet their needs. We are losing ground and need immediate help.

Hospitals were never designed to care for persons with dementia. When admitted to hospitals, persons with dementia suffer avoidable and prolonged deliriums. They often do not make a full recovery. They suffer avoidable deconditioning, and they lose the ability to walk. Hospital-acquired delirium and hospital-acquired deconditioning lead to high levels of hospital-acquired disability. This in turn leads to long lengths of stay at $1,000 a day, high ALC — alternative level of care — rates, and premature long-term care placement. We are wasting precious health care resources without providing the care needed in hospital.

Given these realities, I wonder whether Accreditation Canada should be asked to develop a required operating procedure which ensures that every acute care hospital has a dementia, delirium and behavioural management service, ideally supported by both geriatric medicine and geriatric psychiatry. When properly implemented, these services would pay for themselves in cost savings, not to mention the suffering they would prevent.

Strategies to help hospitals deal with the escalating numbers of persons with dementia must start upstream in the community to prevent admissions in the first place. Due to hospital financial challenges, many specialist clinics that care for community-dwelling persons with dementia are suffering the death of a thousand cuts. Downsizing and closing these clinics will predictably increase hospital admissions of persons with dementia. We are moving in the wrong direction. That is the bad news.

The good news is that this maybe partially offset by the primary care-based dementia clinics that are developing all across Canada. The model that I know best is the Linda Lee primary care collaborative memory clinics that are rapidly expanding in Ontario. We may have as many as 100 in a few years. These primary care teams are linked to specialists in geriatric medicine and geriatric psychiatry, with the goal of creating a collaborative care model and preventing a silo of care. We recognize that one size does not fit all and we probably need a suite or a series of different primary care, collaborative care, shared care models.

The other promising model in Ontario is the Health Links model, which is focused on intense system navigation and care coordination or case management of the most complex patients. Ideally Health Links could be expanded to include the care of medically complex persons with dementia whose needs have exceeded the resources of primary care memory clinics or specialist clinics, in effect an escalation of investment to prevent avoidable hospital admissions.

These acute care and community care mitigation strategies require that we rapidly escalate or increase the number of specialists in geriatric medicine, care of the elderly and geriatric psychiatry. This begins with education and exposure. Despite the fact that almost 50 per cent of health care budgets and 60 per cent of admissions to hospital are accounted for by seniors and that dementia is the number one driver of ALC, the study of seniors care and dementia care is not required in all medical schools and in all internal medicine programs. There is a clear disconnect between societal need and what universities feel they must provide. We need national accreditation bodies to insure that seniors care and dementia are properly integrated into the curriculum.

An all-party caucus on seniors care has been struck. Given the high incidence and prevalence of dementia in the senior population, this should include the study and care of people with dementia.

The federal government has signalled its intent to sign a new health accord. The need for action on seniors care, including dementia care, should be part of that accord.

Finally, a national dementia strategy incorporating some of the elements I mentioned could significantly assist provinces in their efforts to decrease wait times. If properly designed and implemented, this could save money while freeing up acute care and nursing home beds. Any organization formed to take on this critical role must have federal and provincial decision makers with the authority to shift funding to re-engineer or repurpose existing resources. Without that level of control, a national dementia organization will not have the resources necessary to make the widespread changes required.

With federal leadership, provinces joining such an overarching dementia organization could benefit from a number of items, including shared public education; national health literacy resources for persons with dementia and their families that primary care practitioners and specialists could use; the development of a home-care-plus model that integrates specialists in dementia care right into the home care model; a national repository of leading best practices with supporting cost-effectiveness research; the development of robust new acute care dementia strategies; and enhanced accreditation standards for hospitals, home care and universities to insure they provide appropriate and meaningful dementia education, training and services.

In conclusion, the Canadian Geriatrics Society, as the organization representing specialists trained in the care of medically complex and often medically unstable persons with dementia, would be honoured to contribute to such a national organization.

The Chair: I am now pleased to turn to Ken McGeorge, Acting Executive Director of the Alzheimer Society of New Brunswick.

Ken McGeorge, Acting Executive Director, Alzheimer Society of New Brunswick: It is an honour to be here. The reason for the acting title is that I have retired three times. This is my third post-retirement gig. I am doing a maternity leave coverage as the CEO of the New Brunswick Alzheimer Society and having a blast doing it, actually. As my kids would say, it is one of the most fun and most satisfying jobs I have had.

It is an honour to appear before you and share my passion and the passion of every one of the 12 volunteers who constitute our board and form the Alzheimer Society of New Brunswick.

I am a career health executive with experience administering significant teaching hospitals in Kingston, Ontario; Halifax, Nova Scotia; Fredericton, New Brunswick; and a few non-teaching hospitals as far away Red Lake, Ontario. My career also included experience working in the civil service, which afforded me a public policy perspective that has been valuable. I started my career at 19 years of age, delivering direct patient care. I draw on that experience every day of my professional life.

Our national leader, Mimi Lowi-Young, CEO of the Alzheimer Society of Canada, spoke to you on March 23 about the need for a national dementia strategy. Regarding a national dementia strategy, I can say that the Alzheimer Society of New Brunswick wholeheartedly, without any reservation, supports that initiative.

Hundreds of thousands of Canadians living with dementia are counting on the Government of Canada to lead the way.

We know that the risk of dementia increases rapidly with age. In the Atlantic provinces, we boast that we are older than the rest of you. Nova Scotia and New Brunswick are tied now. As a matter of fact, I think someone said recently we beat out Nova Scotia already. That is kind of interesting.

Cancer was the disease of the last century. I have been around long enough to see how the care, treatment and diagnostics process of all that has evolved over 50 years. Now we need to do the same with dementia. Our failure to do that will lead to unprecedented stress in the health system. It's stressed enough now. If we don't act now, then there will be significantly more stress.

For our association in New Brunswick, our vision statement ends with “defeating the dark shadow of dementia.” Every disease has a dark shadow; dementia has that dark shadow, and it goes like this: First, we have yet to beat the stigma that goes with dementia. We should have. We're grown-up people, but that stigma is still there, alive and well, unfortunately. It serves as a source of imprisonment for families, frankly, certainly for caregivers and for the person with dementia.

Family caregiver distress is legendary now. Everywhere you go when you talk about dementia you hear “caregiver burnout.” It's just there as part of the language.

Alzheimer's disease and dementia need to be accepted as major chronic diseases. They are not yet but need to be.

