Proceedings of the Special Senate Committee on Aging
Issue 2 - Evidence, December 10, 2007
OTTAWA, Monday, December 10, 2007
The Special Senate Committee on Aging met this day at 12:31 p.m. to examine and report upon the implications of an aging society in Canada.
Senator Sharon Carstairs (Chair) in the chair.
[English]
The Chair: I want to welcome all of you to the Special Senate Committee on Aging. This committee is examining the implications of an aging society in Canada.
Today's meeting will focus on housing, supportive housing, assisted living and home care. To help us understand the issues surrounding these topics, we have before us Luis Rodriguez and Debra Darke from the Canada Mortgage and Housing Corporation; Sharon Sholzberg-Gray, President and Chief Executive Officer of the Canadian Healthcare Association; Pierre Allard and David MacDonald from The Royal Canadian Legion; Margaret Hall from the University of British Columbia; and, appearing via video conference, Marcus Hollander, President of Hollander Analytical Services Ltd.
We will begin with our video conference witness because sometimes technology does not always work the way we want. While we have him here and know the connection is working, we would like to start with Mr. Hollander.
Marcus J. Hollander, President, Hollander Analytical Services Ltd., as an individual (by video conference): I would like to thank the Special Senate Committee on Aging for inviting me to speak about the research we have done over the past several years and how this research may be able to inform the policy process.
While the current national policy focus is on short-term and specialty home care, and certainly significant contributions have been made in this area, it may now be time to also consider how best to respond to seniors who have on-going or long-term care needs. It is our view that there are two key areas that this committee may wish to consider in its deliberations: The importance of a focus on a broader, integrated system of care for the elderly; and the importance of long-term home care and home support services.
I shall discuss each of these topics in turn.
With regard to more integrated models of care delivery, seniors have a range of care needs that cut across both health and social services. Ideally, one would like to have a system of care that is specifically targeted to meet this diverse set of needs, incorporating a broad continuum of services from home care to housing options to residential care and specialty geriatric services in hospitals.
While there were movements to develop such broader systems at the provincial level in the late 1980s and early 1990s, the recent policy focus has been more on component parts such as home care, housing and residential care — obviously, these are also very important. We are of the view that coordinated, integrated care delivery systems for persons with ongoing care needs are, as Martha Stewart might say, a good thing. They are good clinically because they allow for well-coordinated, seamless care for clients across a wide range of services, from Meals on Wheels to specialized geriatric assessment and treatment centres in hospitals.
They are good from a policy perspective because policies can be made at the broader systems level, across all care services in the system, to the benefit of the client.
They are good economically because such systems allow for trade-offs between, for example, less costly home care services and more expensive residential care or acute care services. Such efficiencies can increase value for money within the continuing care system — home care, long-term care and appropriate housing options — and within the broader health care system.
Finally, they are good because, if done well, it should be possible to simultaneously reduce costs or increase efficiencies and provide better care to clients.
How care delivery systems are organized and structured can have a profound effect on both the quality of care received and the costs of care to government.
I will talk about some of the evidence from our research that focuses on these topics. The history of home care services is one of an amalgamation of professional and supportive services. A new recognition of the importance of preventative and supportive care, and long-term home care is reflected in recent recommendations to enhance home- care funding to allow people to remain in their homes by increasing support to long-term home care and home support services by $700 million and $200 million in Ontario and British Columbia, respectively. In Ontario, this is the Aging at Home Strategy, and in British Columbia this was a recommendation of the premier's council.
There is some evidence about the cost-effectiveness of preventative home support services. A British Columbia study indicated that long-term home care can prevent or reduce the rate of admission to hospitals and long-term care facilities. People who only received housekeeping services and who were cut from service in two health regions were compared to people not cut from services in two similar regions in the mid-1990s. In the year before the cuts, the average annual cost per client broadly for the health care system was $4,500 to $5,000 per year. In the third year after the cuts, the comparative costs were $11,900 and $7,800, respectively, for a net difference of $3,500. Thus, on average, the people actually cut from care cost the health care system $3,500 more in the third year after the cuts than people who were not cut from service.
Total costs over the three-year period after the cuts were a little over $28,000 and $20,000, respectively, for those who were cut compared to those who were not cut from care. Most of the differences in costs were accounted for by increased costs for acute care and long-term residential care services.
We have conducted several studies about the cost-effectiveness of home care, particularly in Western Canada. The consistent result has been that, for people with the same levels of care need, home care services generally cost less than residential care services in terms of cost to government. We also found that the majority of the home care services were for non-professional home support services.
Taking a broader perspective, we also conducted a study in Victoria, British Columbia, and Winnipeg, Manitoba, that looked at costs from a broader, societal perspective and included out-of-pocket expenses for clients and family members. The time contribution of family members who care for their loved ones cost the equivalent of replacement wages for paid caregivers. Even using this broader societal perspective, overall costs were less for home care clients. The quality of care in terms of client and family caregiver satisfaction and the client quality of life were as good or better for people receiving home care. Thus, the lower-cost home care alternative did not result in reductions in the quality of care.
While the contribution of facility care is very important and should be both respected and recognized, there may still be opportunities to substitute lower-cost home care for higher-cost residential care. The literature would indicate that supportive housing may also be less costly than residential care, but this is an area that requires further research.
We also found that the savings from substituting home care services for residential care services are not just theoretical; they can happen in the real world. Actual savings were achieved in British Columbia from the mid-1980s to the mid-1990s by holding down future construction of long-term care facility beds and making investments in home care.
An important point here is that what does not seem to be fully appreciated in current policy discussions is a seeming paradox of service provision: While elderly persons with functional limitations have health conditions and need medically necessary care, the appropriate responses to their health care needs are, in large part, often supportive services.
Taking the time to give a senior, who needs care, a bath, preparing a meal, feeding the individual and ensuring a safe and sanitary environment in the home does not necessarily have to be done by a health professional. However, for people who are too frail to shop, cook or take baths on their own due to their medical conditions, this type of personal support allows them to maintain their independence for as long as possible. It may actually save the health care system money by avoiding repeated hospital admissions and premature entry into long-term care facilities.
An extensive program of research on the cost-effectiveness of home care, which I had the privilege to be involved in, called the National Evaluation of the Cost-Effectiveness of Home Care presented a number of policy recommendations about how home care services should be structured. The synthesis report of this project notes that home care, in order to more readily make the types of substitutions required to achieve greater efficiencies, needs to be part of a broader, integrated system of home and residential care, often referred to as continuing care.
By having administrative and fiscal control over such a large, integrated system of care, senior executives and policy- makers can take steps to ensure that appropriate and cost-effective substitution of home care services for acute care and residential care can, in fact, take place. Simply enhancing expenditures on home care per se may have a limited effect unless steps are taken to ensure that appropriate substitutions of home care services for acute and/or residential care services can be made.
In conclusion, we have moved from provincial care delivery systems in the early 1990s to more regionalized models. There are now many different examples of how to structure care services and also emerging, made-in-Canada, best practice models for structuring these health care delivery systems for the elderly.
A national focus on integrated care delivery systems seems to be lacking. It would be helpful if there could be some way for people who work in this area to share experiences and learn from each other about what seems to work and what does not.
Furthermore, in our earlier work, and this was some time ago, we found that the costs of integrated systems of delivery for the elderly and persons with disabilities — that is the cost for a provincial continuing care system — constituted the third largest component of our health care system in terms of public expenditures, after hospital and physician services. At present, we do not collect — or at least report — national data that would allow us to confirm if this is still the case. Our expectation is that appropriately structured, integrated models of care delivery for people with ongoing care needs would still constitute the third largest component of public health expenditures in our health care system. Certainly, drug expenditures have been increasing, but a significant portion of those expenditures are paid for by individuals themselves.
The challenge of developing the most appropriate systems of care for the elderly and other persons with ongoing care needs is, in our view, deserving of an active national policy focus.
The Chair: Thank you very much, Mr. Hollander. Next is Mr. Rodriguez.
Luis Rodriguez, Senior Researcher, Canada Mortgage and Housing Corporation: I want to thank members of the Special Senate Committee on Aging for inviting Canada Mortgage and Housing Corporation, CMHC, to participate. I hope that our discussions today will contribute to the committee's work. My presentation will focus on seniors' housing choices, where seniors are defined as people 55 years of age or older.
I have organized my presentation into seven parts: seniors' satisfaction with their current housing; seniors' housing preferences; seniors' housing choices model and the continuum of accommodation and support services; aging in place and home care; supportive housing and assisted living; community planning; and CMHC's seniors' housing research information transfer.
Our research shows that Canadian seniors are fairly comfortable in their current accommodations. In a recent national survey, nine in 10 seniors — 92 per cent — said their current housing situation generally meets their needs, compared to 6 per cent who felt otherwise.
According to the same survey, seniors who earn less than $20,000 a year in household income were significantly less satisfied than their counterparts with their housing situation. However, the great majority — 83 per cent — of these lower-income seniors felt their housing situation met their needs. Homeowners who live in a single family detached home and who rate their health as excellent, were more likely than their counterparts to say their current housing situation met their needs.
The national survey I just mentioned also indicated that 87 per cent of seniors 55 years of age or older said that they planned to remain in their present home for as long as possible, even if there were changes in their health status. This preference appears to be getting stronger among seniors of all ages.
Homeowners, those who rate their health as excellent and who say they have little difficulty paying their current household expenses, are all more likely than their counterparts to say that they intend to remain in their present home for as long as possible. Only one in 10 said that they do not intend to remain in their present home.
The reasons for moving vary considerably among Canadian seniors. As up to three reasons could be given by each respondent, the sum of the percentage who gave each answer adds up to more than 100 per cent. About one in six, or 17 per cent, said that the cost of living is too high; 15 per cent said that their current home is getting too difficult to maintain, while 14 per cent said it is too difficult to get around in; 13 per cent of seniors who do not intend to stay in their homes said that they are ready to downsize in general; and slightly fewer, 11 per cent, simply disliked their present home. Not surprisingly, owners are more likely than renters to say that they plan to move because their current home is too difficult to maintain or because they wish to downsize.
Whether seniors live in a house, townhouse or apartment, rent or own their home, they have two major housing choices. They can stay where they are, or they can move elsewhere. Both renters and owners who remain in their home may need to make physical adaptations to their homes to meet their changing needs. To get an idea of the magnitude of the need, one can look at data from the Statistics Canada 2001 Participation and Activity Limitation Survey, PALS. Of the total population of those 65 years of age and older with disabilities, almost one in five either already have made home modifications or report that they need them. They may also need to access various types of support services as they get older.
Homeowners may require major home renovations, such as creating a bedroom, a bathroom or a laundry room on the ground floor of a two-storey home so that they do not have to climb stairs. They may also choose to share their home with someone who can assist with activities of daily living, such as snow removal and house maintenance, or provide companionship. They may also want to create a secondary suite, which they can rent to supplement their income. Senior homeowners can also tap into home equity to supplement their income.
The decision for seniors to move is usually driven by factors that push them from their current home or pull them to a new home. Push factors include inappropriate design or size of the home, loss of a spouse or decline in health. Pull factors include a better home; better access to recreational facilities, amenities or services; a more appealing lifestyle; increased safety and security; greater affordability; or proximity to family and friends.
