STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. William Estabrooks
MR. CHAIRMAN: I apologize again for the voice. I think that Mr. Barnet has passed on his five-week-old whatever he had, cold. It must go with being an old-timers hockey player. I would like to welcome our guests this morning. My name is Bill Estabrooks. I am the MLA for Timberlea-Prospect and I have the privilege of being the Chairman of the Public Accounts Committee. Our proceedings are a matter of interest to all Nova Scotians and us as legislators. This morning we look forward to an important exchange in information on this matter and we welcome you.
I will ask the MLAs present to introduce themselves and, as I mentioned earlier to you, I will ask our guests to introduce themselves. We usually look at about 15 minutes for a presentation. I notice that you have given us a handout and I appreciate the information upfront. So, if for some reason you go over the 15 minutes, that is fine. We will be flexible.
[The committee members introduced themselves.]
MR. CHAIRMAN: I assume Mr. DeWolfe will be joined later by a member of the government caucus. Okay, well we can do his introduction when that particular member arrives.
MS. CHERYL DOIRON: Thank you, very much. I am Cheryl Doiron, Associate Deputy Minister in the Department of Health. The colleagues I have with me today will be happy to . . .
MR. CHAIRMAN: Ms. Doiron, I was going to point out to you that it is not necessary for you to stand. If you feel more comfortable standing, please do.
MS. DOIRON: This is lovely, thank you very much.
MR. CHAIRMAN: Some days these are very comfortable and other days they are not, especially on that side. I won't tell you whose seat you are in, but anyway. (Laughter)
MS. DOIRON: I have no doubt we will be very comfortable, thank you. I would like to introduce the colleagues I have with me today. To my left is Keith Menzies, who is the Acting Executive Director for our Continuing Care Branch and beside Keith is Alan Horsburgh, he is the Director of Finance for Continuing Care EHS and a few other programs in the Department of Health, and to my right is Joanne Bree, who is our new Manager of Eligibility Review. So we thought perhaps some of your questions, she might be better at answering than we would be. So that is the team that is here today.
We will give you a bit of an overview. We are concentrating today primarily on single entry, but touching on a couple of other aspects of continuing care. We will be happy to answer questions in any of those areas that you wish to put to us after we give you a bit of a summary of some of the status of where we are in the department. So I am going to begin and then partway through, I will turn things over to Keith to kind of give you a few additional comments.
First of all, I think that we just wanted to put forward the Nova Scotia Government goals. We won't read them or anything like that because I am sure everybody is familiar with them, but we wanted to simply make the point that everything we do in the Department of Health, at this point now, is built on the context of what is happening with our government and what is happening overall in the department. So as we move forward on initiatives such as single entry, then we do that within the context of what we think is intended by the Nova Scotia Government goals.
We then, of course, rely on some of the foundation that we are establishing and re-establishing within the Department of Health. So we draw on things like our mission and our vision and our current mission statement, as you see it, is through leadership and collaboration to promote, maintain and improve the health of Nova Scotians and ensure an appropriate and an affordable health care system.
Now that statement in itself, as I am sure you will know, is quite a challenge. But I think it is important when we are talking about single-entry and continuing care to note that we are taking a very strong leadership role from the department in terms of setting up the provincial structures, the provincial standards, the policies, and the frameworks that hopefully will allow us to have programs across this province that are accessible and standardized for people in this province, no matter where they live.
Now we do that, of course, with a tremendous amount of collaboration and we do have a great deal of people involved in the projects we are going to be talking about today. Our vision is to have a dependable, caring health system that puts the right response by the right care provider in the right place at the right time. This is, of course, quite germane to trying to look at programs like single-entry and continuing care, because we don't want to be providing institutional care for somebody who could very well be supported in the community. We want to provide support in the community to the extent that is reasonable, because most people tend to want to stay in their homes or in their community as long as possible.
We also want to make sure that if the assistance that somebody needs can be provided by a personal care worker or an LPN that they get the care that they need, but we are also trying to address that point of care most economically so we don't need to always send registered nurses in to provide the right response. We test everything that we are doing in the Department of Health these days against what we call our three points that are critical to our being able to achieve our mission. Every strategic initiative and every strategic direction that we take, everything then that we put forward in our business plans that we want to put dollars against is tested against what we think are our critical two mission points, which means that we ask: Is this initiative going to contribute to an integrated health system? We are moving further and further toward trying to make sure the system is integrated to serve the population in the most efficient way that we can at their community base. So the second point is: Is this system going to contribute to a community-based health system? And finally, will this contribute to sustaining our health system, because we have to be able to sustain what we have and build on that?
The strategic directions that we have that are part of our business plan, there are eight of them that we have been using this year, but the first one that we have is to develop a clear vision and action plan for long-term care and home care to better meet the needs of the aging population of Nova Scotia - and we all know that the population is aging, so we are very cognizant that that is almost like one of the lead strategic directions for the department, and within that we have a number of initiatives that we are working on this year.
The leading initiative, as you might guess, is single-entry access; we are working toward getting that fully rolled out to the province. We have also, this year, gone to the second phase of what you had heard about last year, the Clinical Services Plan, that really addressed a lot of the planning around acute care. We have now moved to Phase II and we are calling that Health Services Planning now and that is because we have now moved into the long-term care sector to better understand that and to be able to understand, based on the best evidence we can gather at this point, how we should be looking at the present and at the future.
In addition to that, we have reinstituted some of the processes in the department that maybe weren't working too well for awhile. So we have a program approval process for all parts of the system, including the continuing care sector. That really means that any request, any proposals for enhanced or new programming are well vetted and reviewed very thoroughly, and have to go through the senior leadership team before there is any approval on moving that forward to the deputy and to the minister.
For the first time this past year, we also were able to work with the long-term care sector and put together with them a business planning template so that that section of the system is now submitting a business plan that contains their intentions, their mission of vision, their strategic directions, as well as their financials and so on. They had never done that before, so they have been quite enthused about that and have been working very well with us.
Finally, one of the major concerns that we've had since we've inherited the long-term care nursing homes has been that there's been no information and no plan around the infrastructure for nursing homes in the province. Consequently, the only way we have been able to respond to the requirements of nursing homes in the last couple of years has been, really, through crisis and trying to respond to crises that arise around some of the buildings.
We have this year gone forward to put in place a software program and an information system that will actually allow us to do the reviews on the nursing home buildings and to input to that information system a number of points of information that will allow the requirements for renovations, replacement and so on to be based on that information system and appropriately priorized. It is actually an information system that could apply to any infrastructure and consequently we could roll that across acute care, it could go to schools, or to any kind of buildings that you might want to use it for.
As we move into talking about single entry, you will see on your slide that there is a model we have worked out with a lot of consultation from the people who actually deliver the care. Basically, the way they see single entry working is as a case management model. So basically what we would be doing is streamlining the processes that take place around the intake and through the assessment of the individuals, then doing service planning and implementation across home care, long-term care, or whatever service is required, and then making sure that the care management is around the individual and that if that care requirement changes, the loop goes right back again to assessment so that people are not assessed only once and then have difficulty moving to other levels when their care needs change.
Single-entry access is, as I am sure everybody here knows, about a coordinated access to that whole continuum of home care and long-term care services through a single point of entry. So the model really is around the individual as opposed to around the requirement for an individual to go to a number of provider points. So single entry provides for the individual a consistent assessment that assures services are provided in response to identified need. It
is consumer-focused, so the single focal point is the access point. It really makes things streamlined for the individual, who can call that one number and know that the appropriate consideration of all their care aspects is going to be dealt with regardless of how many provider points are contained in that.
The information system that we'll speak about in a moment is going to provide us with more information that will allow us to do evidence-based planning for this population. We have never had a good database on this population. As we introduce single entry, we will also be introducing an information system that will allow us to track a great deal of information and allow us then to understand, as the needs of this population grow in our system, exactly where and what points need to be responded to.
In terms of looking at where we're sitting right now with single entry, we wanted to give you a little bit of a status report on that. For the fiscal year that we're currently in, 2001-02 year, we received partial funding for single entry implementation. So we knew at the beginning of this fiscal year that we should not plan to do the total roll-out in this fiscal because it was going to actually take us into the next fiscal year before we would have the total funds available to do that. So that's moving along quite well and the dollars that we were given this year, $1.5 million, are being expended as we move through the year. By the time we get to the end of the year, we will be moving into next year with positions in place to kind of move this forward so that the total dollars that we require for this particular program will be annualized at the full amount that is required to maintain the system for the province into next year.
However, this year, we have continued with some very important aspects of understanding how to move forward and do that well. So we have been continuing with the pilot projects in District 7 and District 8, and we have been learning a great deal from those. We have introduced the placement component of this system in the Capital Health District. There were some areas of weakness in that element of the system in the Capital Health District and they knew that and worked with us to kind of prepare that. So once single entry was fully available to District 9, the Capital Health District, they would be ready to go and roll-out could be fairly swift. Similarly, the intake component needed some work in District 3. So we have been doing that work with them and they will be very ready to roll out on single entry in the fiscal year.
The pilot projects that have been going on in Cape Breton have been very helpful and we have been learning a great deal from them and it shows, I guess, the value of having pilots when during the last month or two, we have been really clearly seeing that there needed to be some refinement in the model. So we have people very hard at work right now. People from the delivery system itself are working with us in the department and they are doing revisions and additions to the standards, the policies, the position descriptions and so on.
They are working on a planned approach and what they say is their party day is December 17th, because they intend to have all that work finished by then.