The next element of the dark shadow is the whole issue of navigating pathways of diagnosis, treatment and support, which is quite frustrating for most persons dealing with that disease. It is less so in some provinces, more so in some others. In New Brunswick, we're working on it.

There are significant inappropriate treatment practices, with hospitals all too often being the default position, and very inappropriately so for many reasons.

Finally, and this one has really hit me big time as I interact with clients who come into our various offices in New Brunswick, there is the loss of hope that families experience once the diagnosis is made. They have dreamed of a wonderful, healthy retirement going to Florida, or wherever they are going to go, and all of a sudden the partner is stricken and all of that is dashed and gone. And that needs to be recognized as a real factor. Everything that we do as a society in New Brunswick targets those elements.

A coordinated national dementia strategy will provide a focus for dealing with the dark shadow in a coherent and systemic way. That is what happened with the national cancer strategy, and that's what needs to happen with the national dementia strategy.

In New Brunswick, we have or are developing a full repertoire of services for persons with Alzheimer's disease. Our repertoire is not yet fully fleshed out, but thus far it includes some of the following items: First, we have our five-part education series, which is first and foremost for people even before diagnosis to give them some really good education on a whole host of issues that they will face through the journey. Second, we are proud of some of the support groups that provide wonderful support to caregivers, and caregivers who are not part of those networks really do suffer for not participating.

We have memory cafés. I understand somebody expressed an interest in that recently here. In any event, memory cafés are a wonderful tool that we are introducing around New Brunswick with phenomenal results, and phenomenal results as well with the iPod project, which is being used in a variety of places as a wonderful alternative to overmedication; it is a fascinating thing.

Minds in Motion is a program we hope to kick off this fall in conjunction with the kinesiology department at UNB. We do a lot of public education, travelling all over the province and speaking to groups. We have a library of phenomenal resources. We do family counselling support, and we have a wonderful program of follow-up with families so that they don't get lost in the shuffle.

Downstream, and flowing from a systemic strategy that we would like to see flowing out of a national dementia strategy, would be five things: a sharper and more coordinated research focus; improved standards of care and improved consistent standards of care across the country; standardized training for those who deliver dementia care; readily accessible best practice information — that is really difficult to come by right now; and, finally, widespread use of all available technologies. There are some wonderful technologies out there that can help caregivers, but in our area, at least, the majority of caregivers are not aware.

The proposed Canadian Alzheimer's disease and dementia partnership is a model that can serve to advance the strategy. It's based on the Canadian Partnership Against Cancer. The cancer partnership is a good working model. The dementia strategy doesn't necessarily need to replicate it entirely, but certainly some of the wonderful principles are there.

The scale, impact and cost of dementia mean that no single province can tackle dementia on its own. Some will do better than others, but a national approach is really needed.

A national dementia strategy would help to ensure that all Canadians living with dementia will have the same level of access and quality of care and services regardless of where they live. It would level the playing field, not only between regions and provinces but between urban and rural communities.

Finally, without a level of pan-Canadian leadership by the federal government, I believe — and I said this earlier and am repeating it for the sake of repetition and emphasis — we will invite some huge problems if we don't deal proactively.

Thank you very much.

The Chair: Thank you to you both.

Senator Eggleton: Thank you very much to both of you for excellent presentations.

Dr. Molnar, in two and a half pages you have given us the state of the nation on dementia in precise terms. You finish off by referring to federal leadership with the provinces joining to form an overarching organization. How would you see we get the ball rolling on that? What organization would take the lead?

Dr. Molnar: The first question is a bit easier than the second question, which I'm sure you struggled with throughout the hearings.

In terms of getting the ball rolling, there are certainly different approaches. One that seems to work regionally and provincially, and you'll have to see if it works nationally, is a project-based approach to start with some things that people can achieve, such as items 1 and 2, the shared public education, which I think Public Health is actually doing fairly well with the national health literacy resources or standards of care. Is there something that all dementia health care providers can go to that's a standard across the country so that they all know how to provide the same care in the same way and they have the same handouts and can provide the same education for families and persons with dementia?

The repository of leading best practices I think is really critical, and that is one I wanted to talk about in greater detail. Leading best practices are tricky. As we've mentioned before, Canada is the nation of a million pilots. We don't move from pilot studies to outcome studies. As a researcher, my definition of pilot study is one that doesn't have a sample size that's adequate to generate the outcome. It just shows you can do the larger study. So we often don't move on.

Some people do promote services that have just gone through a pilot as a leading best, and I've been involved in those exercises where there is really no cost-effectiveness information. We do need a national body that really sets the standards for what is needed to make decisions, what type of research is made, and which of these pilot studies we will invest in going forward.

I think CIHR does that to a degree, but perhaps we need to be a bit more focused in saying we need to know more about dementia health services. We need to see which of these are translatable and how we can move more pilots up.

It's very interesting, in reading the transcripts, a tonne of stuff is being done in research, but it's not reaching the ground. It's not reaching people like me who are providing front-line care. So there are really two worlds: There's the research world, and there's the clinical world, and the two are not meeting very often.

That type of leadership and that type of push to get some of the most promising pilots into larger-scale research or to even try them in the field would be an excellent start. In my experience, starting with specific projects is important. That being said, the point I made in the page before that ultimately this organization needs to have the levers to make change is also critical. If you don't have the financial levers to fund new services or to move funding to reorganize or re-engineer services, we will not get very far.

People love to hear plans about the nature of seniors care, and everyone supports them until they realize that the funding will shift from somewhere else because health care is a zero-sum game; there is only so much money in the pot. We need a combination of both — one, an organization that can push the right projects forward; and, two, an organization to shift money and to re-engineer services. I have no idea who has that kind of authority; maybe it doesn't exist yet.

Senator Eggleton: You think it needs to be an organization outside of government? That is, a partnership of all the different organizations or stakeholders in the dementia care field?

Dr. Molnar: I think it needs to be an organization that integrates government, where government is a central part of it, because we need those people who hold the purse strings to make the hard decisions.

Senator Eggleton: And the role of the Public Health Agency of Canada or Health Canada in all this?

Dr. Molnar: They have been doing a great job in terms of public education, but that needs to be scaled up.

How do you prevent dementia? As previous witnesses have said, it's very much the same things you do to prevent heart attacks and strokes. Some of the obesity work that you have done in previous sessions feeds into that. How do you prevent dementia? How do you align these diseases together? How do you recognize dementia and get help?

