Assemblée Législative de la Nouvelle-Écosse

Les travaux de la Chambre ont repris le
21 septembre 2017

Public Accounts -- Wed., Jan. 29, 1997

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HALIFAX, WEDNESDAY, JANUARY 29, 1997

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:30 A.M.

CHAIRMAN

Mr. John Leefe

DEPUTY CHAIRMAN

Mrs. Francene Cosman

MR. CHAIRMAN: Ladies and gentlemen, I will call the meeting to order. A few of our members have called in to say they will be late as a consequence of road conditions. Again, I would like to welcome the Department of Health. We have quite a number of persons with us this morning. While we do know some of them, perhaps as I call out your name, for the committee's edification, you might just kind of give a little wave so they know who is who. Ed Cramm, Deputy Minister; Mary-Jane Hampton, who has been with us previously, is Executive Director of Strategic Planning and Policy Development; and for Home Care, Bob Fowler, who was with us two weeks ago; Susan McDonald Wilson, Director of Home Care; Alice Middleton, with whom I have worked closely in the South Shore area, is the Director, Western Regional Home Care Services; Ms. Judith Wood-Bayne, Coordinator of Policy and Planning Home Care; and of course we have Roy Salmon, Elaine Morash and David Perry from Mr. Salmon's office. Welcome to all of you and I would gather from the presence of the projector in the Chamber that we are going to begin with a show and tell and I turn the floor over to you, Ed, and your competent staff to lead us into this morning's session.

MR. ED CRAMM: Mr. Chairman, I will ask Susan, who has a presentation which runs 15 minutes or so on the Home Care Program which details many of the aspects of that program which would be of interest to the committee. If it meets with the committee's approval, we would like to begin with that presentation.

MR. CHAIRMAN: By all means.

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MS. SUSAN MCDONALD WILSON: What we wanted to do actually today is take you on a 15 minute tour of the history of home care in Nova Scotia. We wanted to begin by providing you with the context of why we moved from the Coordinated Home Care Program to Home Care Nova Scotia because home care in this province actually began in 1988 with CHCP. However, it was a restrictive program directed mainly toward people over the age of 65 and mainly to people with limited incomes. It had actually had policies in place which separated the hospital and home care sectors and indeed it even had a cumbersome construct to it.

Home Care Nova Scotia, on the other hand, ensured that eligibility was based on unmet need rather than age and income and it expanded the entitlement to services available to people. It also had a different payment structure to it. The program also begins to link the hospital long-term care and home care sectors together and governance of the program was considerably simplified because the governance of the program for the first five years, CHCP, was complex. There were two lead departments, both the Department of Community Services and the Department of Health, plus the involvement for funding and governance of 66 municipalities and that continued for the first five years until in April 1993 the full program was moved to the Department of Community Services. The municipalities continued their involvement.

A few months later, the entire program was then transferred to the Department of Health. Municipalities remained involved and at that time, too, the provincial-municipal service exchange took place in the spring and at that point the Department of Health assumed 100 per cent responsibility for the funding of home support agencies and for the first time took over responsibility from the Department of Community Services for the separate in-home support program.

Then, in the spring of 1994, Nova Scotia published the Blueprint Report and then subsequently a few months later, its sister document, Home Care Nova Scotia Plan for Implementation was published. Now we established a strategic planning environment for the building of Home Care Nova Scotia in December and, starting then, we actually began pilot projects across the province, precursors, if you will, to Home Care Nova Scotia. The government approved the public policies, the expected growth and strategic plan for a step- wise implementation of Home Care Nova Scotia over several years in April and then the doors were opened in June 1995.

Now because we were building a program over several years in a step-wise fashion, it was important to build a strong foundation and indeed that is what we did; first, starting with a province-wide 1-800 number, which allowed callers to make a simple phone call and be returned to their own communities. We moved from a costly joint assessment process to a streamlined generalist assessment model and home support agencies ceased being the intake point and became service delivery agencies. We had care coordinators in all communities

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across the province but for the first time in this province, we placed home care care coordinators in each of the non-specialty hospitals throughout Nova Scotia.

We, of course, opened up with the key policies of eligibility, entitlement and payment, the heart of Home Care Nova Scotia, and because we were dealing with people who were sicker and had greater needs, we ensured there was access to intermittent care across the seven day week.

Because of the importance of home care in the reforming health care system, we started our continuing program evaluation at the beginning and continue to this day. We also invested in a continuing quality management program, ensuring that every month that went by, we improved the quality of services to Nova Scotians and we invested in technology so that we had a good, strong database upon which to make evidence-based decisions and we added remote communication capabilities to deliver service across thousands of square miles; all of this so we could deliver a program to Nova Scotia that delivered an array of services to assist people of all ages with assessed unmet needs to maintain maximum independence while living in their own homes and in their own communities.

We began with chronic home care and the introduction of home hospital care with a view to moving toward the smaller specialty categories in a step-wise fashion because when you look across the country, you will find that in all of the home care programs, about 80 per cent of the people who use home care are chronic home care users. From the beginning, we have talked about the growth that Home Care Nova Scotia will experience for many years and we expect to be serving about 28,000 Nova Scotians by the turn of the century.

You may be interested to know what causes people to use home care, in any province, but particularly in Nova Scotia. One of the key drivers is age, people over the age of 65. In this province we have 12.7 per cent of our population and it is growing, of folks over the age of 65. Of course, the number of people who get sick and who die in any given year, affects how we use home care. Interestingly enough, Nova Scotia has the highest rate of disability in the country and that affects how much we use home care.

Poverty, I don't have to tell you, drives the health status of an individual and the poorer the health, the more likely they are to use the health care system and that applies to home care as well. How well or how poorly we use nursing homes and hospitals also affects how much or how little we use home care and the availability of other services in the community also affects its use.

A lot of people, in fact, have used home care. In the first year, as you can see, more and more people used it every single month. In fact, we saw a 120 per cent increase in the number of people using Home Care Nova Scotia in the first year, almost 16,000 people. That trend has continued so that this year, just until December 31st, we have served almost 17,000 people and we have about two and one-half months left to go.

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Now if you look at the spending over the history of home care in Nova Scotia, you will find that in 1988 we spent between $8 million and $12 million on the program including the Coordinated Home Care Program plus the separate In-Home Support Program. That rose this year to $60 million, $11 million of which was invested in in-home support, the remainder in Home Care Nova Scotia. You will find an attachment to your package to that to provide you with a bit more detail.

Let us put this into the overall health system context. The yellow columns indicate the growth in Home Care Nova Scotia over the last few years. The red columns indicate the changes in the health care system that are happening around us.

Let us look at the larger context, the Canadian context, if you will, because we are in a unique situation in the Province of Nova Scotia because the rest of the country built province-wide Comprehensive Home Care Programs over 20 years ago. In fact, they started in 1974, 22 years ago. It moved from Manitoba over to Alberta in 1975; to British Columbia the following year; and in 1978 in Saskatchewan, they opened their province-wide Comprehensive Home Care Program. Ontario and Quebec had developed sophisticated programs over the last 20 years; and particularly in Quebec, they had not only integrated services in health at the community level, but they had actually integrated them with social services as well. Then the last major program that began in the country was our neighbours in New Brunswick, the Extramural Hospital Program in 1981.

As I look around the room, I think that most people can remember the 1970's because it is important. These are when the Home Care Programs were built.

MR. CHAIRMAN: They say if you remember them, you were not there. I guess that was the 1960's, wasn't it, that is why I could not remember. (Laughter)

MS. MCDONALD WILSON: What is really key about the 1970's, to tease your memories, was that there was a lot of money flowing into the system, exactly at the time when Home Care Programs were being built. So the ones that I mentioned to you were all built as add-ons to an existing health care system. Brand new money was invested into home care in addition to the money already going into hospitals, in addition to the money already going into long-term care. In fact, the first transfer of money from the acute care sector to home care did not occur for another 20 years when in 1993 in an informal way, money was transferred from hospital to home care in British Columbia.

The same year was the first significant closure of a hospital in the country. That happened in downtown Vancouver when a 400-bed hospital closed its doors. It was followed shortly thereafter, in fiscal 1993-94, when over 50 rural hospitals were closed in the Province of Saskatchewan. This is a completely different environment in contrast to the one that the rest of the provinces grew theirs in the 1970's.

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There are some similarities because all of the provinces are going through health reform. We are a couple of years behind some of them; a few months ahead of others. The reality is, those other provinces are far better positioned to manage the shift of care from hospital to home because they have had years to grow policies, years to grow programs, and years to grow partnerships with the other sectors.

Just to give you a sense of what it looked like in the rest of the country in 1995-96, the first year of the program, we spent $49 million. You can see in demographically similar provinces, Saskatchewan and Manitoba, they spent $61 million and $92 million respectively; of course, all the way up to $639 million into home care in the Province of Ontario. When you compare the percentage costs, percentage investment, into home care of the provincial health budget, you will see that it ranges from 2.8 per cent in Nova Scotia up to a demographically similar province, 4.3 per cent in Manitoba.

So, we moved part of Home Care Nova Scotia from being the bottom of the heap in terms of per capita investment in home care across the country. We moved considerably upwards so that we are in far more comparable positions to the rest of the country, although still a little behind.

Let us keep looking at this context because it speaks a lot about where we are right now. One of the oldest programs started in 1975-76, Alberta, you will see a slow but steady rise in the investment in home care. Then if I can direct your attention to the 1990's, you will see at the same time that health reform took off, so did the investment in home care and it was the same in Saskatchewan, a slow and steady rise from the program's start in 1978; boom, in 1990 health reform started and so did the significant rise in investment in home care. Manitoba, same for 1974; Ontario, absolutely classic profile, you can see the sharp trajectory upwards in their investment.