They also have been able to see what adaptations need to be made in order to have the information system working well, and that is being taken care of. The intention now, as we are able to see exactly how this is working in District 7 and District 8, we feel that it is not necessary to have this roll-out of single entry on a sequential basis through the districts. Once we are ready and we have all these corrections and the revisions made to the model, then we will be in a position to roll out concurrently through the whole province, and that is planned to occur in the first quarter of the next fiscal year.
Through all of this, we have had a tremendous amount of assistance from all kinds of people out in the system. We have had, as you see, a number of groups that have been working on this. The advisory committee is composed primarily of external stakeholders and that means people like the Senior Citizens' Secretariat, the Group of Nine, the VON, a number of other groups, multiple groups. There is a group of about 25 that come together periodically to advise us about elements of single entry.
The steering committee is primarily internal stakeholders from the Department of Health, but also with representatives from the district health authorities, in both the acute care, long-term care and home care sectors. Working groups, the groups that are currently working very hard to revise the model, as we mentioned, they're composed of district representatives. We also have, ready to go and doing some work, as well, district advisory committees, as well as an implementation committee in every district that will be ready to go through the roll-out as we get into the next fiscal year. So I think that it is fair to say that this system is truly being built from the ground up. It is not a system simply designed in the department and imposed on anybody. It is a system that people out in the field, both recipients who would be using the system, as well as the people who will be working on the ground, have helped us to put together.
The information system that will be used to support this system is a tool which has been selected some time ago. It is called the REI Home Care Tool. We were very pleased that since we have selected that tool, we have more recently been learning that a number of other provinces in Canada have gone this route, as well. So provinces like Ontario, Alberta, British Columbia and several others are going to be using the same tool, which is going to be extremely valuable as we continue to populate this database and we will be able to do a lot of comparatives with other jurisdictions. In fact, this tool is also being used somewhat on an international basis.
The information system project office is, of course, part of the single-entry overall steering committee and the tool of course has been piloted in the demonstration site. So we've learned, again, a lot from that and that is currently being adapted to the revisions that are being made within the single entry model. So right now the tool is being evaluated for
provincial roll-out and we hope that that will be able to take place on a concurrent basis with the model roll-out. At this point I'm going to ask Keith to give you some additional comments.
MR. KEITH MENZIES: I'm going to speak to a couple of issues that relate to care in the continuing care sector but are not specific to the single-entry access processes. One of those relates to the introduction of universal classification for nursing homes in February. Up until February of this year, if an individual had sufficient resources to provide for their own care costs for up to 18 months, they were able to apply to any nursing home of their choice and, if an offer was made by that nursing home, could move into care without a care assessment having been carried out by the department, although the home would have done a care assessment of its own. Once they've been in the nursing home for 18 months, at whatever point their assets are utilized and they simply have income left and it's not sufficient to provide for their full cost of care, then the individual will become publicly assisted. It would be at that point that the financial assessment and care assessment would be done.
One of the concerns that has been raised numerous times is that when individuals can apply directly to the nursing homes and nursing homes make their own determinations, there was a possibility or potential that people whose care needs could be met in communities with home care support or other supports were actually accessing or entering nursing homes prematurely. So the intent of universal classification was to say that at any point that somebody believes they need care that's provided in a nursing home setting, a full assessment should be carried out through the department prior to the person being eligible for access or admission to a nursing home. The primary objective behind that is to ensure that if home care services can be provided, that we do so and that we keep people in their own home communities and their own homes as long as possible, or as long as it is safe for them to be there.
By moving to a universal classification or universal classification approach, what that did was mean that all of the financial assessments were being done immediately as opposed to 15 months or 18 months after people had been placed in the homes. So universal classification basically says that from February 1st on both a care and a financial assessment are done prior to admission. That also paves the way towards introduction of single entry access where, as we move towards using that particular assessment tool, we've already introduced to the system the need to go through a full assessment.
The second part I want to talk about a little bit and introduce, and certainly I'm sure we'll have discussion on, is the whole issue of financial assessments. In Nova Scotia, as in the other Atlantic Provinces, long-term care services are not an insured service, so any admission to a nursing home for the aged is not an insured service, as the care is in a hospital setting. The Canada Health Act provides for medically necessary care in acute care settings and through physicians, but it does not extend to providing insured services in the long-term care sector. In Nova Scotia, it has always been the social policy here in this province that an
individual is responsible for providing for their own needs so long as they have the assets and income to do so.
It is only when an individual's assets have been depleted and their income is insufficient to provide for their care in a nursing home that the Department of Health, and previously it was the Department of Community Services but basically through the province that we provide support for the individual through the Social Assistance Act. Previously the financial assessments were carried out by municipalities, who did have a role to play in the provision of long-term care services. As the system has evolved, the Department of Community Services took over the role primarily. And then from there, as the Department of Health has become involved, this department has taken on responsibility for carrying out those financial assessments. One of the comments that has been made is that our assessments . . .
MR. RUSSELL MACKINNON: On a point of order, Mr. Chairman, I would ask if the witnesses would wrap up their opening remarks so that we might be able to enter into a question and answer session. I think you have rightfully outlined the protocol for the witnesses and I believe the assistant deputy minister is familiar with the protocol to the Public Accounts Committee. I think we've been very generous; they've gone more than twice the allotted time limit.
MR. CHAIRMAN: Thank you for that point. I was going to interrupt prior to that point of order and I recognize it as a guideline. We began at 8:04 a.m. and we're now at 8:25 a.m. If, Mr. Menzies, you could capsulize, it would be appreciated.
MR. MENZIES: My apologies. I wasn't watching the clock and I should have been. The only other comment I will make about financial assessment, and we'll wrap up at that point, is that by moving the financial assessment to financial staff carrying out those reviews we're attempting to provide more consistency across the province in terms of how those assessments are carried out. I will leave it at that.
MR. CHAIRMAN: That's fine and thank you for your assistance on that.
Mr. Steele, it is 8:26 a.m. The next 20 minutes are yours.
MR. GRAHAM STEELE: Ever since I ran for office earlier this year, it has been very apparent to me that some of the most difficult, emotional, heartbreaking cases are my constituents who are involved with either the home-care sector or getting involved in the long-term care sector because we're dealing with people who are by and large elderly, by and large not very well off, vulnerable. So when you're talking about long-term care and the process of moving someone into a long-term-care facility, you're dealing with people in some ways at their most courageous as they get to the end of their struggle to support themselves at home and for their families as well, and you also see them at their most vulnerable
financially and otherwise, and into this very difficult time steps the Department of Health with their assessment tools.
There are a number of questions that I have today - at least the first part of my time I'm going to focus on those kind of issues. One is something that has been alluded to already today, I think, and that is that in Nova Scotia people who are in long-term-care facilities are paying for more than just their room and board, they're also paying for a portion of their health care costs. As we all know, under the Canada Health Act, you know the basic values are comprehensiveness and universality, but somehow or other we've slipped into this mode where there is a sector in health care where people are in fact paying out of their pockets for health care costs.
The other thing that I think most people in Nova Scotia don't realize is that it's not that way across the country. There are only a few provinces that actually do that, and so I wonder if I could address my first question maybe to Ms. Doiron, or whoever feels best able to answer. Why is it that in Nova Scotia seniors are expected to pay for a portion of their health care costs in long-term-care facilities?
MS. DOIRON: I will begin this answer, but my other colleagues might want to step in as well. Certainly if we had the resources to pay, I think we would. We want to kind of take a different approach; on the other hand I think it has been a real struggle in this province with its tax base and so on to be able to move into some of the arenas. As you know, all of the Atlantic Provinces are pretty well taking the approach Nova Scotia is taking, so we're not alone and I think it has to do really with the revenues and the fact that it is not an insured service.
We will be hopeful that as the debate continues at a national level, with the Romanow Commission and some others, that some of the national approaches to some of these issues may emerge in a way in which we will be able to participate. I think that the history in this province has been to try to make sure that individuals are going to receive the care they need, but in fact call on some of their own resources to some extent to do that, and at this point our formula does not go quite as far as some other provinces. I would like to see if our Eligibility Review Manager has any other points to add.
MS. JOANNE BREE: No, it's true that they are paying towards their health care costs as well as the room and board. At the present time it's not providing all their assets to it. If there's a couple in the community, then we look at providing for the person who remains in the community to make sure that they are not experiencing hardship. So it is a process that we work with the seniors in going through and assisting them in understanding the process and what their needs are as well as what the financial needs are.
MR. STEELE: Recently someone at the Dalhousie University School of Occupational Therapy named Robin Stadnyk did a study and perhaps you're familiar with it. It has been in the news a little bit lately. It's called Funding Nursing Home Care in Canada: A Comparison of Regional Policies and their Social Impacts. I have a summary of it here which I will be glad to table when I'm done with it. Ms. Stadnyk reviews the policies across Canada and she says there's basically three models. One she calls the per-diem based model. The second one is called the income-based model and the third one, which is what we have here in Nova Scotia, is the income-and-asset-based model.
What she was studying was the impact on the individuals of these different models and there are certain things in common to all three models. One that struck me in particular, because I see it in my constituents, is the grief and the sadness that goes with placing a loved one in one of these facilities, but one of the things that is more marked in the system that we have here in Nova Scotia is worry about money.
This is what Ms. Stadnyk says in her study and I am just going to read two sentences, Mr. Chairman, "The Income-and Asset-Based Model produced more themes of financial worries and worries about lifestyle of community dwelling spouses. In contrast, other models produce themes which relate to the placement process and quality of care."