Senator Eggleton: I had a meeting earlier this morning about palliative care with a doctor from the West Coast. You don't mention palliative care in your document here. How do you see that all fitting in? There is some question that we need better coordination.

Dr. Molnar: There is certainly an overlap between dementia care, geriatric care and palliative care. The palliative care we provide to people with dementia is lacking in a scientific foundation and in coordination. It’s what I actually do for a living. I am on consults right now in my hospital, and I help the surgeons realize that these persons will not survive. They will not live, and I help them understand that we have to move on to a palliative care or end-of-care comfort stage of life.

I think there is a big overlap. The palliative care group needs to have input from the dementia world so that we can overlap our efforts and make palliative care appropriate for families who are caring for someone with dementia.

Senator Eggleton: You mention dementia plus. When you were here last, you had a program called GEM Plus. Is that the same thing?

Dr. Molnar: No, it's perhaps a term I like to use too often. With dementia-plus care, in my mind I differentiate two types of dementia care that specialists provide. However, this doesn't account for the other types of dementia. One is dementia diagnosis and drugs. We see that in a lot of dementia clinics. That's the focus, namely, the diagnosis, the drugs, the start of the journey. The other part of the journey is dementia-plus care. That is, what do we do as the person with dementia develops the other chronic diseases? We know that 90 per cent of people with dementia in the community have two or more other chronic diseases. That's why they end up in hospitals, and that's why dementias drive ALC.

How do we start to coordinate that? Geriatric medicine was specifically designed for that. We are cross-trained. We are internal medicine specialists cross-trained in psychiatry and neurology. It is coordinating the diseases together. How do you care for a person with dementia when they have heart failure and diabetes? I think the primary care memory clinics are a nice venue for that because the primary care providers are generalists and they understand the other diseases.

Senator Eggleton: I may come back to you later, but I would like to get a question in with Mr. McGeorge before my time is up.

Memory cafés started in the Netherlands, we're told, in the late 1990s. You seem to have had more success picking them up than any other province in this country. How long have you had them? I understand the general purpose of them, but have you done some evaluation to determine how well those are working?

Mr. McGeorge: We have only been at that for about a year. As of right now, we have eight in this small province. The goal is to get at least 13 up and running by this summer.

Evaluation has been, thus far, unfortunately, anecdotal. Having said that, we are working with UNB researchers to do a more broad-based research evaluation of them, when we have enough experience. Thus far the anecdotal evidence is just — I don't care about the research; I love to hear what the people are saying. You see the smiles on the faces of the people who are coming. They have been terrified even to go to church for a year now because dad is acting a little different, so they bring them to this wonderful, safe environment where there is entertainment and education. It's wholesome, dementia-friendly, and he is smiling. Boy that does it for me. In the eight that we have, those are the anecdotal results we are getting thus far.

The Chair: I think Dr. Molnar wanted to come in on this as well.

Dr. Molnar: On the question of evaluation, we need to be careful because with health sciences research we find that if we try to evaluate them just as they are being formed, or within the first year or two, they invariably fail. They haven't crystalized, consolidated and found efficiencies of scale.

They go through at least three stages. The first is development consolidation; at the second stage you can study process measures and try to increase efficiencies; and at the third stage you look at outcomes on the people and on the health care system.

The Ontario Ministry of Health is developing a dementia plan — we met with them last week — through Cancer Care Ontario. They are doing a large-scale, systemic review of dementia services and dementia bundles of care from around the world. I have done systemic reviews, but this one will be monstrous. It really takes Cancer Care Ontario resources. I would recommend touching base with them when they get that in four to five months because that will be incredibly valuable.

Once again, we will end up with gaps in the research. We will need some faith to pick the best projects to get going so that they can be consolidated and crystallized for a few years, and then we can study them. There are still some gaps and nuances to the evaluation.

Senator Stewart Olsen: Thank you for your presentations. They are very good. Of course, I am very interested in New Brunswick, as I am from there.

I am a bit curious, Mr. McGeorge: What is the iPod project?

Mr. McGeorge: In my last pre-retirement job I was at York Care Centre, where we set the organization up as a centre of excellence. We established a research and development unit called the Atlantic Institute on Aging. Through that process, we discovered the music and memory research project being conducted by a researcher out of New York City. He was looking for some Canadian partners.

By the way, if you google “Story of Henry” on YouTube, that will tell you anything you ever needed to know. It's an amazing story of how music unlocks the brain.

What they taught us was that music resides in a part of the brain that is not affected by dementia, which is beautiful. With the iPod project, we work with the families. We ask them, “What kind of music did dad like when he was in his prime?” For example, they say, “He liked country and western.” So we find some great Johnny Cash, or whatever, and download it to the iPod. When he is feeling morose or agitated, we put the iPod on and pretty soon you see the smile replacing the grimace. You see the eyes light up.

If you look at Henry Story, you will see this gentleman who had been unresponsive for, I think, three years. Suddenly, his eyes are lighting up. He is singing and clapping his hands. His feet are going, and he is starting to talk after a while.

We have a donor in New Brunswick who is interested in broadening that through the province. We now have a pilot going in Fredericton and the donor has now said, “If you do real well, I will double my donation so you can roll it out more broadly.”

Senator Stewart Olsen: On the broader outlook — and this request is for both of you — this is a personal thing, but I am curious about it. I am hearing about caregiver burnout and the difficulties in keeping people at home, but I wonder about the creation of the Alzheimer communities and dementia communities, where people can go and live and be cared for — and perhaps they come home for weekends or something like that — and where they are secure and stimulated. With the best intentions, families are usually not able to keep up therapies. Mostly they're working. They come home and they're exhausted, even if they have caregivers coming in. I think that might lead to more fear in the patients, and more uneasiness. I'm wondering what you would think of a stable community or a stable residence that is geared especially for these people.

Mr. McGeorge: We actually have run, for the last nine years, a symposium on Excellence in Aging in Fredericton. We have had speakers from all over the world, except Dr. Molnar, who will be next. One of our speakers last year was the director of a big facility just outside Amsterdam, where in fact they have taken a city block and redesigned it as a dementia care facility. Several people in our province have gotten pretty excited about that.

How you take those principles and adapt them is not clear. When I was at my previous employment, York Care Centre, we used to say probably about 60 per cent of our people had dementia anyway. Our facility was rapidly becoming a large dementia facility.