The range of choices for those who choose to move elsewhere includes: moving to a secondary suite, such as an apartment or garden suite, to be close to family and friends; moving to a new home located in a community for all ages; or moving to a place where they can live near their peers, such as a lifestyle retirement community, a supportive housing development or an assisted living village.
As mentioned, our research shows that most seniors want to age in place in familiar surroundings until their health makes this impossible. This will mean growing demands for home adaptations to enable aging in place. It will also mean increased amounts for home maintenance and support services, including home care and personal care from family, friends and neighbours; and increased reliance on government and private service providers. Again, from PALS, almost three-quarters of seniors aged 65 and older with disabilities reported receiving help from one or more of these sources. Almost one-third of those receiving help got it from voluntary, private or government agencies.
High repair and maintenance costs can place a heavy burden on low-income seniors. This can be a particular problem in areas outside urban centres, where home ownership rates for senior households are high — 82 per cent compared to 68 per cent in urban centres — and the overall housing stock is much older, with 34 per cent built before 1961, than it is in urban centres, with 29 per cent built before 1961.
Aging in place on an inadequate income, whether in a rural or urban area, can result in overall deterioration of housing and neighbourhoods through neglect of repairs and maintenance.
One promising option is supportive housing, which is a type of housing that helps people in their daily living through the provision of a physical environment that is safe, secure, enabling and homelike; and through the provision of support services such as meals, housekeeping, and social and recreational activities.
It is also the type of housing that allows people to maximize their independence, privacy, decision making and involvement, dignity, and choices and preferences. There can be various forms of supportive housing, depending on the levels and types of service that are provided. The most service-enriched forms of supportive housing, such as assisted living, could be an alternative to institutional care. Supportive housing can be most beneficial to those seniors who need help to carry out the activities of daily living, those who are frail or have disabilities and those who are living alone. It can also benefit seniors who prefer to live with their peers in an environment where they can enjoy companionship and the freedom to pursue different interests and lifestyles.
Supportive housing can be made available in a variety of building types and sizes. These range from small bungalows or cottages to homes shared by a group of eight to 10 people to larger buildings that contain many dwelling units. Supportive housing can also be made available in various forms of tenure, such as rental, condominium and life leases. A range of supportive housing choices is available today in Canada. Several provinces have developed their own definitions of supportive housing to meet specific circumstances, requirements and policy objectives.
With the aging of the Canadian population, our communities — cities, towns and villages — will need to be more senior-friendly. This means that they will have to be more responsive to senior's needs in terms of enabling them to go to the places they need and want to go to and to participate in recreational, social and community activities, and access the types of support services they need.
The overall aim will be to create communities that are accessible, welcoming, enriching and supportive of seniors' overwhelming desire to remain independent for as long as possible. To this end, CMHC is examining the potential of ``smart growth'' strategies that can make communities across Canada more compact, with a good mix of land uses and well-connected streets, sidewalks and pathways that allow easy access to support services and amenities. CMHC is also examining ways of creating liveable communities in which there is a choice of housing and transportation, a range of civic amenities and well-kept public places for recreation and community events; and sustainable communities that meet the needs of current and future generations, while minimizing the impact on the environment.
One example is the CMHC fused grid model, which combines the best features of conventional and traditional street patterns. This is achieved through a large-scale grid of collector streets carrying moderate- to high-speed car traffic, within which are blocks of about 16 hectares — more or less 40 acres — with streets laid out in the form of crescents and cul-de-sacs, thus eliminating through traffic. A continuous open-space pedestrian path system provides direct access to parks, public transit and retail and community facilities. The fused grid also reduces the amount of land taken up by roads, thus allowing for more green space, increasing car and pedestrian safety and minimizing environmental impact. The fused grid concept could better accommodate the aging of future generations.
CMHC is actively involved in research and information transfer activities that address housing challenges for seniors as well as possible solutions. CMHC research activities have resulted in the creation of a number of useful information products. I have brought copies of the CMHC catalogue of research and publications for seniors, which I will leave for members of the committee. I would be happy to provide copies of publications that can be useful to the committee's deliberations. At CMHC, we are aware that the aging of the Canadian population will be one of the most important challenges facing Canada in the next 25 years. I am sure that the Senate committee's work on this issue will be of great benefit.
The Chair: We will turn to Ms. Sholzberg-Gray from the Canadian Healthcare Association.
Sharon Sholzberg-Gray, President and Chief Executive Officer, Canadian Healthcare Association: The Canadian Healthcare Association, CHA, wishes to thank the Special Senate Committee on Aging for this opportunity to contribute to its deliberations. We are a federation of provincial and territorial hospital and health organizations that represent a broad spectrum of health services, including acute care, home and community care, long-term care, public health, mental health, palliative care, addiction services, as well as children, youth and family services.
We are a leader in developing and advocating for health policy solutions that meet the needs of Canadians. Our national association is committed to a publicly funded health system that provides access to a continuum of comparable health services throughout Canada. CHA believes that all health-service components must be adequately funded, effectively organized and appropriately interconnected in order to function optimally, thus providing the appropriate care in the appropriate setting at the appropriate time.
As stated by earlier witnesses, we all know that today's seniors will be healthier than previous generations, will live longer, are predicted to experience a compressed period of morbidity at the end of life and will have definite ideas about what type of health services they want.
There has been considerable discussion concerning the sustainability of the health system, particularly in view of the changing population demographic. Most public discussion on sustainability has revolved around access to acute services without sufficiently exploring the need for continuing care services and the interrelatedness between all parts of the continuum of care.
I would endorse everything Mr. Hollander said on those issues.
The committee has asked us to address the issue of housing, supportive housing, assisted living and home care. However, we would like to look at the essential value of continuing care services as a group. This includes, on the housing side, supportive housing, assisted living and facility-based long-term care. On the home care side, it includes the broad range of community support services and home care that are needed. These are the book ends of the health system and often insufficiently recognized.
We have to say repeatedly that there is a link between all of these services and the effective use of acute care beds. The occupancy of acute care beds by patients who could be living in supportive-assisted living arrangements or in their own homes with adequate home and community services, or whose optimal placement is in a long-term care facility adds to the wait times problem. The focus on wait times in the First Ministers' Health Accord 2004 was appropriate, but wait times cannot be addressed in isolation from continuing care issues.
CHA has developed a pan-Canadian document on facility-based long-term care. We did this because we thought it was a poor cousin of the health system. It includes a comprehensive examination of its role within the continuing care sector. It contains recommendations within the context of continuing care services needed by people — including home care, community support services, informal caregiving, assisted living and supportive housing. Although the document is being renewed, we will leave you with its recommendations because they stand the test of time.
We note the comprehensive presentation given from CMHC. However, in reference to housing, we would note the importance of adapting existing housing for seniors either through rehabilitation, adaptation or emergency repairs. These programs are important, but many seniors are not aware of their existence. If they did, would there be enough resources for all of them to access those programs? This is a key issue for the federal government.
With respect to supportive housing, we heard about various models of supportive housing and the types of services that exist throughout Canada. They all have different names, which is one of the conundrums of our health system. This makes the collection of data and research more complex than it needs to be. Supportive housing is one of the solutions, and CMHC will have to be part of it.
Assisted living is generally grouped with supportive housing. I would like to express a few caveats about the assisted living group of services. The reason I raise this is because I am concerned about quality and the types of things being marketed today to an unsuspecting public.
It is important to note that assisted living facilities usually provide assistance with the activities of daily living, ADLs, such as dressing, bathing and grooming. The amount of assistance often varies among facilities, and there are basic charges plus add-ons for additional assistive services.
Originally, these were quite appealing to the elderly since they offered security, congregate meals, planned activities and opportunities for interaction. This was a good thing. This is a population group that is less frail than those usually found in a typical long-term care facility.
The major drawbacks to most assisted living facilities is the hefty price tag — as they are usually marketed as luxury accommodations — the shortage of skilled care and the lack of clarity as to what constitutes assisted living. They are being aggressively marketed with promises of luxurious settings, dedicated staff and being able to meet all of the residents' needs for safety and care. Some operators of these facilities have been looking for a frailer group of elderly residents to market their services, in some cases palliative care clients. The costs associated with these facilities are very high. Therefore, only people who are wealthy can benefit from them.
We have to be vigilant to ensure that assisted living facilities do not become entrenched as unregulated long-term care facilities with à la carte care. They are not a substitute for facility-based long-term care and should not detract from our need to establish a healthy facility-based long-term care sector whether it is called residential care, continuing care or long-term care centres. All of these centres should be based on appropriate principles of accessibility, affordability, quality and comparability across Canada.
I am afraid that this sector of services may be offering to provide more than they can actually deliver and to deliver services to a frailer group of people than should be in them. This is something we ought to note with a forewarning and caveats.
We know in some cases long-term care facilities are providing end-of-life care as well. The Canadian Hospice Palliative Care Association told this committee that a long-term care facility is not a hospice and should not be confused with one.
There is a patchwork quilt of long-term care across this country with a variety of different charges applied for services and supplies depending on the province.
It is not until the later years of life that most Canadians discover these types of health services, which they believe are available to them because we have a medicare system, are not provided in an all-encompassing publicly funded system. The definition of medicare in our country is, and continues to be, physician and hospital services. I am not saying this is a bad thing, but only noting that fact and the fact that the public often is not aware of it.
When did we have a debate in this country and decide that heart disease and cancer were illnesses for which there should be insured services but dementia or Parkinson's disease are to be treated differently? We have not had an open debate on that. The person diagnosed with advanced dementia is likely to be admitted to a long-term care facility eventually, where the care may be partially publicly funded, and there may be a room and board payment. However, that is not the case if the person is in an assisted living facility with 100 per cent user pay and where the resident pays additional out-of-pocket fees, user charges or co-payments.
I will move on to home care as home care is part of the solution. We heard from Mr. Hollander about how important home care and community support services are in reducing the demand on other parts of the health continuum and reducing costs generally within the health system.
Home care services encompass an array of health services delivered to clients in their place of residence including assessment and case management, professional health services, personal care, homemaking and other services. Home care provides many benefits — individuals often function better, remain more independent, experience a sense of normalcy and enjoy social integration within a home environment.
The amount of home care provided as long-term care substitution and as maintenance or prevention programs has major implications for the facility-based long-term care sector. Adequate home care services can significantly reduce the requirement for space in long-term care facilities. Researchers have shown that these particular aspects of home care are in jeopardy because acute care substitution services have increased and have absorbed larger portions of home care budgets. Because home care dollars are being reallocated to post acute care, the frail, elderly and chronically disabled may not receive the sustained, ongoing home care they need, or they may have to wait too long to be allocated the services they need due to this shift in the use of home care. The deterioration in a patient's health status, which can occur without adequate home care services, may result in admissions to hospitals or earlier admissions to long-term care facilities which could have been prevented or delayed with sufficient home care support.
In many provinces, community support services are included as part of the home care program while in others as a separate array of health and social services and programs within communities. They can be provided in a variety of settings by a combination of public, not-for-profit and proprietary organizations. Support services can include respite programs, adult daycare, homemaker support programs, personal care services, Meals on Wheels, Wheels-to-Meals and others — a tremendous array of services. All these programs — community programs and home care programs — together may prevent or delay admission to a long-term care facility, focus on aging in place and reduce demand on the acute care system. However we design a system, we have to have this broad array of programs.