Now look at the profile of Nova Scotia. Our funding has been very different; our history of policy development has been very different; our program development has been very different and that has affected the entire health care system. So, we had a job ahead of us in year one. We wanted to put a sturdy foundation in place upon which to build over the years, a step-wise evolving program. So we saw considerable investment in all of the things we discussed earlier. We saw a period of significant growth in the first year, the expansion of chronic home care and the introduction of home-hospital care.

In year two, as planned and according to the Home Care Nova Scotia Plan for Implementation document, we reviewed and evaluated Home Care Nova Scotia, and we increased our emphasis on health and safety of the individual and family and, yet, maintained a strong balance of the health and social needs of the client. We managed the growth of the program and we are continuing to refine and evolve that program in order to meet the constantly changing needs of individuals, as well as the constantly changing needs of the system.

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This has all required a shift of thinking, because what we have asked the health care industry to do is think people and care first and to think, secondly, of where they received that care. Obviously, the majority of acute care will always be delivered in hospitals, but now we have the capability of delivering it in nursing homes, at the scene of accidents at roadside, or in the individual's own home. The goal here for all of us is to deliver care in the most safe and effective manner with the greatest of efficiencies, and it is pretty straightforward. It really is as simple as delivering the right services to the right people in the right place for the right cost.

What we do when we talk to individuals is we look first at ensuring we are getting the right service in the right place by looking at what individuals can do for themselves in the way of self-care and care of their home. We look to what available family support is coming into that individual's home, and we look at their communities and the available resources that may be possible for them to tap into. Then we look at what can Home Care Nova Scotia do to supplement the already existing system. We see the people who require home-hospital care and adult protection first, as well as those who are at highest risk and have the greatest needs. Secondly, we look at those with non-urgent needs.

So, for example, in the last three or four months, we have admitted over 1,600 people like the 85 year old gentleman who had a stroke and is being released from hospital; like the 45 year old woman with cancer who is being discharged to Home Care Nova Scotia on IV therapy. We have asked some people to be delayed in their assessment like the 75 year old woman who needs general cleaning every second or third week, but can manage for a little bit before we get to see her.

There has been a lot of work as you can see that has been done by a large group of dedicated staff across the province. We continue to build community-based home care with clear separation of accountabilities; separating the assessment of services from the delivery of those services. We continue to build partnerships with physicians, regional health boards, hospitals, long-term care and the rest of the community. We continue to create innovative partnerships in the delivery of services for home care, building a single-entry access over time to home care and long-term care, and we invest in the pre-devolution linkage with regional health boards so that we can deliver this province-wide program in a devolved way in the next couple of years to all the clients of Nova Scotia through those RHBs. Thank you.

MR. CHAIRMAN: Thank you very much. Ed, do you wish to follow up on that?

MR. CRAMM: Mr. Chairman, at this point in time, I think we would be pleased to answer the questions as they come forward from the committee.

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MR. CHAIRMAN: Thank you very much for the most interesting presentation. Now, I know that there are a number of members who have questions arising out of our discussions with health officials two weeks ago. So, we can anticipate questions arising from that as well as questions arising more immediately from this morning's presentation and our review of health care last week, assisted by the Auditor General and his staff.

MR. JOHN HOLM: There are a lot of questions that one could ask. First, thank you very much for the presentation. I am going to start, first of all, on the home care aspect. In your presentation you talked about the great increase in the numbers who are being seen. What percentage of those new clients are clients who would previously have been receiving in-hospital care but because of the early release program and the shutdown of hospital beds are now receiving in-home support?

MS. MCDONALD WILSON: Well, first of all, let's call it Home Care Nova Scotia because in-home support is actually a separate program that is transferred from the Department of Community Services. That would really lengthen the answer if I went in to describe it. Let's focus on home hospital care.

The introduction of home hospital care, we have anticipated about 15 per cent of the people in any given month will have cause to use home hospital care. What we have found in the last 18 to 20 months is that has ranged in any given month from about 4 per cent of the admissions using home hospital care right up to 17 per cent. It is based on the number of people that require care in the home as a result of being discharged to home.

What you need to be aware of is that people who are coming out of hospital in large numbers use chronic home care as well. It is not a short-term use that is expected but, rather, a long use of the chronic home care component so many of the people discharged from hospital come to chronic home care.

What is important to note is that not only are we assisting people in getting out of hospital earlier, we are preventing and delaying the admission of individuals to long-term care, one of the key goals of Home Care Nova Scotia.

MR. HOLM: Well, I appreciate that but, certainly, a good proportion of the growth in the use of the service is as a result of those who are being released from hospitals early.

In the figures, when we were talking - I forget what slide it was on, I had bent the page back but - it showed the growth in the expenditures on home care going up from about $20 million in . . .

MS. MCDONALD WILSON: Page 18.

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MR. HOLM: . . . 1992-93 to $60 million. Of course, that $20 million does not include the $11 million of municipal contribution that was also going in to providing service at that time, so that is really not an accurate picture in terms of the total dollars that were being spent. If we were to look at comparative figures, the figures have really gone from about $30 million to about $60 million increase in funding, an increase of $30 million, at the same time that the hospital component has been dropped by approximately $140 million, is that not correct, or a net loss of about $110 million?

MS. MCDONALD WILSON: Actually, if you look at the appendix, you will see the breakdown of the amount of money invested in in-home support, as well as CHCP in the early days. Subsequent to the Department of Health taking over responsibility for in-home support, you will see the combination as shown on the graph.

Actually, in 1993, the year you mentioned, it was $7.9 million invested in in-home support. So, yes, when you combine them, there is no question, there is a greater dollar amount but those programs were completely and entirely separate until 1995-96. Not only were they separate from the Department of Health, but they were separate inside of the Department of Community Services, a part of the general assistance budget, if you will.

MR. HOLM: What I am trying to get is the total number of dollars that are going into the pot, whichever pot they came from, whether it is municipal, whether it is Department of Health, Department of Community Services. There were dollars that were being provided for use to assist people in their own homes.

Am I correct in saying that that figure has gone up by approximately $30 million, at the same time that the amount of funding for hospitals was decreased by approximately $140 million for a decrease of about $110 million?

MS. MCDONALD WILSON: Yes.

MR. HOLM: Okay. Now, the second thing that I really want to - and we are taking a look at this, and in your presentation, you talked about what other resources are available to that individual, whether that be from the family, whether that be from the community before Home Care Nova Scotia determines what assessment they are going to be providing. Certainly, one of the things that we are hearing is that an awful lot of what used to have been provided through the Community Services types of programs, for example, you talked about the 75 year old who may be able to wait for a few more weeks for the cleaning services, it seems like that side of the equation, that those kinds of services, have been dramatically reduced, from what I am hearing anyway, and that really some of those dollars maybe are the ones that are being used, in part, to help with the health care component. Is that in any way accurate?

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MS. MCDONALD WILSON: Not quite. The point of Home Care Nova Scotia is actually to not only supplement existing resources that a family may have, an individual may be able to provide and a community may be able to provide, but our goal is to maximize their independence so we can return them to their maximum possible state of independence, either pre-surgery or pre-illness.

MR. HOLM: You are saying maximize their independence but at the same time you are talking what support they can get from their family, what support they can get from the community, that's not necessarily maximizing their independence but it may be maximizing their dependence upon somebody other than Home Care Nova Scotia.

MS. MCDONALD WILSON: Well, Home Care Nova Scotia is a complementary part of any existing support system. What we do first is ensure that we are giving the right service to the right people in the right amounts and that we are building the program in a sustainable way. But let me address your question regarding the concern that somehow the social component of Home Care Nova Scotia has been eroded.

When you look at the history of home care over time from a health and social standpoint, you will see that in the early days of the program, beginning in 1988, there was a dominant emphasis placed on meeting the social needs of individuals and a little bit less on the health component. When you look at June 1995, when we opened the doors, there was a much more balanced or even emphasis on meeting both the health and social needs of an individual. As we evolve the program, we have, in fact, emphasized the meeting of health and safety needs of individuals and reduced somewhat - not much, somewhat - the emphasis on meeting the social needs of individuals. Let me give you the evidence to support that.

In this past year, as is typical across this country, two-thirds of the investment in home care is spent on home support services, the social support services, whereas only one-quarter to one-third of the services are of a nursing nature. So that balance is very similar to what you see in the rest of the country and certainly is evidence to support that we are continuing to be involved in a whole range of needs of individuals including their health and safety and social needs.

MR. HOLM: Continuing on, I guess, in the same kind of vein. One of the major criticisms of Home Care Nova Scotia - and not just Home Care Nova Scotia but of health reform - has been that many of the services, for example, hospital beds were being shut down and I guess contrary to what Mary-Jane had said two weeks ago when my interpretation of what the Blueprint Committee said was a little bit different than what was enunciated in terms of what core services were. Mary-Jane a couple of weeks ago described those as really enunciation of standards whereas I thought that the Blueprint Committee in its report, I think it was around Page 28 or Page 29, defined those as the essential programs at the minimum acceptable level. It strikes me then that with a lot of the health care reform what has actually been happening is that those minimum standards whether it is in home care or many other

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things were not first established, defined and then put in place before the other programs, like the shutting down of the hospital beds, which would, of course, increase the demands on those systems, happened. It is more monetary-driven in terms of the implementation than standards-driven. I would like to get a response to that not totally friendly observation from the outside.

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MS. MCDONALD WILSON: A couple of things. First of all, we have to remember that this program was planned to be implemented in a step-wise methodical fashion. As you may have noticed on the foundation slide, one of our goals was to establish a continuing quality improvement program and we did. So we have begun to develop those standards, in fact, ahead of many of the other provinces in Canada. Many of the other provinces with 20 and 25 year old programs didn't have clearly articulated standards for home care. So in many ways while we started after the rest of the country, we have lapped some of the provinces and have moved ahead. Standards development is one of those areas.