Dr. Bill Thomas, who is the founder of the Eden concept and ChangingAging, is coming to the Atlantic provinces on a tour. He shocked the news media in Fredericton when he was there a year ago by making the pronouncement that we should stop building nursing homes. He was advocating what you were just talking about, smaller dementia-friendly facilities. You're right; the caregiver burnout is — I have lived it. We were there with our family; we know it. It's not a foreign concept, and it's real. They can only take it for so long before something has to happen.

Dr. Molnar: I think what you're highlighting is that we need to invest more upstream — the more we can invest in a suite of respite options. We have caregivers that are integrated into all of our committees now. What they tell us is not one option; they want a whole suite of options that are accessible in urban and rural settings. So this would be one of a suite of upstream investments. That is critical to helping persons with dementia, their families and hospitals. Once again, our hospitals are being crushed by this load because they're a default care setting that they were never designed to be.

I would be very interested, when the Cancer Care Ontario review comes out, the systematic review, whether that model is part of it and seeing how much evidence they can dig up. They are investing a lot in that. Once again, we do need to go back to the evidence. There is a lot of anecdotal information. Anecdotes are a form of evidence, but you need to see how strong and consistent the evidence is when you look at it in broader terms.

Senator Seidman: Thank you both very much. You have given us an awful lot to chew on, as they say. In fact, I was going to ask both of you what you see to be the essential elements of a national dementia strategy, as that's what we keep hearing about. Perhaps both of you have to some extent given a fairly good accounting of that already, but I would like to give you both the opportunity to go beyond what you have already said to us and perhaps add. Then I do have a couple more specific questions, if I might.

Dr. Molnar: Of the essential elements, number one would be composition. Certainly the multiple partners are critical, including persons with dementia, when and how they can participate; including caregivers; including an urban and rural balance to ensure everybody is integrated; including some underserved populations, such as the francophone population and the First Nations populations that we don't serve adequately. So composition is absolutely key.

As I indicated before, I do think government needs to be integrated into this. We need people who have the authority to make the hard decisions, which includes shifting money within that fixed zero-sum pot. So those are key.

Then we need a model of community verses acute care verses long-term care so that we can outline all of the opportunities, all of the evidence for different services within each of those areas within the journey that people experience, and ensure that the people at the table represent all of those elements in a balanced fashion. So we need to have proper representation and proper authority to make the really hard decisions, because everyone is in favour of these ideas until they realize it's their money that's being shifted. We have all lived that, I'm certain.

Mr. McGeorge: To me, with a national dementia strategy, once we get the organization set — and we could argue for a long time as to what that organization ought to look like. By the way, to your earlier question, I do think it needs to be close enough to government to be taken seriously but far enough away not to be subject to political peaks and hollows, somehow.

In any event, the word that comes to my mind is a national repository. Right now, the practices across the country are, frankly, all over the map. We have been talking about polypharmacy in this country for, what, a decade or more? I'm not sure where you go to get really good, honest-to-goodness best practice information on that whole broad, complicated topic. I know polypharmacy is alive and well in New Brunswick and not serving us all that well, so a repository of best practice, a 1-800 number.

Jeffrey Simpson did us a great favour in his book Chronic Condition. I bought copies for my board and made them read it a while ago. He makes it very clear that our system, even as it currently exists, doesn't perform anywhere nearly as well as Norway, Denmark, the Netherlands, Sweden, Germany and Britain, and yet we spend more money doing it. So we need to get a life and make some changes here.

So a repository for best practices and a sharp focus on research. In New Brunswick, we're having some very active conversations with researchers in universities in our province. They want to do research that is of interest to them. We are saying, “No, it ought to be of interest to us and focused on what is going to be delivering better care for our people.” So a sharp research focus.

Standardized training. I like Dr. Molnar's notion of the accreditation standards. That's pretty long overdue as it relates to dementia care in health care facilities. So a base where things like that would be pulled together. That would be it for me.

Senator Seidman: If I might, Mr. McGeorge, continue along this pathway a bit, in your presentation about the importance of a strategy and what would be flowing from a strategy, we talked about some sort of oversight. So we have this model. How are we going to oversee it? Senator Eggleton asked this question. I know our chair asks this question very often to witnesses who are here: How are we going to oversee this?

What you say here is the proposed Canadian Alzheimer's disease and dementia partnership is a model that could serve to advance the strategy that is so necessary in providing the required leadership. Could you please elaborate? You say it's modelled on the Canadian Partnership Against Cancer. You gave that a great degree of relevance in your presentation. If you might explain to us what that model is and how it could be used as a model for us in coordinating and oversight, if I understand correctly.

Mr. McGeorge: I confess that I don't know as much about it as I need to. I know that our national office, Mimi Lowi-Young and her colleagues, are very much attuned to all of the national. The one thing that has resonated with me — we've talked about it nationally — is let's not try to reinvent wheels here. Let's use the principles that are already there with the national cancer partnership. Quite frankly, I would have to confess that I don't know a lot about that. All I know is it has worked.

Senator Seidman: That's fine.

Mr. McGeorge: The results have been absolutely phenomenal for cancer.

Senator Seidman: That's something obviously for us to explore further.

The Chair: We have it on the record.

Senator Seidman: Okay, thank you.

Dr. Molnar, if I could ask you more specific information about the Linda Lee clinics that you suggested were one model among many that would need to be used, what is that model? Does it provide care and support to informal caregivers? I won't use the word “informal” because we have been told that that is not the preferred language. So to caregivers and individuals affected by dementia, what supports are included for them in this clinic?

Dr. Molnar: There are now about 78 Linda Lee primary care collaborative care memory clinics in Ontario. They are growing rapidly. There is a long waiting list of family health teams to join.

Essentially, the way these come about is a family health team will indicate their interest: one part of a large family health team or family health organization, one team of one or two physicians, a nurse, physiotherapist, occupational therapist, dietician, and their staff will indicate a willingness to become these specialists within the larger family health team. This can include dozens of physician practices. So they become the in-house experts.

Through Linda Lee's organization, they receive training at their site on how do you perform dementia care, didactic teaching as well as Linda Lee and her team coming and running clinics. There is a lot of on-site training that goes on for how you diagnose and treat dementia, how you rule out co-morbidity. Then they operate for a while, and Linda Lee will hold annual refresher days with them.

It's still an evolving network. It hasn't reached a full network status yet, but it's slowly becoming a network which will require central governance.

Now these are champions. These are physicians and their teams who really champion dementia care. The physicians earn less money by doing this than they would by not doing this. So it's missing that part of sustainability. Whenever we do that, things can become a bit rocky, but these are people who are really champions.

