HALIFAX, WEDNESDAY, FEBRUARY 25, 2004
STANDING COMMITTEE ON PUBLIC ACCOUNTS
8:00 A.M.
CHAIRMAN
Mr. Graham Steele
VICE-CHAIRMAN
Mr. James DeWolfe
MR. CHAIRMAN: I would like to call to order this meeting of the Public Accounts Committee. We are pleased to have with us today Dr. Tom Ward, the Deputy Minister of Health. Dr. Ward, I would like to invite you to introduce the people who are with you this morning.
DR. TOM WARD: Mr. Chairman, I have on my lefthand side Byron Rafuse, who is the Chief Financial Officer for the Department of Health and on my right I have Mr. Keith Menzies, who is the Executive Director for Continuing Care.
MR. CHAIRMAN: Thank you, Dr. Ward. I would like to ask the members now to introduce themselves, starting with the member for Halifax Needham.
[The committee members introduced themselves.]
MR. CHAIRMAN: I am Graham Steele, the member for Halifax Fairview and the Chairman of the committee.
Dr. Ward, as is customary, I would like to invite you or one of your colleagues to make an opening statement in the order of 10 to 12 minutes, if you choose.
DR. WARD: Mr. Chairman, I would ask Keith Menzies, who is the Executive Director of Continuing Care, just to give a brief overview of the Continuing Care branch within the Department of Health and some sense of the activities in that area.
1
MR. CHAIRMAN: Thank you. Mr. Menzies, you have the floor.
MR. KEITH MENZIES: The Continuing Care branch in the department provides services in three areas - one being the long-term care sector; the second being the home care sector; and thirdly, services under the Adult Protection Act. Since we are here this morning to talk about long-term care, I will basically speak to that piece of the organization and the work we do.
There are 74 nursing homes in this province, along with 35 residential care facilities under the Department of Health and a number of community-based options. Within those 74 nursing homes, approximately one-third of them are private for profit, one-third of them are municipally owned and one-third of them are non-profit organizations or societies.
The work we do in this area, from the department's perspective is somewhat arm's length. These are our provider organizations that provide the direct service to clients. Our role is in providing collaboration and planning along with oversight of business plans and the development of business plans with the organizations and oversight of those business plans and having accountability sessions with the providers around the financial side as well as the care side or the service side through our long-term care advisors and our licensing processes.
For the most part, we work closely with the homes. Over the past few years we have been very successful in being able to assist and enable these facilities to move away from major financial issues and through funding enable them to reach a point where there is greater stability among the homes. I'll stop at that, if that's suitable.
MR. CHAIRMAN: We will now open the floor for questioning, starting with the NDP caucus.
The honourable member for Halifax Needham, for the next 20 minutes.
MS. MAUREEN MACDONALD: Mr. Chairman, good morning and thank you. I want to start by asking probably Mr. Menzies, what the total number of beds are, specifically in the nursing homes, in the long-term care facilities, right now in the Province of Nova Scotia?
MR. MENZIES: There are approximately 5,700. It is 5,713 or so, it is in that range.
MS. MAUREEN MACDONALD: Of that total, can you tell me the number of residents who are currently under the pre-November 1, 2003 financial assessment regulations?
MR. MENZIES: I can't answer that. We haven't got that number. I could give you an estimate on it. We are talking a year now. We have approximately 2,000 admissions a year.
There are probably two-thirds of the residents who are admitted to the homes under the rules prior to November 2002. So that would be 3,800 or 3,900.
MS. MAUREEN MACDONALD: But there would also continue to be people who would have been in the facilities who are still there today under the prior as well?
MR. MENZIES: That's what I'm saying. Those 3,900, if there are 5,700 beds and we have approximately 2,000 admissions per year, you are looking, at most, 3,700 or probably less now because it is, who would be there, who are assessed under the rules prior to November 2002.
MS. MAUREEN MACDONALD: My office, and other members of the NDP caucus in our offices, we continue to have calls from family members complaining about the rigorous enforcement, sometimes the over-rigorous enforcement, of the pre-November 1st rules in the year 2003. I would like you to comment on the extent of the complaints that you are getting and perhaps the appeals you are getting within the department around the enforcement of the financial assessment prior to 2003. I think that basically there is a consensus in the province, across the political Parties, that these rules are unfair and probably immoral in many respects in terms of the way our seniors have been treated. So I would like you to comment on some of the complaints that you are getting and how much time that is taking members of your department to deal with.
MR. MENZIES: I am not aware of any complaints coming forward with regard to that. Certainly the appeal process is there and I can't even speak to the number of appeals that are coming forward under the old rules. I can't answer that for you. We can get that answer in terms of how many.
MS. MAUREEN MACDONALD: Well, if there are complaints, if people are having difficulties with the enforcement, wouldn't you, as the director of this unit, have some knowledge of that?
MR. MENZIES: I haven't had any brought to my attention.
MS. MAUREEN MACDONALD: The Auditor General has indicated that there essentially isn't a long-term strategic plan or, in fact, a short-term plan for long-term care and I would like to ask you why this is the situation in the long-term care sector?
MR. MENZIES: I alluded to that briefly, I think, in my opening remarks in terms of where the sector was and the financial support that has gone into this sector over the last two years to resolve some of the issues. When I came to the department, about three years ago now, coming from the field and having been an administrator, certainly there had been less attention to this whole sector for many years than should have been there. Many of the homes were in financial crisis. We were at a stage at the department where we were managing with
them almost daily in terms of how they were going to meet their next payrolls. It's only in the last three years that many of these issues had been heard within a department in a way that we brought them forward and there have been resources put forward to assist the homes in becoming at least financially stable at this point so that now they are able to concentrate on providing the services they should be providing.
I certainly recognize the comment in the audit report in terms of the need for a long-term strategic plan for this sector as well as all of continuing care. One of the areas that we have identified as a strategic direction is for the branch to develop that overall vision of what is continuing care, where should it be going, how should it be regulated and to do that is a major undertaking that will probably take us a couple of years and some resource to make it happen. Also, in order for us to be able to do it, we need to be able to have the time to go out and collaborate not only with the providers, but also with the public and other interested parties, in terms of how this sector is shaped for the future.
[8:15 a.m.]
One of the difficulties we have had with the severe restrictions on funding at the homes up until the last couple of years is that everybody has been in a crisis management mode. How do you pull people into a process to look at long-range planning, when they're fighting day to day to keep their businesses going? My view is we have to stabilize the system, which I think we're doing quite well now. The number of calls we get from homes in crisis is considerably less now than it was three years ago and when we do have those calls we are able to work it through with those particular homes. We now have the sector, I think, reaching the point where there is some stability. Now that that is in place, we can now ask them to step forward and be part of processes that lead to strategic plans for the whole sector.
MR. CHAIRMAN: Dr. Ward.
DR. WARD: Mr. Chairman, if I might add a bit to that. When I joined the department in the Fall of 1999, within a year or so it became quite evident that there had been some structural underfunding with respect to the long-term care sector. For a number of years, through the 1990s primarily, increased costs of benefits, particularly WCB and other benefits, had not been passed through to the nursing homes. Subsequently over the course of about three years, between 2000 to 2003, within the department, we continued to shift dollars into the base funding of the long-term care sector, particularly the homes, to the tune of over $30 million just to stabilize the base funding pieces.
Prior to that, as Mr. Menzies pointed out, it was very much crisis management, we had a fair number of bankers phoning the department on a fairly regular basis to say, we're in a real financial crisis on a couple of occasions. In fact, the department was advancing money to nursing homes to keep an operating line available to them to keep going. It has taken us a couple of years to get that component stabilized. We are in the process, on the
longer term, of looking at the role of residential care facilities, in terms of the population. As Mr. Menzies has pointed out, we have started that process, we have done an initial look at some sense, in terms of demographic changes and trends, and are trying to pull together some semblance of a long-term plan to build residential care facilities.
There are two pieces in it that are going to be challenging within the province. The first is that at some point in time there has to be a discussion within the province as to what the direction of long-term care will be. That is simply to say, are we going to continue to go down the pathway of providing seniors facilities in what I would define as somewhat more a hotel-like setting, that we currently use, or do we make a decision to move forward with a different approach, similar to the approach used in a number of the OACD countries, in which they have gone to a community-based housing program. If you do travel to a place such as Denmark, in fact, you will see that they don't have any long-term care nursing homes of the size that we have. The bulk of their seniors are managed at the community level. We need to have that conversation about where we are going to be going over time.
The second piece in all of this is we have not had, to link to that, the discussion of what the role ultimately will be for home care and home support services, and that's really the challenge. Are we going to be aggressive about an aging-in-place model in which we work hard to keep seniors as comfortable as we can in their own homes, in their own communities. As Mr. Menzies pointed out, that particular dialogue is a dialogue we need to have with every Nova Scotian and it's not something we can do in two or three minutes, it's really going to take some time. It certainly is in the planning horizon for the department but again, as Mr. Menzies has pointed out, we have a lot of things on the planning horizon for the department and somewhat limited staff.