So what this study shows is that compared to the rest of Canada, the system that we have makes people worry a lot more about money because in many ways it's harsher. The limits are higher. People say that in the United States getting sick can ruin you. I have heard people say that in Nova Scotia getting old can ruin you because you are expected to pay and pay and pay until you have nothing left with which to pay. Because of this system there's a lot of concern out there about the way that financial assessments are done, the rules that are applied, which in Nova Scotia are pretty restrictive even compared to the rest of Atlantic Canada. Now, there has been some talk about a review of that model. What exactly is going on as far as a review? Who is doing the review and by what criteria are they doing the review?
MS. DOIRON: Mr. Chairman, I think what has been happening here is that as we've been going down the road - this review process, of course, is one that we inherited a couple of years ago - and as we've been coming to understand some of the approaches that have been taken, we have taken a look at how this review has been occurring from within the Department of Health. One of the things that happens as we move toward single entry is that we want to make sure that the staff who are responding to any issues have the right competencies and that also we're using the staff who have high levels of competencies for the right things.
For example, previously the care coordinators, who are generally nurses, social workers, very highly prepared people, have been the individuals who have not only been assessing the care needs of the seniors, but they've also been the people who have been starting the financial review process. It has been our determination as we've reviewed this
process internally and have worked with both the acute care sector, the long-term care sector and the home care sector to consult and understand what they think is required here, that what we need is people to do this assessment who are really well versed in doing a financial assessment.
Consequently, what we have done is moved to a system where we have dedicated eligibility review officers and Joanne Bree, who is here today, is the manager of that group of about five people, I think it is at this point in the province, who will be conducting these reviews and will be able to make sure that the approaches that are taken to financial review in this province are standardized, that they're fair, that they're appropriately applied and that they're also sensitive. I think, as Joanne implied here, and I know I have heard her speak to it before, that we need to make sure as we're going through these reviews that we are taking care of the needs of the seniors who are looking for placement themselves, but we need to be very cognizant of the impact on their spouses and make sure they have the resources to continue to sustain and support themselves.
We believe that the processes that we have moved to now are going to be more efficient and they're going to be more fair. At this point, I think that we're starting to find that that's true. We have also started to take a look at, while we do have policies that guide us in this, we're trying to look at how flexible we can be with those policies to keep people moving to where they need to be in the system in the most prompt and efficient manner. So we've made some adjustments already that have helped us to move people from say, a hospital base to a nursing home base more quickly, and we're continuing to review the procedures within that policy and approach to see if we can refine that further.
MR. STEELE: You talk largely about improvements in the process of assessment. Is there a review underway of the eligibility to rules themselves?
MS. DOIRON: The policy itself is something that we have not yet addressed. We will obviously be taking a look at this because there is work that is going on at the federal, provincial and territorial level which is looking across this whole sector and looking at some of those issues. We know that if we change some of the practices that you may be referring to, in all likeliness we would require substantial additional resources, and so far we've not been in a position to be able to do that.
MR. STEELE: Yesterday on CBC Radio, in the morning, a woman was interviewed from Annapolis Royal I think, at any rate from the Annapolis Valley, and she went through scenarios where the existing rules create anomalies in the system that just seem egregiously unfair. The reason CBC Radio had contacted her was because yesterday she was going to make a presentation to the Standing Senate Committee on Social Affairs, the Senate committee, because I guess that was the only forum she had to say publicly what she and her group wanted to say. So what opportunity is there for the public to have input into rule changes around how eligibility is determined?
MR. MENZIES: As Cheryl said, we haven't yet begun any review process in terms of the financial eligibility and the contribution rates. I guess, by contrast, I could say that as we started designing the single-entry access process, we have relied on a great amount of stakeholder involvement, involving people who are working in the system, but also a lot of stakeholder groups or representatives of various groups of Nova Scotians, including providers, the general public in that process of single entry access. I would think that when we move to review the eligibility or the financial assistance levels that, hopefully, we would use the same kind of process there.
MS. DOIRON: Mr. Chairman, the other comment I might add to that is that we have, as you know, moved to having the districts defined and having district health authorities up and running. It is our hope that by having moved the health authorities closer to the communities that individuals will be able to also make some of their concerns and ideas known to those district health authorities, and we of course work very closely with those district health authorities. The district health authorities, in turn, are working extremely closely in developing the relationships they need to have with the community health boards. So I think there are quite a few avenues, through some of the processes that are determined, to take things closer to the individuals' communities.
Over and above that, of course, we maintain regular association with the Senior Citizens' Secretariat and some other groups of that nature who are supported by government, to make sure that some of those groups have avenues and routes through which they can take some of their issues and concerns. So I think there are a variety of methods there now and, as we go forward with any processes that we may be looking at adapting or changing or introducing, it has been fairly typical for our group, at this point, to be extensively consultative in that process. It's one of the approaches that we want to have in the Department of Health, to be extremely consultative with both the providers and the recipients of care.
MR. STEELE: In the document that the Department of Health released yesterday, it's called "Budget Review and Implementation Planning" - Ms. Doiron released it so I know that you know very well what I am talking about, but everybody else may not - there's a short section dealing with long-term care. One of the recommendations says: The department should review the income assessment process and assess options for expanding the assessment to include other measures of financial position, e.g. allow exemptions on certain assets while including others, et cetera. There are plenty of people who think that the current financial eligibility rules are already too harsh, too restrictive, and this recommendation says that more should be included; more of somebody's income and asset position should be included in the assessment. I am not sure that I quite understand. I am hearing mixed messages. Is there or is there not a review of the rules underway? Because this recommendation says there should be, but I thought I just heard you say that there isn't.
MS. DOIRON: I guess the answer that I give to that is that we are aware that this is an issue of concern and question and it does come up. We're also aware of many other concerns that have been in the field. That recommendation, of course, was made by the consultants that we had working with us relevant to the budget review this past year. I don't think we have any disagreement with the fact that it would be an appropriate place for us to go. We will have to do that within a variety of choices that will have to be made. For example, during the past year we did add considerable dollars to the long-term care sector which were only able to address some of the salary equity issues in order to maintain the competency of the competent people in that system. We also know that with the sort of moratorium that was on long-term care for a period of time, we have some additional tremendous challenges that are there for the long-term-care sector. I am sure you also hear from nursing homes that they're under great pressure to be able to sustain the services they're providing. We recognize that, but we know that's a position that has been cumulatively developed over a number of years.
When we take a look at what we're able to do we will have to prioritize when some of these processes can be addressed and where dollars will have to go in order to make that system sustainable but also work better toward improvements. We have not yet - I think we would be in a position to say that with getting the stability within the financial review process up and running, which has just been a recent development in the department, we would now be in a position to be able to move toward those reviews. But we have not yet been doing that because I think we're trying to unroll a number of other initiatives that were identified within this fiscal year before we take on additional ones.
MR. STEELE: Okay, thank you.
MR. CHAIRMAN: Mr. Steele, you have a little more than two minutes remaining.
MR. STEELE: So I will move to another topic entirely. If I go to the grocery store and buy groceries, say I pay my $50 and take my groceries home and then I eat them, I don't expect the grocery store to contact me a month later and say we've raised our prices, you owe us another $20. That would be ridiculous and we'd all say that could never happen, but that's exactly what nursing homes in Nova Scotia have been doing. One of the more offensive practices that people have to put up with is this idea of retroactive billing which was raised in the Legislature in the spring. The idea that you could have a service provided to you and pay for it and sometime later you get a bill saying our prices have gone up, now you have to pay us again for that service you already paid for - in the spring, the Minister of Health said it was a bad thing and he would do what he could to make sure it was eliminated. Has retroactive billing been eliminated?
MS. DOIRON: I am pleased to say that we are moving very close to that and should achieve it this year. We inherited a system where the financial review for long-term care seemed to take place over a very long period of time. The budgets for the nursing homes seemed to be spread out over the years so that I know that a couple of years ago that the nursing homes did not receive their budgets for the fiscal year until February of that fiscal year which is totally unacceptable. So last year we started the process of trying to clean that up and what we were able to achieve last year was moving it backwards and starting the processes with them earlier. So last year we improved it - we didn't achieve our desired outcome but we improved it by getting the budgets out to them by late May. This year we anticipate the long-term care sector having their budgets by the beginning of the fiscal year.
MR. CHAIRMAN: Thank you. Mr. Menzies, you'd like to add something and then I am going to turn it over to the members of the Liberal caucus.
MR. MENZIES: Can I just add one comment to that. In terms of the retroactive billings, and being the operator of a nursing home in Dartmouth until I came to work at the department, individual homes are able to change their per diem rates for their private pay clients simply by giving notice. Some of the facilities wait until they get the public rate approved by the department and then retro bill. Other organizations look at what their anticipated needs are and how that impacts their per diem rate and actually increase their private pay rate in anticipation of the changes coming from government. To a degree, the issue of retroactivity is an individual home decision and, for example, the home I am at, we made the decision that we would anticipate what the rate change was going to be, implement that change as of April 1st and then we've eliminated that issue of retro billing. It is unpleasant for people, undoubtedly.
MR. CHAIRMAN: Let's make it 8:47 a.m. Mr. Downe, you have 20 minutes.
MR. DONALD DOWNE: I want to welcome our participants here today. Yes, your budgetary processes are improving. I think I have brought that to your attention before that the budgets were almost a year behind schedule. I want you to know that in Community Services, there's still the same disparity - they're way behind. In talking to our people back home and the fact that there are these differences between what you're paying for in Health and what Community Services are paying for and salaried persons - that whole area is another issue that needs to be dealt with. I am sure the co-operation of the departments would be helpful. I know that some of the people are now starting to vote in favour of unionizing some homes simply because of the inequities that are there, not because they were unhappy before, but they're unhappy with the system that currently is in place.