I would like to address an important issue for policy-makers, the issue of co-payments. We never talk about this part of the health system, and we have to talk about it. CHA and its members are strong defenders of Canada's publicly- funded health system. CHA's position concerning the appropriate public-private mix in the funding and delivery of health care is linked to the principle of access to health services based on health need, not ability to pay. This is a core Canadian value, and it cannot be jeopardized. CHA is also on record as supporting an evidence-based approach as to when, where and how private financing and delivery can occur.
CHA has always urged that the Canada Health Act medically necessary services must continue to be publicly funded, along with acute care replacement home care services. This is the single tier we always talk about. It is efficient and effective. It is our single-payer system. However, we have also recognized that there is room for co-payments for some services — home support services for some clients, reasonable accommodation payments for facility-based long- term care and co-payments for pharmaceuticals, i.e., a catastrophic pharmacare program — provided this does not reduce access.
There needs to be a social analysis and a fair process for establishing co-payment levels. This opinion was recently expressed by the Honourable Monique Bégin in a presentation at S.O.S. Medicare 2 conference in Regina. We must look at this carefully.
We all know about the public expectations of the baby-boomer generation. They will demand services that meet their needs, and that is the array of services I have been talking about in this presentation. As long-contributing taxpayers, they might not appreciate having to pay again for these services. However, they might be looking to these co-payment models provided that needs can be met, there is quality and access and that no one will be deprived of access to the services they need.
Policy-makers and planners must prepare now for flexible and appropriate continuing care services for future generations of seniors. While people age in a healthier way and health spending will not increase as rapidly as the increase in the number of seniors — because, remember, the aging population is not bringing our costs out of control — an increase in the proportion of seniors in Canada means that we need to plan.
Preferred options will include respite, day and night programs, community programs, supportive living and facility- based care and an appropriate array of home care services. This is also the generation that does not want to wait for acute care services. Do not forget about those. Anything to reduce the need for those services will be worth investing in.
We also need to remember that gradually the pressure exerted by baby boomers will reverse, and health planners must consider eventual attrition and not overbuild or create static systems.
There are challenges. First, we need flexible options to meet needs. Today's families and income earners are mobile. Family ties are often maintained over long distances. The traditional family structure has changed. The amount of support that adult children can reasonably provide to elderly kin is often dependent on the proximity to their parents and their availability due to work obligations. We need to ensure flexible options and appropriate services for seniors and their families.
Second, we need to recognize the variation in terminology and services provided across the country. We need to focus on research and appropriate data collection and understand the services that exist. This is an area in which a lot of misunderstanding occurs.
Third, we need to look at the co-payment picture in the continuing care side and do something to resolve it. We cannot have people losing their homes in some parts of the country in order to pay for long-term care services or home care programs. There has to be a reasonable level and the appropriate social analysis and tests.
Fourth, drug costs are part of this patchwork and need to be resolved as well. In some provinces drugs are in with a home care program and in other provinces they are not; the same applies to incontinence supplies.
Fifth, we have to find reciprocity in the provision of services or portability of services. Portability is a Canada Health Act service. It has nothing to do with the long-term care side. If people want to move to be close to their families, they cannot, because as a senior, one cannot wait a year to access the services.
In closing, there are a number of areas that the federal government can focus on: appropriate co-payment analysis of the continuing care sector; maybe trying to straighten out the patchwork quilt so there will not be these tremendous variations across the country, without, of course, micromanaging of the systems that provinces deliver; and perhaps an acknowledgement that acute care is not everything, that we cannot address the problems of our acute care system without addressing continuing care as a group of services.
The Chair: Thank you very much.
Now we will hear from The Royal Canadian Legion. I understand, Mr. Allard and Mr. MacDonald, that you are sharing this presentation. You may decide how you will deliver it.
Pierre Allard, Director, Service Bureau, The Royal Canadian Legion: Senator Carstairs, honourable senators, on behalf of our national president, Jack Frost, I would like to commend the work that your committee does on behalf of seniors. A number of advocates and academic studies have identified a need for supportive housing for seniors. For example, Mr. Rodriguez has suggested that the need for supportive housing should increase throughout the 21st century, and the statistics that he quoted support this.
What is supportive housing? In succinct terms, we can state that it is the type of housing that allows people to maximize their independence, privacy, decision making, dignity and personal choices. It may be a surprise to many that The Royal Canadian Legion is involved in supportive housing. Actually, with approximately 150 facilities, over 7,500 units, the legion is one of the most successful providers of safe, affordable housing for veterans and seniors across Canada. Let me read from the quotation that is in your transcript:
The Royal Canadian Legion's intense focus on local housing needs may make the accumulated national impact of its efforts less visible than the high-profile activity of for-profit developers.
For more than 50 years, legion branches across the country have been the driving force in planning, building and operating veterans and seniors' housing in those communities where it is needed the most. This came about as a natural extension of our community work.
More recently, in 1995, we compiled a national housing directory. Four years later, we entered into an agreement with Veterans Affairs Canada, VAC, to partner in serving the needs of veterans and seniors. For the legion, veterans are our priority, but we have found that if we can extend benefits to veterans, it will also benefit seniors. A good example of this is pension income splitting for seniors, an excellent initiative.
As a result of a partnership agreement with VAC, we were able, in April 2000, to staff the Legion Housing Centre for Excellence. Our legion consultant, Mr. David MacDonald, who is here with me, is a VAC employee. He is on secondment to the legion. We coordinate this activity through our Veterans Services and Seniors Committee, which is chaired by the Legion Dominion President, Mr. Jack Frost.
Since 2000, the legion consultant has worked with provincial commands and legion branches to assist with housing development and other real property-related issues. The housing centre also updates our legion national housing directory. I will turn it over to Mr. MacDonald.
David MacDonald, Consultant, Legion Housing Centre for Excellence, The Royal Canadian Legion: In addition to what Mr. Allard has mentioned already, we provide hands-on consulting services directly to provincial commands and to legion branches at no cost.
These services include, but are not limited to, dealing with environmental and rezoning issues; preparing CMHC Proposal Development Funding and Seed Funding applications; preparing applications to municipal, provincial and federal governments to take advantage of programs they might offer; assisting in negotiations with lawyers, developers, planners, consultants, appraisers and anyone involved in the business of construction; helping and initiating project planning and working along with the groups to facilitate that planning at all stages of the development; and dealing with other issues involving real property, including best use studies, lease negotiations, acquisition of land, assistance in obtaining financing for projects, and so on.
The centre was involved in the planning and construction of two major housing initiatives, both of which opened for business in 2007. On October 1, 2001, the legion initiated a 24-month study on housing issues for veterans and seniors. This initiative was funded through a Heritage Canada Voluntary Sector Initiative, VSI, grant. This study concluded that the biggest challenge facing Canadians over the age of 75 is bridging the gap between independent residential living and moving to a care facility. We found that many of our veterans and seniors are not ready for chronic long- term care facilities and that many of them can remain in their current homes with the appropriate supports in place.
The legion VSI-sponsored study made recommendations, most of which are still germane today, including a recommendation for a senior's independence program that would allow seniors in need to remain in their homes for as long as possible to avoid institutionalization. This approach, which would be modelled on the very success Veterans Independence Program, promoted by VAC, would allow seniors to age in place and delay the more costly transition to long-term care facilities. We also made recommendations related to CMHC programs; I will talk about those later on in my address here.
Another successful project undertaken by the Legion Housing Centre for Excellence was the production of a handbook on real property development. This generic housing handbook, which can be used by any developer, legion or non-governmental organization, was made possible through a financial contribution by VAC. We make this handbook available for free to any agency involved in affordable housing. We have left copies in both English and French with the clerk for members of the committee.
What are the future challenges facing people who are involved in providing safe, affordable housing for seniors and veterans? Based on our unique experience in dealing with federal, provincial and municipal authorities across the country, we feel that CMHC can play a larger role in addressing these future housing issues and challenges.
The CMHC Seed Funding and Proposal Development Funding programs are excellent programs for non-profit housing organizations. We have been very successful as a legion when we applied for these two programs. We have not yet had an application turned down that has been prepared through our office, and we are grateful for that. Not only are the financial resources helpful, but the information required to complete the program applications is a sound step in the due diligence process.
It is virtually impossible, however, for our non-profit projects to qualify for CMHC mortgage insurance, especially if they are designated affordable or they offer an assisted living component. We have been involved in projects and are aware of other projects where the equity positions have been excellent, but they have not been approved by CMHC insurance because CMHC is concerned about their resale value and marketability should they have to repossess the units. These facilities are viewed as specialty units; that is, like buildings that are unique and built for specific purposes, such as fast food outlets that are designed to be recognized by the shape of the building. CMHC feels that their security is not as great in these specialized instances as if they were ensuring for-market units.
With CMHC mortgage insurance, money is available from any lenders. However, without this insurance, most chartered banks will not consider financing these projects at all. Because of the need for non-profit ventures to be efficient and cost-effective, the ones that are built are usually very successful. They have lower than average fill-up times, and very reliable waiting lists. Banks are usually very willing to refinance these units once they have been constructed; they are just not available to offer the construction funding to get these units on the market.
We feel, and our experience has shown in the six or seven years that our centre has been in operation, that the CMHC mortgage insurance program does not really function like an insurance program, because CMHC is not prepared to accept any reasonable risk. For example, for car insurance, if assessed risk is deemed to be higher than the norm, insurance will still be available only with a higher premium. With CHMC mortgage insurance, if there is any risk at all the insurance is not available. Since risk is an inherent realty in the insurance business, our feeling is that CMHC is not in the insurance business. We have difficulty in accessing that program, as do many non-profit ventures.
Making CMHC mortgage insurance more accessible for non-profit ventures would be a tremendous step forward. This change alone would promote additional housing starts in this important market that could address the needs of an aging population, both veterans and seniors.
In addition, we talked about a couple of CMHC programs that are successful and that are very accessible to non- profit ventures. However, some of the CMHC programs which are, in theory, national programs are not always available on a national basis — at least not in the same context or to the same degree. For example, although the federal-provincial housing program is a national program, it is administered differently across the country. In British Columbia, it is administered through BC Housing; while in Ontario, where the responsibility for housing resides with the municipalities, it is administered jointly by the province and the 47 regional municipality centres. In Ontario, for example, it is possible for municipalities to opt out of the program. Also, each responsibility centre can establish its own eligibility criteria. This means that even though the federal-provincial housing assistance program is deemed a national program, it is essentially not available in most parts of Ontario, for instance, where the municipalities have opted out of that program.
Our recommendation would be for CMHC to provide guidelines for a national implementation strategy to ensure that all regions of the country have equitable access to national CMHC programs, such as the federal assistance housing program.
Mr. Hollander spoke about the need for national information collection and national initiatives. When national programs are developed, there should be a national implementation strategy to ensure that all regions of the country have equitable access to such a program. This would have to take into consideration unique regional and provincial requirements. Because of economics in some regions, there may be reasons why municipalities or regions opt out, but there should be some way that this program could then be delivered in an alternative format to ensure their residents have access . If we are to call it a national program, it should be accessible nationally.
