HANSARD
Printed and Published by Nova Scotia Hansard Reporting Services
Ms. Maureen MacDonald (Chair)
Mr. Chuck Porter (Vice-Chairman)
Mr. James Muir
Mr. Keith Bain
Mr. Graham Steele
Mr. David Wilson (Sackville-Cobequid)
Mr. Keith Colwell
Mr. Leo Glavine
Ms. Diana Whalen
[Mr. David Wilson, Glace Bay replaced Ms. Diana Whalen]
WITNESSES
Department of Health
Ms. Cheryl Doiron, Deputy Minister
Mr. Keith Menzies, Executive Director Continuing Care
Ms. Donna Dill, Director, Monitoring and Evaluation
In Attendance:
Ms. Darlene Henry
Legislative Committee Clerk
Ms. Sherri Mitchell
Committees Office
Mr. Jacques Lapointe
Auditor General
Ms. Evangeline Colman-Sadd
Assistant Auditor General
Mr. Neil Ferguson
Legislative Counsel
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HALIFAX, WEDNESDAY, FEBRUARY 25, 2009
STANDING COMMITTEE ON PUBLIC ACCOUNTS
9:00 A.M.
CHAIR
Ms. Maureen MacDonald
VICE-CHAIRMAN
Mr. Chuck Porter
MADAM CHAIR: Good morning, I'd like to call the committee to order, please. Today we have with us witnesses from the Department of Health, who have been here many times before and know the drill so I don't have to go over that. Welcome.
We'll begin in the usual manner with introductions from members, the Auditor General and his staff, our staff, and yourselves, and then a brief opening comment from the deputy and our first round of questions.
[The committee members and witnesses introduced themselves.]
MADAM CHAIR: Thank you. Ms. Doiron.
MS. CHERYL DOIRON: Thank you very much, Madam Chair, and to the committee, my opening comments will be brief. I would like to begin this morning by giving the committee members a little context for discussion of the Home Care Program, by taking some time to talk about the work done on continuing care; on that front, over the last few years, there have been a number of things done by the department and by our partners.
As you know, in May 2006, we launched the province's Continuing Care Strategy which outlined a 10-year, $260 million plan to enhance and expand the province's continuing care system. Providing programs and services in home care and in communities is the main focus of this strategy. It is focused on making improvements in five key areas and those areas are: support for individuals and families, support for community solutions, investment in providers, strengthening continuing care services, and investment in infrastructure.
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Through the strategy the province has committed to building 1,320 new long-term care beds and replacing 1,616 beds in existing facilities throughout Nova Scotia by 2015-16.
It's important, I guess, to understand that the calculations in regard to bed needs are inextricably linked with the home care and community-based programming because if we did not proceed with enhancing that side of the equation, then even the great number of beds that are being added would not suffice.
Since the launch of the Continuing Care Strategy, we have achieved a great deal. We created nearly 400 adult day spaces; we purchased an additional 558 hospital beds to improve access to hospital-type beds for Nova Scotians in their homes; we enabled 100 clients to participate in the self-managed care program so far; we have assisted nearly 1,300 seniors by providing funds to the Department of Community Services home adaptations and repairs program; we have enabled Nova Scotians in the Home Oxygen Program to have access to a monthly supply of portable oxygen in their homes; we have developed a health human resource strategy to address staff resource issues in the continuing care sector.
Since 2007-08, we have provided 556 continuing care assistant bursaries to students and as of January 2009, 763 students are enrolled in CCA training programs in the province. I probably should add that we also added in this fiscal an additional number of nursing seats and 180 LPN seats in the province to prepare for the future opening of the long-term care beds, or the employment of these folks wherever they're needed throughout the system. We have implemented interim measures to open some additional long-term care beds until the new long-term care beds come on stream.
This is just some of the work that has been done as part of the Continuing Care Strategy over the past three years, with much more planned and envisioned.
Prior to the launch of the strategy, we also implemented some changes within continuing care which helped enhance home care for Nova Scotians. In 2002 we launched the single-entry access program which provides all Nova Scotians, as you know, with one telephone number to call for continuing care services, which are coordinated by the Department of Health. We also introduced SEAscape, which is a comprehensive electronic client assessment tool. SEAscape is an internationally validated assessment tool used to assess all Nova Scotia continuing care clients for the services that they may require. It also collects data which supports our decision support system.
Finally, I can also tell you that we are moving diligently to address issues raised in the November 2008 Report of the Auditor General and in past audits. That is, of course, with respect to our plan to integrate the delivery of continuing care services, including the Home Care Program, at the district health authority level.
With that brief intro, my colleagues and I will be happy to address your questions.
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MADAM CHAIR: Thank you. The opening round of questions will be 20 minutes and I recognize Dave Wilson with the NDP caucus.
MR. DAVID WILSON (Sackville-Cobequid): Thank you, Madam Chair, and welcome again before this committee. I know you have frequent invitations to come here. I think it's largely because of the department you oversee in Health and the importance of health care and the delivery of services under Health here in this province.
I'm glad to be speaking about this issue, home care, and the Home Care Program that we have in the Province of Nova Scotia because it's such an important issue, an important program. Far too often a lot of the attention is paid towards the number of long-term care facilities, the number of long-term care beds in those facilities, the number of transitional care beds. I think the key component to addressing those needs is addressing the needs of Nova Scotians under home care.
We all know the studies, the reports have been done - I don't know how many I've read over my short career here in the Legislature - on how most or almost all individuals would rather be at home than in a hospital or in a long-term care facility. Not only that, but the savings that we could have on the system if the programs and the services are there and are adequate and they meet the needs of the current population that we have. We know the changes in our demographics over the next number of years, the increased aging population that we're going to see, which is going to impact this program, I think. If we don't look at improving and ensuring that we have the controls in place and that the system and the programs are working to the best of their ability, then we're in for some troubling times in the future.
It's no secret - I've said it before in the past - that we feel the government has waited too long to address the needs of our seniors and people going into long-term care and home care. But with this, that's why it's so important to look at the Auditor General's Report and the audit done on this program, to look at what his findings were - the Office of the Auditor General's findings, because I know he doesn't do all the work, he has a large number of staff. So that's why I think it's important we recognize that we need to take the recommendation seriously that the Auditor General has and hopefully see some changes.
I'd like to start with just quoting a little bit from the Auditor General's summary of home care because I think it says a lot. I'd like to just quote:
"Our audit of the Department of Health's home care program uncovered significant deficiencies. Many of these concerns were identified in previous audits of the home care program reported in the 1996 and 2002 Reports of the Auditor General. The Department's response to our recommendations has been inadequate. Only 17% of our recommendations
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from these audits were fully addressed in the six to twelve years since the reports were tabled."
That should alarm people; that, hopefully, alarms you. I know that you haven't been deputy minister since 1996, I believe it's maybe three or four years that you've been at that post and in your capacity as deputy minister. Why has it taken so long for the government to recognize the need to address the recommendations that we've seen almost 12 years ago, concerning home care and the delivery of that service? Why have we seen - I know in your opening statement you said we're moving diligently to address some of them but we're 12 years after we started to identify some of the concerns and today we sit and hear you say that we're starting to look at - why was there such a delay in an attempt to address these recommendations?
MS. DOIRON: Thank you very much. I think that's a very good statement and certainly I agree with the points that you have mentioned. I don't think I can speak on behalf of government, I can speak on behalf of the staff, of course. Obviously, as you say, I haven't been in this position back to 1996, or even in the associate deputy position which I first came into in 2000.
I think it is relevant here to mention, and I don't know that this has really been spoken to very much, but I know that when I came to this province and I was first trying to understand home care as it existed in Nova Scotia, I was having a great deal of difficulty getting the information that would allow me to do that. I finally discovered that basically, as you probably know better than I do, that when home care first started in this province it generally was started in the municipalities. Every office was basically set up independently and every office decided what level or how they would keep any kind of information relevant to statistics or finances or anything else.
Consequently, when all those offices were rolled into government, first under Community Services and then when they were transferred over to the Department of Health, there really had been nothing done to address that at the time. I know that in 2000, which is when I came in, and then very shortly after that when I brought Keith Menzies into the department, we basically had to do some very important, I think, foundational work. For example, we had to stop at that point, design how information would be kept, educate the system on how we were going to be looking for them to compile things, and of course doing that, and then being able to collect even one year of information to start working with takes a bit of time.
I believe that it's fair to say there were many stones of that type that were turned over in the first two or three years that I know I was in the department. So fundamentally what we ended up doing was trying to go back and catch up in defining a system and a system approach basis to the way we could understand home care, as well as other related programs.
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Then basically, on top of that, at the time we were trying to move forward as quickly as we could to keep moving forward on expanding the programming that was there.
[9:15 a.m.]
At the time I came into the province, I also looked at a bit of a - it may be a rough indicator, but nevertheless something that I think is reasonable - I looked at the percentage of Canadians in each province who were receiving home care. When I looked at that across the country and looked at it in Nova Scotia, the percentage of people in this province who were receiving home care was quite a bit less than the rest of the country.
Consequently, we set targets to keep increasing home care, knowing that there was a real burden, even at that point, on both hospitals and on nursing homes. We have over the past number of years now continued to increase significantly the number of hours of home care that are provided in this province. I think, if you look at that statistic today, we're among the highest in terms of the hours of home care provided when you look across the country.