The Ministry of Health in Ontario is taking a long, hard look at how do we create a stable infrastructure that encourages people to do this, be part of this and remain within this.

So far, people have been very loyal to the model because they see great value in it. I think because family physicians are primary care practitioners, are generalists, they understand diabetes, chronic lung disease, heart failure very well, and then they are able to help manage that person with dementia as they are going through these different stages. So it's evolving into not just dementia but more a dementia chronic care model.

Then they will call on specialists to review cases. Sometimes a specialist will come down and actually see patients in the family health team; sometimes they will send them to the specialist clinic. Cases that are hard to diagnose or have multiple co-morbidities, it's a bit beyond what the team can do. So we're slowly creating that collaborative care model. That's a work-in-progress.

In terms of the stages of evaluation, it's still in the formative stages. We're starting to look with the grant at the process outcomes. How efficient is this? How can we make this more efficient?

Down the road, once we have a more stable model, we will have to look at larger outcomes.

Senator Seidman: This is Ontario specific?

Dr. Molnar: This is Ontario specific, but other provinces are looking at it, like people in Saskatchewan have indicated interest, people in the Prairies, people in B.C. There is interest popping around the country.

Senator Raine: As a follow-up, who is Linda Lee? Is she a doctor?

Dr. Molnar: She is a primary care physician who works in the Waterloo area.

Dr. Molnar: While she runs around the province to try to make this happen, she has a thriving practice of her own,

Senator Raine: Sounds like it would be good for her to come and give her experience.

I really appreciate the information we are being given.

Dr. McGeorge, first of all, could tell me the name of Jeffrey Simpson's book? It sounds like it would be worth reading.

The Chair: It's based on our health accord report. The 2004 health accord has everything that is there, plus a number of things that have just been brought up.

Senator Raine: Before my time.

One of the things that concern me is that we have heard from other people that the shortage of caregivers working full-time is already there. So when we go to some kind of standardization of their training — and I guess I'm nervous that we might put roadblocks in the way of encouraging people who are compassionate and wanting to do the work and enjoying this kind of care from being hired even if they aren't trained.

So would there be a way to screen people who are suitable for the work as a standard, and then have level one, level two and level three type of training in place as they are working with people with dementia? I have in my experience seen people with no training very quickly becoming very valuable because of their compassion and their energy and their desire to work with dementia patients.

Mr. McGeorge: We certainly wouldn't want to scare people away by coming out with an incredible set of educational requirements for work. The home care level and the personal support care worker level in nursing homes and other related institutional facilities, what you describe is job number one.

I used to say in the staff orientations that I used to do, if on the first day that you come to work you're not fired up about coming here, please don't come. You have to have it in your heart first. It's not rocket science, but you have to teach people — which we don't do all that well in our province — just a bit about the world that people with dementia live and work in. It's different from the world that I live in. But it's not a six-month course or a year-long course, it's pretty basic stuff. So a graduated level of credentialing that does not scare people away.

The other element of the shortage is the inconsistency as you go across the country in professionalism and compensation. Some people are still paid minimum wage; other people are paid a competitive salary level and expected to do the same job.

So you can't resolve that necessarily nationally, but you can create a framework that provinces can start to use. Even in the Atlantic provinces there are different patterns. It's really quite astounding that Nova Scotia does a whole different thing than we do in New Brunswick, yet we're just miles away.

Senator Raine: The interesting thing today is of course with webinars you can quickly spread these best practices and this standardization across the country, but somebody has to organize it from the centre. With a webinar situation, you can take your best trainer from British Columbia and Alberta or New Brunswick and expose their ideas and experience to everyone. Is that what you envision as the central role for the centralization of this kind of training?

Mr. McGeorge: That would be one major role, making some sense of education and making it user-friendly. It's knowledge transfer big time.

Dr. Molnar: There are a lot of lessons learned in terms of training when one looks at the responsive behaviour services and how they trained people. First of all, the training does start with a didactic training, maybe distance training. We found a lot people don't actually integrate it into their day-to-day practice unless they have a trainer or mentor come and help them learn how to integrate this when you actually provide the care. We need on-site integration mentorship for some of the higher-level functions and then ongoing or recurrent training, because there is a fair bit of decay that happens over time. Then finally access to someone with greater expertise at a moment's notice when things are not going well.

So we have to be careful that we don't put too much reliance on just one stage of the training process. It's lifelong process or career-long process.

Senator Raine: Especially as you say with responsive behaviour training because that could suddenly be in front of you, and you haven't been trained for it.

I have a question about the research. I was happy to hear you talk about research being the need to be focused and responsible. When the Arthritis Research Centre of Canada was being formed, I was on the board, and they worked with people with arthritis to discuss how the research should be structured. They came up with a slogan, which has been their driving mantra: “Practical research for everyday living.” So whenever they are looking at research grant applications, they always view it through that lens. It has been very useful for the organization. It might be something you want to consider.

Dr. Molnar: Can I comment on that?

Senator Raine: Yes, please.

Dr. Molnar: I absolutely agree. There is another thing that I think has been helpful. I do dementia and driving research, and I'm one of the editors of the Canadian Medical Association’s fitness-to-drive guidelines. What we found very useful there is we have had people from Transport Canada and the provincial ministries of transportation help guide our research. They are intimately aware of the research. They tell us what is needed, and then we do it and integrate it into our guidelines.

Having some of the people, once again, who hold the purse strings at the provincial level perhaps being involved in the research is something that doesn't happen very often but would certainly help with the movement of pilot to full-scale research, the implementation. I don't see that happening as often as it needs to.

Senator Raine: Thank you.

Senator Merchant: We have talked about this over the course of this study, but Dr. Molnar, you spoke about the need for universities, for medical schools, to help guide their students and also to become interested in gerontology, and also you spoke about government having a role to play in the whole strategy about dementia.

Could you be a little more specific? When would this education of young people who are interested in going into medicine begin? Would that begin at the high school level when people from different professions go out and speak with high school students? I know a lot of high schools have programs that send young students out as part of their courses to work into old people's homes. They choose the areas where they want to volunteer to have a volunteer aspect to their courses.

Is there a country or countries in the world that have been successful in attracting more people to gerontology? How did they do it?

Dr. Molnar: I agree that it should start at the earliest levels to create dementia-friendly communities so that our children actually know a little bit about aging and about dementia and are comfortable with that, and it should move all the way up.