MS. MAUREEN MACDONALD: Thank you very much for that. Boy, there are a lot of things to discuss there. I'm going to go back to the response you gave around the need to stabilize costs in the sector and the infusion of $30 million. I would like you to tell the committee about the pressures that this has placed on the per diem allotments for nursing home care.
We recognize that there have been quite significant increases in the per diem rates that are being charged to people in these facilities with no explanation or accountability to families or residents for how these increases are coming about and the impact that this has on families and individuals, given the rigorousness of the financial assessment tool that is being used to force people to pay for their own health care, is extensive already. I would like you to comment on what the department has done with respect to attempting to control the per diem increases. Why haven't you done more to control the per diem costs? Why isn't there accountability for per diem increases and why isn't there transparency in this process for taxpayers and for residents and families?
MR. CHAIRMAN: Who would like to answer that one? Mr. Menzies.
MR. MENZIES: First of all, within the long-term care sector, the funding that the homes get is all through the per diem rate. So when we establish a budget for a home, we establish numbers of full-time equivalents, numbers of staff, salary levels that we are prepared to fund in those staffing, the operational costs, capital costs. From that total budget, the number of days of service a particular facility you are going to provide, divided into that total budget comes out with the per diem rate. It is through the per diem that the homes actually receive their money. If an individual is private pay, they receive it from the individual. When the individual is publicly supported, the individual resident's income goes toward his care and the rest of that cost comes from the province. That is the framework within which we are working at the present time.
Eighty per cent of the clients in nursing homes are publicly supported and at any point in time, if you look at it, it's 80 per cent to 81 per cent. That means as the per diem rates go up, it's the department that is picking up those additional costs for about 80 per cent of the clients. The 20 per cent who are private pay are picking up that full cost. That is basically the mechanism by which the nursing homes are funded at this time, through the per diem rate. In order to properly recognize the current salary costs in the homes; recognize the costs of the benefit plans, including Workers' Compensation, Canada Pension and all of the other plans that are in place; the cost of groceries and fuel, in order to recognize all those so the home can remain viable, we do that in their budget and that leads to the per diem rate going up. On the one hand the recognition and proper funding of the cost of service in the homes is the driver behind the per diem rate. Maybe I could pass that on to Byron, if you would like to comment, or Dr. Ward.
MR. BYRON RAFUSE: I was just going to add to what Mr. Menzies was saying. It is the per diem methodology we use to get funding to the facilities, so a by-product of providing adequate funding for the issues he spoke to, by necessity, has to be passed on to those who are privately paid, it's the per diem mechanism.
We go through quite a rigorous planning and budgeting process with the homes. The homes fully understand what the make up is embedded in the per diems, they understand the level of staff that are included in that, the operating costs, the capital costs included. So there is no reason for an individual not to understand, if they were to ask the home, as to why the per diems are set at the rate that they are, it is all justified, it's based on costs, so there is no mystery behind that. Further to what Mr. Menzies was saying, for us to adequately fund our share of those residents, it's necessary for the private-pay people to match.
MR. CHAIRMAN: The member for Dartmouth South-Portland Valley.
MS. MARILYN MORE: I'm curious to know if you have ever analyzed what percentage of the per diems paid out from the department actually go to capital costs?
MR. CHAIRMAN: Mr. Rafuse.
MR. RAFUSE: It varies from facility to facility. Capital projects are approved by the department, there is a rigorous process currently underway of which those projects are approved, both on - I'm going to say - a facility level, and also on an infrastructure level. Within each per diem we can tell you how much of that is related to capital, but it varies from facility to facility.
MS. MORE: But in terms of the department budget, have you ever added those together to get a total figure?
MR. RAFUSE: I'm sure we have. I don't have that with me, but it's quite easy to do that.
MS. MORE: I would be very interested to know what percentage breaks down into the three categories that you mentioned, the private, non-profit and municipal.
MR. RAFUSE: That's certainly readily available. We have the per diems by facility, and to break it into those three groups, that's quite readily available. To break it down further, as you spoke to what's capital, that would cross those lines between profit, not-for-profit and municipal because there's capital support in each one of those sectors.
MS. MORE: No, no. I realize that, and that's what I'm trying to pull out. I wonder if there's a balance in terms of the approvals for renovations and capital costs in the three categories.
MR. RAFUSE: Perhaps Mr. Menzies could speak about the capital approval process.
MR. CHAIRMAN: Mr. Menzies.
MR. MENZIES: The capital approval process, basically it's the same process whether it's for a for-profit organization, not-for-profit or municipal. We use the same processes. We categorize things based on urgency. Certainly anything required by the Fire Marshal's office or the Department of Labour, Occupational Health are high-priority items. Life safety issues in the homes are high-priority items. We can get those numbers; we don't have them here. In terms of the total capital as a percentage of budget, we can get that and we can also break it down between the three categories.
MS. MORE: I would really appreciate getting that information. Thank you.
MR. CHAIRMAN: You have about a minute and a half, if you wish to use it.
MS. MORE: I'm going to start on another focus that I will be able to continue in the second round of questioning. I will just give you a little time to think about it. The Auditor General has pointed out in the last three audits, in terms of long-term care, that the
accountability around performance indicators is much lower than the financial accountability processes that the department has in place for the long-term care sector. I understand, you've mentioned some of the financial crises that various homes have been in, and that was one of your first priorities, especially Mr. Menzies, when you took over, but I've identified a number of concerns that I think might be of priority to residents and their families, around care needs, draft standards of care that haven't been finalized, and that was mentioned in the 1998 report.
In the 1997 report, there was mention - and I understand the situation hasn't changed - of policies to ensure reviews of resident care needs and financial status. That hasn't changed. In the 1997 report, there was mention also of the continuing interim status of the standards for the community-based options homes. I'm just wondering why there seems to be this imbalance between the focus put on the financial accountability and the focus put on standards of care and accountability that might be of particular interest to residents and families.
MR. MENZIES: The Auditor General's Report speaks primarily to the financial side. The role of the long-term care adviser is much more on the care side and the management of the oversight, if you will, and accountability for care in the homes. We have six long-term care advisers. Each of them takes responsibility for a number of homes, in addition to carrying out annual licensing inspections, which are fairly extensive and a fairly extensive document accompanies those. Any time we have any issues brought to us around any kind of care issues in a home, the long-term care advisers go back in to talk with the facility and investigate more fully.
The area of taking that kind of oversight or licensing process and from there leading into developing indicators and outcome measures hasn't been undertaken yet. I want to assure you that our long-term care advisers are in the homes on a regular basis, not only for their annual inspection but also in terms of ongoing operational issues and any care issues.
[8:30 a.m.]
MR. CHAIRMAN: The next 20 minutes go to the Liberal caucus.
The honourable member for Glace Bay.
MR. DAVID WILSON (Glace Bay): Mr. Chairman, if I may, I would like to venture down a different path for the first little while of my questioning, although it would tie in, I would suggest, with some aspects of long-term care, if you use your imagination to some extent. I want to deal with a problem, Dr. Ward, that we have in my particular area of this province, but throughout the province as well. It's a problem that has led, in some cases, to recent deaths that have garnered some headlines. I'm talking about the problem of prescription drug abuse throughout the province. I want to get some answers to some questions that I think deserve answers.
Dr. Ward, it's my understanding that the Department of Health, about a year ago or more, produced a report on the problem of prescription drug abuse, particularly in Cape Breton. Is that true?
DR. WARD: I'm unaware of that report.
MR. DAVID WILSON (Glace Bay): Has there been any kind of research done? Has there been any kind of study done whatsoever regarding a prescription drug abuse problem in Cape Breton or in any other parts of Nova Scotia, by the Department of Health?
DR. WARD: There may well have been. I'm not aware of it at the current time.
MR. DAVID WILSON (Glace Bay): It's my understanding that the report has been completed, Dr. Ward, as a matter of fact, by the Department of Health and that it recommended some immediate action be taken to try to stem a problem that has led to some deaths in my community alone. But you know nothing of this report whatsoever, sir?
DR. WARD: I've not seen the report.
MR. DAVID WILSON (Glace Bay): I asked you if you knew anything of the report, Dr. Ward, but you're telling me you know absolutely nothing about any kind of a report that has been done by your department regarding prescription drug abuse in Cape Breton?
DR. WARD: I would step back from that by saying a couple of things, Mr. Wilson. The first thing is, through the Prescription Monitoring Program, we have looked at the issue of whether there are difficulties related to the OxyContin or the perceived OxyContin problem. What we have seen on our initial look at the data is that the utilization in the sense of per capita prescription rates of those medications across the province appears to be lowest in Cape Breton.
We are concerned about the problem. We received a letter from the chief of police asking myself and the Deputy Minister of Justice to sit down with himself to really have a look at the problem, to understand whether or not, number one, there is a prescription drug abuse problem. I guess the challenge for all of us in this is once the prescription is handed to a patient, we no longer have control on it. If that patient chooses to pass it on, to sell it, to use it in a different way than had been prescribed, those are things that we do not control at the current time.