Provinces should also be encouraged to standardize their eligibility criteria to avoid the potential for national providers having to deal with 47 different approval criteria, which is essentially what happens now when we are dealing with the province of Ontario and the implementation of this one program.
Mr. Allard: We need more flexible CMHC national programs. We have been told this morning that CMHC is collecting national data. They should also establish policy with a national focus. We need to embrace the seniors independence program modelled on the very successful Veterans Affairs Canada Veterans Independence Program. That concludes our presentation.
The Chair: Thank you. We will return to CMHC for their response to what you have raised here.
Last but not least is Margaret Isabel Hall.
Margaret Isabel Hall, Assistant Professor, Law Faculty, University of British Columbia: Today, I would like to speak to my past and ongoing work on the regulation of supportive housing for seniors, which has been sponsored by CMHC in the past, as is my ongoing project.
Supportive housing is currently being developed to provide Canadian seniors with an intermediate housing alternative between living alone without supports, or staying at home, and the heavily regulated environment of institutional care. I use this umbrella term, namely, ``supportive housing'', to refer to the entire range of housing operations between these two poles. The term ``assisted living'' generally refers to supportive housing at the higher end of this range. There is a tremendous problem in conducting any research in this area because of the different terminology used across the country. I resolved that problem by simply making up my own terminology of what supportive housing will be and staying with it. It is a broad umbrella with different combinations of services and housing features being included within this umbrella.
The 2005 study considered alternative approaches to the regulation of supportive housing for seniors and the issues that effective regulation will need to address, and concluded by setting out a range of options for Canadian policy- makers. More details about the study are provided in the research highlights that I circulated.
The task for regulators is to facilitate supportive housing for seniors that is both appropriate and affordable. That is a key feature that was identified through my consultations, through regulation that is neither too heavy, essentially replicating institutional care, nor too light. Referring to Ms. Sholzberg-Gray's comments earlier, there certainly is a need for regulation in this area. Supportive housing should not be considered as an unregulated wilderness as opposed to the care facility. That balance is very difficult to strike. Regulating in this area is tough, and that is why policy- makers here and in other jurisdictions have wrestled with it.
My conclusion is that the balance will best be achieved through a combination of approaches to regulation together with what I call ``supplemental non-regulatory initiatives.''
The first of these options was a comprehensive supportive housing statute that would apply to all supportive housing for seniors, regardless of sector involvement. It would be public, private-for-profit and private-not-for-profit, with supportive housing for seniors defined as housing with services that is provided specifically for seniors.
In my review of different regulatory approaches taken across Canada and also in other jurisdictions, I saw that in some jurisdictions supportive housing for seniors provided by the not-for-profit sector is regulated differently than that by the for-profit sector. When I talk about a comprehensive statute, I am talking about a statute that would not draw those types of distinctions and would apply to all forms of supportive housing throughout the umbrella. The statute could include legislated minimum standards for certain issues and provisions and apply a consumer protection approach for other issues. Therefore, meals could be subject to legislated standards. These are legislated minimum standards and costs subject to consumer-protection-based provisions, for example.
A benefit of the comprehensive supportive housing statute would be the relative clarity of a single-statute approach for providers, consumers and their advocates and for policy-makers. Clarity would be valuable here as the current splitting up of the regulation of supportive housing among different statutes and different policies within provinces — let alone between provinces — made for a significant degree of confusion about which regulations applied.
This clarity, as well as being useful for consumers, providers and policy-makers within provinces, would also promote the coherent and consistent development of regulation among Canadian jurisdictions , another feature that I consider very important for two reasons.
First, consistency avoids the need to constantly reinvent the wheel as jurisdictions are able to discuss their experiences and learn from each other's mistakes. While producing this report, I learned that in each province some type of initiative around supportive housing and then around this thorny issue of ``if we are to have it, how are we to regulate it'' seemed to be going on. However, there was virtually no communication between the provinces as to exactly what they were doing. The problem about nomenclature was a big contributor to this.
These processes require the development of a common language around supportive housing, a development which is made much more difficult where supportive housing issues are dealt with by multiple statutes and authorities within a single province.
Second, older Canadians are mobile and retirement or age-related lifestyle changes may trigger a move closer to adult children, other relatives or to a more suitable climate.
The current widely divergent approaches to the regulation of supportive housing in Canada divided between different regulatory instruments within provinces creates a formidable information challenge for the potential supportive housing resident who wants to move from Toronto to Victoria. In addition, the splintering of regulatory responsibilities within provinces themselves made it virtually impossible for consumers or potential consumers to get the information that they wanted and needed about how supportive housing was regulated in their province.
The model comprehensive statute was the first of my options — and I must say CMHC rejected my idea that I call these ``recommendations,'' feeling it was a little too stern, so I refer to them as ``options.'' This option was the one that I have decided to follow up on and develop in my current project that is underway for CMHC.
I will focus in on the idea of developing the comprehensive supportive housing statute, develop a model statute and then circulate it during the comprehensive national consultation process, which I certainly hope many of you will be part of so that I can get your comments on that approach. I am sure that people will have lots of advice for me and suggestions of what they would like to see included in a statute of that type.
One of the extra-regulatory options, which I also thought would be helpful here, would be to establish a system of elder ombudsman in each province. Each province would appoint an elder ombudsman with responsibility for seniors' housing issues; and also possibly with a mandate to hear and respond to other concerns. The objective would be to have a one-stop shop, easy-to-access system to find information, make complaints, resolve disputes and so on.
If economically feasible, a system of seniors' advocates could operate out of an ombudsman's office. During my consultation with seniors pursuant to this project, the idea of the elder ombudsman and the system of elder ombudsman was received most enthusiastically.
I emphasize this because the problem was identified for me with such force by the seniors to whom I spoke. The problem of accessing information or even beginning to think about where to start accessing information was prominent and identified as, perhaps, the key problem for seniors. They simply would not know where to begin finding information on the options that were available to them.
The third option would be to create national best practices guidelines, which would involve establishing a working group at a national level that would create best practices guidelines. Here, I drew on the American experience, and I will say a little bit about that.
The Americans have been at this thorny problem of trying to regulate supportive housing for longer than we have. A work group on the national level was convened in 2002, I believe, to try to create model best practice guidelines because the United States were struggling and found they were constantly returning to their legislation to revise it because it was so difficult. Perhaps we can avoid that difficult thrashing around stage, cut directly to the chase and simply create a best practices body that could provide a model that would be useful for the provinces.
The fourth option is to establish a supportive housing for seniors' centre for excellence that would also draw on some of the work that your organization has done. This would also build on the work of the national working group that is described in option three. Rather than simply disbanding, once the best practice guidelines were formed, the work of the national centre for excellence would continue and carry on the work that had been initiated by that body.
The fifth option would establish a non-legislated system of accreditation. The centre of excellence would develop this system of accreditation with input from consumers and providers, as well as academics. The centre would be responsible for carrying out accreditation and gathering and disseminating information about the accreditation system. Again, getting information to consumers is key to the workability of this system.
Finally, the sixth option is to establish a central information database, with ease of access being the key. Establishment of a central information database accessible through the Internet, and also through a seniors' housing hotline for those who may not be entirely comfortable using the Internet, is vital to the success of supportive housing as an intermediate housing alternative. Information provided would include availability, costs and rules or conditions of residency. A senior who wishes to relocate would be able to access information about the availability and the way in which supportive housing is regulated in that province.
In conclusion, the big idea that has come out of my work, which I feel is important to emphasize, is the connection between affordability and the provision of a suitable real number of affordable supportive housing units to maximize choice for consumers and the need for less regulation of the sector.
The consumers' ability to vote with their feet, which is the theory behind a consumer-protection approach as opposed to the minimum-legislated-standards approach — like a care facility where more aspects of services and building features within the facility are legislated — depends to a great degree on the ability of the consumer to exercise real choice.
If a consumer choice and consumer protection model is pursued in this sector to avoid replicating the legislated standards that we find in care facilities, it is absolutely crucial that there be real choice for consumers so that they are able to discriminate between housing units on the basis of suitability instead of merely taking whatever they can find and afford.
The Chair: Thank you. Before I turn to others for questions, I would like to know if Mr. Rodriguez has any comments on the comments that were made by The Royal Canadian Legion.
Mr. Rodriguez: Their comments are outside the scope of my work. Perhaps Ms. Darke would like to comment on that.
Debra Darke, Director, Community Development, Canada Mortgage and Housing Corporation: I will try not to get into a lot of detail, but I would like to address two areas. The first is the comment that Mr. MacDonald made about CMHC not really being in the insurance business, given that we are not willing to take any risks. I would also like to speak briefly about the types of arrangements that we currently have in place with provinces and territories, which, as Mr. MacDonald quite rightly pointed out, are largely responsible for delivering the range of programs that are available across the country.
Dealing with mortgage loan insurance first, we are in the business of providing mortgage loan insurance. As many of you may know, CMHC runs its insurance business on a commercial basis. In doing so, we are in the business of assessing risk and of charging on the basis of that assessment. When we are underwriting loans, we look at the viability of a project and assess the risk involved, and our premium is reflective of our view of the risk of the project. Generally speaking, the higher the loan-to-value ratio, the higher the mortgage loan insurance premium; we have found that loan-to-value ratio is a good measure of risk.
I am not too sure about the specific barriers or challenges that some of the legion projects that Mr. MacDonald mentioned have experienced. However, we, at CMHC, will be more than happy to meet with Mr. MacDonald, Mr. Allard or the specific proponents of these projects to try to better understand the projects and the challenges with respect to obtaining mortgage loan financing.
In 2003, CMHC introduced a number of flexibilities to our usual mortgage loan insurance parameters. These flexibilities were specifically introduced to encourage the development of new affordable housing units. These flexibilities are not available to every project, but if a project meets our affordability criteria, we are willing to extend them. There is a range of flexibilities provided: We increase the loan-to-value ratio, for example, that we are willing to insure. This can be quite helpful to proponents of affordable housing because it reduces the equity requirements for them. We have also reduced — and in some cases completely discounted — the mortgage insurance premium payable. We also have various flexibilities that relate to debt-coverage ratios and other technical aspects of mortgage insurance that I will not get into.
Again, we have a staff across the country who are familiar with those flexibilities, and we are more than happy to talk to the legion and others to explain them and see how they might be applicable to their projects.
Perhaps I can just say a few words about our programs and how we work with provinces and territories.
There are currently a range of federally-funded programs available across Canada. I believe that Doug Stewart spoke to this committee about a year ago and outlined at a very high level the different vehicles through which the federal government provides housing assistance.
I will not go through all of that again, although I can try to answer any questions. Most of the programs that we make available, of which there is a range, are made available through provinces and territories, and we do this in the context of some high-level multilateral and bilateral agreements.
The Affordable Housing Initiative, AHI, is a good example. There is an overall multilateral agreement that CMHC, on behalf of the federal government, signed with all the provinces and territories, and then there are specific agreements in place with each province and territory. It is the multilateral agreement and the bilateral agreement that outline overall parameters — high-level objectives, if you will — for the investment. In the case of the AHI, the investment is being matched by provinces and territories. Therefore, over the life of this initiative the federal government will contribute $1 billion, and provinces and territories are matching that.
Program design and delivery is up to provinces and territories within the context of the agreements we have signed with them. Those agreements, of course, also include a number of accountability and reporting requirements.