MR. HOLM: Again, it really hasn't addressed the one issue and that is that it seems like you have talked about the fact that it is an implementation process that is taking place in stages. It strikes me that before you cut something that you would have put in place an alternate program that would have been able to meet those needs before you - and I am saying you and I shouldn't be using that terminology, I should be saying before the government - decided to shut down and eliminate certain other kinds of services. It seems to me you put something else in place before you eliminate if you are, as a government, trying to ensure the continuation of care.

Also, dealing with the standards and one of the other things that we have been hearing is that those who are providing the services in their homes for individuals - I am wondering if you could tell me, first of all, since families and communities are being expected to provide more of the service to family members and so on, what kind of assistance, what kind of training programs have been set up to assist those individuals who are now being called upon to do quite often very often what some would consider to be intricate medical procedures and so on, so what kind of procedures are in place to provide that training and what standards are in existence for those who are providing the care? I will throw in the term privatization because it appears that there is a move by government to be contracting out more of these services to private companies, so I would like to find out what kind of monitoring, what kind of standards and so on are in place in those place areas as well? My voice is starting to disappear.

MR. CHAIRMAN: I am going to give you a break in a minute because I think we should move on to another questioner after this answer by Ms. McDonald Wilson.

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MS. MCDONALD WILSON: Well, I think it will be a long answer because I think there were about 10 questions there.

MR. CHAIRMAN: It won't be too long.

MS. MCDONALD WILSON: If you look at slide 15, I guess Page 7, you will see that there were pilot projects put into place in late 1994 and early 1995 and if you notice the location of those implementation projects, you will see that those are the very areas where hospitals were first affected by the reform process. So there was a clear attempt on the part of the Department of Health to provide in the early days home care services as the hospitals were closing or being changed to have different roles and that has continued throughout the province as we have implemented since 1995.

It is important to note, too, that many additional people have been using Home Care Nova Scotia. Almost 16,000 people in its first year and already three-quarters the way into the second year, 17,000 people have benefited from using Home Care Nova Scotia.

You asked about families' involvement and the involvement of communities. Well, you know Home Care Nova Scotia is exactly like the other provincial Home Care Programs in this regard. There is an expectation that there be participation in the joint investment of an individual's care. So we do in fact check with families to see what they can do. But do you know what we also check? We check to see if they are burned out or if the heavy investment that they are making with clients is going to cause them to become burned out in a short while. So we provide preventive services like respite care to individuals.

When you talk about the more complex medical interventions that we ask clients to become involved in, I think there is a misperception on the part of the general public on just how complicated those procedures are and who, in fact, we ask to assist with them.

Let me give you two different instances. If a daughter who is living next door to a client who is at home on IV therapy needs some assistance, then they may very well become involved in the care of that individual. That individual is a daughter, but she is also a trained nurse.

When you think about IV therapy, people usually get a little bit queasy about needles and tubes and all of that sort of thing, but medical technology has ensured that there are things in place that make it very simple to look after an IV. So a catheter is put into an individual's arm and a little lock is put on it. So when an individual administers IV therapy to themselves, they are simply taking a little twist-tie, undoing it, putting in another tube and letting the IV run into it. A lot of people can do it and with teaching and support, they have the confidence to do it well and safely. That is the kind of involvement we are asking of individuals and of families. We have been very pleased with the response from Nova Scotians

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because they have not only been prepared to do it, they have embraced the participation and the care of themselves and their families.

MR. CHAIRMAN: Mr. Fogarty.

MR. GERALD FOGARTY: Since we have embarked upon questions on home care, I think I will carry on in that vein, but I would like to reserve the right to go back and question Mr. Cramm and Ms. Hampton about their presentation two weeks ago, okay?

MR. CHAIRMAN: By all means.

MR. FOGARTY: Ms. McDonald, I got the impression from your slide presentation that Nova Scotia - and I am paraphrasing here - had a lot of catching up to do. You would agree with that?

MS. MCDONALD WILSON: That's correct.

MR. FOGARTY: There is a perception that the program of reform or renewal within home care, or indeed within any facet of health care renewal in Nova Scotia, was undertaken at a very rapid rate; that perception seems to exist. If that is so, would you defend it by saying that because of the great amount of catching up to do, it was necessary to move into this program of renewal in such a fashion?

MS. MCDONALD WILSON: Absolutely. That is, in fact, exactly how we would characterize it. Because we were starting behind the rest of the country, as clearly illustrated in the slides, but going through health reform at about the same time, we did have some catch-up work to do. We benefited from the experience of other provinces by learning what worked and what didn't work. You can't import a Home Care Program lock, stock and barrel from any other province, but what we did is learned what worked and extricated some of those key pieces and massaged them into Home Care Nova Scotia. So, there is no question that we had to build our Home Care Program much more quickly and, I might add, under greater scrutiny than any other program that had been built in the country.

MR. FOGARTY: Would you also agree that it is perhaps impractical and even unnecessary to have all of the i's dotted and t's crossed before we embark upon this program of renewal and reform?

MS. MCDONALD WILSON: Yes, in fact, the step-wise methodical development of the program over several years was a strategically thought out decision because we knew we couldn't build a Home Care Program in a year's time to its fullest maturity. In the rest of the country it took upwards of seven and more years to build mature programs. Our plan was to do it within three to five years and we have kept reasonably well on track.

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MR. FOGARTY: Then when we hear the comment or the criticism that there has been no plan in place, is it totally necessary to have every last detail in place with an overall plan before implementation can begin?

MS. MCDONALD WILSON: What is absolutely essential is that there is a vision and a strategic plan in the building of a program that takes so long to build to maturity. In fact, in 1994, the Home Care Nova Scotia plan for implementation not only provided that vision, but dipped into a fair amount of detail on what we would see growing in Home Care Nova Scotia over several years. So, without question, Home Care Nova Scotia was well planned and has been well executed in its implementation. I might add that it is one of the more strategically-planned and developed Home Care Programs in the country.

MR. FOGARTY: Do you have any facts and figures, statistics, which would indicate the degree of satisfaction or acceptance with Nova Scotians?

MS. MCDONALD WILSON: When we asked people in the first year of the program what their satisfaction with home care was, we found that 96 per cent of the people who used Home Care Nova Scotia were satisfied with the services that they received. In fact, of those people, 94 per cent said the main reason they liked Home Care Nova Scotia was that they weren't in hospital and they were receiving care in their own home among their family and friends.

MR. FOGARTY: Is it fair to conclude, then, that criticism that is forthcoming, if 96 per cent of those who have had experience with Home Care Nova Scotia are satisfied, to some extent, then we are hearing anecdotes about dissatisfaction and unacceptance, is that coming from those who have had no direct contact with Home Care Nova Scotia?

MS. MCDONALD WILSON: That could well be. Home care is a different kind of health care service than most people are accustomed to. If people haven't used hospital care, they know what it is like because they visited as a visitor to a patient's bed, or they have seen it, if nothing else, on television. Home Care Nova Scotia isn't as familiar to people. You don't see it on TV and unless you have direct contact with it, you can't feel or experience what it is like.

In terms of criticism, there is no question that there has been criticism of the program; when there is something that grows this quickly, no question, there are some pieces of it that we would look at and say, you know what, we need to change how we are doing that. So, based on some of the criticisms which are legitimate, we have modified and improved the program. But let's face it, in the first year of the program almost 16,000 people used it and it comes as no surprise to any of us that a handful of people would, in an anecdotal way, make criticisms of the program. And, you know what, that will continue as long as home care is being built because there will always be a certain percentage of people who don't feel quite

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comfortable or quite satisfied. Our goal is to make the program as satisfactory and as excellent as possible for the vast majority of Nova Scotians.

MR. FOGARTY: So this is all part of change and reform, right?

MS. MCDONALD WILSON: Indeed.

MR. FOGARTY: You said 16,000 used it in the first year. How many are using it now?

MS. MCDONALD WILSON: Close to 17,000, and we expect about 18,000 or 18,500 to have had cause to use it in this fiscal year.

MR. FOGARTY: If I might, Mr. Chairman, now move on to either Mr. Cramm or Ms. Hampton. Two weeks ago, Mr. Cramm, in your presentation under the heading, After Renewal, one of the bullets reads, "hospital beds used appropriately", which would lead one to conclude that before the program of renewal was initiated that hospital beds were used inappropriately. Would you agree?

MR. CRAMM: I would agree with that, yes.

MR. FOGARTY: Could you enlarge upon that as to how they were used inappropriately?

MR. CRAMM: I would suggest, picking up on the comments that Susan has made with respect to home care, that many of the people who were taking space in hospital beds have been moved to home care which is, as Susan has outlined, a more effective way to deal with their particular health situations and certainly a less costly way to deal with those situations, and a more satisfactory way as Susan has just indicated.

MR. FOGARTY: The Pharmacare Program is now financially stable again, looking at one of your highlights from After Renewal, and in the same vein do we conclude that Pharmacare was in an unstable condition prior to renewal?

MR. CRAMM: Yes, that's true. The response there would be that stability was brought about by the formation of a Pharmacare board, the introduction of co-pay and the introduction of premiums to stabilize the program from a financial perspective.

MR. FOGARTY: And, "doctors practising where they are needed". Were they practising in parts of Nova Scotia, to any great extent, where they were not needed prior to renewal?

[Page 15]

MR. CRAMM: I wouldn't say they were practising where they were not needed, necessarily. I think the goal is to have access to physicians reasonably close to wherever you live in the province. To that extent, we are comfortable at this point in time that we have physicians in virtually every community so that people have reasonable access to health care.

MR. FOGARTY: Are you saying then that we are getting a fair amount of feedback to indicate that in those rural parts of Nova Scotia that we are, perhaps, under-serviced, that there is appreciable improvement in that regard?

MR. CRAMM: There is some improvement. I don't know that the improvement is all that we would want it to be at this point in time. It is an area that we continue to pursue through active recruitment of physicians for rural parts of the province.

MR. FOGARTY: Okay, thank you.