We are deeply concerned about these particular issues. We're very aware that it's not only an issue with OxyContin but potentially with other prescription medication and with other addictive substances.
MR. DAVID WILSON (Glace Bay): Dr. Ward, it's my understanding that the Department of Health has been working for some time now with a particular company and has developed and come up with a system that could help with the monitoring of prescription drugs, in particular turning it into what is called real-time monitoring. Is that not true?
DR. WARD: To the best of my knowledge, Mr. Wilson, the department has not been working with anyone. As of last evening, I was made aware of a software company in Cape Breton that has a new product they're working on. It was raised with me as to whether the department would have any interest in it. I said, absolutely, I will be passing that information on to the people in our Addiction Services program and our Information Management Branch to understand, number one, is this a reasonable product; and number two, will it interface effectively with the Meditech product that is currently being rolled out through the Cape Breton District Health Authority.
MR. DAVID WILSON (Glace Bay): So you know nothing about this program whatsoever, nothing about this report that has been presented in calling for immediate action on prescription drug abuse in Cape Breton?
DR. WARD: Well, Mr. Wilson, you seem to know more about the report that I haven't seen than I do.
MR. DAVID WILSON (Glace Bay): Dr. Ward, it's your department, not mine, I'm just trying to get to the bottom of what I understand that the department, through Pharmacare, is ready to roll. But that's not true, is that what you're saying, or you just don't know about it?
DR. WARD: To the best of my knowledge, it's not true.
MR. DAVID WILSON (Glace Bay): One would think that you would know, you are the Deputy Minister of Health in this province, correct on that part?
DR. WARD: Yes.
MR. DAVID WILSON (Glace Bay): The problem is serious enough, don't you think, Dr. Ward, in Cape Breton and elsewhere to warrant some sort of immediate action? Can you explain - and this is not new, this has been years that this has been happening - why nothing has been done to date about this problem, the problem of monitoring prescription drug use?
DR. WARD: With respect to the prescription drug problem, as you are aware, Mr. Wilson, we have put in the PMP, a pharmaceutical monitoring program. The other aspects of that problem have been referred to DEANS, which is the drug advisory group here in the province, made up of professionals, to provide some advice back to the department.
MR. DAVID WILSON (Glace Bay): The pharmaceutical monitoring program right now, could you explain that to me, please, briefly?
DR. WARD: Briefly, the pharmaceutical monitoring program was directed primarily towards the controlled narcotic substances OxyContin, methadone and others. It's a triplicate prescription form in which we track, as best as possible, the utilization of these medications within areas, prescription patterns related to physicians and individuals.
MR. DAVID WILSON (Glace Bay): Does it not take a lot of time, Dr. Ward, to access that information? For instance, the police chief in Cape Breton is calling for help right now in terms of looking for the resources and the tools to monitor this program and get some answers as quickly as possible. That program doesn't provide quick answers, does it?
DR. WARD: No. The police chief is not calling for access to that particular program. I think the police chief is clear in the sense of the boundaries of their responsibilities. As I indicated to you earlier, the chief has written to myself and Mr. Doug Keefe, the Deputy Minister of Justice, asking us to get together with him to talk about putting together a process to look at this problem in-depth, to understand it, and then come forward with some solutions.
MR. DAVID WILSON (Glace Bay): But it has been some time, as I've said, since this problem has been in existence in other parts of the province and in Cape Breton. It was the Bailey inquiry that identified a huge problem with prescription drug abuse in Cape Breton. So your department has done absolutely nothing about it in the time - do you know if it's ever been, at least, talked about in the Department of Health that there is a problem with prescription drug abuse?
DR. WARD: Mr. Chairman, if the member is interested, I'm sure we could organize to have a Public Accounts Committee process to discuss that so that in fact the information and other bits and pieces of paper, the reports and things that he would like to have access to, we would be happy to arrange that. We certainly did not come prepared today to discuss this particular issue. My understanding was we were here to discuss continuing care.
MR. CHAIRMAN: If I could just take a minute to sort of explain the framework that we're operating under here. The topic on the agenda today is long-term care. The Auditor General has studied and reported on that topic, has briefed the committee on the topic, the Department of Health has brought the people best suited to address that topic; however, it has always been the practice of this committee that a member is free to address any topic within the competence of the witness, usually the deputy minister. However, when a member does so, they're running the risk, of course, that the witnesses will not be fully briefed, that the most appropriate witnesses and material will not be available to the committee and therefore that the topic will not be addressed as fully as one might wish.
Within that context, the member is within his rights to put the question; however, I would also say, Dr. Ward, that if your response is that you would prefer to answer it in a context where you do have access to the appropriate human and other resources, that's also, in my view, a perfectly appropriate response. So the member is entitled to ask the question and you're entitled to answer it in the way that you just have.
MR. DAVID WILSON (Glace Bay): Mr. Chairman, I can't think of anyone more appropriate to answer the questions than the Deputy Minister of Health.
MR. CHAIRMAN: The deputy has indicated that there are other people in the department who would be more appropriate to address the question, that there are other background materials that everyone on the committee may wish to review in order to properly brief themselves, Mr. Wilson. But, as I've said, you're perfectly entitled to put these questions but you shouldn't be surprised if the witness says that they're not entirely prepared to address them.
MR. DAVID WILSON (Glace Bay): I will ask the witness a direct question, then, Mr. Chairman. To my knowledge there was a report produced by the Department of Health a year ago that had to do with overdoses of prescription drugs in Cape Breton. To my knowledge, the Minister of Health has that report; it called for immediate action to deal with this problem, but nothing has been done about it. But you're telling me, as the Deputy Minister of Health in this province, that you know absolutely nothing about that report.
DR. WARD: I said I am unaware of the report, Mr. Wilson.
MR. DAVID WILSON (Glace Bay): Could such a report exist without your knowledge, Dr. Ward?
DR. WARD: Yes.
MR. DAVID WILSON (Glace Bay): It could. So you would have no input, you would have no knowledge of it whatsoever? I find that rather strange, to begin with, but you have no problem with that?
DR. WARD: I currently operate a fairly complex department that is, quite frankly, significantly understaffed. Within that department, in addition to sort of directing the operations of the department, I also have significant direct line responsibilities. I have faith in the people in my department. We would be happy to come and speak to you about the prescription drug issue.
MR. DAVID WILSON (Glace Bay): Well, we're talking about it now. Let me ask you, do you think this is a serious enough problem to warrant such action as a task force? Do
you think this is a serious enough problem in this province that something should be done about it immediately?
DR. WARD: I believe I've indicated on two previous occasions that I have received a letter as of yesterday from the chief of police asking myself and the Deputy Minister of Justice to get together with him to put in place a process to do an in-depth look at this particular issue. The chief is very clear, it does require resources; I'm quite happy to bring those resources to the table to make that happen.
MR. DAVID WILSON (Glace Bay): What I'm getting at here, sir, is that it took a letter from the chief of police in Cape Breton to spark any interest in this from the Department of Health when this problem has led to people dying and no one has done anything about it. Sitting back and letting this problem grow out of control when there are things that can be done, such as better prescription drug monitoring - and to my knowledge that has been done and the Department of Health has been sitting on it and not doing anything about it - in the meantime, people are dying in the streets. I attended a funeral on Monday, of two gentlemen, brothers, who died within hours of each other from prescription drug overdoses. That's not right, Dr. Ward. Is the department treating this as a serious enough problem?
DR. WARD: I believe so.
MR. DAVID WILSON (Glace Bay): Well, sir, with all due respect, it would seem to me that there is not too much concern at all. If you're the Deputy Minister of Health and a report has been done and presented to the minister, calling for action and you don't know about it, I would suggest that perhaps, it should be a little more important than that in your department, respectfully so.
How much time do I have left, Mr. Chairman?
MR. CHAIRMAN: You have a little over six minutes, Mr. Wilson.
MR. DAVID WILSON (Glace Bay): Let me leave that topic. Let me get on the subject of long-term care, which I will go back to. I want to ask you, Dr. Ward, about the process involving comfort allowances in nursing homes. Could you explain to me exactly what the process is, briefly please?
MR. CHAIRMAN: Mr. Menzies.
[8:45 a.m.]
MR. MENZIES: I will respond to that question. Within the long-term care sector and the funding that the individual contributes towards the cost of care, if they're publicly
supported, their entire income goes towards their cost of care. They do receive, according to our policy, a comfort allowance of $105 a month. They're allowed to have three months' worth of comfort allowance in their trust account at any point in time, so the most they would have on hand at any point is $315. Then the home does not bill - actually, they can only come up to the $315. If they have more than $210 in their account at the end of the month, the home cannot invoice us for comforts for that month. That's basically the way it works.
MR. DAVID WILSON (Glace Bay): The comfort allowance, if it's three months, which would be . . .