I have three areas of questioning that I wanted to do prior to your presentation - and I found it very informative. The first one was the issue of criteria for access for long-term care, single entry. I will just run through a little bit of that. The single entry has been hailed as being a very appropriate approach and it appears very good, what's done in Cape Breton for example, has been helpful for all people in the system. But it seems to have basically become freeze-framed, that process. The rest of Nova Scotia still has a lot of people wanting to get into the system, but you haven't brought it forward fast enough. You've explained that you have basically kept the single entry system, although you're doing some minor adjustments, basically kept it closed for another year, and hopefully next year you will deal with it. I am glad to hear that explanation - I have been screaming about why hasn't it been brought into, for example, my riding, the South Shore area and I have always been given some sort of weird answer. The answer really is because you're not doing it, the money isn't there and next year when you get the money and the program is up and running, it will be brought forward.
The availability and demographics - I found it intriguing, your comments that the infrastructure management issue in itself is there. There's no question, I think a fair amount of study has been done or certainly work has been done. Roseway Home for Special Care - can tell you exactly what the infrastructure management requirements are for that facility, for expansion and the need. Hillside Pines, I think, have done some numbers on that as well. Obviously, you need to look at the broader issue, but there is an infrastructure fatigue issue out there and there's a requirement of government to seriously look at the investment requirements for infrastructure because if we had put it into infrastructure, we wouldn't have the backlog in the hospital system that we currently have. There's no room for them to go - that's the bottom line.
You did mention the demographics. You said something about we've never had a good database or information or study on the demographics - I paraphrase that. I understand that we have a fairly extensive study done on demographics in the Province of Nova Scotia; in fact some of the criteria used to determine the need that is out there, with regard to long-term care and the continuum of care within the health care delivery system in the Province of Nova Scotia, I think it's very evident that we have a serious problem and it's getting worse every day.
One of the concerns is how many people are currently in the ICU who should be in nursing beds within the hospital system. That's happening in my riding and it's happening throughout Nova Scotia. We have people in nursing care beds in the hospital who should be in a long-term-care facility. They just have no place to go. Whether it's a single-entry system that's been freeze-framed or whatever other arguments you want to make, the bottom line is the system has stopped; the people are getting older, they need the access, but for the last few years the system has basically shut down. That's a poor commentary on all of us for the seniors of the Province of Nova Scotia, the fact that they're stuck in a hospital where they
don't necessarily want to be. They'd rather be in some other facility, that's what is really happening.
You've covered those areas fairly well and I think I have made my point. Because time is of the essence here, I want to move on to the third area, and it seems to be an issue that's in my riding and an issue throughout the province, and that is the whole issue of cost, the cost not only to the province, but the cost to the senior. I have a number of fairly pointed questions and if we could have pointed answers I would really appreciate it because this is to find information.
What percentage of the people in the province using long-term-care facilities are currently being paid by the province? Approximately.
MS. DOIRON: We know that 80 per cent of the individuals who are in nursing homes are receiving some assistance from the province, but that does not necessarily mean that the province is paying the total amount for their care in a nursing home, but there may be some joint contributions. I think that's an accurate number though to say that 80 per cent are receiving government assistance. I don't know if the gentleman to my left can add anything to that - I am trying to be pointed.
MR. MENZIES: That's accurate. The 80 per cent figure is accurate in terms of the number of people who are publicly supported. Most of those people would have a pension contribution that goes toward the cost of care and the province would pick up the balance of the cost, which is probably 65 to 70 per cent of the cost for most people.
MR. DOWNE: Maybe I will point my questions to you; I think you're the one who's really going to be after the cost issues.
The 80/20 rule comes into play here quite well. So that 20 per cent of the people who are currently paying their share, their full cost, has there been any change to the two year rule on homes? I own a home and my partner goes in or I go in or we both go in - has there been any change to the two year rule that was in place?
MR. MENZIES: There's no two year rule regarding the homes.
MR. DOWNE: Three year rule.
MR. MENZIES: In terms of doing a financial assessment, the department reviews financial records going back three years. In terms of the home itself, you can designate that home, which simply means that you're stating that's your primary residence and it is not considered part of the assets when determining your contribution or your ability to pay for care. So once you've designated your house, which is simply signing a form saying I am designating this house as my primary residence, that is not taken into account in determining
whether or not you're private pay or what you would pay towards care. You can then transfer that property to someone and, as long as you don't receive money for it, the house is still free and clear and it is never taken into account in the determination of assets.
MR. DOWNE: That system that's been in place, there have been no alterations whatsoever to that system?
MR. MENZIES: We haven't made any changes to that.
MR. DOWNE: Are there any changes being proposed at this point?
MR. MENZIES: No, there aren't any being proposed at this time.
MR. DOWNE: The average family, 45 per cent of people in the Province of Nova Scotia, live in rural Nova Scotia. In about 20 per cent, the average individual income, take-home, is around $8,000 to $9,000, so it's not a lot of income. So, take a family that maybe have $20,000 or $30,000 or $40,000 in RRSPs, they have a $60,000 home, one of the spouses is forced to go into long-term care, as I understand the system now, that individual who goes in, the spouse who stays at home - I will ask you the question - what then happens to the property, the cash, the RRSPs, in regard to them?
MR. MENZIES: I am going to defer that to Joanne because she deals with that routinely, regularly.
MS. BREE: The primary residence would be designated, if that's what they chose to do, so that would be removed from the financial assessment. If they had, as you say approximately $20,000 in RRSPs or investments, then 50 per cent of that would remain with the spouse in the community and then the other 50 per cent would be used towards the cost of care by the individual being placed.
We then look at the income that each individual receives and we total it, but we also look at what the needs of the person are remaining in the community and we assist them in completing a monthly budget, looking at their actual costs. So rather than doing a determination of the 50/50 split in income, we actually are leaving most spouses with approximately 70 per cent of the income and then approximately 30 per cent would go with the spouse into the long-term care residence to use towards their costs. So very, very few, unless their pensions are very high and their income is very high, do we actually do a 50/50 split in income. It is more or less a 60/40 or 70/30 split. If you're dealing with young couples and there's an earned income, the earned income is exempt.
MR. DOWNE: What is very high to you? What's very high?
MS. BREE: High pensions? It's usually over $3,000 a month, we've seen pensions, and more when there's private pensions and, again, we always complete a budget with the person who remains in the community. We have developed forms to assist them through the process and to relieve them from some of the anxiety.
MR. DOWNE: So if I understand it correctly, it almost appears like we're going through a divorce here. We're in a situation, my wife and I, I end up going into a home, Darlene is at home, if 50 per cent of the RRSPs are gone, some percentage, whether it is 30 per cent, or whatever percentage of my income is going to pay for my health care delivery, basically Darlene's at home with a limited amount of income and a home to try to look after and additional requirements and needs obviously, because she's now all by herself. It's like if you went through a divorce, it's not much different. So is that really how we're treating the people of Nova Scotia, currently?
MS. BREE: No, I wouldn't say that. We do use the Matrimonial Property Act as a guideline but, again, it is the 50 per cent of the assets because, again, they are still together. They are a couple and they are a family unit. It is just that one person is now being placed in long-term care. So they still have the enjoyment of utilizing joint incomes as well as joint assets.
MR. DOWNE: It is interesting, in my area, they're hardworking individuals, very proud individuals. They saved their money and maybe don't have an awful lot, but at the end of the day it's taken away. I think there was a comment this morning that maybe some seniors want to pay for their health care, but it is their families who are wanting them to not have to pay because they want the money. I have never heard that by the way. I have never heard anybody in my community ever say I want to keep my mom and dad's money. I have never heard a senior ever tell me that my kids are telling me they want my inheritance before I die. I never heard that, but nevertheless the system is that they're going to take away the RRSP component, some cash component and some of the asset component. What happens if, and I will just use Lunenburg County as an example, . . .
MS. BREE: Can I just intervene, we don't take the money. The government does not take the money. The money is not assigned to the government.
MR. DOWNE: So where is it assigned?
MS. BREE: The client pays their cost of care. They utilize the funds. It is never signed over to the government.
MR. DOWNE: Okay, it goes into the general revenue of the Province of Nova Scotia.
MS. BREE: So the term that the government takes the money, is not true. What it is, is that we advise the clients . . .
MR. DOWNE: The government charges a fee for service for the clients.
MS. BREE: Through the nursing home, yes, they pay their costs of care.
MR. DOWNE: All right. Back home there are a number of people who would have a woodlot. They have a woodlot for getting their own wood for the winter. They might have 100 acres, and that's not uncommon in my community. What happens to those assets besides
a house? What would you do with those assets?
MS. BREE: In this situation, under the Social Assistance Act, you are allowed to designate the primary residence. Then we also look at the additional acreage that is required for the home to function as the primary residence. Anything beyond that acreage that the home requires is then considered an asset.
MR. DOWNE: So that is sold and then the capital gains is charged, obviously, and whatever is left over - there is a fair amount of capital gains, maybe on that land. They probably owned it for gosh knows how long, and then it is sold and half of the assets, after you pay the capital gains and that, would be used to pay for the long-term care facility?
MS. BREE: If it is a spousal situation, a couple, yes; 50 per cent of it would then be used by the person in long-term care.