It should certainly be better integrated into medical school. So in medical school, 100 per cent of students are required to do pediatrics even though only 2 per cent of them will practice pediatrics. I was required even though I knew I was going into geriatrics. Medical schools do not require rotations in geriatrics or seniors care, even though the vast majority of the students will be providing seniors care. There is a disconnect between what society needs and what is being provided. The decisions are being made on a political basis, the strength of different specialties rather than on what society needs. So that certainly needs to change.

Psychiatry has done a great job. They require that all of the psychiatry residents do a geriatric psychiatry rotation, and that has really brought a lot of people into geriatric psychiatry. That's a bit of a success story. They can certainly use a lot more, but they have had great success.

It's not required that internal medicine residents go into geriatrics. Many of them avoid it because it is not sort of a sexy area. It's an area that can be challenging, that can really challenge them but can be very rewarding.

So certainly I agree with you. You have to have the exposure throughout, and you have to mandate it or at least make sure it's proportional to societal need.

Has any country done this well? I'm not aware of that, but I don't really know the educational systems in the other countries. When I was here last time we discussed the U.K. having more geriatricians than the U.S., but those are very different specialties. They provide more primary care than we do.

Mr. McGeorge: Just to Dr. Molnar's point, it's kind of interesting as I'm interacting with family doctors in Fredericton, and I'm interacting with quite a few right now because I co-chair our provincial Council on Aging, which is trying to find some provincial solutions to all of this, doctor after doctor will tell me, “My practice has now become a geriatric practice, not by design, but by happenstance,” which is interesting.

We were struggling with some of these educational issues when I was at York Care Centre. We could never hire nurses to begin with, and so we went to the university and sat down with the nursing faculty and said, “How about introducing some required rotations?” They did that. We started getting them at fourth year, then third year, then second year, then in the first year. And we did do some evaluations of those rotations. Every rotation we did an evaluation, and to a person the students would say, “I thought looking after old folks when I came here was dull and boring, and I didn't want to come here. Three weeks later I discovered it's fun, it's exciting, and it's not anything like I expected it would be.” So we went from couldn't hire nurses to having a waiting list, and we did that over just about a three-year period, which was kind of cool.

We visited a geriatric centre in Boston in pursuit of some neat, new ideas. Driving on the campus of this big centre we saw a soccer field, basketball courts. We're thinking, “This is a geriatric centre? Soccer field, basketball courts?” And this building over here, and they said, “Oh, yes, that's our school. That's a full K to 12 school program. We believe in integrating our elders with the kids from day one.”

In our environment in Fredericton we have been able to integrate with several of our schools and get them thinking, and as a result of that, a lot of kids have gone on to take gerontology in school. We haven't found any geriatricians in that cohort yet, but we have attracted them to our environment through a program that we call Narrative, which didn't force kids but encouraged them to interact in a systemic way with families and elders. Through the iPod project, we found the same thing. We got elementary and high school kids coming in, interacting with families, and in the process they discover that old folks aren't as weird as they thought we were, that it's really kind of nice. We have developed that some way.

Senator Merchant: One thing that happens to people as they age, because I have seen this with my parents, is they lose their doctors. Sometimes their doctors were a bit older than they were when they started out, and then suddenly the doctor that knows you best is gone. It's hard for you to retrace all that memory if you find a new doctor to have a continuum. That is a very difficult thing to face.

Dr. Molnar: I think the practice that we see occurring more and more of primary care being brought together into family health teams, and now Ontario is looking at larger networks, is the way to go because they can do succession planning, the senior physicians, and I see this. They are starting to recruit junior physicians who they find have the right attitude and skills and they can integrate them slowly into their practice so that they'll be ready to take over when the time comes. I think the days of the solo practice are slowly being left behind, and that network practice may help address some of this with succession planning.

Senator Merchant: You said there were certain communities that were under-represented, and we know that; we have heard that before.

In the kind of plans that you make, some of these homes where you say perhaps they should be more specialized to Alzheimer's people, will that be something that is financially available to everyone? Is there an extra cost? I am thinking about First Nations, for instance. Maybe some of the poorly represented may not have access to some of these programs. Is there a cost? Is there a difference in the cost for these sorts of systems?

Dr. Molnar: There will be a cost to not providing these services. If we don't provide them, then we will provide for people in acute care hospitals at $1,000 to $1,200 a day. It is a matter of shifting costs and providing the right care in the right setting. People with dementia lose their secondary and tertiary languages. They revert to their primary language, and that's what you have to serve them in.

Senator Merchant: I didn't express myself well. Is there a cost to the individuals?

Dr. Molnar: Residences are available at a high cost, thousands of dollars per month. If people can't afford it, then they end up in long-term care at a very high cost. We need more subsidized residences if we want to save money and prevent hospitalizations, but we are not willing to shift that money to the right places.

Senator Frum: Mr. McGeorge, when you were talking about the iPod program, you spoke about the problem of overmedication. Could you speak briefly on the problem of overmedication and the consequences of it? I presume it is done mostly for the benefit of the caregivers, not necessarily the patients. How does overmedication fit into a national strategy?

Mr. McGeorge: Since polypharmacy has been identified by the CMA as one of the major issues in seniors care, clearly it needs to remain there and be dealt with. It is well recognized as a chronic, long-standing issue. There are many research papers and publications which clearly show that too often drugs are the treatment of first resort rather than last resort.

This is interesting. We didn't set out to do this. We just wanted to help people. We found a significant decrease in the need for sleeping medication with the iPod project. We found a significant decrease in the need for mood altering drugs, some of the psychotropic drugs. We also found better appetite and improved cognition. We weren't expecting any of that. We were just hoping for folks to be looked after better.

As part of a national dementia strategy, it would be my hope that there would be a real focus on polypharmacy.

I was asking this question last week as we were having discussions around our own council: Is there a clinical pharmacologist in the province of New Brunswick? I don't believe there is. That would be a pharmacologist with significant advanced training who would be the advance trainer to clinicians, physicians and others. That is more Dr. Molnar's domain than mine, but we recognize it as a serious public policy issue.