MR. KEITH COLWELL: Just a couple of things. When you are giving your presentation on home care, there still seems to be a point of view that it is more what money we spend on this in Nova Scotia as compared to other areas. I think it is time we really look and see what value we are getting for the money we are spending. I think the government has to do this and has to do it more and more at all levels.

Part of your presentation really touched on that but it still disturbs me to see, well, Manitoba is spending this much money per capita and so on. I really look at what value we are getting out of that money we are spending because that is the key. We don't have the dollars to spend we had in the 1970's. We don't have the sort of, throw-more-money-at-it-and-it-will-go-away problem, because that just creates more problems.

I really think it is important that we look at the value that we are getting for the money we are spending. Could you address that, in Nova Scotia, how it compares with other provinces, at the present time? I know it is difficult because you are in the infancy of really putting your quality control systems in place.

MS. MCDONALD WILSON: What I alluded to before was that while there are certain disadvantages to beginning the development of a comprehensive home care program as we begin to go through the reform process, there are some benefits from it as well. For example, we were able to not only import pieces of other programs but actually build upon them and add value to existing policies or standards and so on.

An example that I might make is that some of the other older provinces in the country, for example, had not addressed the bumpy ride along the continuum of care that some patients experience. They may be in hospital; they may be able to go home, but in other provinces they do not want to go home and pay for the medications and pay for the services that are going to come into their home.

[Page 16]

So we developed, I think, a state-of-the-art policy for home hospital care where individuals move from hospital into home hospital care at no fee for their nursing or home support services, no fee for the supplies and services that are given to them and no charge to them for the medications related to their acute illness.

This is one of the most unusual and, I think, creative value-added developments that has occurred in Nova Scotia, as compared with other provinces who have more mature programs but have not had the pressure to develop, immediately, state-of-the-art programs.

MR. COLWELL: Yes, I would agree that that is what I have seen in my constituency.

One thing that was brought up a bit earlier by the previous speaker was that the municipal programs and the money being spent on that - I would just like to make a comment and I would like to get your feedback on it.

From what I have seen in the municipal programs in my area, they were, to say the least, inadequate. They provided more of a babysitting service than any real service in the home in a lot of cases. I have talked to a lot of seniors and they were afraid to complain about it because they might lose what they had.

Basically, the home care worker would come in and sit there and talk to them for four hours, do absolutely nothing in the home, there was no accountability. When they mentioned it to the supervisors, the supervisors would sometimes come out, sometimes they would not. It really did not provide the absolute necessary services that they were providing.

When they blended the whole program together, the sense I got from it from my constituents was that it was a much-improved program, the services were monitored and the facilities were more coordinated. Is that a correct statement?

MS. MCDONALD WILSON: Yes.

MR. COLWELL: Another thing I would like to mention, too, is, I had a constituent, or still have the constituent, thank goodness, (Laughter) who at the very beginning of home care, was in the hospital with a very serious illness. She had missed home and she was supposed to be in the hospital for three months, even under the new rules put in place at that time. She had been in the hospital many times with a very serious back injury.

After two weeks being bored stiff in the hospital, waiting out time to get better, she insisted so badly with home care that she wanted to go home. She did go home, after a great deal of intense discussions with the home care people at the time.

[Page 17]

At that time, they were just setting up the hospital in the home program and the first week was sort of difficult because the structure was not in place but after the first week, things went very well. She did recuperate. Instead of three months, she was a month and one-half and she was literally better. She has since written me a letter to that effect outlining the whole thing. It appears that the program is working, even in the infancy part of it.

How far have you come? I can't remember the exact date but that would have been just after you started the integrated Home Care Program. How easy is it to get into that program now as compared to what it would have been then when she had to insist to get it just to get home?

MS. MCDONALD WILSON: Well, I think all sorts of components of home care are running even better today than they were in the early days. Access from hospital to home is one of those areas where the ride between hospital and home is much simpler, much easier and, I think, much less traumatic an experience for clients.

MR. COLWELL: That's good, thank you.

MR. ALAN MITCHELL: I enjoyed the presentation very much. I thought it was very informative and well done. If I could, I would like to ask a few questions just to clear my mind, some of the early history of home care.

You pointed out that home care started in 1988. Looking at the history, it was first the responsibility, jointly, I believe, of the Department of Health and the Department of Community Services. In April 1993, it was transferred to the Department of Community Services and then a number of months later in the same year, it was transferred again to the Department of Health which would appear to be a bit erratic but I think it is important to understand that there was a change of administration during that period. Dr. Stewart became the Minister of Health in between that.

My understanding is that prior to that, the Home Care Program was not a health-oriented program and that it was more a program of in-home support designed for seniors. It was only after November 1993 that the health-oriented Home Care Program started to develop. Am I correct in that interpretation?

MS. MCDONALD WILSON: I need to do a bit of a correction. The Coordinated Home Care Program did offer both social services as well as health services. Nursing and home support services were provided in the first five years of the Coordinated Home Care Program. The greatest restriction, however, was because the population that that program targeted was quite narrow, the program was directed mainly to people over the age of 65 and mainly to people with limited incomes. So there was a large population in Nova Scotia that couldn't access home care services through a provincially funded program until 1995.

[Page 18]

MR. MITCHELL: So after 1993 and then April 1994, this is when the modern Home Care Program started to develop that would be more comparable to home care programs in other provinces?

MS. MCDONALD WILSON: The key year when the change took place was at the end of 1994 and the beginning of 1995. That is when the Home Care Program in Nova Scotia became far more comparable to the rest of the country.

MR. MITCHELL: The funding for that, as well as the usage, has been fairly dramatic. One thing that has always confused me, I have heard some people complain to me about cuts in home care that this government is making, but I think it is important to realize that there has been a dramatic increase in the number of people using it as well as the funding, as you have pointed out.

I would like to maybe just deal with one of the points that Mr. Holm raised. In one of his questions he led the fact that there has been a decrease in spending in hospitals and an increase in spending in home care but the decrease in spending in hospitals has been significantly more than what has been spent in home care. A couple of questions on that. It would appear to me that the amount of money spent on a program does not necessarily equate to better care. I wonder how that compares to other provinces as they move through health reform, reduction in hospital spending and increases in home care spending, how these two have balanced and the level of care that people are getting for the level of dollars that has been spent?

MS. MCDONALD WILSON: All jurisdictions in the country have experienced decreases to their acute care budgets as part of their Departments of Health and every single jurisdiction in the country has also experienced an increase in the investment in home care at the same time. When I reviewed the slides for Alberta, Saskatchewan, Manitoba and Ontario and contrasted them with Nova Scotia, you could see that although there were well established Home Care Programs in those provinces, until the reform process began to take place there wasn't full utilization of home care. Let's take the example that I gave in fiscal 1993-94 when over 50 hospitals in rural Saskatchewan were closed. Although that was a comprehensive and sophisticated program, that was well utilized in the urban areas because bed closures had already begun to occur, because bed closures hadn't occurred in the rural areas the home care in Saskatchewan was not fully utilized. The rise that you see in the investment was a direct result of an increased use or utilization in the rural areas along with hospital closure.

MR. MITCHELL: Another question, if I may. With service exchange, we took over the in-home support for the 66 municipalities. Can you tell me a little bit about the type of programs that were taken over? These were not all homogenous programs, there were different levels and any difficulties the Home Care Program had in taking these over in the

[Page 19]

fact that they were not similar and integrated them into the Home Care Program. Can you tell me a bit about that?

MS. MCDONALD WILSON: Yes, it is first important to separate out two pieces though. Let's separate the In-Home Support Program from the home support or homemakers services provided by the municipalities. Let's talk about it first.

On Page 2, slide number 4, you will see that in April 1994 provincial-municipal service exchange had an impact on the funding relationship between the municipalities and the province. At that point, the province assumed full responsibility for supporting the home support agencies which up until that point had contributed 25 per cent of the dollars for the homemaker or home support services, less user fees. At that point, 100 per cent of funding became the responsibility of the Department of Health as part of the provincial-municipal service exchange.

The next paragraph, new program, In-Home Support Program, it was a program that had existed in the Province of Nova Scotia that was operated by the Department of Community Services as part of their general assistance budget. It was completely different than home care in the early days, CHCP, or more recently Home Care Nova Scotia. It was a program that was not available, as you indicated, in all municipalities, in fact, there was a wide variation. In some municipalities there was no In-Home Support Program available at all; in others, the more urban centres, particularly Halifax, Dartmouth and Sydney, had more sophisticated In-Home Support Programs available to it. But remember, some of the municipalities had nothing and some had much simpler versions of in-home support.

It was at the same time, in April 1994, that the Department of Health received this new program; for the first time it was linked up to Home Care Nova Scotia. Our goal, as we build in a step-wise, methodical way Home Care Nova Scotia, is to look at the appropriate integration of the In-Home Support Program with Home Care Nova Scotia and that will happen over time.

[10:30 a.m.]

MR. ROBERT CARRUTHERS: Mr. Chairman, at the last meeting I indicated that I had a matter that was of great concern to me and my local district. It centred around the question that was publicized indicating the pain clinic at the QE II, a doctor had indicated that he was no longer going to take patients that were not located in a certain geographic area. This, of course, is a great concern to the people that I represent in Hants East and I pose my question again in two areas: one, particularly with regard to Hants East, which was a district that was divided between the two health boards, where we have members on both health boards and where there was a specific undertaking to ensure that the facilities located in the central region would be available to those people that I represent; and secondly, with regard to the whole of Nova Scotia that is outside this particular region, the concerns with major

[Page 20]

facilities such as the QE II and the Izaak Walton Killam-Grace Maternity, these hospitals that are unique in that they are almost within their own jurisdiction.

I wonder what comfort you can give me and the people that I represent along with the people in all of rural Nova Scotia that this type of facility, this type of program will be made available to all?