MR. MENZIES: It's $105 a month, and three months is $315.
MR. DAVID WILSON (Glace Bay): After three months, what happens to the money?
MR. MENZIES: It isn't that there's a set amount of money sitting aside somewhere. What the home does is at the end of the month they look at the balances in the trust accounts or the comfort allowance accounts, and they invoice us for the $105, so that we're paying it to those who need it. Otherwise, the home doesn't have access to it.
MR. DAVID WILSON (Glace Bay): There are certain stipulations and regulations regarding what you're allowed to use that money for, is that correct?
MR. MENZIES: That's correct.
MR. DAVID WILSON (Glace Bay): What are they?
MR. MENZIES: It's intended to be for personal use and comfort, meaning the individual's personal use and comfort. The policy that's there does restrict it from being used for things like insurance or gifts, and any family member who's monitoring or doing the purchasing on behalf of a family member has to submit the receipts and so on for purchases in order to be reimbursed.
MR. DAVID WILSON (Glace Bay): Do you ever get any complaints about that program?
MR. MENZIES: Yes, we do.
MR. DAVID WILSON (Glace Bay): Some of the complaints would be along the lines, I would think, that perhaps if it's three months before Christmas and the person involved wanted to save some money up, maybe to buy their grandchildren Christmas presents, they wouldn't be allowed to use that money for that purpose, would they?
MR. MENZIES: That's correct.
MR. DAVID WILSON (Glace Bay): Has it ever increased, the amount, lately?
MR. MENZIES: The amount of $105 was standardized across the province in the nursing homes in 1992.
MR. DAVID WILSON (Glace Bay): In 1992?
MR. MENZIES: Yes.
MR. DAVID WILSON (Glace Bay): It's my understanding that the Premier, before the last election campaign got underway, made a statement that he was going to increase the amount of the comfort allowance. Were you aware of that statement? It was the day before the election.
MR. MENZIES: I've heard the statement, yes.
MR. DAVID WILSON (Glace Bay): You've heard the statement. It hasn't happened, has it?
MR. MENZIES: We've had no direction to increase it.
MR. DAVID WILSON (Glace Bay): Have you had any discussions with the Premier's office or the Premier himself or the minister or anyone regarding whether or not the allowance should be increased?
MR. MENZIES: There have been discussions.
MR. DAVID WILSON (Glace Bay): Aimed towards increasing the allowance?
MR. MENZIES: I think the position that's been stated so far, by the Premier and others, is that it would be addressed, or something would be addressed, in the next business plan or the April budget.
MR. DAVID WILSON (Glace Bay): In the April budget?
MR. MENZIES: It is my understanding that that's the information that's been put forward at this time, and the discussions are around that.
MR. DAVID WILSON (Glace Bay): So we can look forward to hearing about an increase then, in the April budget, of the comfort allowance for people in nursing homes. It's encouraging. We will hold the Premier to his word, he said he was going to do it. Don't you think it's basically unfair - maybe it's unfair of me to ask you that question. Do you think there's room for improvement, in terms of what the comfort allowance could be used for? If this money is accrued for three months, six months or whatever the case may be, you can't use it for extra nursing, you can't use it for extra help, and depending on what items you're going to buy, you can't use it to buy certain items. If you needed a nice new winter jacket and the winter jacket cost $400, I wouldn't be able to go out and buy it, because after three months my money is gone, or there's not enough to pay for it.
MR. MENZIES: There are clothing allowances available as well.
MR. DAVID WILSON (Glace Bay): How much is the clothing allowance?
MR. MENZIES: It's about $150 two or three times a year. So people can apply for that through special needs as well, separate from the personal use.
MR. DAVID WILSON (Glace Bay): It would appear to me, anyway, that there should be some changes. Number one, if it hasn't changed since 1992, I would think that inflation alone has eaten up what that would be worth in terms of purchasing power. Wouldn't you agree?
MR. MENZIES: Yes.
MR. DAVID WILSON (Glace Bay): How much time do I have left, Mr. Chairman?
MR. CHAIRMAN: You have 30 seconds, if you wish to use it.
MR. DAVID WILSON (Glace Bay): Well, I will tell you what I will do, Mr. Chairman, I will hold onto it and pass it on to my colleagues in the Progressive Conservative caucus.
MR. CHAIRMAN: We will move on to the Progressive Conservative caucus.
The honourable member for Pictou East, for the next 20 minutes.
MR. JAMES DEWOLFE: Dr. Ward, I can appreciate the situation you're in when you come into this Chamber. Heading a department with a budget of $2.2 billion is quite a challenge, and to be expected to be on top of every report that's generated would, to say the
least, be ridiculous. The honourable member for Glace Bay is putting the questions to you, whether you should be on top of it when his own Prime Minister was not aware of a $100 million slush fund that they went through. (Interruptions)
Dr. Ward, do you feel that there's enough information at this point to really come out and say that we have a crisis in this province with regard to prescription drug overuse?
DR. WARD: No.
MR. DEWOLFE: So that's why you're working with officials from Cape Breton Regional Municipality and the Department of Justice to study the matter further, is that correct?
DR. WARD: I think very clearly there is a problem with addictions, not only related to prescription drugs but other pharmacologic agents, including alcohol, that are present across the province. A singular approach related only to prescription drug programs may be a beginning point, but there are other fundamental issues that have to be brought into that. The desire to have a province-wide electronic real-time prescription monitoring program would be a wonderful thing, and it's certainly within the purview of the department or the opportunities as we're moving forward in our current discussions with ABCC, who runs the Pharmacare Program with us, to put that in as part of the contractual discussions which are currently occurring.
MR. DEWOLFE: I know drug use is a serious problem. It's a serious problem in Pictou County. Our caucus has been briefed by local police. We've also been briefed by the RCMP and deputy commissioner, and we fully realize the importance of it. I think you're going in the right direction by working with the municipality, the police and the Department of Justice in coming to a determination on how best to handle that situation.
Having said that, the Auditor General has commended us for the considerable progress made in long-term care, and that is indeed the topic we're here to discuss today, over the past five years. The Opposition job is to find fault and, indeed, that's their job, to oppose. You've indicated that there are a few things and Mr. Menzies had indicated that, for instance, there are fewer homes facing financial crisis now than there were when he was working right in the system. I believe you came from administration in that system, Mr. Menzies. You gentlemen over there, your job is to manage and improve the long-term care planning in Nova Scotia, not to make the system less effective. So when the Auditor General indicates that progress has been made, I believe that to be true.
My question is, in what other ways has the system improved? You indicated that the homes are more happy now, because they're obviously managing their finances in a better manner, but there are, no doubt, other ways. I don't know who would like to answer that. Mr. Menzies or Dr. Ward?
MR. MENZIES: Well, I indicated that funding has increased and in the homes there is greater stability there. I'm not so sure I would go so far as to say they're happy. There are still major pressures on the homes, in terms of being able to manage effectively and to have costs fully recognized in some areas. We are working towards that. We've made tremendous strides, I think, in terms of agreeing on where the issues are now. How we move forward then becomes a strategy we need to work through. Of course that all takes resources.
One of the areas that the sector has seen considerable change in is in the introduction of single-entry access as a mechanism by which we do assessment, not only for home care, but also for clients whose care needs are such that they need to go into a facility-based or residential-based program; we now manage that through single-entry access as well. This has enabled us to begin to fully understand where the pressures are in the system, what the true wait lists are.
Up until we introduced single-entry access about a year and a half ago - I will go back a little further. As of 2001, when we said everybody has to at least be classified to go into a nursing home, up until that point, we did not really understand and were not able to any way influence some of the admissions to nursing homes. There were times when people were being admitted perhaps when their care needs were relatively light and they could have been managed at home.
Since introduction of universal classification as a precursor to single-entry access and then putting single-entry access in place, what we have been able to do is at least ensure that everybody going into the nursing homes now needs the level of care provided there and we have at least looked at the issues around, can we provide home care instead. So it has provided us with an opportunity to identify the care need first and is enabling us to better understand how many people are in need of care now which will allow us to fully understand the wait list, where the pressures are in wait lists, and also what kinds of wait times we have. We recognize there is very little flexibility in the health system at all, the resources need to be used appropriately.
Undoubtedly, with the demographics of not only this province but this country, there is need for additional service. It doesn't necessarily have to be in the area of nursing homes. Through this single-entry access assessment, we are better able to understand care needs which will then allow us to start looking at alternative levels of care besides nursing homes. It is allowing us to better manage the system.
MR. DEWOLFE: Is there any consultation planned? What consultation will take place in the new year to determine the best way to address the province's demand for long-term care in the future?
MR. MENZIES: I think I mentioned that very briefly earlier. One of the initiatives that we would like to undertake this coming year is to begin that larger vision work with the sector, with people in the communities, with other providers including the district health authorities, about proper planning and proper development of the full continuum in alternative services, to ensure that we provide the best care for seniors in the most appropriate places. The whole philosophy of aging in place is what everybody says we want to move towards but in doing that it means we have to change the way we provide service now quite radically. I think we need to have that discussion and we need to, from there, move forward in redesigning the system and services so we can do that. So the vision work needs to be undertaken and it is our hope that we will be doing that this year.