Dr. Molnar: We have to be careful in terms of how we use the word “polypharmacy” because polypharmacy sometimes can be good. The medications are keeping people alive. We see that sometimes when we stop the medications and people pass away quickly. What we are talking about is inappropriate polypharmacy. It is a huge problem. It is estimated that one third of the admissions to hospital are related to medications, either taking them inappropriately or double dosing. This is an even bigger problem with people with dementia because people with dementia are exquisitely sensitive to these medication errors and to the side effects of the medications. They might tolerate the medications for many years, but once they develop dementia, they develop all the cognitive side effects, all the delirium side effects of the medications. It is a moving target. The overall prescriptions must change over time.

There are two problems occurring here. One is the silo focus we apply when we are treating diseases. The cardiologist will use their evidence-based slew of medications, the respirologists theirs, the geriatricians theirs, and they don't mix. What we do not have now is integrated chronic disease management, a platform where the specialists in a complex situation can meet and iron things out. We need to get that integrated chronic disease management, which is dementia-plus care.

The other is behaviour. People are not well-versed in how to manage behaviour, so it is medication first rather than non-medication approaches. Those are two contributors.

Deprescribing is not taught in medical schools. I have never been taught how to wean a patient from a medication. If you wean them inappropriately, people go into withdrawal and end up in hospital. You have to slow down, decrease the dose, and stop things appropriately. That is poorly taught across the board. Physicians are taught to prescribe, not deprescribe. It is a huge education gap.

The resources are being built. A lot of provincial governments are investing in this. There will be resources on the Web and more courses, but we need drivers or levers and billing codes. We get paid to prescribe medications, not to deprescribe medications. That will not happen.

We did this when there was a code for reporting people who were not fit to drive. The reports went up, and the crashes went down. This is an effective lever to manage behaviour. There are some unintended consequences which must be managed.

There is an old expression which I will paraphrase incorrectly; it takes 10 seconds to write a prescription and a million seconds to stop it. You do need appropriate billing codes. Ultimately, those billing codes will save money. They will save the cost of the drug and the cost of the admissions to hospital. Once again, we need to make those investments.

The Chair: This discussion on the appropriate use of medications in this area is one I was going to pursue. You have covered it very well. It's obviously a critical area. I was concerned when, Mr. McGeorge, you indicated there isn't a specialist on that issue in New Brunswick. We have been asking this question about the various group housing situations, and so on. It's a challenge. We haven't moved as far as we had hoped, even though we did our report on the 2004 health accord. The issue of available electronic records to make those interpretations, Dr. Molnar, is a real issue for us.

In Canada there is a difficulty in getting any innovation moving. There is an inability of the federal system to motivate and achieve agreement of the provinces to meet certain targets, to report effectively and to be held accountable for those.

Let's suppose we had dementia identified as a specific category of funding in a new accord, and some base funding was set out. The drive to accountability that could be that there would be no increase to any province in that category unless they showed that they have met certain criteria. That is, they are rewarded. If they have met them, they would be rewarded with perhaps increased funding based on some sort of system.

Dr. Molnar, I don't want to go through it in exhaustive detail, but are there elements in that approach that you think might work in terms of this kind of situation?

Dr. Molnar: Certainly if the things they are accountable for are achievable, it wouldn't be pie in the sky.

The Chair: Right. Let us assume it is designed appropriately.

Dr. Molnar: It could work if there is a trickle-down effect to the provinces, the regional health authorities, the hospitals and to the actual programs providing the care. Once again we have these great innovations, but if they don't get down to the front lines, then it's hard to practise.

The Chair: That could be one of the measures in terms of rewards as well because the feds can't tell the provinces to trickle it down, but they can reward if it meets those objectives. You think there might be possibilities in this kind of area if appropriately developed?

Dr. Molnar: If appropriately developed, that's certainly a lever to improve care.

The Chair: Mr. McGeorge, do you have any comment on that?

Mr. McGeorge: One of the markers, as an illustration, might be another reduction of ALC admissions in hospitals. The progress is all over the map across the country. I am aware of the some of the practices or non-practices in some of the provinces that are ranked the poorest. As certain as I am sitting here, the reason that we don't score well in New Brunswick is that we have not made that our priority, and it should be a priority. It's not rocket science. People overcomplicate it, and it really isn't.

The Chair: I just want to stick to the principle today. We have a number of examples, but thank you for that.

The issue of remuneration has come up in a number of ways. Today it has come up a couple of times. Dr. Molnar, the specific example is remuneration for deprescribing as opposed to prescribing.

One of the major things we identified in our study of the whole health accord is that the inflexibility in the remuneration system was a major barrier to innovation and the ability to take a pilot project that had worked well and move it forward because it simply didn't meet the established processes for rewarding activity. In other words, clinical activity that is cooperative can't be recognized under the billing systems. I don't want further comment on that necessarily but to indicate that is an issue that has come up before us many times as a key issue. We will attempt to identify that.

The question that I really wanted to ask you, Dr. Molnar — and I want an overview from you, if you can — is we are not dealing in our study with fundamental scientific and medical research into the issue of dementia — that is, from the scientific point of view. However, what we are hearing throughout this study is that there is increasingly a view that we should be able to detect dementia long before visible signs occur, and second, that if early identification could occur, then we could perhaps make much faster progress with regard to staving off the onset of dementia and dealing with it much more effectively with treatment.

From your perspective, from your viewing of the world out there, do you think we are progressing in this area? Do you think the research community is tackling this aspect of the health research area? Are you hopeful that progress either is being made or that you can see, perhaps in the near term, progress might well be made?

Dr. Molnar: To be honest, that's not my area of research expertise, but I'll comment on it.

The Chair: I realize that you have a perspective on the comment that is unique for us.

Mr. Moreau: I do attend conferences where they discuss some of the research that's been going on. I think it is promising looking at biomarkers, be they blood tests or tests of the cerebral spinal fluid or PET scans. I think researchers are taking this seriously, and in the next decade or two we will have some great breakthroughs so that we can predict who will develop dementia and start to look at prevention of the disease. Yes, I think they are taking it seriously and are making some great ground.

The Chair: Thank you very much. I know from your background, but I wanted your perspective as opposed to the specialists' perspective.

Senator Eggleton: Dr. Molnar, you suggest that Accreditation Canada should be asked to develop a required operating procedure that ensures that every acute care hospital in Canada has a dementia, delirium and behavioural management service in place, ideally supported by both geriatric medicine and geriatric psychiatry.

Well, Accreditation Canada is a non-profit organization. It does the accreditation for hospitals, but it is not compulsory. Is it widely accepted? Is it accepted by all hospitals?

Dr. Molnar: I think Mr. McGeorge could probably speak to that better than I could.