As Mr. MacDonald pointed out, provinces and territories have made different choices about how they choose to deliver those programs. In some cases, they have chosen to deliver the programs through municipal service managers, and he cited Ontario as an example. However, they are national programs, and it is expected that the national investment will be available across the country. It is up to provinces and territories to ensure that in fact that is the case.
As I said, I will not go into further details now, but I can certainly try to answer any questions.
The Chair: I do not want to belabour this issue, but I must tell you that The Royal Canadian Legion is not the only one that has raised this issue with us.
There seems to be a perception, whether it is real or not, that non-profit organizations that would like to build this type of assisted housing cannot get funding from CMHC.
I would like to know — not today but in some way — what could the government do, if anything, to make that funding more accessible? Is there a guarantee that the federal government could provide that would make this type of insurance more readily available? As I said, I do not expect an answer from you now, but could you perhaps get back to us as to whether there is any availability?
Ms. Darke: Again, there are the two components to that.
From the mortgage loan insurance perspective, if we can understand what the concerns are, what the barriers are that groups have been experiencing, that would be very helpful to us.
Back in 2003, as I said, we introduced a number of flexibilities because we had heard from groups developing affordable housing. They were challenged on a variety of fronts, and the flexibilities were introduced to provide assistance in that regard.
From the perspective of the programs that provide subsidy assistance, these, as I said, are directly delivered for the most part by provinces and territories.
In these cases, it may be that groups are suggesting that they cannot or do not have access to that funding. It is difficult to know why. I do know that there is wide-spread interest in accessing the assistance that is available. The provinces and territories do their best to identify the projects that they will be able to assist. However, to the extent that the interest or demand for funds exceeds the available funding, that may determine whether or not a group is able to access program funding.
Senator Cordy: You have announced extensions for a number of renovation programs at CMHC, ones that Sharon Sholzberg-Gray made mention of in her presentation. That would be the Residential Rehabilitation Assistance Program, RRAP, the Emergency Repair Program, ERP, and the Home Adaptation for Seniors' Independence, HASI. Could you give us the status of those programs currently, and is there extension, does it have a time line on it or is it depending on how many people are going to be accessing them?
Ms. Darke: You are referring to what we call the suite of renovation programs, and it includes the RRAP, with which many people are familiar. You also mentioned the HASI, ERP, and a few others.
Those programs were extended for two years this time last year. Funding for those programs will be in place until March of 2009. CMHC will be going forward to government in 2008 to seek direction on the future of the programs.
Senator Cordy: Would you make a recommendation to the government as to whether or not it should be continued?
Ms. Darke: Yes, we would.
Senator Cordy: We heard a couple of our panellists mention communication: How do seniors find out about programs that are available? This is something that we have heard not just in relation to housing but also in relation to a number of programs that the government offers.
How do we let people, in this case the seniors, know about what they can access? It is a big road map out there with respect to the federal government, and I know as a senator that it is challenging to search for answers to people's questions about what programs are available.
The information needs to filter down to provincial governments, municipalities, seniors groups, and we had one mention of a seniors' ombudsman. Right now there are so many facets when looking at care for seniors. For a senior to sit down at a telephone or a computer to try to zero in on which department they should be looking at is very challenging.
How do you go about delivering your programs? Can you talk a little bit about the role of the ombudsman?
I believe the legion does a pretty good job of networking through the communities. How do you do it? How do you communicate?
Mr. Allard: A number of initiatives should be looked at, one of which is in Ontario, where there is a single portal to access information on municipal, federal and provincial programs. I believe it was trialed in Brockville. I do not know what the status of that program is at this time, but this is a very good way to communicate.
With respect to an ombudsman, we are also trying to see if we would like to advocate for an ombudsman for seniors or even a bill of rights for seniors. There is another challenge there again, in that many of the regulations pertaining to care of seniors are provincial in nature. How do you look at a national policy that could reach all the seniors across the country? I am sure you are having the same challenge.
Having said that, maybe the solution for an ombudsman is to have a federal ombudsman office with a legislated mandate that would have a number of ombudsmen below its legislated mandate at a secondary tier responsible for certain programs, such as veterans, Canadian Forces, tax payers, seniors.
By putting a legislated mandate on top of that structure, it would give more power to an ombudsman, or an ombudsman office, to achieve its aim.
Mr. MacDonald: My office at the Legion Housing Centre for Excellence tries to coordinate this information and gather it up, so when I go to the branches I deal with across the country, and the commands, I am able to offer them some type of package that takes into consideration all the parameters and such.
It is very difficult for me, and that is what I do. I go to Ontario, for instance, and I find 47 different sets of regulations. I have to be very careful what side of municipal boundary I am on, because the information is not the same, necessarily. Those situations are what make it difficult. Sometimes when I go to a province it is very difficult to find out even what ministry in the province is responsible for the program. Then when I find out what ministry is responsible, it is very difficult to find out what people are responsible for the program.
It is something that I do on a daily basis, so I can understand the frustration for people who try occasionally to get information at that level. It must be very difficult because it is difficult for me.
Ms. Hall: My idea for the ombudsman would be to have seniors' ombudsman at the provincial level. Partially, this is based on an American model. I believe almost every state has an elder ombudsman; some more particularly associated with housing, some with a broader mandate of issues that they are to provide information about. All offices are at the state level but have funding from the federal government. That is the model I was looking at.
As I continued in my very interesting consultations with seniors, which taught me a great deal, I became increasingly convinced that this figure, the ombudsman, should have the broader mandate to deal with the whole scope of issues with which seniors are grappling. They may not even know how to make that first step in characterizing the issue — of whether it is a health issue, a housing issue or a financial issue — and then proceeding to find the appropriate person who is going to help them with that.
This idea of the one-stop shop and the high-profile individual and office, which is easily identifiable as the place to go with a problem, just seems so key to me here and for a range of issues.
The Chair: Ms. Darke would you like to reply?
Ms. Darke: Yes, I knew it was coming back to me.
I will try to answer your question in two contexts. The first is related to promoting programs. You talked about the challenge of communicating the availability of programs to seniors. The second context deals more with what my peers have been talking about: how to deal with inquiries and help direct people to the appropriate source of information. That is a little bit different in nature.
I will start with promotion. Canada Mortgage and Housing Corporation directly delivers the renovation programs in some provinces and territories but not in all; in those places where it is our responsibility to promote the availability of the programs to seniors and others who may be interested in benefiting from them. Where provinces and territories deliver, of course promoting programs is one of their areas of responsibility.
In the case of seniors, we have, over time, developed a number of different approaches. You quite rightly point out, it can be a challenge. We have found that trying to ensure that a range of different players are aware of the availability of the programs works best. Health care professionals are one audience that often gets inquiries from seniors about the types of assistance that might be available to them. That is a group we try to make aware of our programs, such as the Home Adaptation for Seniors' Independence. Family and friends are also groups that have influence and from whom seniors may seek advice and support. We try to ensure we target some of our promotional efforts to them, and then seniors themselves.
We have a number of methods: We advertise in papers and journals that we think seniors will see; prepare fact sheets and materials and try to ensure they are available in places that seniors frequent; and undertake, from time to time, market research to find out what works best to reach that particular audience. Therefore, there is a range of different approaches.
With respect to dealing with inquiries, as I said, that is a slightly different set of issues. Here, too, we try to take a variety of different approaches. We do work, for example, with and through Service Canada. Service Canada develops a number of guides, summaries of programs available. They have, in the past, put together guides that summarize programs available for seniors, I believe. We always ensure our programs are included as part of that. They have a 1- 800 O-Canada number, so we provide scripting, so to speak, to those operators. Therefore, if they get questions on the different programs, they know where to direct them.
CMHC also has a 1-800 number. We get inquiries from a range of different groups, including seniors across the country. Our own staff members manning that 1-800 number also have a script and know where to direct people. If they are inquiring about the renovation program and it is within a province that we deliver, they will refer them to the relevant CMHC contact. Alternatively, if they are asking about the AHI or renovation program where a province or territory delivers, they would have that information as well, and they would be in a position to refer the individual to the appropriate organization.
We have staff across the country in the CMHC Affordable Housing Centre. They are knowledgeable about the different CMHC programs, products and services and also about what the particular province or territory in that area has to offer. Oftentimes they will get calls and inquiries, and they are able to refer individuals to the appropriate point of contact.
Senator Cordy: Mr. Rodriguez, I know you work in policy and research and you talked about one of the examples in your community planning, the fused grid model. Is this just research that you have done or are these things that CMHC is implementing?
Mr. Rodriguez: CMHC has done a substantial amount of research in this regard for the whole Canadian population. We are particularly focusing on the fused grid model to give you an example of how these types of options could work for seniors.
CMHC has worked with several municipalities, and the graphic you have in the deck that we provided to you shows one of the examples that was used by one of the municipalities in Canada. Presently, there are at least three or four municipalities pursuing development of this idea. This has taken a great effort, but we are moving along very well, and we hope in the end this will be a winner.
Senator Cordy: Are these models being implemented?
Mr. Rodriguez: Yes.
Senator Cordy: Where are they being implemented?
Mr. Rodriguez: I forget the name of the municipality north of Mississauga, but we can provide you with the information on the how we have promoted this model across municipalities. That will be something we can do for you.
Senator Keon: Thank you very much. This is truly a fascinating subject. It is very interesting that Ms. Sholzberg- Gray, as she usually does, raises the interface of the public and private sector in health care.
It is interesting, if we flip through the newspapers, they say if we are rich enough, when we get old, we can buy anything we want. We can make one move into one of these luxury developments, and we just move from floor to floor until we turn up our toes, right? Everything is provided.
We should not dismiss that, and we should not be sarcastic about it because it speaks to the genius of the private sector. It is a lot of money, but it does speak to the genius of the private sector. They simply rise above the great Canadian bureaucratic mosaic and build something like this and have it up and running in the course of a year.
The real challenge — and Mr. MacDonald pointed to it very effectively — is the 47 municipalities in Ontario. It seems in every socially related study we undertake in the Senate, the same situation happens. We hit such suffocating bureaucracy that we sort of want to fold up our papers and go home.
This subject, I feel, is one of the most complex of all. It would seem to me — and I would like you all to comment — that this whole area of seniors' care, whether it be in their own home, in a community facility or through building a special community, must get simplified. There may be a dozen options or fewer. If people such as you could look at — as Ms. Hall said — a few options, and then try to address this dilemma through these options.
Senator Carstairs will have to hone down some of these options before our final report comes out, but let me try to get you people one by one. Just go through what options you can look at. Forget for a minute that this may not be affordable at all; just talk about what is out there, and then someone can sharpen the pencil and come in with what is affordable.
How can we take care of our seniors, from a housing point of view?
Mr. Hollander: I would basically reiterate some of the points made in my presentation.
We completed a study a few years ago looking at systems of service delivery across the country for people with ongoing care needs, and we found a couple of areas that were fairly interesting. We found that they obviously had need for care on an ongoing basis, so there was a commonality there. We found that, in fact, the services they used were also very similar, so the response was similar.
We found exactly what you are alluding to, which is that there are gaps in service and different policies. To the extent that the various components of services that are appropriate to seniors are seen as separate, we will continue to have the types of issues and problems that have been alluded to because there are issues of eligibility. They may differ, and there may be co-payment issues that are different, for example.