MR. DOWNE: Thank you. I will have questions later on. I will move over to my colleague.
MR. CHAIRMAN: Ms. Doiron, would you like to add to that?
MS. DOIRON: Yes, thank you, Mr. Chairman. I just wanted to add that there are situations where sometimes land is not in a position that is going to be very useful for sale. It is one of the challenges that we have sometimes, I think, in terms of trying to comply with the legislation that is there but also being flexible enough in terms of making sure the individuals are getting the care they need as promptly as they can. So we have had some discussion about making sure we have the appropriate flexibility there to recognize when probably there is not ease of sale and making sure that we are still moving people as quickly as we can to the appropriate care.
MR. CHAIRMAN: Thank you. Mr. MacKinnon, you have five and a half minutes remaining, or thereabouts, in your caucus's time.
MR. MACKINNON: Mr. Chairman, through you to the assistant deputy minister. What is your department's definition of a user fee?
MS. DOIRON: I don't know that we have a formal definition of user fee. Generally speaking, we have used that term in health care when we have looked at it. For example, some provinces, at times, have imposed user fees for use of emergency departments or things of that nature.
MR. MACKINNON: So what you are telling us, quite succinctly, is you do not have a definition of the user fee. Yes or no?
MS. DOIRON: We don't have a single definition of user fee and I think that . . . No, we don't.
MR. MACKINNON: With regard to this single entry process, what I am finding is that many of the hospital administrators are saying that in the ICU, patients are spending anywhere upwards of seven, eight or nine days at about $3,000 a day and then they are required to go home because there are no regular beds for those people to move into. My question would be why?
MS. DOIRON: We know that currently in the system, and particularly as we have heard, I think, quite a bit through the media in regard to the Capital Health District, there is a considerable shortage of nurses and some other professions. At times, that is making it difficult to have all of the approved beds operational. We know that there have been, at times, difficulties in keeping unit staff. We are also aware that many of the districts have been utilizing a fair bit of overtime in order to try to maintain the beds that they have.
MR. MACKINNON: So really what you are saying is that because of this situation, this single-entry process is actually jamming up the system because these individuals don't have nursing homes to go to?
MS. DOIRON: No, that is not what I am saying. I am saying that . . .
MR. MACKINNON: Would you agree that that is the case in certain areas of the province?
MS. DOIRON: No. First of all, we don't have single entry operational through most of the province at this point. So I certainly wouldn't attribute anything to single entry at this point. I think that we do have variation in the number of nursing home beds through the province and the work that we are currently undertaking will help us to address that better and understand it better. I think that some of the backlog that we are seeing in the system right now - your example of using the intensive care beds and the hospital unit bed is a little bit of a different situation.
MR. MACKINNON: It appears, from what I can see, that we are turning hospitals into nursing homes. That is really what is happening in many areas of the province.
MS. DOIRON: We do have a number of individuals who have been medically discharged in the hospitals awaiting nursing home placement. What we did see, of course, as we introduced the system in Cape Breton is that there has been some improvement to that through single entry.
MR. MACKINNON: So you are acknowledging there is a backlog for individuals waiting to get into nursing homes?
MS. DOIRON: There has been some backlog at times, but I think that backlog is really not worse this year than it has been in previous years. I think single entry will help to improve that somewhat.
MR. MACKINNON: How many on the backlog?
MS. DOIRON: I think the percentage of beds that have been utilized with alternate level of care patients is somewhere between 15 per cent to 19 per cent.
MR. MACKINNON: And what is that in numbers? Can you quantify that?
MS. DOIRON: I would have to check that figure. We can get those figures for you and send them on to you.
MR. MACKINNON: The lady to your right, she's in charge of the process now?
MS. DOIRON: She's in charge of eligibility review.
MR. MACKINNON: So she would have a list of all the individuals who apply and would have an idea of how many have applied, how many have been accepted, and how many haven't. Am I correct?
MS. BREE: No, not necessarily.
MR. MACKINNON: So you have no idea what the backlog is then?
MS. BREE: No, we don't.
MR. MACKINNON: Does anyone in the department know what the backlog is?
MS. DOIRON: That is somewhat of a moving target but we can get those figures and send them on to you.
MR. MACKINNON: I noticed the schedule of fees for Nova Scotia. It is perhaps the highest in the country. Is there any particular reason for that? I know if you compare it to the Yukon, which is $18 to $21; the Northwest Territories, less than $24; British Columbia, anywhere from $25 to $50; Alberta, $25 to $28 and so on and so forth, Nova Scotia seems to be extremely high, in fact, one of the highest, if not the highest in the country. Why is that?
MR. MENZIES: The fees for?
MR. MACKINNON: The daily rate for the average accommodation.
MR. MENZIES: In nursing home sectors?
MR. MACKINNON: Yes.
MR. MENZIES: It goes back to our earlier discussion of the requirement in Nova Scotia, the policy in Nova Scotia and Atlantic Canada, where individuals pay the total cost of care . . .
MR. MACKINNON: They're paying for it but it is a user fee, right?
MR. MENZIES: They're paying for the service, all right, if you want to call it a user fee.
MR. MACKINNON: So if it is a user fee, then you don't know what a user fee is.
MR. CHAIRMAN: Excuse me, I will allow that answer and then turn it over to the government caucus.
MR. MENZIES: In the Atlantic Provinces where individuals pay full costs if they have the assets and income to do so, the cost is there, it is up to 100 per cent. In other provinces, in western provinces, where they have established a per diem rate for the individuals' contributions, they are in those ranges and it's simply a different approach. I think referenced by Mr. Steele, in terms of the study that was done by Robin Stadnyk, bears that out.
MR. CHAIRMAN: It is coming up to 9:08 a.m. I would like to introduce the "late" member - incidently, as in "tardy" - for Queens; welcome.
The honourable member for Kings West.
MR. JON CAREY: Mr. Chairman, this is an area that has had my interest for some time so I am pleased we are able to be here and get some information on this today. In a perfect world with unlimited resources, some of the issues the Opposition have talked about would be perhaps of no concern, but we have limited resources and we're trying to get the
province a balanced budget and so on. If I understand you correctly, this program started and it was only partially funded in 2000-01 or 2001-02. Was the amount of money about $175 million going out to . . .
MS. DOIRON: The amount of dollars we approved for single entry this year was $1.05 million. We calculate the cost of having that program up and running fully from $3.5 to $3.8 million. The positions we have been hiring this year and are continuing to hire will be in place so that the annualized dollars next year will be to the extent of the full budget. By the time we finish this fiscal year, we will have the positions in place to roll it forward for the rest of the province.
MR. CAREY: I was interested in Mr. Downe's comment. Perhaps I could ask, I know you just started doing the assessments with your division, they had been done previously by the various municipalities or other organizations. How many people have you run into with an annual income of $10,000 who had RRSPs?
MS. BREE: Very few.
MR. CAREY: Would there be any?
MS. BREE: There could be a few but, again, I can't give you the exact numbers. It would be few.
MR. CAREY: They would be excellent money managers, I would think, if they could do that. It's interesting that approximately 80 per cent of the clients are government-funded to some or a total degree. As I understood, it's not broken down exactly what percentage actually gets total coverage and which percentage is paying some of their own.
MR. MENZIES: Very few people would be totally supported by the province, particularly with the seniors' group, they would have OAS and GIS as income. That would go towards the cost of their care, so that's approximately $1,000 a month that people would contribute as a minimum.
MR. CAREY: I guess the point that I would like to have clarified is, the level of care, I think one of the concerns brought up by one of the other members was that if the assets were put in a fund to pay their care that their lifestyle would change, is there a different level of care in the various homes? I realize, from a health standpoint, that people require different care, but in general would the standards be pretty much the same?
MS. DOIRON: Yes, Mr. Chairman. Regardless of the level of contribution of the individual, the quality of the care, the standard of care is the same and we attempt to meet the needs of the individuals based on their personal needs. The amount they are contributing to care has no relation to the standard of care.
MR. CAREY: The reality is whether you had all kinds of money or whether you were totally dependent on the government, everything would be on the same playing field, it would be a balanced service. Is there a way that someone's lifestyle - I realize when you go in there your lifestyle changes, but once you're there, there would be no difference.
MS. DOIRON: No. As far as the residents in the nursing homes are concerned, regardless of whether they have all kinds of dollars and can pay for everything or whether they have no dollars and have to be totally subsidized, the approach to their care, the amount of care they receive, the way they are treated, the lifestyle they have is basically based on their needs and the culture in the nursing home. The actual resources that the client has really has no relationship to that. You're quite right in stating that there is no difference in the standard of care or lifestyle that is received by the resident, regardless of their income.
MR. CAREY: The district health authorities, as I understand it you have had a couple doing pilot projects, are the other district health authorities involved in this to the extent of gaining knowledge and keeping up to speed on the process, and are they interested in taking this on?
MS. DOIRON: There's absolutely no question, they are very much looking forward to having single-entry in their own areas. We have extensively involved people from all of the districts in the work that is going on. Even though the model is running in District Nos. 7 and 8, the experience of being involved in that model is being discussed with representatives from all of the districts in the province. In fact, the staff that we have working on the modifications to the model are representative people from throughout the province, so it's basically a joint learning experience for people from all districts. We feel that that will better enable the system, when it's introduced, to be introduced smoothly in the other districts. Lots of involvement and lots of knowledge being shared. I think that there would not be one district that would not come up to the plate and say that they are very anxious to get this going.