I think we've been moving in the right direction about enhancing and moving forward in volume, in having the staff and having the staff available during challenging times, to be able to continue to support that increase in volume. Having said that, there are a number of areas where we have been working in trying to be more responsive to the issues and the directions that basically came to us through the Auditor General's Reports, as we continued to develop programming and move forward so that we didn't stop everything while we caught up on some of the other issues that involved how we deal with things, processes that we use, standards, and so on.
On a concurrent basis we've been doing all of that work and it has been considerable work. We are getting to the point, I think, where we're basically serving people much better than we had been and we still have some work to do to respond fully to the Auditor General's Report. We are, in a number of the areas that are mentioned, I think, in a position at this point where probably we should ask for another sit-down with the Auditor General, or his staff, to go through some of the work that has now been accomplished.
MR. DAVID WILSON (Sackville-Cobequid): So when this audit was done - I think it was delivered in November - the Auditor General's Office indicated that only 17 per cent of the previous recommendations were done. Have you kept track of, since then until now, roughly how many more recommendations - do you have a percentage maybe that you could give me that you feel you're at right now?
MS. DOIRON: I don't have the percentage because part of what has been happening is that almost all of those recommendations are either - some of them are accomplished and now ongoing, but just about every one of them is in progress, so there's attention being paid to all those areas. But I think it's important that we do take stock of that and we can continue
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to relate with the Auditor General's Office in our ability to satisfy the recommendations that came.
Generally speaking, and I think in our response to the Auditor General, we very much agreed with the areas that had been identified and I maybe should defer some of this to Donna Dill, where she's responsible for standards and monitoring. She can probably give a little bit more comprehensive perspective on that question.
MR. DAVID WILSON (Sackville-Cobequid): I'll probably maybe ask a question, just because I know I'm limited in the time that we have here. No question, I don't think anybody on this committee would question the work that you and your staff do in the Department of Health. But I think the key component in trying to address recommendations from the Auditor General, or implementing a program to the best of your ability, is that there needs to be a will on the government side. Government needs to agree to this, they need to support this, they need to fund the infrastructure and fund the necessary support for implementing this.
I don't question the work that you and your office have done over the last number of years. What I question - and I know you can't comment on the government's priorities - I question their appetite and their level of will to try to address some of the concerns we've seen since 1996 and we know the current government has been in place since 1999, so that's the key thing, government needs to step in and ensure that you have the resources you need to implement these changes.
One of the things that we see and hear so often is the wait list for home care and the ability to gain access to that. It doesn't help a family, an individual, or a spouse if they're at home knowing that they need support and there are months upon months of wait lists and time that they need to wait before they get some help and some services. What have you seen over the last number of months or last number of years on the wait lists? Why are we continuing to see people wait for such a long period of time when, ultimately, when they put those requests in they need immediate support? Why have we seen such long wait lists here in the province?
MS. DOIRON: That has been an issue and we have been working with a number of partners on that. We are now seeing a real move in the right direction, so I'm going to ask Donna Dill to give us a bit more specifics on it.
MADAM CHAIR: Ms. Dill.
MS. DONNA DILL: Good morning. I'm happy to say that in six of the districts in Nova Scotia there isn't a wait list for home care, there is in three areas, being here in Capital, the Valley and also up in District 6, but there has been a lot of movement. For instance in the Valley, where we were a couple of weeks ago over 1,100 hours per month, we're now down
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to just over 700 hours per month, so that has been a significant improvement. The VON is in that area and they're working very hard to reduce that wait list.
The other thing that we're doing is we're working also to help recruit a lot more CCAs, so they'll be available and also looking at why those people are on the wait list. We have put out a prioritization guideline, so those people who have the highest needs, palliative care, adult protection and so on will get the services first, they will not have to wait. If it is something like housekeeping, which is also important, it's essential housekeeping for a lot of people, it can maybe wait a little longer, so those are the prioritizations we put in place.
Also, if you've had home care, you've gone to hospital and you needed to get back home again, you also have a higher priority to get back on the home care list. So there are some things that have worked that way.
The numbers are definitely down now. I think in metro, there is only 306 hours waiting and the biggest area right now is District 6. So, those hours also sometimes are due to specific times. For instance, I want to tuck in at 11:00 p.m. Friday night. Well, that might not be that easy if everybody wants it then or people who want respite for church on Sunday morning, a lot of people want that, it's important they get it, but we need to find the staff that we can put there at that time.
MR. DAVID WILSON (Sackville-Cobequid): That actually was leading into some of the other questions I have. We look at veterans, for example, in the VIP program, just helping someone with their laundry, helping someone clear their driveway, or those housekeeping duties play such an important role in ensuring that that individual stays healthy, for one, and stays at home. I think we need to ensure the importance is placed on those services that we deem not essential, I guess, especially when you're talking about health and the well-being of an individual, but that does leave individuals, like you mentioned - we hear often at the office that the only time they can someone come in to assist them into their bed, for example, is 6:00 p.m. or 7:00 p.m. You have individuals who, if they don't take that opportunity - they have to really - are placed in their bedroom, in their bed at 6:00 p.m. or 7:00 p.m. and have to wait until the next morning. So when do you foresee possibly addressing more of those concerns around either housekeeping and those non-essential services, plus the fact that, as you mentioned, maybe assisting someone to get out to go to church or go to bed at a reasonable time? When do you foresee being able to address those components of the Home Care Program?
MS. DILL: We definitely do address housekeeping now. I personally think it is essential because it not only is doing the housekeeping but it has somebody in the home on a regular basis who can do more of a preventive and see when that person might need other needs.
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It's some of those client-specific times that are more difficult. It is a case of, how do you balance the needs of the client with the staff - you can't have 20 staff around just so they can all go at 11 o'clock at night to do this. What are they going to do the rest of the day? So we're trying to balance that out but we are working towards that and for some it will work that yes, I just want an hour of work.
MR. DAVID WILSON (Sackville-Cobequid): Now I know most of the services are outsourced to other agencies, but what role do you play in ensuring that those agencies are working efficiently? For example, I know of many home care providers or care assistants who live in my community, for example, but are required to travel to other communities and they drive right by an individual, their neighbour, who could use their services but because they're required to go outside the community. What role do you play to ensure that these organizations are working to the best of their ability?
I would think if your neighbour needs assistance, then the first call of your day should be when you leave, go next door, assist them to get them out of bed or whatever services, then move on. So what role does the department play in ensuring that the agencies and organizations provide the best, most efficient services?
I look at the example of the emergency services, for example. Years ago an ambulance was very territorial - he would only do a call in this area of town. He'd come to Halifax, drop a patient off, he'd bypass emergencies or calls. I mean I'm hearing the same thing within home care. So when will we see a system, a province-wide system that's somewhat regulated that if you're next door to a person who needs assistance and you work in that capacity, then you go there because it makes sense to do that? When will we see the changes so that the services are delivered more efficiently?
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: Thank you, Madam Chair. We, I think, are on our way to that. I don't know if we'll ever be 100 per cent with it, but I think it is improving and we can improve it more.
One of the methods through which we are doing that is basically to now have developed standards that the home support agencies are basically held to, both in the qualifications or staffing that they provide. Although that is not a legislated requirement, it is a standard. We are now at the point where we, on an annual basis, audit home support agencies so we are able now to take them through processes that hopefully are going to be like accreditation processes, learning experiences - an opportunity to improve the kind of care delivery.
I think the other thing that's going to have a dramatic influence on that is basically the transfer of home care to the district health authorities, which is coming up soon, and then
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the integration of all aspects of care, including the community-based care - essentially, I think, with people who are closer to the home base being able to manage those services and to oversee the relationships that occur and basically how people can move from one part of a system into the other more efficiently. So there are issues like that that basically we have been able to develop that are starting to give better results.
The other thing that I think is an important aspect of this is having adequate staff. We all know that we are in and probably heading toward even more stress, in terms of health human resource availability. Having said that, we've done some very targeted planning, in terms of what kind of resources we need, both in the long-term care sector and the home care sector. We've moved on that through the creation of additional seats, the numbers of people who are in the programs, the kind of assistance they can get to go into the programs and things of that nature.
We have the agencies themselves, sometimes VON, who often subcontract the home support agencies, working in concert as well with the objectives that are set and aware of the standards that we're trying to reach. So I think there has been a response now that can be demonstrated that is better than it used to be. I even know personally the number of letters or calls or complaints that used to come into the department to my awareness about individual situations and cases, and while we still get occasional ones, it certainly is much decreased from where it was a few years ago.
[9:30 a.m.]
MADAM CHAIR: Order. The time has expired for the NDP caucus. I recognize Mr. Wilson for the Liberal caucus, you have 20 minutes.
MR. DAVID WILSON (Glace Bay): Thank you, Madam Chair, and good morning everyone. Deputy, it's good to see you at Public Accounts again. You survived another Cabinet shuffle, you've got another rookie minister to retrain, start all over again from the beginning, so good luck with that.
MS. DOIRON: Thank you.
MR. DAVID WILSON (Glace Bay): You seem to have gone through quite a few over the years. I'm not asking you to comment on that, that's just my . . . (Laughter)
MS. DOIRON: I'll just say it has been great people that we've had.