MR. DEWOLFE: I expect there will be a growing demand for long-term care in the future, given the numbers, the baby boomers and so on that are starting to age, like the honourable member next to me and I fit that bill, I think, but we're moving toward that, anyway. We are the younger generation of the baby boomers, I guess, but there is an aging population.
MR. MENZIES: There is an aging population and we really have to think about the sustainability of the system. If we continue to provide service at the higher-cost end of the spectrum, then undoubtedly we are going to have even greater financial issues to deal with. I will pass over to Dr. Ward.
MR. CHAIRMAN: Yes, Dr. Ward wishes to add something.
DR. WARD: Two or three pieces that are important on this. Very clearly in the planning process, we need to understand some of the very significant demographic shifts that we are beginning to see in the province. There has been a fairly substantial migration of younger population to the urban core where there are jobs. We do recognize that that leaves a growing residuum of seniors in smaller communities, where it is now becoming more difficult to provide services. If you cannot attract young professionals to those communities, it does add problems.
[9:00 a.m.]
The second thing we are recognizing particularly is while seniors may be comfortable aging in place in their own community, at the point in time when they do become burdened with chronic illnesses, their desire to be close to families and regional medical centres plays a significant portion on what we do see as a growing trend of individuals wanting to move to the metropolitan areas to be close to families. It's great to build a facility now but if you build it and in five years you can't put anybody in it, it becomes a problem. Certainly, the experience in Ontario with putting in place almost 20,000 long-term care beds, there are a number of facilities scattered throughout the province that are currently empty and nobody
wants to go to them. This dialogue with the population about where it is they would like to be at the end of the day is going to be very important and how we service them.
I do think, as Keith pointed out, the conversations with the public about the aging in place piece, how are we going to do that? What are we going to do about formal and informal caregivers? The future for the system, I think, is that conversation with the public on how can we support individuals and families better to manage their illnesses at the community-based level. Everybody can't go into hospital and long-term care facilities, we would just not have the resources there to manage those particular problems.
This visioning dialogue process is vitally important, as I said before. There are some real fundamental decisions that have to be made as we are moving forward. The challenge, just even on the construction side, is quite remarkable. Where do we build those new facilities? How do we build them? Do we provide them to private operators who can raise the capital, or further stress the finances of the province by going out and borrowing hundreds of millions of dollars to build facilities? Those are some very significant decisions and discussions that have to take place.
MR. DEWOLFE: So you are talking about going back to the communities. Is the department planning to devolve long-term care to the district health authorities?
DR. WARD: The discussions have always been to move the responsibilities for long-term care and home care to the districts. The other piece, at some point in time, that very clearly must be moved is physician services. You cannot ask somebody to manage the continuum of care effectively if you don't give them all the components to manage. Very clearly, if one looks at the changes in the country over the decades, particularly through the 1990s, the significant downsizing in acute care hospital beds, was the result of changes in technology and a recognition of early discharge programs.
What is unrecognized in that process was that those care responsibilities were transferred to unpaid caregivers and we now have to recognize and begin to think about how we assist the community in caring for people on a long-term basis, whether it is in residential facilities or at home. Are we going to have a program for aged for daily living that would provide the family with a patient lift if they chose to care for a loved one at home? Would that be an appropriate thing for us to do? I absolutely believe that is the right way for us to go but we do have to have the conversation with the public to understand their expectations and help manage their expectations.
For Cape Breton, quite frankly, it is going to be a huge challenge in the next decade. We do recognize a significant out-migration of the young population, leaving a fairly large population of growing seniors. Those are challenges we recognize and to plan and have the conversations with the community about how you are going to manage that is vitally important and we're absolutely committed to doing that.
MR. DEWOLFE: I'm not sure how applicants' and residents' needs are assessed. What components are looked at in the assessment process? Mr. Menzies, maybe you could answer that.
MR. MENZIES: You are speaking of the care process?
MR. DEWOLFE: Yes.
MR. MENZIES: We use a comprehensive assessment used internationally, actually, it has become fairly accepted across this country as well, it is called the MDS Inter-RAI tool, Minimum Data Set. It allows the care coordinators to identify care needs in various ways so that you're basically looking at a functional assessment, what is a person capable of doing or where do they need help, what kind of help do they need. From that, a professional staff member can then identify what the care needs are and how those care needs are going to be met, what family is able to do and what do you need the formal system to do.
The care assessment itself is fairly comprehensive. It is functionally based, so it does not require - if it generates an answer that may indicate a need for medical assessment then you refer people for medical assessment. But it's basically to identify what the individual is able to do for themselves still or where they are going to need some kind of assistance. It's allowing us to be more consistent in identifying the care needs, which then will lead to us being better able to provide service for them.
MR. DEWOLFE: Dr. Ward or Mr. Rafuse, or perhaps both can answer this question. I am just wondering, what challenges are associated with developing an overall funding formula for a long-term care program? We talked a little bit about funding formulae when the Opposition was addressing this issue, but what challenges are associated with the development of this? This must be one of the biggest challenges that you're facing. (Interruptions)
MR. CHAIRMAN: Mr. Menzies.
MR. MENZIES: Certainly, with the announcement being made by April 1, 2007, we will be moving towards funding a long-term care sector along the lines of the western provinces, which is basically people contributing towards the cost of accommodation based on their income. With that commitment having been made to go there by April 1, 2007, what that brings is an opportunity to look at the funding mechanisms within the long-term care sector and develop, really, a new approach to funding in long-term care.
Again, it's something we will need to do with the current providers, from the perspective that, with any system - and our system right now is based on a per diem basis - there are a whole host of rules that come into play on how you manage a system that's funded based on a per diem basis that you're only paid when there is somebody in the home. If there
are vacancies in the home, that immediately impacts the revenue coming into the home but it doesn't necessarily impact the expenses of the home. The per diem basis that we use right now is fairly difficult to manage effectively for both the home and for the department because it's sort of open-ended.
The advantage we will have in terms of looking at a funding formula is that we will be able to look at a different mechanism for payment as well. So there will be challenges with that in that we not only need to establish all the baselines for what kind of staffing, what kind of expenses will be funded through the system, but we need to do it with the sector as well, we wouldn't be doing that in isolation. But that will bring an opportunity to go to a completely different approach in terms of how we interrelate with the sector. I think Mr. Rafuse would like to comment as well.
MR. RAFUSE: Just further to the challenges. When you move to a per diem, which is really based on cost, to a funding methodology that may more appropriately be based on another kind of mechanism, there are going to be challenges as you move the system from that funding to the new methodology. So it will take a while for the facilities to adjust to that. Under any methodology there could be winners and losers; people will have to maybe adjust their operations to become more efficient based on the methodology, where before if we're just paying costs, there is really less of an incentive to become efficient. So, there will be challenges as we transition the system, I guess, is what I would add.
MR. DEWOLFE: With regard to the facilities themselves, what do you do to monitor the facilities, how is that handled?
MR. MENZIES: Are we speaking of the financial side or the care side?
MR. DEWOLFE: On the financial side of the facility.
MR. MENZIES: In the past few years, what we have implemented is that mid-year we ask for a current financial position along with a projection to the end of the fiscal year. Then in the business planning cycle, when we're seeking their business plans for the upcoming year, we ask again that that be updated so that we have fairly good estimates now on where their costs are running. In addition to that, we require every home to be audited, to have an audit report completed and what we introduced this past year was a requirement that a supplementary part of that audit is that the information be provided in a manner that we prescribe.
MR. DEWOLFE: They're audited each year?
MR. MENZIES: They're audited each year and their auditor has to provide that information. They can seek their own reporting framework for their own use, but part of the audit is that they convert that to the framework that we want, so that we are now able to look
at financial information across the homes and be able then to start looking for areas that we would want to follow up with individual providers.
MR. CHAIRMAN: I believe we have time for 12-minute rounds. The next round is for the NDP caucus.
The honourable member for Dartmouth South-Portland Valley.
MS. MORE: I would like to go back to my issue of performance reporting. I see part of our role as a committee looking at the value-for-money side of things and I'm a little concerned because I don't seem to be able to get the information, because I don't think it's available. I would like to get some clarification on this, in terms of whether or not there are clear expectations and whether there is some transparency around that from the department to the long-term care facilities regarding standards, efficiencies, performance. Are there any expectations that they report on those things for the money that they receive from the public purse?
MR. MENZIES: There is a financial reporting side that I just spoke to, but the other side of it is in terms of the annual licensing inspections and reviewing the home's operations by the long-term care advisers when they do that licensing inspection. It's more than simply going into the home and looking at the general condition. It involves chart reviews to look at the kind of care and kind of service being provided to individual clients. It involves looking at the various operational plans they have in places in terms of preventative maintenance, in terms of emergency planning. So the review that we do annually with the homes is very extensive.