MR. CAREY: That's good to hear, because I think it's very important that the district health authorities are onside with whatever program is put in place, and that it's universal across the province. I'm pleased that's the direction it's going.
Another issue that I would like, maybe, a little clarification - Mr. Downe has had many years experience and I just wondered - he said no family had ever come in and indicated that they were interested in keeping any of the resources that the family had. I can believe that they would not come in and say that. But I can also - from people I have talked to, they had a three year plan - it appears that a lot of people have registered prior to actually having a need for the care in the past and this has, maybe, caused difficulty in the system.
I think maybe the relatives were not concerned, but I know parents would like to leave what they have to their estate, to their families, and help them out. But in our world that is not perfect and our finances are not up to par, you must - I expect you would run into, occasionally, people that, maybe, are trying to get around the system a little bit. Are you finding that in your assessment, that there is something going on there occasionally?
MS. BREE: I wouldn't say that they are trying to get around the system. I would say that there is, probably, a lack of understanding of the system. So since the unit has been implemented and up and running, I have been out speaking to seniors since September. I have been out right across the province. Even just two weeks ago, I was in Sydney and I will be going back again in January. That is to educate them on the process, to create an understanding and also to remove some of the myths.
I wouldn't say they are trying to get around it. I would just say that they require an understanding of the process which we are making them aware of now. So it is creating an education and awareness for the seniors as well as their families.
MR. CAREY: At the present time, I understand there are facilities that cost the province or cost the client approximately $80-odd a day and it can go up to $120 or $130 a day. Why is there a difference?
MR. MENZIES: Budgets for the facilities are based on a number of factors, including staffing, operating costs, capital amortization that is included in their budget and size of the facility as well. So all of those factors come into play.
In past, also, there have been tremendous discrepancies or disparities in the wage rates that are paid within the nursing home sector. I think about five years ago, a PCW at Ocean View would be making $10.43 an hour and there are places in the province where doing that same work, a person would be making $6.75 an hour. There are that many discrepancies.
We see the move towards standardizing of those wage rates, which I think will bring the per diem rates together more closely as well. But it is a combination of the factors of your staffing levels, and we try to maintain the same standards of staffing in the facilities, the wage rates and the benefit costs, and so on. So it is very individualized.
MR. CAREY: The process that you are working on now, is this going to close that gap or what is going to happen? What is the future plan?
MR. MENZIES: I think we will see that gap shrink considerably, partly, as I said, as we are trying to staff the homes to the same standard. So if we are using a base of 2.25 hours of PCW care per day, we are doing that across the province and that will standardize the number of staff considerably. Staffing makes up about 80 per cent of our costs in long-term care. As we standardize the numbers of staff, as the salary rates are standardized because of provincial-based collective bargaining, then the variables are fewer.
One of the big variables will be whether or not you are in a newer home or a home where the mortgage is totally paid off and those kinds of issues. So they will come considerably closer together.
MR. CAREY: Last session of the House, we heard some - I guess it is fair to say - complaints about the $50 that was charged to people who stayed in the hospital, who were not in a position to go back home, yet there was not a facility for them. Did your department or you people have anything to do with this $50 fee? I mean, it seems to me to be a tremendous deal when we look at - to go into the home, it is a minimum of $80, if you are paying the shot, and if you can't afford to pay, you didn't pay in the hospital either. I mean, I think we took abuse for that, but it wasn't mentioned this morning, but (Interruption)
Well, it costs to live no matter where you are, if you are home or if you are in the hospital, whatever; $50 a day looks to me like a bargain but could you just expand on that.
MR. CHAIRMAN: Ms. Doiron. Welcome to the House and the banter on the opposite side.
MR. CAREY: We would have had no health care system, the way it was going.
MS. DOIRON: We are very appreciative of the civil approach in this committee. Thank you.
Mr. Chairman, I think in relation to the fee or the cost of $50 that has been referred to - when we went through the business planning process last year, many of the district health authorities, in submitting their business plans, noted that they had a number of individuals who had been medically discharged, and we have talked about the fact that there is that group in hospital. We are trying to decrease that group but right now there are a number, and there
will always be some, waiting for placement. We never expect or want to really be in a position where we can do that on a daily basis.
Basically, their suggestion was that, given that the budgets were challenging and if these individuals were in the nursing home, as you have pointed out, they would be expected to be paying a contribution toward their care. The hospital-based CEO suggested that, in this case, there should be some contribution to the hospital that is continuing to pay for their care, for their room and board and all those costs.
That suggestion came from so many of the district health authorities, we decided that it seemed like an appropriate approach to take for the province. We put some guidelines around that so that it could be applied in a similar way throughout the province. Of course, within those guidelines, as you have mentioned, if in fact individuals did not have the resources with which to pay that $50 per diem, then they were not expected to do so.
I would certainly acknowledge that we would want to make sure that with an approach such as that, we actually review it after a period of time. It has only been in place, of course, for less than a year, but it is our intention, certainly, in the fairly immediate future, in consultation with the district health authorities, to take a look at how that is actually working. That review will be taking place within, probably, the last quarter of this year before we move into another fiscal.
MR. CHAIRMAN: Okay. Perhaps I am the only one here that is not up to speed on these abbreviations, letters and so on, but the RAI-HC - I assume the HC is health care, but what is the RAI?
MS. DOIRON: The RAI is basically the brand name that the company has chosen to apply to this - I think, the interRAI set of information system tools that have been developed to be working in the home care and long-term care sector. The HC refers to home care.
MR. CHAIRMAN: I didn't even have that part right. (Laughter)
Okay. This program that is being rolled out, when it is in place, the projection is that the money - I think you said over $3 million would be going into the process. What actual - along with improving the system and the health care system, what is this going to do for the hospitals, themselves, from a financial standpoint and for providing the change in care, the change in systems that is coming about?
MS. DOIRON: Well, Mr. Chairman, it has been purported, of course, if people can receive care in the appropriate place, that that should lead to an outcome where hospital beds would be used only for those people who really require hospital care. Of course, the implication being that there are people in hospital beds now who could be better served either at home or in a long-term care sector where the costs are less.
It has been difficult to get information from other jurisdictions to determine exactly what the nature of those dollars or those savings might be. Of course, as soon as we free up beds in the hospital sector, there has been use, it seems, for other purposes. We don't have good information on that, but I think, intuitively, it would seem to be appropriate that if somebody does not require a hospital bed, then we support their care in another place or another setting. In fact, we think that is a better place for the individual as well as for the system.
In some areas where single entry was introduced, then there was a better utilization of the long-term care beds so that they were able to either close beds or at least go into some avoidance in terms of building additional beds. I think that the introduction of single entry will, hopefully, have some impact for us in this province that might lead us to not having to invest in new beds as soon as we would otherwise have to do.
MR. CAREY: Mr. Steele brought in a document that stated three different types of systems that were used and ours fell in the income and asset based model. Did we look at all of the systems, and what caused us to finally make a decision to use the one we used?
MR. MENZIES: The approach we're taking in Nova Scotia, the model we're using here has been in place for a long time. It's not that we've deliberately moved to that model recently. Well, I've been in this province 25 years, it has been in place long before that. So it isn't a matter of anybody having decided that this is the model most appropriate for Nova Scotia at this time. I think if we wanted to have any discussion about changing processes, it would have to be in relation to what we can afford to do as well.
MR. CAREY: I guess - I've been told I'm running out of time, but the system that you see of this being implemented and so on, do you really see where there needs to be any change from the government's standpoint, legislation, that type of thing, that would help you implement this program any better, or are there things that are detrimental to putting it in place that you see at the moment?
MS. DOIRON: I'm sorry, do we see that making the system better, is that your question?
MR. CAREY: Yes, actually, and is there something that can be done in the near future that would help you implement this?
MS. DOIRON: There is no question in our minds that having single entry and processes like that in place definitely will lead to making the system better. Basically, what we're aiming for in the health care system, and it's a joint intention I think of the districts as well as the department, is to try to bring all the aspects of care as close to the community as we can do.
In addition to that, eventually, of course, it's our intention to put in the hands of the districts responsibility for both home care and for long-term care. I think that the intention there is supported by areas that have moved toward more integration of care. So the hope is that by placing the components of the delivery system in the hands of the district health authorities closer to their own communities, that the actual impact for the clients being served in any part of the system will work better for them, they will find there's more ease of access to the system without having to continually repeat their demographics and other clinical data every time they move from one spot to another, and the system will take care of providing care around them and moving them through whatever component system that is required, as opposed to the individual or the family having to go out and pound on 15 different doors to get 15 different resources.
So I think at the end of the day the system that we're moving to will be much more integrated. It will be much more client-focused and I think it will give a lot better satisfaction level as well to the caregivers in the system. We're quite enthused about that, as are the districts, and they're working very closely with us to try to make sure that the transitions in terms of transfer service to those districts take place efficiently. And eventually what we would like to see the Department of Health doing is be predominantly out of service delivery, out of direct service delivery, and actually continuing to work with the system around things that government should be doing, which are setting standards and provincial policy, funding the system, and doing the appropriate monitoring and evaluation.
MR. CHAIRMAN: To allow for a bit of a wrap-up at the end, I have allocated eight minutes each to the remaining time. So I will turn the time over at 9:30 a.m. to Mr. Steele.
MR. STEELE: So many questions, so little time. I would like to start by talking about this $50 a day charge which in Department of Health literature is referred to as the alternate level of care policy or the ALC, which is, you know, wonderfully non-descriptive. I prefer to think of it as the bed tax. My colleague over there, the member for Kings West, says, well, it's actually a good deal because if they were in a home they would actually be charged more, which is true, but only in a very limited way. It would be fair, if there was widespread agreement that the fairness eligibility rules are fair and there isn't that widespread agreement.