MR. CRAMM: Mr. Carruthers, at the meeting of two weeks ago you did raise the question and at that time I said we were in the early stages of having discussions with the senior management of the Queen Elizabeth II Health Sciences Centre. We have had continuing discussion with the senior management of that institution. We have clarified and agreed that access to health services is in no way, whether you are from East Hants or elsewhere in the province, limited to citizens on the basis of geography.

MR. CARRUTHERS: Well, that is very good news. I know my local media was seriously concerned about this, as I was, and that is very comforting to hear.

I just want to move into a couple of other areas. One of the things that was mentioned earlier was a question of improvement in being able to have doctors available to people who live in rural areas. In my district, we have a doctor who has been a doctor in the area for a very long time; he has reached his retirement and his tax number was purchased, or whatever the system is in that regard, but we just don't have anybody yet to replace him. So he is really continuing to practise medicine, in many ways, ex gratia and it is because he is such a community-minded citizen; he was a warden for many years, a councillor for Hants East. I wonder, has there been any progression in dealing with that particular situation?

MR. CRAMM: I am going to refer you to Mary-Jane to address that if I can.

MS. MARY-JANE HAMPTON: Mr. Carruthers, the issue of recruitment of doctors to practise in communities throughout Nova Scotia has obviously been a very important one to us in the last several years. A challenge which, I should point out, is one that every province in the country faces; the difficulty of attracting doctors, particularly to practise in rural communities, for issues that I am sure you are well aware of. In Nova Scotia, we have had an incentive program to encourage physicians to practise in what have been identified as under-serviced communities. We are also aware of the general demographics of the physician population in many rural communities where an older doctor or an older medical practice has been functioning for some time and we need to build in plans for physician service replacements.

So, the quick answer to your question is, yes, there are strategies in place. The issues that we need to deal with though in making rural communities attractive to doctors wanting to set up practice and then attractive for them to stay when they have gone is very complex. If you would like to explore those, we can certainly do that.

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MR. CARRUTHERS: Well, I wish you luck in that regard because it always has been, there is nothing new in this, this has always been a problem for us in the rural areas, especially when there is no town. You could sort of have a small town and then it can draw in from miles out, but when you really don't have any town near you at all it makes it difficult. I know it makes it difficult for doctors also. So, it is a tough problem. I am glad that we are turning our minds to it. I am sounding a little parochial today, but I guess that is just sort of the luck of the draw.

MR. CHAIRMAN: I am sure your constituents would appreciate it.

MR. CARRUTHERS: Well, I try to be general but there is another area that seems to be of concern and once again I want some clarification on this. The way I recall when I was in municipal government, in the 1980's, the 1970's, prior to 1993 in my area in Hants East, I don't recall any home care system at all. We had no VON. I don't think we have any now. The only program I recall at all was a homemaker service that effectively was provided through the municipal system. I don't recall any type of other home care at all prior to 1993.

Now, I am wondering if anyone knows if I am accurate in that because I find it somewhat disconcerting sometimes to hear people complain that the home care system is not as good as it was because, as I recall it, there wasn't any in my area at all. Perhaps you can help me in that. Am I right? 1988 was mentioned at one point and I just don't remember anything other than some homemaker service might mow the lawn or clean the table, supplied by the municipal unit. Can you help me there? Am I right?

MS. MCDONALD WILSON: The Coordinated Home Care Program did begin in 1988 and during the period that you are mentioning, it did exist in all parts of the province. It was though, remember, limited in who it was able to serve - primarily those who were older and primarily those with limited incomes. There were nursing and home supports available to those narrow targeted populations, but one of the things you may have encountered was during the period 1991 to 1994, there were wait lists in almost every jurisdiction in the province for either nursing services or home support services. So, some people were, in fact, receiving services but new people were not able to get on the program and receive either nursing or home support services.

MR. CARRUTHERS: So, just to clarify then, say in 1988 there was some home care other than this homemaker service that I am talking about? Do you know what I mean by the homemaker service?

MS. MCDONALD WILSON: Yes.

MR. CARRUTHERS: It was sort of cleaning up and things, but there was some home care in all areas of the province in that year?

[Page 22]

MS. MCDONALD WILSON: That is correct.

MR. CARRUTHERS: You mentioned that it varied between municipal unit and municipal unit. This program you are talking about, does it vary between municipal unit and municipal unit?

MS. MCDONALD WILSON: Home Care Nova Scotia is a provincial program that is delivered at the regional level, and our goal is to ensure that no matter if you live in Yarmouth or Sydney, given your circumstances are the same, given that your unmet needs are the same, you would receive the same services.

MR. CARRUTHERS: I am talking about 1988.

MS. MCDONALD WILSON: In 1988, with the Coordinated Home Care Program, if you were old and if you had a restricted income, you could receive a minimum number of services. We have broadened the services that are available to people. So, just to give you an example, in 1988, or 1991 when there may have been waiting lists, you may have been placed on a waiting list or you may have gotten nursing services. Those nursing services, however, would have been restricted to one nursing visit in an ongoing way, whereas Home Care Nova Scotia does not have those restrictive guidelines. What it does is it figures out what the individual needs in order to maintain them at home in equal or better care circumstances for the same or cheaper costs.

MR. CARRUTHERS: I understand that. It is a greatly improved system and I congratulate it because it is just a godsend to the rural areas. I just want to make sure I understand. In 1988 or 1989, the program that then existed, the one that you talked about with regards to older people and economics and those things, was it absolutely equal treatment from one municipality to another in 1988?

MS. MCDONALD WILSON: Yes.

MR. CARRUTHERS: Thank you.

MS. MCDONALD WILSON: The In-Home Support Program was where the inequity existed, and it is a separate program.

MR. CARRUTHERS: That is the one, the other program that you talked about, and that other program I take it we just did not get much of it in Hants East?

MS. MCDONALD WILSON: That is correct.

[Page 23]

MR. ALFRED MACLEOD: Mr. Chairman, first I would like to apologize to our guests for being late, but the roads were a little worse than I had figured. I even left one-half hour earlier but it still took me longer. I will apologize if any of the questions I ask have been outlined in your presentation but, nonetheless, I feel that I have to ask them.

I see in the presentation, through a quick glance, that you have charts that show the increase in the number of people served, and you have charts that show the increase in the number of dollars spent, but I could not find a chart showing me or giving any kind of an indication of just how much time a client is receiving on a case basis. There must be some way of knowing what the average amount of time a client is receiving overall in this program. If it is in there, I am sorry I could not find it.

MS. MCDONALD WILSON: Actually, on Page 5, slide 10, you will see the third bullet indicates the development of an automated system for client information, management information and program evaluation, as well as remote communication people in the field. That was a decision that we made in the early days of Home Care Nova Scotia. There was no significant existing database for existing home care clients. There wasn't an automated system that enabled the massive collection of information such as you are suggesting.

So, we decided that we needed to have a look at that and either build our own system or buy one, if you will, and build it so that it made good sense for Nova Scotia. What we were able to do in 1995 is through a North America-wide search find that the Province of Manitoba was in the early stages of developing a screening assessment care planning automated tool, SACPAT. So, through an interprovincial agreement, we received that early version and have invested in the last year on building that system, adding value to it so that we can answer precisely the question that you ask, what are not only individuals but aggregate numbers of people receiving in any given region or community of the province.

So, at this point we are not able to provide you with that specific kind of information but we will be able to in the next short while, in the next several months.

MR. MACLEOD: I still believe that just because there is more money going into the program, it does not equate to a better program. You have more clients. You have a smaller amount of money going in; it is more, it is 157 per cent I think you said in your presentation, but the number of people that are actually going into the program have greatly increased. I am not sure how you will come up with this number but I know there is a fair amount of travelling time and whatnot that would be equated into the hours and the dollars that are spent. I am not convinced that people are getting the best bang for their buck and that they are actually getting better service now than they were prior to.

In the question of assessment, how is assessment done today for an individual who requires the service of Home Care Nova Scotia?

[Page 24]

MS. MCDONALD WILSON: The individual calls, actually, a province-wide number, a 1-800 number which returns the caller back to their local intake office. At that point, information is collected on their situation and circumstances. In effect, they are screened to try to determine how emergent or a non-emergent their needs are. They are assigned to a single care coordinator and the visit may occur in a hospital or in the living room of the client's home, and the care coordinator, what we call our assessors now, looks at the physical and psychological health and history of the individual, looks at their support system, what they are receiving already from their family, looks at their financial situation and looks at their activities of daily living, how they are able to manage the care of themselves and the care of their home.

They then look at what is being contributed through the community, through the family or what the individual can do themselves, and that results in the determination together, the client and the care coordinator, figuring out what are the assessed, unmet needs; what help we need to provide through Home Care Nova Scotia. The client then begins to receive services and based on their stability or instability, they are seen either quite frequently or not so often by the care coordinator. There are routine progress notes delivered to the care coordinator through the nurse who is providing care, or the home support worker who is providing care to that individual, to keep them updated.

MR. MACLEOD: This weekend I had the opportunity to meet with a group of people who have been involved with Homemakers Services for 17 years; since they started the program, they have been there. Some of the things they asked me about, and they questioned, are some of the reasons why I am asking you these questions today, because I couldn't provide the answer. One of the things that was mentioned by this group of people was that it is almost impossible to get the 1-800 line, that there are people, when they do get the 1-800 line and are given to the intake person, they are suggesting names of private companies for these people to contact; rather than fully evaluating them, they are suggesting they go to a private caregiver.

First, I don't think it is right that they aren't doing a full assessment, if I am understanding my information correctly; and secondly, I don't think it is proper for any government official to be suggesting private companies over any other company, I guess is what I am trying to say. The individuals receiving that information have no idea if these companies are bondable, what kind of references there are, or anything else. Do you want to make a comment on that; do you think that is happening; is that a fair statement?