The point that I am trying to argue for is that sometimes the whole can be greater or more efficient than the sum of the parts by having a broad mandate with administrative and fiscal authority for a range of services for seniors. We cannot cover everything. We need to make appropriate linkages with hospitals, primary care physicians and the housing sector.
However, we can have a system of care with a broad community base and a wide range of services that are also integrated horizontally and vertically; that is, the system includes community-based services, long-term care facilities and perhaps some specialty services and geriatric centres. We have had these systems in Canada before, and they have worked reasonably well.
By doing so, you can provide more seamless care because they are all part of the same system. If someone needs the use of an adult daycare centre, a home support service or a nursing service, those would all be managed through a process of case management or care coordination. Similarly, if a senior needs to go from the community to a hospital to a long-term care facility, back to the hospital and so on, these are difficult and important events in seniors' lives, and they can be made much easier with appropriate care coordination.
If we have a broad system with good care coordination, we will not completely reduce some of these problems, but certainly our experience is that they can be mitigated considerably. In addition, because we have this broader system, we are able to make policy and financial choices to, in fact, increase efficiencies.
For example, in the early 1980s, we had a severe recession in British Columbia, and the government revenues were simply not there. Once the situation improved, we developed a planning and resource allocation model. The point of this is that what we did, either through necessity or design, was to hold back bed construction and reinvest the funds in the community. On a proportional basis, we were able to look after the same number of people in the mid-1980s as the mid-1990s but in a more effective manner because more of them were being cared for at home at a lower cost.
This is something we seem to have gotten away from in Canada for a variety of reasons. Fortunately, I have had some experience with that system in British Columbia, and I am familiar with similar systems across Canada. There was a lot of commonality between these systems in the late 1980s and early 1990s in Western Canada.
One of my ways of thinking about this is to figure out what population we want to serve, such as seniors or people with disabilities. What is the range of issues they have? Are they health issues, housing issues or social services issues? What is the problem, so to speak? That is, what do they need in order to basically meet the type of care requirements they have? Then we design a system that is responsive to all of that.
My approach would be to look at whether we can get better care and greater efficiencies in the system with some of these more integrated models or with the opportunity for people to discuss them in more depth.
The whole notion of these integrated care models does not seem to be on the policy agenda at the present time, and part of my presentation is to make the case that perhaps they should be.
Ms. Sholzberg-Gray: First, I agree with many of the points that Mr. Hollander put forward. I would like to go back to Dr. Keon's first remarks.
The magic of the private sector facilities that wealthy people can purchase services from is an interesting model, but you rightly said there is only a small percentage of people who can benefit from it. This committee is grappling with trying to serve the needs of the vast majority of people who cannot afford those services. While it seems magical, it is not that magical because most people cannot afford it.
Let us look at what we can afford as a country and perhaps ways we can work together to accomplish those things. Certainly, integrated approaches to the whole continuing care side is one of them. I am looking here at the potential role of the federal government.
The federal government, until now, aside from its work through CMHC on housing, has really kept its nose out of continuing care. Remember, the Canada Health Act is acute-care based, but we know the linkages, and I do not need to repeat them.
That is why our association is actively promoting that the federal government enter this continuing care field. It is difficult at a time when people are trying to restrict the future use of spending power. Until that is accomplished, we will not grapple with the bookends in an appropriate way.
Therefore, we have recommended a federal contribution, starting with, for example, $1 billion a year for a home community and long-term care program that would have certain pan-Canadian objectives. We would not want to micromanage what the provinces do, but the objectives should include integrated approaches to continuing care and an acknowledgment that some parts of this continuing care sector are health services. Health services need to be part of universal funding because they are part of our single payer system. A certain number of them are social services, and they can either have various co-payments associated with them or a social analysis of who ought to get them.
For instance, it is not possible that we can afford as a country to pay — even though it would be terrific — for everyone's housekeeping and snow removal services, which would improve health, just as we cannot buy everyone food in this country, which would also create a better health status. We have to have a social as well as a health analysis in this legislation, which holds out a carrot to provinces to participate in it.
Rather than micromanaging this new continuing care program, we ought to say we want to achieve these objectives: integration, the acknowledgement of social services and an array of one-stop shopping that must be available.
The federal government will have to go into it using the Social Union Framework Agreement, noting that six provinces not constituting necessarily the majority of the population is enough to move the program forward. There can be negotiations and discussions. Again, we need to acknowledge that each province has its own needs and stress general objectives. The idea of pan-Canadian objectives is not a bad approach, with some accountability to achieve those objectives without stating precisely how. Then we would have the array of programs that some people get as a result of the social analysis and everybody gets as a result of a health analysis. That is one of our solutions.
Our association strongly supports the Canada Health Act. We have heard many people proposing massive continuing care investments by saying, ``Let us put it all into the Canada Health Act.'' We are saying, ``Let us not.'' Let us have this separate approach that acknowledges the difference between social services and health services and tries to use minimum resources to achieve the best health status for the best possible number of people.
Frankly, in most provinces of this country, there exist regional approaches to organizing ourselves. Many of the provinces group health and social services, so this is not impossible to achieve. There is that regional infrastructure.
In order to achieve access to roughly comparable services to all Canadians, the federal government will need to be involved. Some provinces will not want to take a directed approach. They will say, ``Just give me the money, but do not tell me what to do with it.'' However, if we are simply providing broad program objectives, the provinces may opt in.
You will notice the 2004 First Ministers' Accord on Health Care Renewal contains an acute care home care program. One reason that it is not broader is due to the, correct, I believe, insistence on the part of the federal government that it ought to be first-dollar coverage because it is acute care replacement. However, if we only talk about that coverage, we will not get beyond that to the home support services that keep people aging in place. That is why that debate has to change.
That is the reason we have this type of proposal. We are actually proposing that more federal money be expended. We hope that because it will be expending money on this, things will be better allocated down the road. If we take care of the bookends, the acute care system will be more manageable. We consider this will be the way to go.
There is almost no health system in the world that has a publicly-funded health system that does not include non- acute services and pharmaceuticals in different ways. The time has come to do it, to provide an integrated approach to continuing care across the country.
I hope I am clear on this; we have written about it quite a bit. We do not want to micromanage; we want to be able to achieve common objectives in this country.
The Chair: Before we leave that and go to Senator Stratton, you have identified the fact that the 2004 First Ministers' Accord on Health Care Renewal did have a home care component, as did its predecessor, the 2003 First Ministers' Accord on Health Care Renewal. My understanding is that very little was accomplished other than to deal with those acute care beds they wanted to free up. Therefore, if they could take the surgical patient off the surgical ward and put him or her at home and spend some home care for that particular person, then that was a good use of the service. What I understand both from you, Ms. Sholzberg-Gray, and from Mr. Hollander is that this is just a small component of the need for home care. A large group of aging people want to age in place but cannot do so if there is not a ``basket'' of home care services available to them. The accord did not seem to address this.
Ms. Sholzberg-Gray: We need to describe the basket, the objectives and note the differences between the social and health services so that we can find out where co-payments would be needed. I do not know if Mr. Hollander agrees with me about the co-payments. People often buy their own services in this area as well, but it can be agreed upon that the vast majority of Canadians cannot afford to buy those services. They require what the public system will support. We need to find a way to make our dollars stretch. That is why we need a social analysis as well as the health services that are universal.
Mr. Hollander: The tradition in Canada has been different in various jurisdictions. In some jurisdictions, people, with regard to the home support services and, in fact, residential services, may have means tests instead of just income test. A number of provinces have income tests, so co-payments are already in place in many jurisdictions. There are a few jurisdictions with no co-payments. However, given the realities, I have no objection to that. It is consistent with how we have operated in B.C.
I strongly support, first, the need for a renewed consciousness at the federal level of the need for integrated services that are targeted to particular populations, such as the elderly. How services are organized, statistics collected and so on: everything else flows from that. Second, if, in fact, this idea finds favour with this committee and the Government of Canada, then I also strongly agree with Ms. Sholzberg-Gray that the Social Union Framework Agreement may be an ideal model. We have not used it very much in Canada, but it could be a very good vehicle for federal-provincial collaboration in a new initiative with some federal leadership.
Let us not forget that the provinces are already delivering these systems. They have histories of providing care to the elderly with both health and social components. The infrastructure that is in place would benefit greatly from both policy and financial support; that would make a huge difference to the benefit of seniors.
Therefore, it is this consciousness about the need for such a system, and the mechanism to make it happen in Canada that I would agree would be the Social Union Framework Agreement.
Senator Stratton: Thank you. It has been quite an interesting presentation on all your parts.
The Standing Senate Committee on National Finance met last week concerning the Canadian Pension Plan, people's access to it and the ability of seniors to be aware of CPP.
The minister for seniors has put in place a program over the last year whereby they are trying to identify particulars and take it down to the local level. In other words, they actually send people from CPP into seniors' housing projects to educate people about available programs because many of them unaware. However, those numbers are diminishing as we progress through this.
I would be interested to hear from you about whether you feel we should be doing a similar case scenario for seniors. I have known family members, friends, et cetera, who are not aware of their options; they grow older, and their families do not know what their options are. You say that you can send letters and advertise, but that does not work necessarily. Therefore, how do you get to those seniors to tell them what is available to them by way of home care? How do you communicate directly with individuals? That is critical, and needs to take place.
Ms. Hall: I have thought about this a great deal because I feel this is a key issue. I was attracted to the idea of the high-profile, one-stop shop, identified as the place that seniors go with their inquiries, perhaps similar to an ombudsman office. In addition, a high-profile advertising campaign is needed — signs on the sides of buses, signs on those little placards inside buses, television spots and so on — advertising that this office exists with a 1-800 number, similar to the kids help line, for seniors to phone with any inquiries. That is really the only way to get this information out.
Frankly, the people who need it the most are not the active, engaged, involved seniors who show up at seniors centres and go to the presentations given by me about supportive housing. Those individuals would probably be able to find that information themselves in some other way. Therefore, in my opinion, placing information in newspapers, on the sides of buses, inside buses, on television in this very public way is how to go about it.
Ms. Sholzberg-Gray: That is the correct approach provided we have all the programs in place. I have a caution here: My association gets many calls from seniors who ask about their entitlements as residents of Ontario. I tell them that they are entitled to health care in hospitals and physician care; that they might wait a little longer than desired, but the entitlement is there. As to other entitlements, that is dependent upon the region in which they live. Perhaps the community care access centre in that area ran out of money; they will not get home support in that instance. Maybe they do not even have enough for their acute care replacement home care. If there is a consistent approach to CMHC across the country, seniors might be able to approach them about what is available and get some of the information on programs for home adaptation and such.
That is the type of answer I have to give. I do not know who this brilliant person is who would know for a fact what people would be entitled to. These programs are called entitlements in the United States. When I have heard people ask these types of questions, I have told them that I did not know; it is dependent on a number of factors. In the absence of any common objectives or objectives even for those types of services, that is one of our challenges; we are not 100 per cent sure of the facts.
Yes, there is a need for more information, but the more information and the more publicity, the more problems possible. I fear, for instance, that the CMHC program on adaptation and emergency repairs will only operate for another year — although maybe it will continue. If everybody who could use it knew about it, you probably would not have enough money for more than the first two weeks of any year. That is another issue; whether the resources are sufficient.