The other thing that it seems to me the government is not taking into account is the incentive that it provides to people, and the incentive that it provides to people is to leave the hospital even though a bed in a long-term-care facility is not available and go into inappropriate care settings, either trying to look after themselves in their homes or having their family look after them in circumstances where it's agreed by everyone that that's not the best alternative because the incentive is to get out of the hospital as quickly as you can because there's no bed for you and it will cost you $50 a day to stay in there. That's the perverse incentive of the bed tax and that's why it is a bad idea.
On top of that we hear that there is inconsistent application and collection among the different district health authorities. We hear that even within district health authorities, on a particular day or week there is inconsistent application of the rules, and inconsistent collection. Some people are pursued; some people are not. Some people are billed; some people are not. The whole thing just seems to be a bit of a mess and something that was not fully thought through before it was implemented. But the problem is that real people are getting real bills and are suffering real stress because of this bed tax. Will the Department of Health withdraw the tax until there can be a complete and thorough review of the efficiency and effectiveness of this $50 a day bed tax?
MS. DOIRON: Mr. Chairman, the Department of Health will do the appropriate review and, following that, take whatever action it seems appropriate to take. An interesting comment because the other comment that we have heard is that the motivation through the $50 a day charge is motivation to stay in hospital as opposed to move to a nursing home. Obviously, when the client moves to the nursing home, they're going to be paying more than $50 a day. So I think that there are variations of issues and topics and opinions in regard to this. On the other hand, I think there have been enough questions that have arisen with it that it is legitimate to call for a review of this policy, and that is our intention to move forward on that review in the very immediate future.
MR. STEELE: What I'm asking, will the department suspend the charging of that fee until that review is done?
MS. DOIRON: It's not our intention to change that until we take a look at the issues associated with it. So I hear the suggestion; it has not been a suggestion I've heard before this morning, but that's not been our intention. Our intention has been to continue with the process and to do the evaluation on the process and then determine what action to take.
MR. STEELE: It's my understanding that, at least in theory, all decisions in the long-term care sector and home care sector should be subject to appeal. In fact, I believe I'm right in saying - but I may be wrong - that under the Canada Health Act there is an actual requirement that there be an appeal mechanism for people who are dissatisfied with the judgments made by the government with respect to things like their eligibility. Am I correct that there is in fact no appeal procedure in place in Nova Scotia dealing with long-term care decisions?
MS. BREE: There is an appeal process for the financial determination decisions and it is a two-step process. If an individual or their family does not agree with the decision, then they can appeal within 30 days of receiving the decision and then we have 10 days to review it, and it has to be an individual who was not involved with the original decision in reviewing and auditing the file and possibly speaking and meeting with the family and then we have to render our decision within 10 days. If they're not satisfied with that decision, then they can appeal further and an appeal board hearing will be scheduled.
MR. STEELE: And what's the nature of that appeal board? Who is on it?
MR. MENZIES: I can respond to that. The appeal board is constituted under the Social Assistance Act and appointments to it are through the Department of Community Services. We're simply using their appeal process; they're administering the appeals.
MR. STEELE: So are you referring to the board that is known as the Social Assistance Appeal Board?
MR. MENZIES: Yes.
MR. STEELE: The highly-politicized and inefficient Social Assistance Appeal Board? Sorry, you don't have to answer that. It's a rhetorical question. The single-entry access system, the original intention, the original announcement, was that it would be rolled out across the province in April 2001. Clearly that didn't happen. There has been no real, I think, clear public announcement about why exactly it didn't get rolled out. Now what we've been told is that the biggest problem, the biggest single reason, was getting Department of Health staff trained and able to use the new computerized assessment tool. It took them a long time to learn it and become comfortable with it, and to a certain extent they're still not used to it and comfortable with it. Is that true, or are there other reasons?
MR. MENZIES: That's not the reason behind any of it. As a provider in the community, from Ocean View Manor, I was on the advisory committee when it was first set up, when we first started looking at implementing single-entry access. I have been involved with it from the provider side and now I am involved with it from the department side. Initially, the dates that were set for implementation were target dates. The whole health care sector is so anxious to have single-entry access put in place that we were pushing very hard, from the provider side as well, that we move this forward quickly.
When the pilot project started in Cape Breton, what we had happen in the Capital District, where I've been working, is still a tremendous push to move things forward. We in Capital had moved forward on the standardized wait list and placement process. Another part of the province approached another part, being intake. The pilot started in Cape Breton in November; the intake and so on processes in other parts of the province were begun at various stages after that. What we saw happening was that we were starting to develop three different systems again. What we said was well, no, we want a system that will work across this province, totally. Whether you are in Yarmouth, Sydney or Halifax, we want the same processes.
We stepped back, and we have the staff who are going to be working with this continually being part of the design process. It has also allowed us to evaluate more fully what has been happening in Cape Breton. The implementation of the MDS assessment tool and automating it is not the part we are revisiting. That part will move ahead. In fact, we have
access to a CHIP grant, a federal grant that will help us move that part of the process forward.
MR. CHAIRMAN: Let's make it 9:39 a.m. Members of the Liberal caucus, please.
MR. DOWNE: We're all wondering, how are people getting the right level of care in the right place at the right time. Ultimately, that's what we're supposed to be trying to find out. I've heard seniors refer to the fact that when they came into the world there was money paid to make that a reality out of their own family income and as they are moving on in life they are now paying as well. Some of them are very frustrated, and I am not talking about the rich and famous. I'm talking about the ones who are caught in the trap in the middle, who have just scrimped and saved.
My question is to Miss Bree, your reviewing of all the criteria that you have in place - do you have any intention or direction to change any of the criteria to make it harder or more restrictive, in regard to financial contributions by individuals, to get into the health care long-term facilities, or are you looking at changing it to make it easier or less expensive for individuals to get into the system, or keep it the way it is?
MISS BREE: As the manager of the unit, the direction we have been provided is that we have the Social Assistance Act that governs us which allows us to administer the eligibility determination. Then we also have the Community Supports for Adults policies that we have to adhere to. Our direction is that we apply the policies consistently across the province, which we are doing, as well as educating the seniors and their families on our policies.
It is not our position or our responsibility to change policy or to change legislation. At the present time, we are working within the Social Assistance Act, as well the community supports for adults policies.
MR. CHAIRMAN: Mr. MacKinnon.
MR. MACKINNON: Mr. Chairman, on that particular issue, I am looking at the requirements for financial assistance application, and I want to continue with that line of questioning. I am absolutely astounded at the requirements for seniors, everything from income, life insurance policies, investments, bank statements for three years. The only thing you haven't taken here is a DNA. Quite frankly, I'd say the Department of Health should be ashamed of itself for trying to balance the health care budget on the backs of seniors. That's my personal observation for starters, particularly since the assistant deputy minister doesn't even know the definition of the user fee that is being applied to seniors in this province.
My question - aside from the lack of seeing a violin here to play the music for these poor individuals or a box a food stamps, because that's about what some seniors are being left with because of the actions of the Department of Health. I say that not to just be facetious, because I think it's absolutely disgraceful the way the Department of Health is treating seniors in this province. They are trying to balance the budget on the backs of seniors, and I think that is absolutely astounding.
My question is, when did this new policy come into effect, and how many people apply on an annual basis to go into these nursing homes?
MS. BREE: My understanding is the policies were created in 1998.
MR. MACKINNON: Yes.
MS. BREE: The Social Assistance Act has been in existence for years. As far as the number of applicants per year, right now we are responsible for completing the financial assessments for Districts 4, 5, 6, 7 and 8. In my review of the province and the number of intakes per district, we are looking at anywhere from 250 to 300 intakes per month.
MR. MACKINNON: And what's the backlog on that?
MS. BREE: Right now, again we are only responsible for half of the province. The backlog in doing the financial determination, I wouldn't say there is a backlog because as soon as an intake is received then we automatically review the file to determine what additional information is required. If the information has been provided by the applicant and the family, then we are able to make a decision on that file almost immediately. If we're waiting on bank statements or other financial information in order for us to do the financial determination, we sometimes might have to wait a month before we have all the information.
MR. MACKINNON: Of the 200 to 300 that you assess, how many of those actually go into a nursing home?
MS. BREE: Again, once we complete the financial determination, we advise the placement coordinators in District 7 and 8 or the care coordinators, who are responsible for assisting with a placement. At the time that we do our financial determination, we may not be advised after that as to when they are placed. Again, that is information that is centralized with the districts. It is not with us.
MR. CHAIRMAN: Excuse me, Mr. MacKinnon, I am aware of the fact that we have a couple of associates who would like to respond to a couple of those questions.
MR. MACKINNON: I'd like to continue my questioning with this witness, Mr. Chairman.
MR. CHAIRMAN: Please continue then. Not a problem, go ahead.
MR. MACKINNON: What you are saying then is, once the department is able to determine the financial capacity of an individual that information is passed on to the appropriate body, whether it be a nursing home, private sector, public, whatever, and from there they make the determination as to whether they'll accept that individual or not. Is that what you're saying?
MS. BREE: I'm going to pass this over to Mr. Menzies.