MS. MCDONALD WILSON: As I indicated earlier, because we are dealing already, this year alone, with almost 17,000 people, it makes good sense that there might be individuals who would have concerns when they phone the 1-800 number. What is important to us and why we have a continuing quality improvement program in place and why we continually evaluate the program, is to determine where there are areas where we need to

[Page 25]

further develop the program or shore-up the program. So, we would certainly be happy to talk about that individually afterwards.

MR. MACLEOD: This group that I had been talking to represents over 21,000 clients; they have done that much work for people in the industrial Cape Breton area. They have told me that through the assessment program their clients have been called up by Home Care Nova Scotia, and 37 out of 42 phone calls have been rejected over the phone. People who were already receiving services, a phone interview was done, and 37 out of 42 calls, the people were taken off the program and were told they no longer required a service. Does that make any sense to you?

MS. MCDONALD WILSON: Let's just step back and look at the context here. If you look on Page 5, the ninth slide, third bullet, you will see that in 1995 there was a significant change structurally made to the system. So, in the old Coordinated Home Care Program, the intake agency, the entry point into the system, was actually through the homemaker or home support agency. In Home Care Nova Scotia, there was a clear separation of accountabilities separating out the assessment and administration of the program from the actual service delivery, making it far more similar, for example, to the relationship that home care had with the VON.

That change has resulted, no question about it, in adjustments on behalf of the 25 or 30 home support agencies that exist across the province. It has been an adjustment because their role has changed from that of intake agency to that of service delivery agency, and therein may lie some of the concerns you are talking about.

MR. MACLEOD: I think maybe somebody is missing the point here. The whole idea behind Home Care Nova Scotia is to look after people's needs. If people have been getting a service for a number of years on a program and all of a sudden they get a phone call and are told they are cut off, that is not the way I believe the government would want to handle this problem.

We are dealing with people, not with machines, buttons or anything. These are real live people that believe they are entitled to and need this service. To get a phone call and be told they are cut off regardless of the change in the system is not the proper way it should be handled.

I really believe that your department has to look at the way they are handling people because it is people that this is supposed to be all about, and re-evaluate how you are handling that. It is very frustrating to a lot of individuals.

I hear what you are saying about the change from homemaker to home care but I am not a person that is getting that. I am not a person that has had it for 10 years. The flow and the way you are doing this is hurting more people than it is helping.

[Page 26]

I have one more question, Mr. Chairman.

MR. CHAIRMAN: I wonder, did anyone want to respond to Mr. MacLeod?

MS. MCDONALD WILSON: I am going to repeat what I have said before and that is, 17,000 people have received services so far this year, almost 16,000 people the first year. When we asked people repeatedly in the first year of the program if they were satisfied with home care, indeed, they said yes, 96 per cent of them said that they were, in fact, satisfied.

MR. CHAIRMAN: Was that an anonymous survey or was that a direct survey of the clients?

MS. MCDONALD WILSON: It was a scientifically administered survey, I think, 19 times out of 20. It came within 0.01 accuracy.

MR. HOLM: Were the people on the waiting lists surveyed?

MS. MCDONALD WILSON: We are in the process of doing that, actually. We want to make sure that people who are receiving services, people who have been discharged from services, all of those people are checked with, so, yes.

MR. CHAIRMAN: It would be helpful to the committee, I am sure, to be able to see that survey. Mr. Cramm, if you could provide it to the committee, I would be pleased to have the secretary circulate it to all members.

MR. CRAMM: I would be pleaded to provide that.

MR. CHAIRMAN: Thank you.

MR. MACLEOD: If I could, Mr. Chairman, were the home care agencies that were across the province providing the service, were they are a part of the group that helped to develop the new Home Care Program and have they ever been taken into a room and explained what their new role is compared to their old role? There seems to be a lot of confusion out there as to what their role should be and what their role has been over the years, and there is a lot of care about what they have done.

This particular group that I mentioned, again, they were able to provide, for example, snow shovelling for all the seniors, all the people on their program for a cost of $500 a year, $250 to two different groups of volunteers who went out and did it. There is no government department that I am aware of that could ever do anything like that for $500 a year. They could not even plan it for $500 a year let alone do it.

[Page 27]

The other part they were able to accomplish with no cost was delivering over 6,000 meals. Those kind of components are out there and the people that have administrated them over the years are willing to still do that and be part of this, yet, they feel, rightly or wrongly, they have been shut out of this program. If the idea is to help these people, I would like to know how we can incorporate them back into the process and maybe cut down on some of the bureaucratic red tape that is out there and making them feel like they are not a part of society.

MS. MCDONALD WILSON: A couple of comments. The comment about snow shovelling, perhaps anchoring this back to earlier comments, there were inconsistencies in the area of home maintenance across the province from 1988 onward.

You should be aware that in this past year, we have invested $140,000 in supporting volunteer services in various areas in the province; namely, meals programs, visiting programs and so on, because there is simply no question that we need to support not only the maintenance but growth of volunteer services in the province and that costs some money, to invest in it, and we hope to increase that funding over time.

In terms of inclusion or participation in developing Home Care Nova Scotia, if you look at Page 24 of the Home Care Nova Scotia - A Plan for Implementation, you will see the approach that we took from the beginning, in including as many people as possible as we very speedily developed the program. So we incorporated folks who had interest or expertise on development teams and in focus groups so that they were at many different tables. The organizations that you are talking about, I am not quite sure who they were but what I can do is give you an example of the kinds of tables that we had that were inclusive of a lot of people who participated in home care.

When we were developing what our automation needs were, when we received the Province of Manitoba system, we brought together care coordinators and managers from the Department of Health. We brought together home support agencies. We brought together nursing agencies. We brought together a lot of people, like the Home Support Nova Scotia, so that they could contribute from their perspectives what they thought we needed in terms of developing a client information and management information system. Could we include more people? Absolutely. There is no doubt about it. We don't always have the luxury of time to do that but we do our best to ensure that the primary or key stakeholders are as involved as possible as we adjust and modify and evolve the program.

MR. CHAIRMAN: The last question, then we will move on to Mrs. O'Connor.

MR. MACLEOD: Mr. Chairman, just a quick comment on what you said earlier. I don't see any need for reinventing the wheel. If we had people in place who were willing to shovel snow and to provide Meals on Wheels, then those people should have been incorporated into the program. Even if it wasn't all over the province, it is already in place

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in some areas and it should be used and incorporated and maybe some of those ideas moved on to other parts of the province so that the program could grow at an efficient rate.

The last thing that I would like to ask you, and again I am only going by what I was told and I am not sure how this is and I am looking for clarification more than anything else, is that at one time these home care workers had the ability to send a client back to the hospital. If they felt that the client was endangering their health by being home, they could make the decision there to call the hospital and say, this client should go back. My understanding is that a similar situation took place a week before last and it took three phone calls to find somebody in the system who would give them the authorization to make the initial phone call to the hospital. As a matter of fact, the calls went all the way to Antigonish before someone would give permission. Now that is a little bit ridiculous if a person's life is in danger. I guess the bottom line here is the worker doesn't know what their authority or what their position is anymore and were scared to make a decision.

MS. MCDONALD WILSON: Well, there are standards in place for all staff who deliver home care services that provide them with the approach or the process they need to take when there is an emergency situation and they need to ensure that . . .

MR. MACLEOD: Does that include calling a number of supervisors?

MS. MCDONALD WILSON: No. If the home support worker or nurse arrives at a client's home, the standard indicates that they should, in fact, if it is available, call 911 and immediately transport the client to the hospital. If it is a non-urgent situation, they may, in fact, make a phone call to their care coordinator, as was the case in the former Coordinated Home Care Program.

MR. MACLEOD: Thank you very much.

MRS. LILA O'CONNOR: I also apologize for being late. I just want to make a comment on what Mr. MacLeod has said about people having phone calls to no longer be on the service or to receive the service. I know of incidents from 1988 to 1993 of how people were taken off the service and it wasn't nice. Things just didn't happen now. It has been going on for a long time if you were on the service.

MR. MACLEOD: It doesn't make it right, though.

MRS. O'CONNOR: No, it doesn't make it right and I am not trying to say it does make it right, it is just that it hasn't just happened because of home care now. It was there before and it wasn't right then and it is not right now.

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[11:00 a.m.]

I can only speak for Lunenburg County and in Lunenburg County, I feel home care is working. I won't say it is working 100 per cent because nothing ever works 100 per cent but it is working and I believe a lot of the reason is because of the relationship that the VON has with the home care coordinator and with Alice over there. I know that she is also responsible for the western end, and I can't speak for that, but for Lunenburg County it is working. Whenever there have been any problems or concerns, we have been able to work them out and the client has always come out, I would say, the winner.

I would like to ask a question on the increase we have, and I realize the home hospital is a new program so we can't compare that, but with the in-home support numbers, and I know that we have enlarged the program to include more people whereas before it was 65 years and over, but can you give me an idea maybe with just the 65 years and over, or you are not keeping that sort of statistic so you can't tell, on how many more people we have taken in. The program now has 17,000 people across the province. What is the number with the home care and what is the number with the home hospital?

MS. MCDONALD WILSON: In the former Coordinated Home Care Program, on average there were about 7,000 people receiving care from that Home Care Program and, as you have indicated, that has increased to almost 16,000 in the first year and about 17,000 year-to-date.

For home hospital care, what we had planned from the beginning is that in any given month, we would admit somewhere in the neighbourhood of, 15 per cent of our admissions would actually be for home hospital care. What we found over the last 18 months to 20 months is that has ranged in any given month from 3 per cent upwards to 17 per cent. But remember, and I mentioned this earlier, one of the primary reasons that one builds a Home Care Program is to prevent and delay admission to long-term care and secondarily to help with preventing or delaying admission into hospital or helping people to be discharged earlier but the primary goal and the overwhelming success of home care is in the prevention of admission to nursing homes.