I am only putting that caveat there. We need more information, but we first have to know what we are informing people about.
Senator Stratton: Should not the senior have the right to know what is available regardless? I have a very dear old friend who is a loner. He lives by himself; he does not connect or click. How does that person get involved?
Although you do not know for sure what he is entitled to, there is still the problem of how you get to him. Right now, it is not happening. How do we develop a system to help that take place?
Mr. Rodriguez: I will give you some comments on what I have seen happen in communities. For example, in Lambton County, Ontario, seniors themselves developed a community centre. They shared with me that seniors are the best route to access senior services because they know each other in the community and talk to each other. Sometimes, it is possible to develop a network that reaches everyone in the community.
In this case, they developed a service centre where the services are provided by seniors themselves. They are people who have retired, who have been carpenters or electricians and so on, and they provide all types of services. It is affordable for the people in the community because the volunteers do the work themselves.
It is an opportunity for seniors to participate in a process and to make sure that all seniors in the community know what is available to them.
Senator Stratton: I still want to know how you get to that guy I was talking about.
Mr. MacDonald: I would like to comment on what Ms. Hall said, which is a very positive step. However, I see that as evolving, a work in motion. Hand in hand with that, we have two other components. One is that when seniors call whoever they call, that person has to have the information.
The Chair: They have to be at the end of the phone as well.
Mr. MacDonald: Yes, it is very difficult now, unless you have 11 fingers, to talk to somebody in real life. They have to be at the end of the phone and have that information.
The second component is the evolving part that I see. Right now, we have a situation where there is a myriad of information out there. It is very difficult sometimes to pull it all together. As part of that piece, in the long run, we should go back to that simplification idea, where we develop a national entity so that the information gets less complicated over time. When seniors call that person, they have to able to tell them what they need to know whether they call from Alberta, Newfoundland or from my province of Prince Edward Island; that information should be relatively consistent wherever they are in the country. That is the problem we are having now.
Therefore, one part of the problem is accessing the information, and the second part of the problem is accessing the correct information. The third part is actually using that information, wherever one is in the country, to get whatever services are available. That is difficult also.
If we go back to what Professor Hall said, that is the ideal piece, but it is an evolving one. In order for that to work, it has to work hand in hand with simplifying the information over time in order for it to be accurate and consistent.
Ms. Hall: To making the information available is the first step to lead to this process that you are talking about.
Mr. MacDonald: Exactly; that is right.
Ms. Hall: It is probably true that a level of confusion exists among the people who theoretically are supposed to be providing the information. There is likely a lack of clarity among them about exactly what is available and what the different levels and chains are. That would need to be dealt with if there was a requirement to provide this information to people who were on the other end of the phone. The difficult process of claification will not take place without a prod; that is the way in which this process will flow.
[Translation]
Senator Chaput: I am making no announcement in saying that we have a multitude of associations, societies, committees and different levels of government that are concerned about the implications of aging, especially because of the health-related costs. Our committee is studying the implications of an aging population and is trying, with the help of the witnesses we welcome before us, to look at everything that is going on within this sector. I believe — and this is my personal opinion — that we sometimes devote so much energy to ensuring that we have programs aimed at reducing health care costs — programs for the elderly — that we neglect to look at the means used to inform these people about such programs.
I would like to use a typical case, that I am rather familiar with, and go over the last 15 years in the life of a couple in order to demonstrate the weaknesses of the system as it now exists. I will not be telling you anything that you do not already know at least as well if not better than myself. Let us take a couple in their eighties in the year 2007; they are aged 85 and 86 years respectively and they have a total annual income of approximately $25,000. The gentleman comes from a rural environment — he was a farmer — and his wife stayed at home to raise their children; she therefore was never part of the labour force. They still live in their home and wish to remain there. With the help of their children, they were able to identify the programs they required in order to adapt their old home so as to make it accessible and safe. Then, one day, the wife broke her hip and suffered a stroke. When she returned home, she required home care. Some services were provided during the first months and they were sufficient because the children were lending a hand as well. In 2006, the roof of the house began to leak and had to be repaired. When I went to visit them, I asked the husband: ``Was it expensive?'' and his answer was: ``Yes, $5,000. I thought I would be reimbursed, but they refused.'' I then asked: ``Where will you get the money?'' and he said: ``Do not worry, we always manage to find money somewhere.''
The offers of credit cards that the elderly receive in the mail are absolutely unbelievable. There have been times when I have seen four different such offers on his table. I was wondering if he was going to take out another credit card or ask for a loan in order to cover the renovations. The protection of the elderly is a concern for me: who is there to protect them when at some point in their lives they become vulnerable, they do not have enough money and they make decisions that they perhaps would not have made when they were 65 years old?
There is also the matter of how these people who continue living at home get about, and this is very important for their continued independence.
Getting back to this couple that has an income of $25,000, they live in a small rural community, and the husband still drives his car to go shopping, to go to the post office, to go to church, to go to the club, to go and see the doctor, 10 or 15 minutes away. This becomes a life network. The last time I went for a visit, he asked me why, given that senator Carstairs' committee was studying aging, we would not discuss an issue that is very specific to them, to 85 year olds, who still drive for their little daily errands, within a 10 or 15 minute radius, during daylight only — they do not drive in the dark because they do not see clearly enough — and as long as it is not in the middle of a snow storm? And even though they do not use their car very much, they still must pay automobile insurance like everybody else, and it costs them $1,000, which is a lot for them.
Everyone probably knows of at least one similar case. I am wondering why we could not implement some policies, at whatever level, to ensure that these people, who truly wish to continue living at home, receive assistance where they really need it at this stage of their lives and not necessarily on the basis of programs. Because if things were simply to continue on like this, this couple will be able to die at home. This is a challenge I throw out to you.
Mr. Allard: There just might be a solution, at little cost. I am familiar with the research done by Mr. Hollander and other researchers who have been able to establish that the housing costs for an elderly person in a long term care facility are probably double what they would be if the person were allowed to stay at home as long as he or she were able to do so.
If, nationally, there were put in place an independence program for the elderly, that would allow them to provide for themselves in their home, without them having to be transferred to a long term care institution, it would be much more economical for the government, be it provincial or federal.
There already exists such a program for veterans — the Veterans Independence Program, or VIP — and I believe that a similar program aimed at Canada's seniors would be a good thing.
I also very much like the scenario that you described with regard to communicating with the elderly. We must be able to communicate with them in order to understand their problems and what solutions there are.
Senator Chaput: I find the idea of an ombudsman very interesting. The elderly become more vulnerable and if they need help, they will perhaps speak more freely to an ombudsman than to their children. It is not easy for a father to have to tell his children that he is just no longer able to cope.
Mr. Allard: I agree with that suggestion. The only problem I see is that there might be a proliferation of ombudsmen. If we could create an office of the ombudsman to overarch them, with a very clear legislative mandate giving them authority to carry out investigations, with junior ombudsmen working underneath the general umbrella, then these people would be able to carry out the necessary investigative work.
When we study seniors' needs, our concern is not just with health-related matters; there are also their finances and federal subsidy programs, such as Old Age Security and the Canada Pension Plan. It would be logical that an Office of the Ombudsman be able to look into those things that have an impact on seniors.
[English]
The Chair: I will put a question concerning an issue that has become increasingly bothersome to me.
A number of people are aging who have been extremely independent all of their lives. They have lived on their own for the most part. They may have lived with families, and when the partner died and the children grew up, they continued along the same path. The children are very concerned because the parent is truly failing — mentally alert but physically significantly incapacitated. The children want to put the parent in a long-term care facility, but they meet with determined resistance from the parent.
How will we deal with those people? What is their right to personal autonomy? Can they insist on remaining in their homes even though those around them feel they need more care than is available to them? Will we protect their autonomy and allow them to remain in place if that is what they want to do, or will we, as a community, insist they move to a place where they can receive the help they need?
We are just beginning to look at this growing issue. Does anyone care to comment?
Ms. Sholzberg-Gray: First, it is clear that the vast majority of frail elderly who go into long-term care facilities have problems of dementia, which lead to placement in a facility because they are not in the best position to make decisions about their safety and care. Combinations of ailments occur when there is dementia, such as incontinence. People diagnosed with dementia cannot stay alone for 20 hours each day, assuming they can get assistance for four hours each day. However, there are not that many home care programs that will give four hours per day to maintain people's health. Rather, they will give one or two hours per day or a certain number of hours per week or month. Such people might have to be placed in care facilities to ensure their safety, but I would still try to give them the right to choose.
Then, there is the issue of these ongoing obligations on the elderlies' children; many work, raise their own children or have children in university. To make them take care of their elderly parent by buying the groceries, changing the bedding, doing the laundry and many other chores places an unfair burden on them.
However, many children in this country do just that. The number of hours that family caregivers provide is unbelievable. The health system could never afford to compensate them for those hours. However, they can afford to and must give these family caregivers some relief in the form of very flexible respite. We cannot tell people, when they are in an urgent situation, that four months from now they might be able to find a way of getting help for their parents. Programs have to be flexible because someone might need the help sooner rather then later. Flexibility will be an important element of those programs.
If federal money is to fund any such programs one day soon, then one of the objectives with home, community and long-term care ought to be that as long as the total cost is less than the cost to the government of a long-term care facility, then people ought to have the right to remain independent.
It would be very difficult for people to say that they have the right to live independently in their homes even if it cost $10,000 per month — unless, of course, if they have that amount of money per month. A good rule of thumb to follow would be that the cost has to be cheaper to remain in the home than to enter a long-term care facility. However, dignity, choice and independence ought to be values incorporated into any legislation. However, how to fund it without placing unbelievable burdens on families needs to be addressed.
Mr. Hollander: My point is that in some ways the system is the solution. If we have separate budgets and administrations for the home care program and the residential care program, we are stuck with the available resources. If we combine them into a broader system, we can make trade-offs.
Some jurisdictions have a rule of thumb — I do not believe it is a formal policy — that is consistent with Ms. Sholzburg-Gray's comments. That is, try to keep patients in the home as long as it does not cost more than in a facility.
When I was responsible for the continuing care system in British Columbia in the mid-1980s, that was an approach we used. We had budget constraints and could not provide everything. However, dependent upon compassionate grounds, we sometimes even exceeded that rate.
Creating greater efficiencies and getting better value for money are significant points. If we can get better value for money, we then have excess funds that could be used for the type of circumstances that have been described. For example, in the case outlined, there may be additional money for respite or additional home care.
That is not to argue against getting a larger pot of money to start. However, we are in a better position if we understand the needs of seniors, have taken the steps possible to make the system of care provision as efficient as possible and can demonstrate that. Then we have a stronger argument for additional funds. However, if we continue to have splintered systems, we are locked into splintered budgets, and we cannot make the trade-offs possible in a broader system.
Ms. Hall: We have been talking about the two poles — staying at home alone or institutionalized care. That institution, the nursing home, strikes terror into the hearts of everybody, young and old. I want to talk about this third mid-way approach of supportive housing, which I discussed.
When I talked to seniors during these consultations, they found the idea of supportive housing very compelling and attractive. This surprised me because the message I always hear is that seniors want to stay in their homes as long as possible. The roadblocks in their minds are over information and affordability. They do not know how to find out about supportive housing, what is available and what it is really like. The cost is a big concern. They would say that if they own their own home, at least they know they can stay there and control the costs.