MR. DAVID WILSON (Glace Bay): I'll continue along another line, deputy, if you don't mind. (Laughter) Regarding the in-home support program, is where I wanted to ask you a few of the questions.
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As you're aware, the government announced that the pilot program started in the Guysborough Antigonish Strait Health Authority was to be expanded to the South Shore, the Valley and South West Nova. As you're, again, I'm sure, well aware, that program is able to take some of the pressure off wait lists for home care support and services. Can you tell me, is the program expansion of the in-home support program in the South Shore, South West Nova and the Annapolis Valley District Health Authorities started?
MS. DOIRON: No, it has not started. Basically, the work to develop it, to understand it and to be able to relate the circumstances, the costs, et cetera were all worked out and the government of the day has had information, as does the member for the Liberal Party who was involved in representing that issue. Of course, as you probably know, we have kept him up to date on the status of that caregiver allowance or in-home support program, I guess, as you call it. Essentially, we are - at this point from a staff point of view - awaiting direction as to when and how we should proceed but clearly the work is all done and in our opinion, once we get a go ahead, we believe that we could have that program up and running within approximately two months.
One of the issues that has been holding this up and I think we'll be having to get a determination of whether we continue to wait or not, is a concern that if we provide an allowance to caregivers in the home, basically, they end up having to pay income tax on that amount of money. When the program was started in Community Services, we believed, at least in part, that had a great influence on the number of people who were willing to request the program and consequently there was very little uptake of the program.
So the program, as we've developed it now, basically provides additional funding, or more funding than that initial program did. We have been working with the Department of Finance to see if there's a possibility of getting a Revenue Canada exemption from tax on the dollars that would be provided, which would certainly make it a much better program when it does start. So, it's essentially information that we have prepared and basically it rests with government decision at this point.
MR. DAVID WILSON (Glace Bay): As you stated, there was one of our MLAs who was briefed in late December and was told that the program was to be implemented by the end of January. So you said you are waiting for word to get the go ahead to this program. Is that word you're waiting from Revenue Canada or is that word you're waiting for from your - for lack of a better phrase - political masters?
MS. DOIRON: I guess in a sense both because the government of the day wanted to see if there was a possibility for that exemption and we have been working on that issue. We don't have that resolved yet, so given that we're not certain of the time that it will take to get a response through Revenue Canada, probably the government will have to determine whether they want to move with or without that exemption, but we have not yet had that direction. The member for your Party actually had an update on that again yesterday.
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MR. DAVID WILSON (Glace Bay): I'm aware of that. Is the program expansion for those three areas - are you talking about just those three areas or is that going to be expanded now to cover the entire province?
MS. DOIRON: At this point, we've developed the information to illustrate the costs that would be associated with it on a pilot basis or an enlarged pilot basis from the initial program, or within the entire province. Once again, while the information is there, we have not yet had direction from government on how we should proceed or when we should proceed.
MR. DAVID WILSON (Glace Bay): So why is it, deputy, what do you think is holding this up, really?
MS. DOIRON: I don't think that is for me to answer. I think that the government has the right to make their decisions and to have the debate and certainly, there has been a very interested discussion and questions that have come back to us. So I know that it has been seriously considered, but obviously, not for me to make a statement about something that's a government decision.
MR. DAVID WILSON (Glace Bay): But this program is ready to go, is what you're telling us right now? As it stands and it's a program that allows families or people to be paid, is that right, to look after the client in the home?
MS. DOIRON: That is correct, it's a caregiver allowance, essentially. The information is there, so we would be ready to proceed if we were told to do so, but we will probably need about a two-month startup time frame, even if we were to get a go forward.
MR. DAVID WILSON (Glace Bay): So it's quite conceivable - and I know you won't comment on this, but I'll say it anyway - that two-month startup and this whole thing could be just waiting for an election to be called and then, as an election goodie, this program is rolled out where you cover the entire province and people are given this allowance as caregivers and it would look pretty good - a pretty nice little item to put in an election platform, if you're the government. Otherwise, why wouldn't you take a program that you have right now that you know is going to work and you know you have ready to roll out, why wouldn't you have started that long ago?
MS. DOIRON: As you say, that's not my decision and it's not appropriate for staff to comment on that, in my opinion.
MR. DAVID WILSON (Glace Bay): I told you you wouldn't answer it.
MS. DOIRON: But I would say that staff often will develop information and programs and basically provide the government of the day, whomever that might be, with
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approaches and options that might be able to serve the people of the province. There are always choices that have to be made in health care and those choices, especially when they require new programming and new dollars, are basically in the hands of our elected officials.
MR. DAVID WILSON (Glace Bay): Then as the senior bureaucrat, have you advised your minister - your former minister or your current minister - that this program is ready to roll and that it should be implemented?
MS. DOIRON: The minister understands that we would be prepared to have the program up and running within two months.
MR. DAVID WILSON (Glace Bay): Let me just change focus here if I can. I wanted to talk to you a little bit about the role in home care and the challenges that exist now in terms of nurse practitioners, both primary care nurse practitioners and specialty nurse practitioners in regard to home care. Both types of nurse practitioners, especially over the winter months do a fair bit of home visits in their collaborative practice arrangements. Some of the smaller communities, where seniors are not as mobile in the winter months - and I'm aware of one nurse practitioner who specializes in geriatrics in the Capital District who does nothing but home visits. Her sole job is trying to keep seniors out of our emergency departments.
In the process of devolving continuing care programs to the district health authorities, has there been any discussion as to what type of role a nurse practitioner could play in the delivery of continuing care programs such as home care?
MS. DOIRON: Basically, with or without the devolvement to the district health authorities, that has been a subject that we have been working on over time. We've had different activities going on to even assess the effectiveness and the efficacy, if you like, of placement of nurse practitioners in different settings. For example, there is a pilot project going on at the Northwood Centre with a nurse practitioner working on a full-time basis at Northwood to respond to that resident population there. Based on what we see at this point, we would say that the results are very positive. So as you say, we have been - as have the district health authorities been - fairly creative, I think. Often the submissions will come in from the districts about how we might approach or use nurse practitioners differently.
Essentially in this province we started out with a number of nurse practitioners in specialty areas in the tertiary care facility, such as cardiac and things of that nature. In the last number of years, as you know, we have worked very hard to introduce nurse practitioners into the primary care settings in a whole variety of ways, because we don't have just one model, so we can take different approaches to that. We now have them working in geriatrics, in emergency departments and in long-term care facilities as well.
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I expect that there will potentially be even other models of how we can most effectively use the nurse practitioner or other professionals who may be able to work in different ways and in different settings than what we've done in the past.
MR. DAVID WILSON (Glace Bay): May I ask, Madam Chair, how much time I have left, please?
MADAM CHAIR: You have until 9:50 a.m., so you have nine minutes.
MR. DAVID WILSON (Glace Bay): Thank you very much. Deputy, just quickly if you could, that nurse practitioner at Northwood, has that program been placed on hold while you are evaluating it?
MS. DOIRON: I would have to check on that. Do you know, Donna?
MADAM CHAIR: Ms. Dill.
MS. DILL: The program is still ongoing. It was put in as a pilot for three years and we have Dalhousie doing the evaluation and the evaluation is underway. There may be a slight gap between the time that the program finishes and the evaluation is fully out, we're not sure exactly when that will be.
MR. DAVID WILSON (Glace Bay): Is it on hold?
MS. DILL: It's not on hold at this time.
MR. DAVID WILSON (Glace Bay): But it could be?
MS. DILL: It's possible. When you put in a pilot, if you continue to run it, there's always the danger of, why isn't it somewhere else and until you know whether it's good or not, those are the things that would have to be examined when we come to that time frame.
MR. DAVID WILSON (Glace Bay): Okay. I know our office has been contacted lately by several concerned nurse practitioners that the Registered Nurses Act, which was passed in this House of Assembly in 2006, has not been fully proclaimed. Am I correct?
MS. DOIRON: It has not been proclaimed, that's correct.
MR. DAVID WILSON (Glace Bay): Why is that, deputy?
MS. DOIRON: Basically, the activity that goes on, of course, after the changes to the Act are accepted and the development of regulations that has to go on at that point can take a fair bit of time. There has been activity going on on that file constantly - the last submission
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that we had back from the College of Registered Nurses, I believe, was about mid-February. We think that we are now at the point where we're in agreement with regard to the regulations.
Now prior to that, there had been discussions going on back and forth between the College and the Department of Health, but also between the Department of Health and the Department of Justice, through which we have to vet our regulations on every Act. So the process that we've gone through, I think, has pretty well come to a conclusion and I would think, based on where we are, that it's quite likely that that Act should be in a position to be proclaimed within approximately two months.
MR. DAVID WILSON (Glace Bay): Within two months?
MS. DOIRON: I would think so.
MR. DAVID WILSON (Glace Bay): As I understand it, one of the issues is that nurse practitioners are unable to practice to their full scope and there are, for instance, a couple of conflicting lists of prescriptions that can be prescribed, one from the College and one from Seniors' Pharmacare and they're not the same. For example, if a senior is at home and the nurse practitioner believes that a drug such as Lipitor should be prescribed, according to the College of Registered Nurses, they're able to prescribe it, but according to the Seniors' Pharmacare list, a nurse practitioner can't. A prescription is written, the pharmacist fills the prescription only to find out in a Seniors' Pharmacare audit that they will not be reimbursed for that drug because the script was made by a nurse practitioner.