Mr. McGeorge: Pretty much most hospitals. While it is voluntary, you don't get to train nurses, doctors and other people in a clinical setting if you aren't accredited. There is some leverage there.

Senator Eggleton: That's what I am trying to determine: How much leverage is there here? This could be quite useful.

Mr. McGeorge: Absolutely.

Senator Eggleton: All right. Perhaps it is also something we could put in a future health accord? Maybe there is a possibility for it. Maybe even from here, we could recommend it in this study.

Beyond that, Dr. Molnar, you said that many specialist clinics that care for community-dwelling persons with dementia are slowly suffering the death of a thousand cuts. Furthermore, downsizing and closing these clinics predictably leads to hospital admissions for persons with dementia. I understand that, but then you go on in the next paragraph to talk about all these new clinics that are formed on the Linda Lee model — you said 78 in Ontario alone. Then you mentioned the Health Links model as well.

Is this Linda Lee primary plus the Health Links making up for the loss here, or is there a gap here somewhere that we still need to pay attention to?

My second question on this is what is the difference between the Health Links model and the Linda Lee primary care collaborative memory clinic model?

Dr. Molnar: What is happening now, although it wasn't designed that way, is exactly what we need. We need to shift from hospital-based services, which are the specialist clinics that operate within a hospital budget, to community-based services. That is where we all know health care needs to go. It is not being done in a planned fashion. As hospitals' budgets are getting cut, they are looking at ambulatory care as a soft area to cut. They will start closing or shutting down these clinics.

The Linda Lee model is voluntary at the moment. It is not being designed by the Ministry of Health, although the ministry will look at this. We are not creating that infrastructure. The shift is happening organically, as much as I hate to use that word. It is happening naturally as physicians realize it has to happen. Are there gaps? Gaps may open up, unless the ministers of health realize quickly that we need to build good infrastructure into these community-based clinics.

In terms of Health Links versus Linda Lee, I always think of the Kaiser Permanente Triangle. The primary care physicians would be the initial care for people with dementia. The mid-level would be the Linda Lee clinics. You are increasing the investments, so some money is required to continue to train these teams. At the top might be the Health Links, where you have dedicated money and staff to do intense case management, whatever that means, so that you can keep the person safely at home and keep the caregiver safe. It is a matter of escalating investments, not for everyone but for the people who absolutely need it. We don't have those escalation plans in place for many areas of health care, including dementia, so people, by default, end up in hospital.

Senator Eggleton: Health Links is another step up the ladder. It is a little more costly and intensive.

Dr. Molnar: Yes, Health Links have not dedicated themselves to dementia care.

Senator Eggleton: Is Health Links for more advanced cases?

Dr. Molnar: Health Links in Ontario was designed for the 5 per cent of patients who cost the most to the health care system. There is some thinking out there that maybe it is not the top 5 per cent where you have the most return on investment; it is the next 10 per cent below that. It is an experiment that's ongoing.

Senator Eggleton: Thank you.

The Chair: I want to come back, Mr. McGeorge, to your memory café experience. I was impressed when by coincidence I caught a piece on the news that New Brunswick was pursuing this. I checked into it, and at that point it was unique in Canada that you had come into the worldwide experience on the memory café.

You have provided us with an excellent overview that answers a lots of questions that I would have wanted to put to you.

You have several of these in New Brunswick. What is your experience with communities when they say, “Well, we'd like to have one, too,” or however it works. How difficult is it for them to get under way? Is the accumulating experience in New Brunswick making it increasingly easy for the next one to join into the program?

Mr. McGeorge: It's getting easier for sure, as the word gets out. The irreducible minimum, though, for any of these in any of the communities is can you find two or three wonderful volunteers — because it has to be volunteer-driven — who really have a passion and a heart for people with dementia. Once you find those two or three people, then they will attract three, four or five other people with them as volunteers to make it happen. With our manual, we do some basic training with them, and there is no reason why we couldn't go into any community, if they have two or three wonderful volunteers, and have it up and running in a month.

The Chair: In terms of population, what is the smallest community in New Brunswick that currently has one?

Mr. McGeorge: Probably Plaster Rock. I think there is the home of the world pond hockey tournament. The population may be 1,200 or 1,400, or something like that at most.

The Chair: That's excellent.

Senator Eggleton: I see you have some pamphlets, and one is the Salvation Army location. Is it mainly churches, church basements or community centres that you put these in? Do you have many of them that would be storefronts, like a regular coffee house might be?

Mr. McGeorge: To begin with, we have to find a place that is rent free. We're not paying. Providing it rent free is a manifestation of the heart you have for the issue. Churches are one source and schools are another. We just opened one up in Saint John at the Loch Lomond Villa Wellness Centre. It is a very futuristic geriatric long-term care centre. So we're doing one there as a pilot. That is working very well and will not be a pilot for very long.

I am trying so think of some of the other locations.

Senator Eggleton: There are a variety of locations. Does any one type of location work better than others? I guess it depends on how many volunteers you have and who runs the program.

Mr. McGeorge: We started out thinking we shouldn't do them at nursing homes because there might be a little bias, but we're getting over that, too. We're about to open up one in the French peninsula, in a nursing home location, so wherever.

The Chair: Thank you very much. This has been excellent.

Dr. Molnar, we are delighted that you were willing to come back and speak to us from your personal point of view on this. We appreciate that very much.

Mr. McGeorge, we were certainly looking forward to your testimony here. As I said, I think there would have been a lot more questions had you not provided us with such a nice summary of how you go about setting one up, which answers a lot of the questions that we might have asked to begin with. But your additional information has put the human character on it.

We clearly recognize that the study we have undertaken has taken us into areas where we realize it's an enormously important issue for the country and for the population as a whole.

When you leave, if you would continue to think about the question that Senator Eggleton put to you at the outset, which gets into the business of how we would recommend a government-involved process that could actually work, which deals with the fact that we are a federation, we have a federal government, we have the provinces and territories, and we know the difficulties. We don't need any further advice on what the difficulties are. They are outlined in our study on this area. However, the kind of model that you've touched on, and very good advice today, would you think about that a bit more and if anything occurs to you could you get it to us through the clerk? We would really appreciate it because, in the end, that may be the most critical link in anything that we can recommend as we go forward. It's one thing to think of all the things that are needed in the strategy. It is quite another thing to translate that into a vehicle that can actually deliver it within the complexity of a federated system.

With that, I declare the meeting adjourned.

(The committee adjourned.)