A lot of that time and energy is spent in looking at the care areas themselves; what kind of staffing is in place and, quite often, working with the homes where we have concerns about, perhaps, some of the staffing that needs to be allocated differently to work with them directly. That, unfortunately, doesn't necessarily come through in any kind of report in the way of being an indicator, but the work is being done by the long-term care advisers. It is completed prior to providing them with a licence each year. There is always follow-up from one year to the next in terms of any recommendations that came through in their letters. Sometimes it takes more than a year to resolve some issues. Some things will be ongoing but it is a matter of working closely with our long-term care providers to work closely with the homes on the basis that we're all here trying to do the same thing, which is to provide good care to the clients who are in those homes.
Sometimes the issues that are identified by the advisers are fairly costly items that then fall into the business planning cycle, you know, like when you run into situations where there are building issues, for example, it's not simply a matter of turning around the next day and authorizing major projects, it becomes part of a business planning cycle, but those are identified by the advisers.
We require that the Fire Marshal's Office inspect, annually, each nursing home, and that those reports be made available to us as well, along with a follow-up that the homes are providing or what follow-up they're intending to follow through to meet any recommendations coming from the fire marshal. So there is extensive accountability there, in terms of responding to care needs.
[9:15 a.m.]
MR. CHAIRMAN: I know Dr. Ward wants to add something, but, Dr. Ward, given the time constraints the members are under, I wonder if I could ask you to be brief in your addition.
DR. WARD: The question raises a very interesting point in that the health care sector has been very slow to develop performance indicators based on outcomes or patient satisfaction for the entire continuing care sector, whether it's somebody in residential care or home care. That is just beginning to burgeon in the country.
MS. MORE: I just want to quickly go back to Mr. Menzies' comments. I appreciate that information, but it seems to me that the things you've mentioned are somewhat the mechanics of the process and don't really give us a clear picture of the impact of all of that on the patients or the residents and their families. I guess my last question before I turn it over to my colleagues is, are there any plans in the department to move up on your priority list discussions and action around measuring the impact, so we can see whether the money is being put to good use and some expectation on the part of the facilities to make an accounting for this and not just on the financial side of things?
MR. MENZIES: I understand what you're saying and I agree that what I spoke to was the mechanics of it. At this point, that's where we are in terms of going in and actually looking at it from that perspective. The whole issue, though, of monitoring and evaluation and looking at it from the outcomes perspective is where we intend to go. We've recently allocated or reallocated some duties so that we actually focus some staff in the area of outcome and evaluation, performance evaluation, not only by the homes but by home care. We do a lot of the work in terms of the mechanics, you're right, but it's stepping back and building these quality outcome indicators that we need to do next.
As Dr. Ward has just said, that's sort of something that's coming in across the country, and I think we're well positioned right now to be able to have some staff do that in a way that does allow us to have confidence or to at least understand if there are issues the way you want to be able to understand them. We're moving in that direction.
MS. MORE: Thank you, that's very encouraging.
MR. CHAIRMAN: The honourable member for Halifax Needham.
MS. MAUREEN MACDONALD: The Auditor General has looked at long-term care before and has recommended, in 1997 and 1998, that the Homes for Special Care Act be updated. It's a 30-year-old piece of legislation. I have to say I'm not comforted by some of the information we've gotten here today about where we're at. We spend $222 million in this sector, and you sit here and tell us today that there is no vision and that a conversation needs to happen with the public. When I hear someone say there is no vision, we need a vision, I see that as code for there is no plan, we don't really know what we're doing or where we're going, where we want to be going. I know from my own constituency and from around the metro area and across the province there are major capital renovations going on in the long-term care sector right now, with high capital costs, throughout this province, and I hear the deputy say, we don't even know if the beds, those beds, are where they should be. They could be empty, like they are in Ontario. And we're spending a lot of money.
The Auditor General's office told us last week, and I will quote, "The void that we still see is that the Department of Health doesn't have a process in place to know whether the homes are well managed, they don't have an audit function or they don't have any staff going into the homes to look at financial management . . ." We don't know, in fact, whether the homes are well managed. "From this audit our key findings were there is no long-term strategic or operational plan for the program."
So I have a very simple question, Mr. Chairman, and it is, when are we going to have a plan, when is that conversation going to take place, and will it be too late to have the conversation when we're spending all kinds of money and passing on a significant portion of these costs to residents and their families as their per diems continue to climb and the small amount of subsidy that had been announced four months prior to an election has been completely obliterated and eaten up by these increasing and growing costs? We don't seem to have any handle on - we don't even have public tendering in the long-term care sector. I would like to know, when are we going to have that conversation, when will there be a plan, where are you at in this stage of starting that conversation and having a plan that will reassure members here in the House and the public that the long-term care sector is being well managed?
MR. MENZIES: We have already indicated that we will be undertaking that vision work this year. We anticipate it's going to take a year and a half to two years, if we look at the kind of work that was done to develop the vision work around the mental health system. In the meantime, there is some money being spent on capital and in maintaining the system that is there. Every time we move forward with a project - and we've moved forward with very few - any capital that's been spent in the past five years has been the replacement of existing beds. There have been no additions to the numbers of beds, so we're not building facilities. Part of the reason we're not building additional beds is because we need that vision work done first, and we need to understand what kind of service we should be building.
Regardless of how that plan unfolds in the future or how we do shift much of the system away from nursing homes, we will, I would expect, still have some facilities. So the work that we've done and the capital that we're spending is to maintain the facilities we have, to at least maintain a standard there. In a few places where we've done replacement facilities, it's to ensure that there is still some service in that community that is safe and that those kinds of steps are interim, until we get a good vision and plan in place in terms of where we need to go. I will stop at that.
DR. WARD: We do not do financial audits of the long-term care sector in nursing homes, the for-profits are private companies. We do not have the right to audit them. The not-for-profits incorporated under the Societies Act will file an annual report. Those pieces are there. With respect to the Homes for Special Care Act, that is currently under revision. That responsibility sits with the Department Community Services, which is leading the process in conjunction with the Department of Health.
With respect to the longer term planning piece, we do anticipate, later this summer, bringing out the clinical services planning Phase II, which is to look at the continuing care sector. We do have a sense about some of the growth pressures in the long-term care bed piece, which would appear to be primarily in high population density areas, that being HRM, around the Kentville area and in industrial Cape Breton, as being pressures for us in the future.
The challenge again comes back, are we building community-based nursing homes or are we building large hotel-style pieces. That's a fundamental decision that has to go in that piece. The second piece is, how are we going to do it, is it going to be owned by government or are we going to set up more privately-owned facilities? The major component in that, and the most difficult, quite frankly, is determining the home care side of it. If we move to a chronic disease management program, trying to manage disease better at the community level, as being the direction of primary care reform in the province, and I believe that's the way we must go, then, in fact, we do need to have some significant understanding of what that workforce is going to look like and how we need to move forward on that.
Through our own clinical services planning process, we are beginning discussions with Dr. Janice Keefe and the Maritime Data Centre for Aging Research and home care policy at Mount Saint Vincent to access their expertise and their database, which is now national, to begin to help us plan for Nova Scotia for the future.
MR. CHAIRMAN: Before we move on to the Liberal caucus, I do want to just gently chide the member for Halifax Needham, who I believe was quoting from the transcript of last week's in camera briefing. The purpose of an in camera briefing, of course, being precisely that it not be for quotation or attribution. The member may not have realized that, but I certainly wanted to let the members of the committee know that quoting from those in camera
transcripts is not permitted in this committee. (Interruptions) I would like to move on to the Liberal caucus.
The honourable member for Halifax Citadel.
MR. GRAHAM: Thank you, guests, for coming again to speak to us about this important issue. Dr. Ward, perhaps as my third topic that I would like to touch on, we will deal with the private-public-non-profit issue with respect to long-term care. There are a number of complex issues around this, and I appreciate that our time is very limited and in some respects we can only scratch the surface, but in the 12 minutes that we have, at least for my portion of that 12 minutes, I would like to touch on three subjects. First, and I think that any one of our guests might be able to answer this, have you been asked to cost the cost of covering the health care portion of long-term care for this upcoming budget?
MR. CHAIRMAN: Who would like to answer that? Mr. Rafuse.
MR. RAFUSE: The cost of the nursing costs of long-term care was costed out at the beginning of the process, so it has been well-known as to what the overall cost would be to take that. It wasn't part of this upcoming year's process, it was part of last year's, really.
MR. GRAHAM: I'm asking whether or not it's part of the deliberations and part of the questions that you have been asked to consider for this upcoming budget?
MR. RAFUSE: That's part of the deliberations in front of Cabinet. I'm not sure if we can speak to that.
MR. GRAHAM: I'm asking what you know, what's in your knowledge, whether or not you have been asked whether you will cost the cost of long-term care, the coverage of the health care portion of long-term care, for this year's budget?