I would think that you would say that that has the potential to be very harmful, would you not, to collaborative relationships if the pharmacist calls the nurse practitioner and says, you can't prescribe that and the nurse practitioner says it's a medication she can prescribe? Let me ask you, why is the government allowing that to continue to happen? Is it a cost containment issue because, surely, it is a waste of a nurse practitioner's time to determine whether a senior is on Seniors' Pharmacare and then determine that the drug that she's going to prescribe is one that she can but she can't. All of that doesn't make much sense to me and that's a pretty lengthy process. I mean you're coming on three years to proclaim a bill that was passed by this Legislature. It's not very efficient, is it, deputy?
[9:45 a.m.]
MS. DOIRON: I think that some of those issues - one of the things that I think we have in this province which works extremely well, is a council of all the colleges. So when we get into these questions of whether nurse practitioners should be able to prescribe certain things, or whether, in fact, pharmacists should be able to prescribe things that only doctors now prescribe and issues of that type, we have a regular group that meets to kind of deal with issues.
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Now sometimes when you get these things going on between the professions, it basically takes a period of time for that dialogue to work its way through, so that you're able to move down a road where you have a change that is something that everybody now understands and accepts. I think occasionally there will be issues where there may be disagreements that have to be worked through.
I believe that the changes in the Act where the College of Registered Nurses is basically promoting some good, additional activities and responsibilities and scope for nurse practitioners - essentially those issues have now been worked through.
The other time-consuming aspect is the number of regulations or other issues that are in front of the people at the Justice Department that have to be turned around. So once we kind of go through some back and forth debate between professions and come to a conclusion where we can, on an agreed basis, with everybody understanding the change in direction, and also have worked through all the issues we need to adjust this - it does sometimes take a lot of time but I do agree that it is basically far too long and I think we finally are now at the point where this Act can soon be proclaimed.
MR. DAVID WILSON (Glace Bay): You're saying then, again, within a couple of months we can look forward to that actually happening?
MS. DOIRON: I believe that it will be there within that time frame.
MR. DAVID WILSON (Glace Bay): Let me ask you just a few questions about home care and the budgets. I note from the most recent Supplement to the Public Accounts that home care was underspent in 2007-08 by about $5.7 million, approximately. Most notably there, the district with the largest budget under expenditure was Capital District, by about $3 million or so and the home care provincial programs were underspent by about $5 million. All of the remainder of the districts exceeded their budgets slightly.
Can you tell me, where did the remainder of Capital District's home care budget end up? Was it funnelled into acute care or was it spent in other areas?
MS. DOIRON: I'd have to go back and check to get specifics of where any dollars were redirected but as you know, while we allocate the budgets by district, at this point those budgets are Department of Health budgets. So once we do the transfer, then we will be transferring funds as well.
Having said that, as I mentioned before, we have deliberately been trying to push more activity into the home care sector. Sometimes some of the districts have had some difficulty basically either getting co-operation of physicians to do that, or the opportunity for staffing at appropriate times or various issues that may influence their ability to use all of the additional funding.
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When we recognized part way through a year, because of course we're monitoring the budget regularly - if we see that we are not going to be able to move on that front perhaps at this point, we will make an assessment to say, do we want to transfer those funds to something that may be one-time, so that we can put them back out again the following year and attempt again to push it into home care? Or are we meeting some kind of a maximum where it would be okay to transfer those funds into another program? Usually we would start with programs in continuing care.
Basically, the decision then becomes a decision of the Department of Health, sometimes in consultation with government, as to how we then reallocate those funds. In a couple of cases, we have allowed some funds to drop to the bottom line for the current year because we do not want to reallocate them and we want to move forward the following year from that base.
MADAM CHAIR: Order. The time has expired for the Liberal caucus. I recognize Mr. Porter for the PC caucus, you have 20 minutes.
MR. CHUCK PORTER: Thank you, Madam Chair, and again welcome to our witnesses today, thanks for being here, a few questions. I'm going to talk a bit about continuing care and, as well, a few other points I wanted to raise. I just want to pick up where we left off, with unspent dollars or unallocated dollars going out to continuing care.
Continuing care is a pretty broad term. I'd like to know what the Department of Health's description and terminology is about continuing care.
MS. DOIRON: Thank you for the question. I'll defer, if I may, to Keith Menzies.
MADAM CHAIR: Mr. Menzies.
MR. KEITH MENZIES: Thank you. When we talk about continuing care services we're talking broadly about three areas. One would be the residentially-based services, like nursing homes, residential care facilities and some community-based options that we have. They are, by far, the largest part of the budget.
The second area is areas of home care and other community support programs. So we have home care nursing, largely purchased through VON; we have home support provided through various agencies around the province that we contract with; and then there are some smaller programs that are run somewhat provincially - like the equipment loan program through Red Cross - some very small programs like that that make up the home care service basket.
Within continuing care, the third part of our budget is really the whole care coordination role of our staff, in terms of carrying out the assessments the deputy mentioned
[Page 17]
earlier, the MBS assessment, to determine eligibility for services. We have care coordinators across the province who carry out this work.
Often we, and this isn't all of the answer but I know often when we have surpluses, we will have them in those care coordination budgets simply because of staff turnover and transition. That's part of the reason why we will often have a surplus at the end of the year, but it is primarily those three areas.
Also, I guess, from the provincial perspective or provincial office, we not only have the service delivery which is all of that piece but we do the monitoring evaluation work through Donna Dill's shop, standards and policy development and in the system planning.
MR. PORTER: I find the words "surplus" and "health care" - I don't know how they go together, how they can be anywhere near relative, especially the way things are. I know you can appreciate that as well.
You talked a little bit about their staffing issues, so we've got money left over in certain areas of the province. I know, and I'll only speak for my own area, my own constituency - we take calls for assistance, getting home care when folks are going home and so on. The reason I'm getting a call is because it's going to take a little while and they want to know how can that be sped up. The issue always seems to come back to, there's only so many people doing it.
Do we have some plan to make this better? I mean, are we taking perhaps some of the surpluses, is some consideration going to be given to - I don't know what the numbers are but if there's $1 million left in a district, is that being transferred into the education piece, so we can train more people? I know there are people looking for work, I get those calls, too. I know they're out there, so I'm just kind of curious as to where we're at with that.
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: Yes, actually you've provided, I think, the right answer to your question in the sense that one of the problems, and it varies from area to area, is the availability of staff. Particularly in the home care area, one of the most frequent kind of hires is, of course, the continuing care assistant.
When we were looking at the numbers that we were going to require for the staffing of both the additional community-based programming and the long-term care beds they're going to be opening over the next year or so, we were calculating - of course we know what the staffing ratios and so on are for the units, but we also identified that the current system was short about 400 CCAs across the province. So when we put our numbers forward to say, basically what we want to do is to promote this program, open up lots more spaces than we previously had, provide many more bursaries than we had previously been providing, we did
[Page 18]
get government support to go forward with that. So during the last year, I believe that we provided something in excess of 550 or so bursaries for the CCA program. I believe we have something like 750 or more actually enrolled in the programs this year, which is pretty close to double the number that we used to be educating.
MR. PORTER: What's the intent there, deputy, just on that? It's great that we're increasing the spaces and encouraging people to go - and you talk about the bursary program, what does that mean? Does that mean that somebody . . .
MS. DOIRON: It means that we will pay up to 70 per cent of their tuition to go into the program. We also have arrangements with a number of the providers that also support this and will attract people to come to their place. We'll provide the bursary to the organization, so they can give it to a staff member who is then willing to come and work with them.
MR. PORTER: So just for clarity - Dykeland Lodge I'll use just as an example because it's in my backyard - you put the bursary to Dykeland Lodge and they then are the ones who choose and award that bursary appropriately, that way?
MS. DOIRON: That's correct. As well, there are a couple of other approaches to our ability to be able to educate or to attract CCAs. One is through a program of assessment that because of the experience that they have and through a rating process, they may be able to be forgiven some of the education programming.
The CCA program is a nine-month program, so they may be able to qualify and perhaps not have to do the whole program. The second . . .
MR. PORTER: Is that based on - I'm sorry, I didn't mean to interrupt you there but just while I'm on it, is that based on if they have a degree or something, or if they have Grade 12, or education? How is that split?
MS. DOIRON: I think Donna Dill can speak to this very much more clearly than I can.
MADAM CHAIR: Ms. Dill.
MS. DILL: Yes, that's prior learning assessment recognition that we do, so it's based on however you got that skill set. We assess to see that you have the skill set and then determine which parts of the curriculum you won't need to take because you've already done that.
Another thing we've done, if I may just add, is we've looked at course recognition from other courses across Canada so that when people are coming back to Nova Scotia, like
[Page 19]
we want, then they don't have to take the course all over again. We say yes, your course had this many components of ours and, therefore, this is all you have to take, instead of the whole program.
MR. PORTER: How does this course fit in with the folks who are on unemployment insurance?
MS. DILL: Certainly there are other programs. In fact, a new one that just came out is the links program that is working with them, which will take over two years. That doesn't cost the participants anything but we are working with that program so that there will be return-for-service agreements, as well, with those students and their prospective employers. This does two things. It allows the employers to plan how they're going to work these people into employment, but it also gives those students an incentive, knowing that they have a place to go to work when they graduate.