MRS. O'CONNOR: True. I agree. With the wait listing, and I notice that we have 96 in the western district and a wait list of 467, when you are involved with the nursing aspect, that was always a very scary word and we tried to ignore it. My involvement was with the VON and I know whenever we heard it with the VON, we just pretended it was a word that wasn't there and continued along the way it was. There is no wait-listing at all for the home hospital or you haven't taken anyone off the hospital component earlier than they needed to be taken off in order to put someone else on?

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MS. MCDONALD WILSON: That is correct. If you look at slide 42 on Page 21, you will see that there is absolutely no delay for those individuals who need home hospital care or adult protection as well as those who are at the highest risk and have the greatest need but we do ask, over the last few months, that those folks with non-urgent needs may actually have a little bit of time to wait before they receive their assessment but we have a wait list manager who continues to have contact with those individuals so if their situation or condition changes, then they would be seen right away.

MRS. O'CONNOR: Thank you.

MR. CHAIRMAN: Is that all, Lila?

MRS. O'CONNOR: Yes, I missed the programs.

MR. MACLEOD: Mr. Chairman, when I was speaking before, I said 21,000 clients and that was a mistake. That was 21,000 hours. It was actually 190 clients. I apologize.

MR. CHAIRMAN: Well, I think I will take my opportunity to leap into the fray. This morning, I think, Ms. McDonald Wilson has provided us with what I might call an evangelistic approach to exalting the program as it currently stands. One is left with the impression that we have left chaos and are now striving to reach nirvana. I am not convinced that that is entirely true and I suspect that I am not alone in that. However, it is good to be enthusiastic about your work.

I was surprised a moment ago, in response to a question put by Mrs. O'Connor, to hear the response that this is essentially a program designed to help people avoid being admitted to nursing homes.

What surprised me is - and I think the record will bear me out in this - everything we have heard up until 11:02 a.m. - and I happened to glance at the clock - that is for an hour and one-half - has been entirely focused on health care, hospitals, home hospital services. There was absolutely nothing in the presentation up until 11:02 a.m. which would suggest that, in fact, the primary function of the program is to help people stay in their own homes, rather than moving into nursing home settings.

Now, I have listened pretty attentively and I do not think that I, from what we have heard this morning, do anyone a disservice with respect to reviewing what has been said this morning.

I was going to make the following observation on the basis of what I had heard up until, now, four minutes ago, but I am not sure any longer that this observation is correct. The observation I was going to make is that home care has evolved from an, essentially, community service-oriented program to an, essentially, health care program. It has moved

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from a program focused on seniors to a program which has the broader focus of the general population.

I guess that observation would no longer be correct. That is an observation that arose out of the discussions we had last week with the Auditor General's staff. You have really got me confused and I would sure like to be straightened out.

MS. MCDONALD WILSON: Okay, I will straighten you out.

MR. CHAIRMAN: I am sure you will.

MS. MCDONALD WILSON: On Page 1, slide 1, you will see the second bullet under Home Care Nova Scotia indicates that this program is intended to begin to link home care, long-term care and hospitals, that continuum of care, if you will.

Then we go on to mention on Page 22, third bullet, On the Road to the Future, that we are building partnerships with hospitals and long-term care. Then, when we talked about a lot of the hard work we have ahead of us, one of those big pieces is developing single entry access into home care and long-term care.

When you look, not only in Nova Scotia but at the rest of the country, you will find that between 78 per cent and 85 per cent of the people that use home care are over the age of 65, highest risk for admission to long-term care facilities, highest risk for use of hospitals.

MR. CHAIRMAN: You will just have to chalk me up to another confused Nova Scotian. (Laughter)

I guess I would have to put this question to the deputy minister who may wish to redirect it.

We now are going to have services delivered, essentially, through the regional health boards. Have there been demographic studies done of each of the regions so that we can understand whether there are significant differences between the regions, such that the provision of home care will have to be delivered differently in one region from another?

MS. MCDONALD WILSON: The reason that we have a provincial program that is operated at the regional level is in preparation for devolution to the regional health boards. We knew that was going to happen and that is how we actually structured and developed processes in Home Care Nova Scotia, in 1995.

What the goal of the provincial Home Care Program is, is to ensure that there is standardized access to a standardized group of services. We recognize, because there are big differences in delivering services in downtown Halifax, as compared to delivering them in

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downtown Neil's Harbour, that there is a need for each of the regions to work on how best, how most efficiently and how most effectively, to deliver those services. We have provided support to those regions to provide services in a way that makes good sense in each of the regions. That is our long-term goal, even after devolution, that there aren't significant differences between each of the regions, not only for home care services but for the delivery of many health care services; that there be a standardized approach but that it may manifest itself differently from region to region based on geography, based on weather and . . .

MR. CHAIRMAN: Probably the age profile of the community, I would think, would be a significant factor.

MS. MCDONALD WILSON: That is right. Cape Breton, for example, is upwards of 15 per cent of the population over the age of 65; whereas in downtown Halifax, it is about 9.6 per cent over the age of 65.

MR. CHAIRMAN: I do not want to detain you and we have others who wish to raise questions so I will move along quickly. Again, I go to the deputy minister. When talking about coordination, the deputy minister will be, I am sure, aware that up until January 1st of this year, we had a coordinated administrative arrangement in Queens County with respect to Queens General Hospital, Queens Manor and the North Queens Nursing Home, one administrator for the three. The vision of the community, up until it blew up on January 1st, was that we would evolve that into a much tighter administrative arrangement possibly with the three institutions one day having a single board, single administration, and working in a very coordinated way with each other.

January 1st came; the administrator has now gone off to the hospital in Kentville; we now have an on-site manager for the Queens General Hospital; and we now are back where we were three years ago. Now, that does not strike me as a forward step and I would like you to address why, in fact, a good arrangement was not maintained and why it was not used as a model for other communities?

MR. CRAMM: I am not sure I can address that to your satisfaction, Mr. Chairman. The moves you are talking about January 1st, are really reflective of the designation of hospitals on that date and the attempt, therefore, to put at the regional health board the administration for all hospital facilities within, in your case, the western region.

How that drills down, I guess, in terms of its impact on the coordination of delivery of services at the community level would be a matter that I have not had the luxury of discussing with either the Chairman and/or the CEO of the western region at this point in time. I do and would suggest that they are certainly very cognizant of the need to maintain the mechanisms that had been in place to ensure the type of coordination in service delivery that heretofore has been the case. I would not suggest that the move represented by designation would necessarily be the end of that coordination simply by the removal of the

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hospital administrator to a site manager position which may have as part of the responsibility one or more facilities. I don't know if others here would like to comment. Bob?

MR. ROBERT FOWLER: We have recognized in the process of moving to designation that there were a number of innovative arrangements made between long-term care facilities and hospitals throughout Nova Scotia. Queens is not the only one. We, in fact, have had dialogue with the CEO of the western region and are working our way through the discussions. The whole goal would be to maintain both the administrative efficiency and the service coordination efficiency that one would get through those arrangements. What one has to remember is that the long-term care facilities in this province are either owned municipally, owned by private not-for-profit organizations, or in some cases by private businesses. So, the ownership from the government's point of view rests in different organizations. So as we move to designation, those were not facilities that were subject to the provisions of the Hospitals Act and the Regional Health Boards Act, but the dialogue continues to look at how we can maintain that innovation and better partner in those administrative structures.

MR. CHAIRMAN: In our case, of course, Queens Manor is owned by the municipality and the North Queens Nursing Home, as used to be the case with our hospital, is owned by the community. We no longer own our hospital, as you know.

MR. CRAMM: Mr. Chairman, if I might, Mary-Jane would also like to add a brief comment to your query.

MR. CHAIRMAN: Sure.

MS. HAMPTON: If I can just add a bit of additional information, Mr. Chairman, although I understand that you want to talk about regionalization and regional health boards more specifically next week. I feel that we are building the TV guide approach to Public Accounts.

In the western region, as a result of the administrative consolidation of hospitals in that area, I can actually tell you that just over $1 million has been saved in administrative expenses which, as you know, was one of the assumptions predicated on the movement toward regionalization and the regionalization particularly of the government's acute care institutions. The opportunity then exists to reinvest the money that we were spending on duplicate administrative structures into activities of direct patient care.

MR. CHAIRMAN: Well, I hope you are correct. We heard that in education and that certainly is not happening. Perhaps it will happen with health care. Last comment, and I do not seek anybody to respond to this. An observation, and this comes as a consequence of many telephone calls I have had since last August, when significant change occurred with respect to the delivery of what one might call non-essential services to this program. While some of your coordinators exercise very high diplomatic skills, there are others who could

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well afford to go back to school. They make life more difficult for the client and they make life more difficult for you and they make life more difficult for the members who have to take the angry phone calls, and you could stand to do some homework there.

All right, we will go on. Mr. Hubbard has not had an opportunity yet and he is with us today sitting in, I think, for Mrs. Cosman. It is a pleasure to have you here, Richie.

MR. RICHARD HUBBARD: Mr. Chairman, first of all, just a quick observation. We are talking about the program and the people who are complaining about it. I think it is very easy to complain about the way that the program is moving along.

I might tell you that in Yarmouth, we had a call from a gentleman who told us he was being visited too often. So, you are going to get all these little things. People who are firing against you and here is a guy who did not have time, I cannot plan my time when I am going to get out or get shopping because I am being visited too often, but you do not hear about those kinds of calls. I am sure that there are many people out there who are not saying that. It has actually happened to them but we do not hear from them, but this guy called.

On a scale of 1 to 10 with complaints, I do not know if I am in a good area or what, but I would say probably a 1, if that. So, I do not get any complaints about home care. Now, I do not want anybody to jump on the phone and start calling Yarmouth and say, look, you are not getting any complaints down there, stir things up. (Laughter) I don't get them. (Interruptions) Well, you know, I am trying to make a point here. The second thing, another question which was already answered, the Chairman asked, and that was the regional demographics about how each region is functioning. So, that was answered with many thanks.