MR. CHAIRMAN: Dr. Ward.
DR. WARD: As Mr. Rafuse has pointed, the costing has already been done. The process of implementation will be a decision of Treasury and Policy Board.
MR. GRAHAM: I'm asking whether or not this is a matter of active consideration.
DR. WARD: My answer remains unchanged.
MR. GRAHAM: And your answer is, on whether it's a matter of active consideration?
DR. WARD: It's an issue for Treasury and Policy Board, to make a decision, I presume.
MR. GRAHAM: So it is a matter of active consideration right now?
DR. WARD: I can't speak to what Treasury and Policy Board does.
MR. GRAHAM: I'm asking about what's being considered in the Department of Health.
DR. WARD: No response.
MR. GRAHAM: I would like a response, frankly. I would like to know whether or not your department has been asked to cost the coverage of long-term care health care for this upcoming budget, and whether or not the implications of that are active in your minds.
DR. WARD: Again, the costs have been done. They were done last year. The question as to whether, and the process for implementation, is not a decision for the Department of Health, it's a policy decision of government.
MR. GRAHAM: Dr. Ward, surely you know what's being considered for your department in the upcoming budget. I'm asking whether or not . . .
DR. WARD: Mr. Graham, we're in budget discussions with Cabinet and Treasury and Policy Board at the current time.
MR. GRAHAM: And one of those discussion items includes the coverage of the health care portion of long-term care, does it not?
DR. WARD: I can't comment.
MR. GRAHAM: Because?
DR. WARD: It's a discussion of Treasury and Policy Board.
MR. GRAHAM: So you're refusing to comment?
DR. WARD: Yes.
MR. GRAHAM: I will put it to you just one more time. The implications and the cost of covering health care costs in long-term care facilities for this upcoming budget - you refuse to comment on?
DR. WARD: The costs, Mr. Graham, have been established, last year.
[9:30 a.m.]
MR. GRAHAM: That wasn't my question, Dr. Ward.
DR. WARD: That was your question. It was two parts, whether we talked about the implementation piece as a discussion. My answer was that costing has been done.
MR. GRAHAM: Is it a matter of active consideration as a result of discussions that you're aware of that are happening between one of the Opposition Parties and the government?
DR. WARD: I'm unaware of discussions between the Opposition Parties and the government, Mr. Graham.
MR. GRAHAM: I will move on to item number two. How many more long-term care beds do we need in Nova Scotia?
DR. WARD: At the current time, we have some sense, to adequately cover the current individuals awaiting placement, some place between 150 and 200.
MR. GRAHAM: Has this number been growing over the last number of years?
DR. WARD: The number has decreased in the last couple of years. The single-entry access did manage to move a fair number of patients around more effectively, but the number remains pretty constant at approximately that level.
MR. GRAHAM: What is the principal reason for our inability to close that gap, or to attend to that 150 beds or so?
DR. WARD: There's two components at the current time. One of them is certainly - our sense is that we still have some gains to be made on the home care side, about having people remain in their own home or being moved to a home, we are challenged in finding enough case coordinators, case managers and other individuals on the home care side. Our sense is some individuals do enter into the long-term care cycle earlier than they should because of that. The second piece, again, very clearly relates to the fact that we do have a bit of a deficit in beds. As you are aware, as of this year additional beds were put in place in the Annapolis Valley, recently in the Capital District, and some additional beds were approved and planned for Cape Breton.
MR. GRAHAM: I would like to move on to the third subject and it relates to the different costs that have arisen with respect to per diems. There appears to be quite a range in those costs. Mr. Rafuse, you may have, at the top of your head, a quick indication of what per diem rate is at the bottom of that range and what is at the top of that range. Thirdly, what's the average or median?
MR. RAFUSE: I don't have the bottom and top with me, but the average is about $155 this year. The reason why it varies primarily has to do with the capital component that's embedded in the per diem. A new facility with a large capital outlay would have a larger per diem.
MR. GRAHAM: The low and the high, do you know that?
MR. RAFUSE: I'm going to ask Mr. Menzies if he has it at the top of his head, I didn't bring it with me.
MR. MENZIES: Around $130 would be the low, and the high is just over $200. Just to build a little on what Mr. Rafuse is saying in terms of why the ranges are there, we are dealing with a group of facilities, some are very old and have no capital component, no mortgage left in them, others are brand new and have a high mortgage, and some are in the middle, where they were built 30 years ago with a mortgage at a particular level. For the most part, though, I can tell you that the staffing ratios are relatively close. There are always going to be variations. We do go on the basis of funding the facilities based on their costs. Because of the age of a facility and the layout of a facility, you may have slightly different staffing. I'm confident that, particularly on the care side, our staffing ratios are fairly close. So the big variance you're going to see is on the capital side, a little bit in terms of staffing, within a fairly close range, and then there are still some operating costs that some homes have that others don't, like property taxes.
MR. GRAHAM: Anecdotally, it's our sense that the higher costs are in the private institutions. Is that correct?
MR. MENZIES: Not totally. One of the highest costs is a very small publicly-owned facility.
MR. GRAHAM: But as a general rule, the privately-owned operations appear to have per diems that are higher.
MR. MENZIES: Slightly higher, yes.
MR. GRAHAM: Slightly, do you have a sense of what slightly would mean?
MR. MENZIES: If I look at the overall ranges, taking all the for-profits versus the not-for-profits, on average it's somewhere around $10 a day more, on average.
MR. GRAHAM: If we quickly do math on that range and frankly, again, intuitively, the range between $130 and $200 per day, appreciating the capital costs up front and all the rest, is pretty significant. If that $70 a day - if my math is correct - applied to all of the people, the 5,000 people, we're talking about a potential increase in the cost in the range of $100 million or so, if everyone was brought up to that. Is there any notion that we're going to bring in a per diem that is more level across the board?
MR. MENZIES: As part of a funding formula and where we go in developing a funding methodology, that is one of the options. Ontario certainly went that route, they provide so much per day. Other western provinces, we're looking at how the different provinces are actually funding their facilities so we're open to discussion on that.
MR. GRAHAM: Thank you.
MR. CHAIRMAN: The honourable member for Glace Bay.
MR. DAVID WILSON (Glace Bay): Mr. Chairman, before we wrap up I wanted to clarify a few points regarding the prescription drug problem. Number one, on March 12th in an article on the CBC, the province admits that the program is too slow to catch some abusers. It hopes to computerize the system within a year. And from March 13th in an article in The Cape Breton Post, a spokesman for the provincial Department of Health said that the need to update computer equipment is being addressed, which will help nab abusers.
There is a report, Dr. Ward, it does say there is a problem, it does recommend immediate action. You have said that you don't think there's a crisis in this province because you don't have enough information. I'm suggesting to you that that information is available within your own department, that there is a crisis that needs immediate action and that over a year and a half ago, then Health Minister Jane Purves was supposed to deal with this problem. It has not been dealt with and it needs to be dealt with immediately. That report does exist. That report was done by the Department of Health, in conjunction, who contracted Blue Cross. There is a system that is ready to go, it should have been done some time ago. I am wondering why your department has not acted on this sooner, sir?
MR. CHAIRMAN: Dr. Ward.
DR. WARD: The report in question that Atlantic Blue Cross did was to review utilization rates of OxyContin across the province over a three-year time period. It showed no difference in the utilization rates between Cape Breton or any other place in the province. With respect to the computerization piece, as Mr. Rafuse and I have pointed out, it is part of
contract discussions with our current manager of our Pharmacare Program, ABCC, to put in place a proper computerized system.
I have been made aware that the department did receive an unsolicited request from a software company, to look at a potential drug monitoring program. Our expectation is that upon the completion of discussions with ABCC, any upgrades to the system will be publicly tendered as is required.
MR. CHAIRMAN: Thank you very much. Now I would like to move on to the Conservative caucus.
The honourable member for Chester-St. Margaret's.
MR. JOHN CHATAWAY: Mr. Chairman, I welcome these people to the discussion because it is a very important discussion for all parts of Nova Scotia. I think there was a joke made about how the baby boomers are now the geriatric boomers. Dr. Ward, you mentioned the demographic has more and more people getting older and certainly, we want to have them treated as well as we can. I think the information that I do have certainly emphasizes the great ways we are going forward.
Dr. Ward, I think you said, we have gone from crisis management to better management. Everybody realizes that we have some challenges but we are certainly on the right track and we are making progress. I think a very good explanation of the single-access entry has not only made it more efficient for the people who want to get into homes for special care, but also it gives us a far better accurate account of what people need - not three years ago, not two years ago - at the present time.
Mr. Menzies, you talked about vision work and we thank all of you for having this vision work but we certainly very much appreciate that you have some challenges, you don't go into the office every day and dream of what could happen, you have some real challenges. To that end, talk was mentioned that we might devolve to the district health authorities. Do you have a critical path, do you have where it is going to go from the Department of Health
out to the district health authorities, in that respect?