MR. PORTER: So just on that, and the reason I asked that question, Ms. Dill, was again, people call or they'll come in and they're on EI, they want to go and they want to do something different. They see where they've been is not going to be a long-term career. They know that health care - there seem to be jobs in health care, if you can get trained, but there are some issues getting the EI piece resolved. Is that a Service Canada issue, totally outside the Department of Health, or how do we interact with all that to make it better? It's not working well.
MS. DILL: I think this is something we all need to work together on because EI only knows where the need is if other people tell them, sometimes, so we have to work together with those. Local communities are one area that do that. For that, we've really encouraged all the different providers in each area to have district level committees where they go together and say, all right, how do we treat this problem in a whole group so that if we need to recruit to Hants County, then let's go together - I need two, you need two, let's put a course on, sort of thing, and where can we get them?
There are some requirements that must be passed before they can take it and one is a criminal record check. So sometimes you have people who won't pass that so they don't qualify. The other is they need to have Grade 12, or at least literacy, but we work to help them get that, and there is a mature student admission as well.
MR. PORTER: And you touched on a couple of points there, one being that - I'll use this example. When the military knows that they need people they go into schools, they advertise. This is not new for Nova Scotia, we've always had a bit of an issue. I have a little bit of a background in health care and when I was with EHS, they did quite an excellent campaign and today we have more than ample paramedics working in the streets. Why aren't we out there in the schools saying, this is a career in CCA, this is a career in nursing, here are the incentives, here's how you get there - why not choose us, for lack of a better slogan?
[Page 20]
[10:00 a.m.]
MS. DILL: We actually started there last Fall, we had street teams, they called them, to go out and hand out things on their breaks, and so on, but we are targeting that more. In fact, right now we have a pilot with the community college that not only is targeting the young, but also males and people of diverse backgrounds, so we're going to pay special attention there. But the other thing is to focus more on how we attract these younger people because you're right, you need to go and make these people aware that this is a career path, and early on in high school, so we are targeting a lot more there and putting special efforts to that.
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: I just wanted to add that I think we do need to make those efforts in attracting young people into various aspects of health care, but certainly now speaking specifically about home care. The CCA program, given that it is a nine-month program, given that there are tremendous supports for it, given as well that many employers will actually take the individual into the nursing home setting with the introduction of specific courses that they have to have to start out, they can then go into part-time work while they finish off the rest of the course. So it's a very attractive program in many respects.
For people who are in situations, for example, through the province where we have some issues with job layoffs, male or female, who may be looking for another career, we now have the CCA program with equitable wages, pretty well throughout any of the health sectors. So these individuals can work in home care, long-term care, acute care, and it makes it very feasible for people of various age ranges to find this an attractive career, or even an attractive second career, so there are lots of opportunities. Given the placement of where the education can take place, both at the community college level and in the nursing home setting, basically people don't all have to come, for example, to Halifax to achieve it.
MR. PORTER: Thank you. Just on that whole CCA piece, my first question is, how much does it cost to take the course?
MS. DOIRON: May I defer, please?
MADAM CHAIR: Ms. Dill.
MS. DILL: If you're at the community college where, of course, it's already subsidized, it can range from just under $4,000, up to about $8,000 to $9,000 when it's with a private career college. Most of the time the places try to keep the costs as low as they can, but of course they have to . . .
[Page 21]
MR. PORTER: So if I have someone come in off the street who says, hey, I want to be a CCA, I have to direct them to NSCC or to the home that's choosing and doing the bursary piece?
MS. DILL: No. The best thing to do would be to direct them to the local homes where they might want to work, or the home support agency, because that's where they can get the bursaries. They can also call the CCA Program Advisory Committee, Pam Shipley - and there is a Web site for that, as well, novascotiacca.ca - and get all the information they need about where it is and see if they want to do it through the PLAR assessment so they don't have to take the whole program, then that is less of a cost and can be quicker. If they do take it through a customized program, sometimes it's down to six months as opposed to the nine months. So there are some options.
MR. PORTER: But that private piece you just talked about would be when they refer to the specific home themselves, the home puts the course on there?
MS. DILL: Or the home hires somebody to put the course on there. But we do put the bursaries through the agencies so that we know there will be a return for service and these people will be working in the industry, instead of just taking the course because they have money to take a course and go on to the next one.
MR. PORTER: Thanks. You mentioned the number of 400 positions short - that's province-wide obviously. Are they then broken out to districts? Do we have any idea in local areas - if I asked you, how many in Hants County or Hants West even?
MS. DILL: There has been a recent study done by the health sector council on supply and demand across Nova Scotia, which is just about due to come out - you'll probably see it out next month - and it has all that kind of detail in there that can show the different areas. There was 400 short in the facilities when we started, but those numbers are going down. There still is a shortage because there's always attrition, turnover and so on. But yes, we could get that - I don't have that number for you right now, but I certainly could get it for you.
MR. PORTER: And the education piece was a big part. I guess this is sort of a topic for a different day, but once upon a time we had guidance counsellors in the high schools and you sat down and you talked about careers and maybe, I'm assuming it was quite helpful in the day. I know when I went to school it was, what do you want to be when you grow up, sort of thing, and you thought you might want to be this and they would go through and assist you in making those choices. Right now we need to look seriously at someone, people in a department whether it's Education, whoever it is, delivering that message to our young people who are still looking for that choice in life because I think it could be very attractive, whether it is CCA, RN, NP, et cetera.
[Page 22]
MS. DILL: You're bang on on your observations because that is one of the weakest areas for people who are recommending people to take this program, so it's certainly another area we're targeting, as well as mass advertising.
MR. PORTER: Right now, unfortunately, we're seeing some people get laid off from jobs, some of them are career jobs that hopefully they'll go back to. Those people probably aren't looking for a new career and maybe they're a little bit older and have been around for a while, but there are also other jobs that are not career jobs, they're today's, next week's and maybe next year's, maybe. We have a number of those kinds of jobs too where people move around and are still looking. Are we out going into businesses? Not that we want to steal employees away, but there has to be a better way. I don't see anything on TV, maybe that's just me, I don't watch a lot of TV, but are there ads on TV saying, hey, we need CCAs in Nova Scotia?
MS. DILL: You will see that within the next week or two, it will be on the cable channel where it rotates through.
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: I don't know if I should be telling this story or not, it just happens to be a true one.
MR. PORTER: Please do.
MS. DOIRON: A few months ago I was going off to a meeting in Toronto or someplace and I was at the airport, early morning. As I went through security they were just kind of going around with their magic wand and some alarm went off and everybody, except a very few people from the area, went scurrying off to wherever the alarm was called for. The security person, a reasonably young woman who was attending to me said, I can't do anything until this is resolved, so we'll just have to wait here. I thought, fine, but then I started to engage her in some conversation and I asked her if she liked the job she was doing and a few questions about that.
As we got talking, I talked to her about a career as a CCA and the potential that had both for a reasonable wage at this point, and pretty well in all of our organizations there are benefit packages as well. That day she basically took my card and some information and I'm not sure if she's actually followed up, but I think we all have to do our recruiting wherever we can.
MR. PORTER: Thank you. I want to talk about a couple of - how much time do I have left, Madam Chair?
MADAM CHAIR: You have until 10:10 a.m., that's two minutes.
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MR. PORTER: Thank you. I'll get into it just a little bit then on the NP program, the nurse practitioner you were talking about a little bit earlier; questions with regard to scope of practice, who's prescribing what, how much of an issue and why is that an issue? I thought that this was: the doctor obviously, here's your scope of practice; druggist, here's your scope of practice; paramedic, here's your scope of practice. Why is this an issue, I don't understand?
MS. DOIRON: I think part of the issue here is that we have over time been looking at changing scopes of practice. In past years essentially we went through a period of time where doctors, often in acute care settings, actually assigned some of what they saw as their duties or responsibilities to a nurse and there was a process for doing that where actually the nurse went through some teaching around it, went through some practice and the physicians signed off in terms of the readiness of the nurse to be able to perform a particular function.
Now that we are basically in a different time and looking at scopes of practice differently, looking at different kinds of health workers as well, looking at nurse practitioners, looking at physician assistants and others, we basically have been looking at some of the changing of the scope and that's where we generally find there is a need for more discussion and understanding of where people have a comfort level. I mentioned previously, although we don't have that in this province, that pharmacists generally across the country and in several provinces now have achieved the ability for them to directly prescribe certain drugs, whereas before that resided only with physicians. Nurse practitioners are in a position to prescribe certain drugs, which never used to be the case.
Because we have very good relationships and working groups in this province, we're able to sit down and work those through, but it often does take a period of time because we are going through change. There will often be different opinions about change and we're dealing with entire professions and not just the one individual at the table, so we do take a considerable amount of effort now to say, how can we best use every profession that we have out there to the full scope of what they already are allowed to do under their licensing process and how do we shift any of those responsibilities to make the system more effective.
MADAM CHAIR: Order. The time has expired for the PC caucus. The next round of questions will be 13 minutes per caucus.
Mr. Wilson, you have until 10:24 a.m.