I will go back to something that Mr. Carruthers touched on a while back and that is the relocation of doctors from one area to another. I had a situation recently in Yarmouth, and I do not know whether it is going to happen or not because I heard yesterday that it may not. The situation was that a doctor was being invited through the recruitment team package to move from Yarmouth down to Long Island in Digby County. I wondered what the criteria was for a doctor moving and I was under the impression that perhaps it was to move the doctors from the metro area to the rural communities, rather than from the rural communities to another rural community.

I guess perhaps for Mary-Jane, are there sort of guidelines as to how that works? I know it is not moving 20 miles. With that I probably would have a problem, I guess, if somebody moves 10 or 15 miles, but in fairness to the doctor he was moving from Yarmouth to Long Island which is probably 65, 70, 80 miles, I am not sure. It was a little bit of a concern for me last week in Yarmouth that this fellow may be moving. I heard yesterday he may not be.

[Page 35]

MS. HAMPTON: I am afraid I cannot speak to the specific circumstance but I can certainly answer your question in the broader context. It is clearly a more appropriate strategy to address what we call the maldistribution of doctors, having the greater number of doctors in our large, urban communities and not enough doctors in our rural communities. By moving doctors from those larger urban centres into those rural communities it obviously just makes sense. However, there would be nothing that would dissuade a physician from moving from one rural community to another. There certainly wouldn't be a concerted strategy to encourage or promote that but there would be nothing from stopping that either.

MR. HUBBARD: Would he or she be eligible for that package?

MS. HAMPTON: Again, I am not able to speak to the specific circumstance, although there are certainly several communities in the province that have been identified as under-serviced for which physicians who choose to set up practice are offered an incentive program. Again, there is no concerted strategy to move people from one rural community to another. However, a physician is welcome to identify himself or herself for service in any of those communities which are under-serviced and if it happens that it is a rural doctor who chooses to move from one rural area to another, in some respects that is not entirely surprising, given that they are already exposed to the realities of what it is to work in a small town or village.

MR. CHAIRMAN: We have about 12 minutes left and both Mr. Holm and Mr. Fogarty have (Interruptions) You wanted to get in as well? All right. Let's try to give four minutes each to Mr. Holm, Mr. Fogarty and Mr. Mitchell. So if everybody would watch the clock. It is now 11:22 a.m.

MR. HOLM: I will be crisp. First of all, the programs that are wait listed or put on a waiting list as of last August, I believe, all except for the immediate hospital one, my question, first of all, those on the wait list, have they all been assessed prior to being placed on that wait list? Are they all people who have been approved for a service and are now currently on a wait list?

MS. MCDONALD WILSON: They are actually screened at intake.

MR. HOLM: So they have all been screened.

MS. MCDONALD WILSON: They have all been screened at intake.

MR. HOLM: Okay, second question then, will you provide us, do you have a listing of all of the services that are currently wait listed and the length of time that people are remaining on that wait list before they are receiving the services that they require?

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MS. MCDONALD WILSON: We can give you some examples of that but what you need to be aware of is that an individual could come onto the waiting list today and then actually end up having a change in their situation or condition and come off it.

MR. HOLM: I appreciate that and they may come off it because they may have gotten better while they are waiting but also they may have gotten worse. What I would like to find out is the average length of time. Originally when that wait list was announced, I believe it was only supposed to be up until the end of October and it is now January and programs are still being wait listed. Surely to heavens the department has a record of the number of people who are on the wait list for each of those services and I am asking, will that be provided to this committee?

MS. MCDONALD WILSON: Yes.

MR. HOLM: Okay, second question, and it is as much of an observation as anything else. I am taking a look at the slide where it says, "Shift of thinking". Then it goes on, "So how do we do it? Its as simple as . . . Providing the right service, right people . . .", et cetera. One of the things, of course, the determining factor of what kind of service and how long people stay on it, is what it is going to cost, $2,200 in 15 days. If the cost is more than $2,200 I understand that they don't get covered. My question is, do you have standards? Are there standards of service that people should be entitled to? We say you have to have the right service, well, does the department have standards as to the quality and the level and the number of times that people will receive the service or is it something that is really, like you know we have a wait list, that is monetary driven in part because we don't have the people to be providing it, are the right services and the people who will be delivering that service and the right amount of time, et cetera, are those things also being driven financially or are they being driven by a set of standards that the department can table with this committee so that Nova Scotians will know what they are entitled to?

MR. CHAIRMAN: One minute and one second for the answer.

MS. MCDONALD WILSON: We look at each individual who comes into Home Care Nova Scotia individually. That is why we have individual care plans and do individual assessments but we also have standards for the delivery of services. Further to my comments earlier, we have a continuing quality management program and, in fact, we have, in the fall of this year, released the second edition of Services for the Delivery of Home Support and Nursing Services to Nova Scotians. We would be happy to make that available to you.

MR. FOGARTY: Mr. Chairman, I have a question for Ms. Hampton, if I may. The debate in the province, it seems to me, is ongoing as to the primary motivational factor in the need for a program of renewal and reform in health care in the Province of Nova Scotia. On one side of the debate is that because of the government's financial situation that that is the only consideration, that it is budget driven. The other side of the debate is that that indeed is

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not the primarily motivational factor, it is that we must come out of the dinosaur stage, if you like, and get onside with other provinces in this country who have moved well ahead of us and have started much earlier in the program of renewal. I would like a comment from you on that, Ms. Hampton; is it entirely budget driven?

MS. HAMPTON: Mr. Fogarty, there are five principles of the Canada Health Act: comprehensiveness, accessibility, portability, public administration and comprehensiveness. There ought to have been a sixth principle which was one of sustainability. It is our job to meet the expectations of the first five in the context of what I think all Nova Scotians would regard as an important sixth, ensuring that we are able to afford what we do and that we provide services that are at all times of the highest quality. As a result, of course, decisions that are taken and plans that are made occur within the context of the amount of money that is available from the public purse to pay for them. But it is in the context of achieving the five principles of the Canada Health Act and making a publicly-funded health care system sustainable for this generation and the next.

MR. FOGARTY: Well, I thank you, but I am not sure I got an answer to my question. With respect, Ms. Hampton, I am not sure I got an answer to my question.

MS. HAMPTON: The answer to your question, Mr. Fogarty, is yes we need to make decisions in the context of the money that is available from the public purse to provide quality services to all Nova Scotians. It is important, therefore, to ensure that any decisions we take about things like the growth of programs, such as home care, happen in the context of what Nova Scotians can afford, and our public trust is to ensure that the services that we provide are portable, comprehensive, accessible, of the highest quality and accountable to the public through public administration. We live in an environment where health care is not free; we pay $1.2 billion tax dollars each year to provide those services. It is our trust, through public administration, to each Nova Scotian to ensure that each dollar that is spent on the health care that they pay for is of high quality and sustainable.

MR. MITCHELL: Just a couple of short questions. I am interested in your comments on starting to collect a database, information on how the program is going, which is very important for a measurement, determining whether you are meeting your objectives and determining what future direction the program should take. You mentioned about the SACPAT agreement that you have with the Province of Manitoba; I guess what I would like to ask you a bit about is a question on integration with social services. You also mentioned, I believe, that Quebec was moving in that area and I think there are similarities to some extent of services.

It seems to me, somewhere in the back of my mind, that the data that was collected on the earlier Home Care Program, when it was the responsibility of Community Services, wasn't able to be transported to Health, that there was a problem there, and I assume that that is something that is going to be worked out. It also seems that the Department of Community

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Services were also looking at a program to be able to better deliver their services using laptop computers going into visit the client. Is that similar or the same as the SACPAT program and can you talk a bit about that area and about integration with social services? I guess I am concerned that we don't have two systems again which can't communicate in the future.

MS. MCDONALD WILSON: Yes, the SACPAT II, the enhanced value-added version of Manitoba's system, works very similarly to how you describe; instead of taking a file out of a central file room and putting it into a briefcase and taking it to the client's home or hospital room, the home care coordinator takes her laptop, downloads the information from the central file room, if you will, and takes that file out on her laptop and she immediately enters the information as she is receiving it from the client. That enables us not only to have a management information system but it allows for the system to be more efficient, because that care coordinator can hook up their laptop to a telephone line in the client's home and actually transmit that information electronically to the service delivery agencies, even if they don't have a computer, they can simply transmit it to their fax machines. So services can come out far more quickly if that is what is required.

[11:30 a.m.]

In terms of the development of a linkage, an automated linkage to the Department of Community Services, as we added to and rebuilt in many ways SACPAT from Manitoba, we ensured that we framed in an interface so that we could connect not only with, in the future, the Department of Community Services' automated system but with our own MSI system, for example, so that we could exchange even elementary things like demographic information. So, yes, we have given it due consideration and in fact have built it in; it is part of the construction of SACPAT.

MR. MITCHELL: The sort of thing that Quebec is doing, are they doing anything further advanced than that or different than that?

MS. MCDONALD WILSON: They have integrated services at the program level but are not as advanced from an automation point of view as Nova Scotia has had the benefit of doing.

MR. CHAIRMAN: Well, I think that is a good note for us to close on today. On behalf of the committee, I offer thanks to our witnesses from the Department of Health today. It has been another interesting morning and we look very much forward to meeting with you, Mr. Cramm, and others of your staff in two weeks time when regionalization will be the topic of the day and that's always a hot one. So thank you.

MR. CRAMM: Mr. Chairman, I have a question with respect to the next meeting before the committee. Is it just the topic of regionalization or are we to assume that Pharmacare and emergency health will be part of that presentation as well?

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MR. CHAIRMAN: The potential is available for those other two areas to be touched upon as well. We will be meeting in camera next week and I think as a consequence of our discussion a week from this morning, by noon hour next week we can give you specific directions with respect to where we would hope to head and that would give you a week to plan.

MR. CRAMM: That's fine. That would be helpful, thank you.

MR. CHAIRMAN: Thank you. We stand adjourned.

[The committee adjourned at 11:33 a.m.]