I am not surprised the homeowners were the group that were most comfortable with the idea of staying in their home until the last possible minute. Their fears include not being able to control the costs once they are in a supportive housing environment; doubt over whether they would be able to remain in this stable environment, which seems attractive today, for the rest of their lives; the possibility of increased rates; their own funds diminishing and where they go at that point. There is an appeal to remaining in their homes, where they have a higher degree of control over the situation.
That was a significant factor for them in not pursuing the supportive housing option. It reinforced my idea that the provision of sufficient numbers of affordable units to provide choice and regulations to deal with this issue of permissible cost increases was essential to making it a real option.
Senator Cordy: Ms. Sholzberg-Gray, I was interested in the challenges that you presented in your paper. I have heard four of them before in our health care report, and we have discussed them. However, the last one that Canadians are not free to move to their location of choice for continuing care services hit me because you are absolutely right.
When I grew up, aunts and uncles lived in our neighbourhood or not too far away. Today, children are moving farther away. We often hear people of my age saying that they are staying in their homes now, but in a few years they might move to where their children are.
You seem to be saying if people have money, then they have portability. If they do not have money, then it is not very portable. Portability is one of the components of the Canada Health Act.
Would you explain this in more detail, please?
Ms. Sholzberg-Gray: First, I noted that the Canada Health Act applied to physicians and hospital services. Even then, there is a waiting period. We are covered because of our former province of residence. There is portability under the Canada Health Act.
Looking at the vast array of services that seniors might need, they are not Canada Health Act services. They would include home care programs, home support programs and residential care, such as facility-based long-term care. With those, they have to wait. The problem is that they are not necessarily able to wait. Different provinces have varying waiting periods, some for as long as one year. This means that if someone lives in a long-term care facility in Saskatchewan and wants to move to another province, they will get a shock because the co-payment in Saskatchewan might be considerably less than the co-payment in that other province. Until a couple of provincial governments lost or almost lost their election, the co-payments in some Atlantic provinces were $4,000 or $5,000 a month, until patients lost their homes and depleted of all their resources.
A province such as Ontario has means testing. Seniors cannot pay more than their combined OAS and GIS, plus they are given a comfort allowance to be able to afford it. The problem is whether they can wait for a year or can pay 100 per cent of the costs in a private place while they wait for that year; most cannot.
In our document on long-term care endorsed by the National Advisory Council on Aging, NACA, we recommended what we called reciprocity. We need to find a way of facilitating reciprocal arrangements between the provinces to take people from another province. For example, if Saskatchewan and Ontario wanted to make a deal, they would have reciprocal arrangements, and hopefully all the provinces would participate. Provinces are saying that they can make arrangements amongst each other; they meet together under the Council of the Federation.
We thought there could be reciprocal arrangements so that when children do not live in the same province as their parents, we could facilitate the parents living near them to create a support mechanism, which would reduce costs and enhance quality of life and health. We want to find a way to move that idea forward.
Senator Cordy: Has there been any discussion on your idea of reciprocity?
Ms. Sholzberg-Gray: Not at the government level. We were impressed that the NACA thought it was perfect and endorsed that, among other things. It should be there. If we had future federal funding for this continuing care continuum that we would like to see integrated, and if the provinces wanted to take the money, then one of the conditions would be reciprocity. This continuum includes the whole range of services from the housing options to long- term care to community support services to home care to all these things. In the end, that will actually save resources because of the help of family.
Senator Cordy: I agree, yes. Thank you.
Senator Keon: It is interesting that again today the questions of the Social Union Framework Agreement and integrated services come out. Ms. Sholzberg-Gray and I have been talking about integrated services for 30 years.
Ms. Sholzberg-Gray: I do not know that I am old enough for that, but yes, I believe we have.
Senator Keon: You were only in school.
Ms. Sholzberg-Gray: It may be 40 years.
Senator Keon: Mr. Allard and Mr. MacDonald, and maybe Professor Hall, the big problem with all of this is that we do not have the correct community entities in Canada to do the integration at the ground, to pull the stuff together and make it work at the local level on the ground. They can do it in Sweden and Britain because they have a simple sort of government structure. We have this tremendously complex system of government — federal-provincial-municipal. Some of our Native peoples also have their own government.
Can you think of any community entities that you thought worked best or that you have come across in conversation with your peers across the country that were able to pull together health, education, sanitation, housing and such to create a good environment for people?
Ms. Hall: There is a place in Maple Ridge, B.C.
Mr. MacDonald: The legion has an infrastructure of 1,700 branches across the country. Many of these branches are located in small communities, and others are located in large urban centres. They also have over 85 years of history in providing service to the community. An entity such as that often is what is necessary. Very often, when legion projects get started in an area, the legion is the catalyst. They do not generally make these projects work all by themselves. They start them, and other groups come in and everyone gets involved. Some of these facilities end up having menus of services, so we involve health care and the transportation people. We get bus routes changed to come to legion facilities. I am not advocating for a minute that the legion would be the ideal entity to do this, but I am saying that it is possible.
In Maple Ridge, a prime example, we have four facilities now, or three. One is an assisted living facility, another is a life lease facility, and we have an apartment facility. Everything is there so healthy seniors can move in, stay there and just move from one building to another to have their needs met. I believe there are ways to do that.
When we start development programs and policies we have to be wary of the tendency to oversimplify matters. I find that somewhere between how simple I feel it is and how complicated someone else thinks it is, is when we arrive at the reality. Generally, we develop policy the wrong way. We start at the top, make them work, and when we get to the ground, we find changes need to be made to make the policy work properly. We would be much more effective if we started with our policies from the 85-year-old man who is having trouble getting the roof on, understand those issues and work backwards.
At the end of the day, we will have developed policies that are meaningful and real because we have talked to the people who will be affected by these policies rather than adapting policies as we move down the line to the point that when we start administering them, they look nothing like what we intended.
When we begin policies, we have to look at ways to make those policies work in the community. It works for the legion. It will probably work for other organizations, too.
Mr. Allard: I look at Ms. Darke here. She is much younger than I am. A simple solution also would be to insist that the people who develop policies are then mandated to implement them.
Ms. Sholzberg-Gray: We should not forget about existing models. There is a regional model of care in most provinces now, and some of them are doing very well with integrated approaches to a variety of health and social services, so we could use those as a basis. Sometimes the integration, you are absolutely right, is more at the top than at the bottom, and that is our challenge. The purpose of regionalization is integration.
If I could put in an advertisement, our annual conference will take place in Saskatoon in June. The title of it is ``Regionalization: Lessons Learned, Lessons Lost.'' Over a hundred proposals have been put in to share best practices for integrated approaches to health care. It seems that everywhere in this country something is being done really well. There are many wonderful experiments and ways of integration, and a number of those will be presented. I would caution everyone to look at the best practices everywhere to see if we can transfer the knowledge. We need to do some more sharing; we do not do enough of that.
The Chair: Thank you. I will end with one question. I hope can I get a ``yes'' or ``no'' answer. I suspect I cannot, but I will try.
One of the issues we have to grapple with, because it is a constitutional conundrum, is that some of these issues are provincially dominated and some of these issues are federally dominated. In this area, is there, in your view, a federal role in preparing us for the needs of an aging society and helping to coordinate programs? Not by directing those programs, however, because programs are usually directed best at the lowest possible level of the delivery of their care. Do you see, to provide this continuum of care, a need for a federal presence?
Mr. Hollander: I do see a role for the federal presence. Numerous initiatives have been initiated to provide additional funding for certain types of services. That is a role that the federal government often plays. Also, this notion of some form of arrangement with the provincial governments where there can be a working together, whether it be through the federal Social Union Framework Agreement or some other, is perhaps a vehicle for that.
This whole consciousness of how to organize the health care system in Canada is missing at the present time at the federal level, but exists at the provincial level because they are delivering services. What are the key components of it? I would make the argument that one key component is care for seniors and other people with ongoing care needs. We have hospital services for people who are acute; we have medical and primary care services for the broader population; we have public health services and so on. Right now, there seems to be a vacuum at the federal level in terms of this notion of care delivery for people with ongoing care needs.
Simply getting the federal government and the provincial governments together to agree that this should be in fact seen as an important component of the Canadian health care system would be a significant contribution and may not even cost very much money; but that would be a first step. Once we agree on that, then we could enter into discussions about what would be the key elements or the core elements or the principles of something like this.
I do see a role. In fact, the federal government could play a significant role in a form of partnership with the provincial governments where a number of these initiatives are already happening and really facilitate and find ways of coming to agreement about how we can both provide the best possible care and do it in a way that is cost-effective.
Ms. Hall: From my own perspective, being concerned with regulation, I feel the federal government has a very powerful and positive role to play in the development of model policy and legislation. Of course, it is up to each province to determine how to implement legislation on this particular subject. Drawing some lessons from the American experience, that is a very positive role for the federal government to facilitate the exchange of information on that; if only to prevent this reinvention of the wheel that really seems to be happening at different levels and stages in different places, which seems very counterproductive.
Mr. Allard: Strictly as a not-for-profit provider of affordable housing, my comments will be probably linked to CMHC's role. I would like to emphasize that we get along very well with CMHC. We believe in cooperation and partnership. They have some very good programs. They have asked us recently to post a link to their best practices, and we intend to do that.
Ms. Darke talked about the flexibility that was introduced in their mortgage insurance in 2003. That flexibility was linked to a larger equity ratio for not-for-profit providers, which is more difficult in our cases. The federal government could provide basically a repayable loan in that context that would cover the equity gap required to get this mortgage insurance.
Ms. Sholzberg-Gray: I believe there is a federal role. It all would depend though on the philosophy of the government in power at the time. If the government feels there are watertight compartments with some issues under provincial jurisdiction and others under federal with no opportunity for joint activity, then that is a problem. I want to remind everyone though that the federal spending power is a constitutionally approved power — the Supreme Court. The federal government has the right to spend in areas of provincial jurisdiction. I am not suggesting the federal government ever impose it in the future on provinces, but it presents an opportunity to tell the provinces that they will provide money for a program if they will achieve certain pan-Canadian objectives that they all agree with because they believe it is good for everyone wherever they live in this country. They have done it for medicare, hospital and physician services, for CMHC and all other areas. One could ask why with an aging population, with the importance of seniors' health, programs and continuing care, why the federal government could not go to the provinces and say, ``We would like to propose a new program. You do not have to go into it, but we would like you to. If you do, you will get this money; and, by the way, if you have programs that already comply with the current objectives, you will get it anyway because that is essentially the Social Union Framework Agreement.'' We feel this is so important for the provinces, and it is an area where we could use the federal spending power. Also, catastrophic pharmacare is another area.
I would say use the federal spending power together with the Social Union Framework Agreement, and if you do not take these steps, acute care costs will go up. Therefore, what is the point in not doing it? If we do not do it, this will harm the ability of our country to sustain the program on which we have already used the federal spending power.
The Chair: Thank you. I will not ask our last two guests. It is a bit of a conflict of interest for them. I do want to thank each of you for coming before us today. I hope that you will see some of your thoughts expressed in our final report.
The committee adjourned.