MR. DAVID WILSON (Sackville-Cobequid): Thank you, Madam Chair. I want to pick up where my colleague had asked a few questions around the status of the changes to the self-managed care program. No question, many Nova Scotians could benefit from implementation of changes to that program - hundreds if not maybe even a thousand or more Nova Scotians and their families could benefit right now if those changes went through. You mentioned that you're ready to implement the changes and address the programs and, of
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course, we're awaiting the okay, I guess, from government. It's very disappointing to see the current government hold off on making a decision on implementing these changes and giving you the okay to go ahead and do that.
One of the things with self-managed care, one thing that we've called for and many of my colleagues have, is the ability to pay a family member to take care of you. The other portion of it too is, currently the system under self-managed care is only available to someone who has the cognitive ability to take care of their own care. We've had an individual in the House of Assembly a number of time, Mr. Stewart, whose wife has a brain injury. Laurie Stewart has come out very publicly to say he needs assistance. He's unable to access self-managed care because of his wife's cognitive impairments. They live in rural Nova Scotia, the services are limited and his hands are tied on what he can do for his wife, basically because they can't gain access to this program. So with the changes that you were looking at, do you foresee changes in that requirement where an individual has to have the cognitive ability to make their own decisions and not a family member? Are we going to see changes to that part of the program?
MS. DOIRON: Thank you for that question. We do anticipate that this program is going to change and evolve. We started out with trying to enlarge the self-managed care program for people who could manage themselves and through that, we've seen 100 or so people who are now in that position and basically have either prevented the requirement for them to have to go into say, residential care or even a nursing home. In a few cases, we've actually been able to remove people from a nursing home and back into their own home setting, so that's good and that has been going quite well.
The next step that we thought we would take is for people who actually can make a decision, but don't wish to manage their own program, to give them the ability or opportunity to assign it. Then the third phase would be to go to the situation you've currently described where we may have the opportunity for somebody who has Alzheimers or another form of dementia or confusion for some reason, who would not cognitively have been able to manage their own program, but has a relative or caregiver who would be able to do it on their own behalf. We would like to see those phases continue so that we can enlarge the program to include that.
MR. DAVID WILSON (Sackville-Cobequid): I think that is so important that we see that. I hope Nova Scotians who are in those circumstances like the Stewarts continue to come forward and put pressure on it because it's a sad situation to think of being in that situation and not being able to help your loved one, just because of government's unwillingness to implement these programs. As my colleague said, no question, I don't doubt for a minute we'll know how close the next election is when we hear the implementation of these changes.
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[10:15 a.m.]
I'd like to go - one of the things we hear about a lot is from seniors and people with disabilities who can't access transportation. So even though we're talking home care, no question, I think transportation to services, transportation to appointments, physiotherapists, whatever an individual's needs are - is a transportation strategy in the works so that we can address that component of accessing health care and home care and other services in health?
MS. DOIRON: We have not yet started that strategy but as you probably know, it is identified as a strategy which we do need to develop and I think it's about a year out before we anticipate formally trying to organize that.
Having said that, I think we hear as well - and not just Health but I think we hear through Health, Community Services and other government departments - that transportation at that local level for people who are infirm or for seniors who can't drive and so on, can be a significant support to allowing people to stay at home.
We know that there are several communities in the province that have actually, just through just a volunteer approach or some very small community-based dollars, have actually brought together programs that will offer a service to take somebody to a doctor's appointment, to get some groceries, that kind of thing. Although we've not formally entered into trying to frame that program, I believe this is one area where we need to be respectful as well about the ability and opportunity for volunteerism. I'm not sure that this is a program that should be a 100 per cent government-driven type approach but I do believe that we need to participate and we need to try to orchestrate and try to help this to be defined better on a provincial basis.
MR. DAVID WILSON (Sackville-Cobequid): I think those organizations are out there. I know, for example, in my area the Silver and Gold Club offers a driving service for seniors and for anybody, really; I mean they are geared towards seniors but people with disabilities. Every year I get the same letter, I have the same conversation with the director, that we don't know if we can provide this program on an ongoing basis, because of funding.
Really, when you look at the scope of it, it's not a huge amount of money. I mean a little bit of help for those volunteers, especially we hear about it when the gas prices are up, but I think it's important and I hope that will continue to be a push.
As I said earlier, we continue to hear from people who come public and often our role is to ensure that they have an opportunity to voice their opinions, especially around the long wait times, especially with individuals who have complex health needs.
I refer to a recent case that was brought forward in the media around Robert Norris, who was a civil servant for many years and developed RLS - it's a form of ALS. I don't
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know, I'm sure you may be aware of this case, but he has severe needs, complicated needs and requires a lot of help, a lot of care. The family's decision was to bring him home and apply for home care, which they assumed would be there to support them, but were told that there is a long wait list. I think it wasn't until they were front and centre, and here's a family with a real situation, real concerns, that all of a sudden they were able to gain some access; Not that I think that's the most appropriate way to do it - I think anybody who needs it should have it - but here is a case of a family who were in dire need of help and are starting to get some assistance.
Why do we continue to have examples like this, of the Norrises, who have complex needs and support? With that case I think the best place for him is at home, with some support, and the cost is such a reduced rate, I guess - if they had chosen to place him into a long-term care facility. So why do you think it seems like we have to bring people forward, get them in the limelight, show that there's a human side of these issues, to get government to recognize the importance of this. Why do you think that happens? I know it's kind of an open-ended question.
MS. DOIRON: It's a bit of a conundrum at times when you get into this area and, of course, obviously we won't talk about specific cases. But, having said that, what we do see sometimes is, somebody having a wait-list issue and maybe then finally getting there and it may or may not be just coincidence that they get the service or we may try to make some effort to push this case forward, if we see that there are real special circumstances that need to drive it faster or push them higher on the priority list. So occasionally that can occur.
But over and above that, I have seen cases over time where you have situations where people have such severity of need and an interest and a willingness to live at home, and sometimes even family members who are willing and interested to have them at home, but have such extreme needs that we do not have any defined program in any area of government to be able to respond to the extent of the need, for example, in a situation where perhaps a person needs care on a 24/7 basis. If, in fact, the family says, we want the person at home but we also want to have the 24/7 caregiver - and the family certainly is very important and integral to that person's life and value and socialization and so on. But at the same time the family may say, we don't believe that we should have to provide the care if the care is severe, we need the 24/7 coverage.
This come down to some level of choice, I guess, as to where does government go with policy or the practices of what we support? What is the right thing to do or the right choice to make, on behalf of the larger population? When you see the individual cases, you want to be able to go forward and resolve them but you also need to be aware when you're saying that, that if we take a policy issue and treat it in that manner, we could be starting then to drive all kinds of resources and costs because it may open the door for many others who would want to say, well, if I can have 24/7 care at home, that's what I would prefer to do. So there are many, many considerations that go into that.
[Page 27]
We work diligently with other government departments as well, to see if there's any way that we can combine Departments of Health, and Community Services programming, in cases where the people are young enough - education programming, et cetera - to try to bring together a bundle of services and dollars to provide support. There are times when we can do something reasonably effective and times so far we haven't felt that that's a right position to take.
MR. DAVID WILSON (Sackville-Cobequid): No question, I think with the possibility of changing the self-managed care program, the palliative care program province-wide, even though I think the former Minister of Health and I - at times, he feels there's appropriate palliative care coverage throughout the province and I feel there isn't a continuity of that.
The sad part about this case - I know you won't comment on this personal case - is they were told that if Mr. Norris was under or deemed to be a recipient of palliative care or in that circumstance, that his care would be provided quicker to him. Unfortunately, with his illness, it is a long progression and he's not terminally ill at this time. That's a sad thing to tell a family, that you don't qualify for that program. So one last question, maybe . . .
MADAM CHAIR: Order. I'm sorry, the time has expired for the NDP caucus.
Mr. Wilson for the Liberal caucus, you have until 10:37 a.m.
MR. DAVID WILSON (Glace Bay): Thank you, Madam Chair. Deputy, I'll need your co-operation here with a few quick answers, if you don't mind, so I can share with my colleague, the member for Kings West.
MS. DOIRON: Absolutely.
MR. DAVID WILSON (Glace Bay): Just a couple of things to clarify. If the in-home support program was ready at the end of December and it was ready for the end of January, then why are you now saying that if it was approved, it would take a couple of months to implement? Wasn't it ready to begin with?
MADAM CHAIR: Mr. Menzies.
MR. MENZIES: Well, I guess part of implementing a program then is to put the final details around the policy and to train the staff so they can apply it. We haven't done that work until we know exactly what's being approved. As soon as we have an approved program with the parameters in place, we then need time to spell those out appropriately, to do the documentation on it and to train our staff so that they apply it appropriately as well. So that would take a couple of months to get that work done.
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MR. DAVID WILSON (Glace Bay): Okay, that hasn't been done. That wasn't done. The program was ready but you're saying the training and that - I understand.
Let me ask you, deputy - and this you might be able to summarize in a yes or no answer but I'll leave that up to you - did the current Minister of Health put a halt to the end-of-January start date for that in-home support program? Did she say, don't go ahead with it?
MS. DOIRON: No, not in that context. I think the minister has continued to have that under discussion and there have been a variety of issues or questions around it that she has been asked to address and she has been doing that.
MR. DAVID WILSON (Glace Bay): Then was it the former Minister of Health who said, don't go ahead with it?
MS. DOIRON: Basically it's a program that at the end of the day would be approved by Cabinet before it proceeded.
MR. DAVID WILSON (Glace Bay): So it never did get to that stage?