MR. MENZIES: That's not the case at all. In terms of process, Joanne Bree's staff carries out the financial assessment, that information goes to the placement coordinator in the district who is a Department of Health employee at this time, still. Information that goes to the nursing home relates to the income that the home should see, that the individual should be paying to the home directly, and a tentative date as to when the province will begin providing some subsidy. Information on the assets of the individual are not divulged to the nursing home, am I correct on that? And the individual or the family themselves maintain control of all of those assets and pays the cost of care at . . .
MR. MACKINNON: Who rates the individual?
MR. MENZIES: In terms of their ability to pay?
MR. MACKINNON: In terms of their eligibility to enter a nursing home.
MR. MENZIES: That relates to the care assessment that is done. When somebody is in need of care, there are two assessments done. One is the care assessment, to determine the care needs of the individual. That is the basis for admission to a nursing home or a referral to a nursing home. The financial assessment piece is parallel but it's a separate process.
MR. MACKINNON: So the likelihood of someone who has a good financial basis has a much greater chance of getting into the nursing home than . . .
MR. MENZIES: No, the other point is that when somebody approaches the system looking for services, approaches the care coordinators, and the care needs are such that the service should be provided in a nursing home, the person's name goes on a wait list. It's a chronological wait list, so regardless of your financial status, your name would come up on that wait list.
MR. MACKINNON: How often do you inspect nursing homes?
MR. MENZIES: Nursing homes are inspected annually.
MR. MACKINNON: How often are they supposed to be inspected?
MR. MENZIES: Annually.
MR. MACKINNON: So, all nursing homes are inspected annually?
MR. MENZIES: Nursing homes and homes for the aged are inspected annually.
MR. ESTABROOKS: I want to recognize Ms. Doiron, because your time is almost up, Mr. MacKinnon.
MS. DOIRON: Mr. Chairman, I think the member has raised a very important point, that has to do with his comments in regard to penalties to seniors. I think that this is a very serious issue, and it's a serious issue probably across our whole nation, that is really about what is appropriate in terms of the contribution that individuals should make toward their own care in a long-term care setting. I don't think it really has anything to do with balancing the budget. We really haven't changed that over a number of years, in terms of looking at various business plans. However, I think that the question has to also focus on the ability of the province and even the nation to pay all costs associated with seniors' care that tends to go on, in many cases, for an extended period of time. What is the right social answer to some of those issues and some of those questions? I think we welcome that kind of a debate.
MR. CHAIRMAN: Mr. MacKinnon, your time has elapsed. Ms. Doiron, do you have anything more to add?
MS. DOIRON: No, I think I would just like to make that point, that it is a huge question, a huge issue for, I think, public and national debate. I don't think we are going to be in a position in this province to simply make a business-based decision on that issue.
MR. CHAIRMAN: Mr. DeWolfe.
MR. JAMES DEWOLFE: Mr. Chairman, ladies and gentlemen, we are delighted to have you here today. Prior to my opportunity to speak, during the first round, Mr. MacKinnon, during one of his speeches - and I choose to ask questions rather than make speeches - talked about the single-entry access backlog. His suggestion was it was created as a result of the financial assessment process. My question is, is this process of reviewing individuals' financial background something new that came about as a result of the introduction of the single-entry access?
MR. MENZIES: Mr. Chairman, the requirement for financial contribution in this province has consistently been there for some 25 years. When reference was made to the policy being 1998, that was the point in time when the Department of Health took over responsibility for carrying out the financial assessments. Up until that point, they were carried out through the Department of Community Services. Before 1992, the homes for the aged and nursing homes were under the Department of Community Services, they moved to Health in 1992-93, but the financial assessment didn't follow and didn't become a part of the responsibility of the Department of Health until 1998. It's the same policy, the same standards are being applied that have been applied for many years.
MR. DEWOLFE: Mr. Menzies, the same standards with regard to property, the dividing of property, based on the criteria before are being used today?
MR. MENZIES: Correct. In fact, in raising that point, at one point, probably 10 or 12 years ago, the primary residence was not exempt. People, at that point, were being required to sell their primary residence as well. I have forgotten the exact date at which that changed; it's within the last 10 years that that changed, that primary residences were removed from the equation.
MR. DEWOLFE: That's very interesting, because that's sort of contrary to what was mentioned earlier. Can you give us some sense of consistency within the system prior to the single access? Is there consistency throughout the province, in the system, through the districts?
MR. MENZIES: In terms of the financial assessment?
MR. DEWOLFE: Yes.
MR. MENZIES: That was one of the issues that I think has been raised by the Auditor General's department, that because we have had care coordinators actually applying the financial assessment, there were a number of inconsistencies coming out of the processes that he was aware of. One of the reasons that led us to move to having financial eligibility review staff carry this out is that with a smaller number of people carrying out the process it would be more consistent, and with a manager to oversee it, you can ensure greater consistency.
MR. DEWOLFE: Mr. Menzies, during your opening address, your portion of that address, you were unfortunately cut off before you had the opportunity to respond to the alternative level of care policy, that being the numbers who have been medically discharged from hospitals and are required to pay the $50 a day. There has been some upset over that. I just want to reiterate my position on it, that I feel it's very reasonable and I assume the average per diem in a long-term care facility would be much greater. Again, I just want your affirmation on the fact that those patients who are required to pay the $50 a day in the
hospital, who are medically discharged, would indeed have to pay a great deal more in any nursing home.
MR. MENZIES: The per diem rates in a nursing home range from about - I don't even know if they're as low as $85 anymore. The average cost in nursing homes is $130 a day. If the individual has the assets and income to pay for those costs, they would be expected to do so.
MR. DEWOLFE: Thank you very much. I am going to leave the closing questions and remarks to my colleague, the member for Colchester North.
MR. CHAIRMAN: Mr. Langille. You have about three minutes.
MR. WILLIAM LANGILLE: I just have a comment, I guess. I want to bring it to you in a quick question. I think the Opposition members would like for us to leave here today believing that single-entry access is a process developed by Department of Health bureaucrats. From what I've heard today, it sounds like that is exactly the opposite of what has actually happened. There has been considerable consultation and direct involvement with key stakeholders. You've partially answered this. Where do we go from here?
MS. DOIRON: Where we go from here is to continue to work with the multiple stakeholders that I mentioned earlier, which include a number of public groups that are involved with seniors or other organizations. Also, where we go from here includes continuing to work with the caregivers, the care coordinators and others who are on the ground with this particular system to make sure that it is being put together in a way that is truly going to work. As we continue to kind of develop this work and roll it out, we will continue to have that kind of interface with the system. Once we get to having this system rolled out through the whole province, we will then, of course, continue to stay in touch with that so that we can periodically evaluate and improve any of the processes that are actually rolled out.
Where we go from here also includes what I mentioned around the database and the information that we would be collecting. That was not intended - I'm sorry that was misunderstood. We were not suggesting that we don't have any information related to demographics. What we don't have is specific information in a data bank pertaining to this population of people who are in our care in some area, whether it's in home care or long-term care.
We will now be able to be collecting, in a database, information pertaining to care needs, the changes in care needs, the rollup that should indicate to us where we need to adjust the system, where we need to add services, and where in fact we don't need services. I think the database that will develop over time will be extremely informative in providing the evidence that we will need to properly further redefine the system.
MR. CHAIRMAN: Thank you, Ms. Doiron. You have six seconds left, but I would like to use it to encourage our witnesses, any of them, all of them, to wrap up in an appropriate time limit of two to three minutes, please.
MS. DOIRON: I would simply say at this point that we are very excited in the department, because we feel we are starting to truly come together in teams across the department, to work across the various sectors that represent the system. Whether it's acute care, long-term care, continuing care, mental health, we are truly starting to work across the teams within the departments. We are also starting to see that in the system the same kind of working across what used to be "silos" is starting to break down. What we're wanting to do is to truly achieve an integrated system out there that is accessible for the public, so that we can provide the best possible care in the most efficient way and provide easy access to that care. An integrated health care system is what we're working towards, and we are extremely excited that some of our initiatives are allowing us to truly see some of that materialize.
MR. MENZIES: The only comment I would add to that is in terms of single-entry access the overriding objective of introducing this system is that it will provide, for Nova Scotians, seniors and their families, a much easier access to services and understanding what those services are. As an administrator of a nursing home, I was routinely getting calls from family members asking how to access any number of services. We will have that system in place, and it will make a great difference for people.
MR. CHAIRMAN: Just a point of clarification, if I may. It's been brought to my attention that a document circulated, headed Department of Health, Community Supports for Adults Program, was a 2001 document. We are wondering, is there a comparable document from 1998? The request has been brought forward in that manner. This is a document entitled Requirements for Financial Assistance Application; it was earlier referred to by Mr. MacKinnon. The point that we would like clarified, is this is a 2001 document, Ms. Bree?
MS. BREE: It's a document that has been updated as changes, and it has been most recently updated regarding the appeal process that came into effect as of August 1st. That is the only part that was updated in that.
MR. CHAIRMAN: Okay, then I will take that as a point of clarification. If there are further matters on this, I would request permission, if I may, to be in contact with your office, Ms. Bree, to clarify this further.
MS. BREE: Yes.
MR. MACKINNON: Perhaps our witness from the Department of Health would be kind enough to supply that 1998 document. Okay.
MR. CHAIRMAN: Thank you, Ms. Bree. We would like to thank you for your time this morning. I would like to remind the witnesses we are going to actually recess right from here, if you could just stick with me for a moment. Our next two sessions involve the Department of Health, and the deputy minister will be, with appropriate staff, at both sessions. I would call for adjournment.
Is it agreed?
It is agreed.
We are adjourned.
Thank you for your time this morning.
[The committee adjourned at 10:00 a.m.]