MS. DOIRON: We have not yet had final approval.
MR. DAVID WILSON (Glace Bay): To your knowledge, did it go before Cabinet?
MS. DOIRON: My understanding is it has been addressed, at least at Issues Committee of Cabinet, if not full Cabinet. So we do not yet have a Cabinet decision nor an Order-in-Council to tell us to proceed.
MR. DAVID WILSON (Glace Bay): If, again, back to the proclamation of Registered Nurses Act, when nurse practitioners have been told - and they have been told, apparently - that the final draft of the Act is in the department now, why would it take two months to act on a proclamation of that Act?
MS. DOIRON: I believe that we received that Act just very recently. I know that our folks who are following up on any of the other specific directions that were agreed to, from Justice, for example, and that were agreed to by the profession, just need to now finalize and tidy that up so that the final agreements that are attached to the regulations can receive final wording and so on and be put together to take forward to Cabinet for approval.
Of course the reason I say a couple of months is to basically allow them to finalize that drafting within the department, based on any new directions that may have been agreed to, as well as the time it takes us - usually about a two-week period, minimum - to be able to schedule and get the document reviewed in Treasury and Policy Board and on to Cabinet
[Page 29]
for final approval. So there are two or three weeks engaged there; it could be 45 days, I'm basically saying approximately a couple of months.
MR. DAVID WILSON (Glace Bay): One final question, Madam Chair, and then I'll share the remainder of the time with my colleague, the member for Kings West. In the December fiscal update, deputy, the Department of Health found savings of $13.3 million. How much of that $13.3 million can be attributed to savings in Home Care Programs and in the delay of the in-home support program; how much have you saved?
MS. DOIRON: The budget that was allocated at the beginning of the year for the in-home support program that I tend to refer to as a caregiver allowance, to differentiate it from the program that people self-manage at home, but having said that, the amount that was in the budget that was approved in the House was $1.8 million.
The few people who entered the program while it was in Community Services initially, essentially are using approximately $200,000. So we had $1.6 million of unspent dollars this year and basically that formed part of the $13 million that we put forward into that estimate for the end of December.
MR. DAVID WILSON (Glace Bay): I promise this will be the last one. If you can provide me, if you can tell me off the top of your head - I don't know if that's possible or not - if you've briefed the minister on that in-home support program, can you tell me how many times you've briefed the minister and when exactly you met with her and the latest date - and Cabinet, if you met with Cabinet? Can you tell me those dates or how many times you've met with them?
[10:30 a.m.]
MS. DOIRON: I know that of course the minister only came to the Department of Health . . .
MR. DAVID WILSON (Glace Bay): I'm sorry, I couldn't hear you. There's some noise at the other end of the Chamber.
MADAM CHAIR: Order, Mr. Muir.
MR. JAMES MUIR: I was just wondering, Madam Chair, whether that is an appropriate question. It would be communication between the deputy and the minister and obviously going into Cabinet which is confidential.
MADAM CHAIR: It is an appropriate question. It's up to the witness whether or not they want to answer it. Thank you. Ms. Doiron.
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MS. DOIRON: Basically I think that the minister has had adequate briefing that she understands the program and I think how government then treats it from there, I would agree, is not really my purview to further comment on.
MADAM CHAIR: Mr. Glavine, you have until 10:37 a.m.
MR. LEO GLAVINE: Thank you, Madam Chair, and thank you for coming in today, all three of you. In particular, deputy minister, I always appreciate the insights and frankness you bring to Public Accounts.
Just to further a little bit a question of my colleague, knowing the situation at the Valley DHA 3 clearly is one of the areas that still remains with home care pressures - although I must publicly say that Mr. Dow has done a fine, fine job in moving us from A well down the line to Z. Have you advised government of the need to move forward with in-home support program in the Valley area, where wait times we know remain a problem?
MS. DOIRON: We basically have looked at the program from the point of view of the definition of various geographic areas. So there is information that includes the Valley.
MR. GLAVINE: The other area, the MLAs representing Kings - we just recently met with Janet Knox, the CEO at the district health authority, and they're ready to take on the devolution to the district of home care. When is it going to proceed? They all feel that it will make a significant, positive difference.
MS. DOIRON: There has been a lot of work going on in that. There are working groups dealing with the issues that needed to be addressed relative to any of the labour relations issues pertaining to staff, relative to any issues pertaining to policy which we needed to ensure prior to transfer. That's all going well. It's the intention that the staff of the , who are going to be moved to the district, will transfer effective April 1st of this year.
MR. GLAVINE: Thank you very much, I appreciate that. What I'm about to explain here as briefly as I can, in meeting with a few families recently, is I think once it comes to the DHA, there will be some cost benefits because the whole question of the centralization and the scheduling, for example, of the providers, of the LPNs and so on, is still very problematic and troublesome.
In meeting with a couple of families, here's the sort of thing they reveal. I know Mr. Menzies, knowing geography can, in fact, emphasize this with you after. You have a VON that would come from the Harbourville area to look after somebody in the Kingston area and the family I met with said that they have a lady next door working for VON who went by her house, on the way to Kentville, and then coming back to look after somebody else in the Greenwood area. That leads to this reality that I've had from VON providers as well, that they sometimes have mileage pay equal to their actual pay.
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I worry about the sustainability of the program if we don't move quickly in this area. I was wondering if you could comment, please?
MS. DOIRON: I think that we have been making changes and making progress with the kind of accountability that we require from VON. For a number of years, there was not a very robust contract or set of deliverables. That has been developing, and particularly over the last two to three years we've been developing that significantly.
We have looked at a variety of options in terms of how we move into the future with that because given that this is a contract, I think at some point once we have more of the deliverables framed and there's potential for something like that to go out to an RFP - not to say that the VON have not been providing a very good service because they have - but just looking at it from a process point of view. We also, in the process of talking about the transfer of the Home Care Program with the district health authorities, of course there is dialogue with the CEOs and with their staff about how we proceed as we go through that process. The transfer of staff is one thing, but what changes once we actually have that transfer.
There are a variety of models for how things might work or continue into the future. We could continue to contract the nursing services as we do through the VON, mostly on a provincial basis, there are a couple of exceptional areas, but mostly a provincial contract. We could go to individual contracts with VON to the districts. The districts may find, after a period of time, that they would like that nursing staff to be their own employees. There are a whole variety of issues that, over time, I think we need to sort out.
In initial discussions with the CEOs, I think basically we have wisely come to the position to say, let's walk before we run and we will continue with the contract we have and continue to work on the framework and the deliverables for moving into a more robust accounting process.
MR. GLAVINE: I know that this probably doesn't reach your level, but in terms of when somebody is in hospital and can go home with home care, is there a policy about working with Community Services where there is need for some upgrade in the home? I just dealt with an issue that was really discouraging to say the least, 14 months in hospital probably could have been reduced to six if Community Services had worked very closely together with the Department of Health. Is there a policy?
MADAM CHAIR: Order. The time has expired for the Liberal caucus. With the indulgence of the PC caucus, can we allow the deputy to answer that question? Thank you. Ms. Doiron.
MS. DOIRON: Did you wish me to respond?
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MADAM CHAIR: Yes, please.
MS. DOIRON: We have developed a much stronger relationship between Community Services and the Department of Health and basically have fanned that out to our district bases. We have teams that meet on a regular basis at that community level. We also have, through our Home Care Program, staff coordinators who basically spend most of their time housed at the hospital itself and essentially part of their role in connecting with both the discharge planning and social service people within the health authority, as well as any other program relationships they need on a community basis, which would include Community Services. So it's feasible that that's done, whether we're doing it as effectively as we should 100 per cent of the time is another question.
I truly believe that once the Home Care Program is transferred to the districts, there is an opportunity for that to be much more effective.
MR. GLAVINE: Thank you very much.
MADAM CHAIR: Thank you, very much. The time has expired for the Liberal caucus.
Mr. Bain for the PC caucus. You have 13 minutes for questions.
MR. KEITH BAIN: Thank you, Madam Chair, and thank you all for coming here this morning. I just have one question, I know my colleague has a couple of questions he would like to ask as well. Mine is dealing with home care and I know the rural areas offer a challenge in the provision of home care. In my particular constituency, which is large geographically, small in population, it's possible that home care workers travel great distances between clients. Are there challenges as a result of this more so than in densely populated areas, both in recruitment and the delivery of home care? If there is, what's being done to ensure that home care is adequately delivered in areas such as this?
MS. DOIRON: I'll defer to Keith Menzies.
MADAM CHAIR: Mr. Menzies.
MR. MENZIES: Thank you for the question. What we found actually is that in rural areas there are always challenges with staffing and having the right number of people working there, but it's even more of a challenge in metro, in the Halifax area, largely because there is so much competition for workers. When you look at challenges, there are times when people will say, the nursing homes can't recruit or home support agencies can't recruit and it's particular pockets or areas of the provinces that are having that struggle more than others. Yes, there are challenges, but they are not any more significant in rural areas than urban.
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MR. BAIN: Okay, that's fine, Madam Chair. I'm going to turn it over to my colleague.
MADAM CHAIR: Mr. Muir.
MR. MUIR: Thank you, very much, Madam Chair. I do have some questions, but just before I get into them, I learned recently that the Deputy Minister of Health is going to be leaving the department at the end of June. I just want to recognize the contribution that she has made to the province during her time, first as the associate deputy and latterly as the deputy. You've done well, deputy, and despite the fact that the Health Department does get its share of criticism from time to time, you have done a great job and we're grateful for what you've done.
MS. DOIRON: Thank you.
MR. MUIR: Having said that, I'm going to go back to a question which they both know I will probably ask and it has to do with long-term care facilities and some of the smaller ones that are not currently recognized by the Department of Health. I've been in the business for 11 years and for 11 years I have been pursuing this with, I was going to say mixed success, but virtually no success, I guess. Where are we with that because clearly we have a number of those facilities out there that right now actually have a number of vacancies that could take some pressure, at least in the interim, until we get the more formal system up and running.
MS. DOIRON: I believe I'll defer that to Keith as well.
MADAM CHAIR: Mr. Menzies.
MR. MENZIES: Thank you for that. Certainly, the issue for us is that many of these seniors' homes that are in the communities that are unlicensed are providing a boarding-home level of care with a little bit of supervision and really do not qualify or do not provide the level of service of a nursing home. The challenge for us is that with our wait list for care, the majority of those people waiting to go into care are needing nursing-home level service, so it requires ongoing nursing supervision and intervention. Many of the areas where we have these homes, these boarding homes that are looking to be licensed in some way, some of the residential care facilities that we do licence in those areas have vacancies as well. We haven't been able to move forward yet and I'm not sure when we will be moving forward with any of these homes.
MR. MUIR: I guess the argument that was first presented to me and I don't think it has changed over the period of time is, you tell us what criteria you would like us to meet and if we meet those criteria, licence us. The challenge that comes from people who operate those facilities is, you won't tell us what criteria you want us to meet. Where are we on that?
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MADAM CHAIR: Ms. Doiron.
MS. DOIRON: Basically, if an organization or a home wants to qualify for admission of people under residential-care level or nursing-home level, they can make an application to do so. I think there was a period of time where there were no new approvals being provided, but we have not maintained that policy. If, in fact, a residence of whatever type wants to do that, we can then go out and examine the residence to see if they would qualify or tell them what they would have to do in order to position themselves to qualify.
We have had occasion two or three times to go into organizations of the type, I think, that you're referring to. What we will usually find is two or things that generally have come to attention. One is that often these are facilities that are not constructed on a basis that would lend themselves certainly to nursing home care or sometimes even to the type of residence that we would approve for residential care.
[10:45 a.m.]
We don't licence or pay for boarding homes so it must be at least a residential care level or a nursing home level if they want to qualify under our system. We found that in a couple of situations if they were going to qualify, that there would have to be some renovations or investment of funds to position them to be able to care for a certain kind of people.
The other thing that we find if we go out into these facilities at times is that individuals may have gone to the boarding home and basically the level of their need has changed over time and they do not wish to move from the home that they're now in because it is their home and they have relationships there. But, on the other hand, if the organization is not in a position, for example, to provide Level 2 nursing home care, then essentially once they call us in, then we are obligated to place that person in an appropriate and safe care environment. That can become troubling if they're concerned about moving people out.
We also find that there are locations that might qualify for housing some patients or residents who do not wish to become part of the single-entry system, which is a requirement, or residences which might say well, we want to become licensed for one or two beds but not for our whole facility. There is a whole variety of situations that we've run into.
Our concern right now has been that while we do know that there are some vacancies occasionally in some of these residences, that with the beds that are being built for residential care and for long-term care, taking over homes that are not already registered and qualified would require significant additional funding, without adding significant additional capacity to the system. So those have been some of our concerns.
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MR. MUIR: I guess I was prompted to ask - I visited one of those a week ago to deliver a 102nd birthday certificate. I happened to meet another resident there who was the mother of a person whom I happened to know and I ran into her a little bit later and I said, I met your mother, and she said yes, she loves to have visitors.
Anyway, she said she had been assessed to go into the normal system but she was being so well cared for and so happy in that basically small situation, that they kept her there - and are paying for it, by the way, full care.
The other thing with those things is that their cost of operation is roughly about one-third - between one-third and one-half - of what you would pay to one of the major providers. So if we can get that moved up in the priority list, I do think that it would be a good thing.
Back in 1999 - you came in 2000, deputy, I think - what was the continuing care budget?
MS. DOIRON: We could get you that figure.
MR. MUIR: Well let me then continue the question; how much did the continuing care budget increase from 2007-08 and 2008-09?
MS. DOIRON: I know that during a period of time, and I believe you were minister at the time . . .
MR. MUIR: A good minister, too. (Laughter)
MS. DOIRON: . . . that there was a period of time when the home care budget increased over a two or three year period by something like 200 per cent and we have continued to add to that budget, so we could definitely get you that figure but I believe we've been adding to that budget in the order of, would you say that 10 per cent to 15 per cent a year would be fair? I think we're in that territory.
MR. MUIR: So I guess that continuing care has been a very big priority of the Department of Health and the government during that period of time and the additional financial resources that have gone into it would be, I think, perhaps proportionately greater than went into the acute care system.
MS. DOIRON: Well there's no question. I know that we continue to add dollars to the acute care system but by far, the percentage basis of growth in continuing care has been far greater in significance, multiple times what we've been putting into acute care.
I would like to point out, because again this is something I don't think that has been pointed out much in the past - you would know that when you were there as minister, and I
[Page 36]
came in about a year later, I guess - we often get the question or perhaps even the criticism that we haven't moved fast enough with the long-term care beds. There was a reality that existed where, for a decade or more, prior to 2000, nursing homes were not being given the additional funding they needed to run. They were given no inflationary dollars, year over year. They were having costs, like increasing workers' compensation or other things that they legally had to pay. Most of them had started to move their dollars around.
The first thing that would go is dollars that were going to maintenance. Consequently, the shape of some of the buildings we ended up with; some of them were dipping into care dollars to do other things. Most of them actually went out with lines of credit. At the point of around 2000, we found out that many of them weren't able to meet the interest on their lines of credit, let alone the principal, and we essentially had somewhere around 30 per cent to 40 per cent of the beds in this province that were ready to go into receivership.
That didn't get a whole lot of public attention but what happened, over a period then of a few years, that system had to be totally stabilized. We also had a situation where things like this occurred - over and above salaries, the benefits that were paid to the nursing homes varied; I think it was somewhere between about 11 per cent and 30 per cent. So again, we didn't take money away but over a period of several years, we started to add to the homes that needed to be stabilized. We now have a system that is equitable.
We also started with per diems in the nursing homes with absolutely no idea what was in there. We didn't know how much was capital, we didn't know how much was care, we didn't know any of that for all the homes in the province. We worked through all of those things to basically sort it out, to make sure we now have a constant and equitable care budget that goes to every nursing home and we understand the capital costs that are going on with every single home across the province.
So basically, in my opinion, with both home care and long-term care, there was so much rebuilding from the ground up that had to be done, we've only been in a position to significantly move forward in the last several years.
MR. MUIR: That was a point that I was going to make . . .
MADAM CHAIR: Order, the time has expired for our rounds of questions. I would now invite the deputy to make some concluding remarks, if you would.
MS. DOIRON: Thank you, Madam Chair, and I will be brief. It is always a pleasure for us to come to Public Accounts Committee, believe it or not. I have found always that we have been treated with the utmost respect, albeit sometimes we get challenging issues or questions, which is more than acceptable.
[Page 37]
I do want to say that in this area it has been, in a sense for us, a decade of rebuilding and development. We are still on our way to that. I particularly want to mention the support and direction and the ongoing, I guess, co-operation and patience that we get from the Auditor General's Office because we have not yet 100 per cent met everything that was referred to in these audits but we are very close. I think that within the next short time frame of a year or two, that we will be able to tick off every item that was on the Auditor General's point of concern.
So a lot of progress is being made. We still have a ways to go but I feel comfortable that we are now on a path which is going to more appropriately serve the people of this province. Thank you.
MADAM CHAIR: Thank you. On behalf of the committee, I would like to thank all of you for being here today. To the deputy, I don't know if we'll have an opportunity to have you in front of us before the end of June, but I'm sure some of the members will do their utmost to make that happen, so we'll have to wait and see.
MS. DOIRON: I don't want any special attention, thank you. (Laughter)
MADAM CHAIR: I believe that Mr. Porter requested additional information, a breakdown of the worker shortages by districts, I think he had raised that. If you're able to provide that information to the clerk, that will be very beneficial, we'll have it circulated to all of the members. Mr. Colwell.
MR. KEITH COLWELL: My colleague as well asked for some information. On the in-home support program, I'd like to know when you or members of your staff - I would like to know the dates and number of times that you've briefed Cabinet or Treasury and Policy Board. Not the content of what was discussed by any means because I'm not asking for that, just the dates and times that would have been brought to Cabinet over the last two or three years.
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: Madam Chair, I think I'd be looking for a point of order on that as well. I'm not sure that that's a requirement that we should respond to.
MADAM CHAIR: We'll have some further discussion on this then in the subcommittee.
MR. COLWELL: Okay.
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MADAM CHAIR: So, that concludes this portion. We have received information from previous witnesses, the Sydney Tar Ponds Agency, that has been circulated. At this stage there is no further business. Our next meeting is scheduled for March 11th.
Thank you. We stand adjourned.
[The committee adjourned at 10:56 a.m.]