MR. CHAIRMAN: Who would like to take that? Dr. Ward?
DR. WARD: With respect to the whole spectrum of continuing care, the movement of the home-care-services piece to the districts, we believe can be accomplished reasonably easily. We are in some discussions with Treasury and Policy Board about moving forward on that. The devolution of long-term care becomes a little bit more difficult in that it is a relationship in many occasions with private operators, some for-profit, some not-for-profit. The question is, how can we put in place a mechanism that will allow the districts to have
access or at least direct patients towards those facilities across the continuum of care. We've been very pleased with the single-entry-access piece, in terms of using that as the vehicle.
To date, pretty much all the nursing homes in the province have come to an agreement, voluntarily, with us that they will use the single-entry access for the placement of patients. We think that the next step, on a voluntary basis, going to districts and saying, would you like to try this, is something we certainly think we can do, and again we're in some discussions with the Treasury and Policy Board staff about how to move that forward.
The challenge will remain, as was pointed out earlier and was raised by Mr. Graham and others, is the question of moving to some sort of equitable and fair funding formula for those facilities. When we reach that point, then, in fact, we think it will be legitimate for us to transfer some sense of financial control or responsibility through to the districts to manage that particular piece. It would be inappropriate beforehand, to give the districts the financial component when we haven't sorted it out ourselves, but if we can at least give them the opportunity to control or direct patients across the continuum of care within their own particular health authorities, then that would be a very appropriate thing for us to do, hopefully within the next few months.
MR. CHATAWAY: Certainly in my riding and I think in many ridings of Nova Scotia - there are 52 of us, of course - there are what are sometimes referred to as granny flats. Basically people are helping out their community. I know in the bigger ridings anyway there's opportunity that if a person has lived for many years in a community and can't live alone but the nearest home is a long way away, they have sort of granny flats, where they look after one, two or three people. Do you have any contact with the proverbial people who keep senior citizens in their homes, in the upstairs, downstairs or whatever?
MR. MENZIES: Those kinds of services are provided fairly extensively across the province by various providers. Because of the limited numbers that any one of them is dealing with, one, two or three, they fall outside the scope of the current legislation. Basically the relationship there is between the individual and the operator. The compliance requirements for them are around the Fire Marshal and any local ordinances, in terms of municipal bylaws. The department doesn't have any involvement in most of those kinds of services, other than a number that we inherited or received from Community Services three years ago, where they've operated a number of community-based options and some of those people are now seniors, so they now come under our jurisdiction. We are involved with those ones but for the most part, across the province, that's pretty much an independent kind of operation.
MR. CHATAWAY: I just wondered, because there are some challenges, obviously safety is the number one discipline for everyone. Hopefully, you might want to encourage that, because it's private people and you're basically keeping a community together in that regard. It's certainly a good way to go. My last question . . .
DR. WARD: Mr. Chairman, I was just going to say that really is at the crux of the question about community-based long-term care facilities for the future for the province. The second piece, the safety issue, I think, is vitally important, and I would just put a pitch forward to anyone, conversations with service clubs, and others if they're looking for something to do, putting in place community-based programs where they're going into current seniors homes, doing assessments, putting in grab bars in tubs, walkways, making sure there is safe lighting, that, to me, would be an absolutely wonderful focus for service clubs.
[9:45 a.m.]
MR. CHATAWAY: I think everybody would certainly appreciate it, not only the people using the service but everybody who would miss the people if they're not in the community. It's very good. My final question one-third of our homes are profit homes, one-third are homes for special care run by municipalities, and one-third are non-profit associations. Do you people have any preferences? You get the per diem rates and so on, do you have any preferences in that regard?
DR. WARD: Preferences in what sense?
MR. CHATAWAY: Are the municipal homes better than the profit homes or are the non-profit homes better than the profit homes?
MR. MENZIES: From my perspective, in terms of the service, you really won't see a significant difference between the for-profit homes versus the not-for-profit versus the municipal. Every home has its challenges, every home has its issues, and occasionally we have complaints about every home. They're similar. The service provision, I think, is relatively consistent across the system.
MR. CHATAWAY: I believe so.
MR. CHAIRMAN: The honourable member for Waverley-Fall River-Beaver Bank, with about three minutes remaining.
MR. HINES: Mr. Chairman, recently in my jurisdiction, which is a suburban riding, we had a citizens meeting regarding diversity in housing. During that discussion, we determined that many of the residents now have seniors apartments built into their structures, which, under the Department of Environment and Labour, are illegal because they're overloading the on-site sewage and so on. It was a discussion that took place around that, at that meeting, indicating that there are some roadblocks in specific geographic areas or jurisdictional areas where the private sector cannot build long-term seniors housing or care facilities. Do you have any interaction with Housing and the municipal units that have these different structural formulas? There was a desire to build facilities in my jurisdiction and the
developer backed off because it would have taken him four years to get through the red tape. Is there any discussion going on between your departments?
MR. MENZIES: We've had some discussions with Housing around issues. I would need to understand more clearly. You're saying there is a developer in your area that wants to build a nursing home?
MR. HINES: He wanted to build a nursing home, yes, and he couldn't do it because that particular area, which is the Fall River area, the building guidelines - and I believe there were municipal jurisdictions that were governing that - didn't allow it. It had to be government-built structures, the private sector could not build them. He would have had to have gone through an extensive process of changes to allow him to do that.
MR. MENZIES: I think he would also have an extensive process to go through in terms of getting permission from the Department of Health to build licensed beds. I think that would be a minor issue. If the province were looking to build beds in that area, and a private operator was looking to operate them, I don't know what the municipal bylaws would be, but I assume they would find some way to work through that.
MR. HINES: There were some zoning problems and land use bylaw problems, and in the municipality there are four different jurisdictions, I believe, and in my particular area didn't allow it, so it would have had to have gone through an extensive process. Anyway, I would like to move on to the single-entry access. Could you give me a brief description of how the single-entry access works?
MR. MENZIES: In terms of long-term care clients?
MR. HINES: Yes.
MR. MENZIES: When a person's needs have been assessed using the care assessment and it's determined that a nursing home placement is appropriate, there is a financial assessment carried out as well.
The person's name goes on the wait list for whatever area of the province they are in. The individual has a choice of nursing home to which, if they are accepting the fact that they need to go to a nursing home, it's their choice as to which nursing home they enter. We simply manage the wait list. When the person's name comes up on that wait list, they are offered a place in that nursing home. People can make up to three choices so if they are in Halifax and they want to be in any of the homes around here, they can say which homes. They can say one home and stay on the wait list until that comes up.
The area that is more challenging for us and for families is that when an individual is in hospital, we do require that they take the first available bed within 100 kilometres of their community. Part of that rationale is that hospital beds are a scarce commodity. If someone is truly ready for nursing home care and can be moved to a nursing home, we ask them to take the first available bed within 100 kilometres of their preferred facility. Their name stays on the wait list and they do transition back to their nursing home of choice at the earliest possible time. So our commitment to the people is if they accommodate the system by going to a home that is a little way away from their home, our commitment is we will get you back at the first available opportunity.
MR. CHAIRMAN: Thank you very much. That concludes the time for questioning. I apologize to the members of the committee. I think my calculations were a little off partly because I am never sure how much time the witnesses will request for a closing statement but Dr. Ward, as is customary, you or your colleagues may have up to five minutes to make any closing statement you wish to make.
DR. WARD: No, that's fine.
MR. CHAIRMAN: Thank you very much. Mr. Rafuse, I believe in response to a question from the member for Dartmouth South-Portland Valley, you made a commitment to obtain and submit certain information. I would ask you to submit that at your earliest convenience to the clerk of committees who will distribute it to all the members of the committee.
This committee will meet again next week at 8:00 a.m. The topic is the Department of Finance, SAP, Financial Management Software System, on which the Auditor General had extensive comments and recommendations in his most recent annual report. The following week is Mr. Andy Barker, the former CEO of the Liquor Corporation and that session, I just wanted to alert members in advance is set for three hours instead of the usual two, from 8:00 a.m. until 11:00 a.m. on Wednesday, March 10th.
Are there any other items that require the attention of the full committee before we adjourn?
The honourable member for Chester-St. Margaret's.
MR. CHATAWAY: I'm just bringing forth a wish to the Subcommittee on Public Accounts. I think we have entertained the idea of Mr. Cal Lees, a constituent in my riding, talking to us about assessing sales tax on non-Natives, I think the whole committee is aware of that. Basically, the reply has come from the federal government saying thank you very much, thanks for bringing this to our attention. They have gotten no answers doing this and literally for three or four years, they are not collecting provincial income tax and they should be. So I would very much like to have that discussed sometime and hopefully on the schedule.
Maybe I'm naive, maybe I'm stupid - I know some people would say that - but maybe I'm naive about other issues but I think it should be discussed so we should address that.
MR. CHAIRMAN: I'm hoping to arrange for a meeting of the Subcommittee on Agenda and Procedure within the next week or 10 days and that is certainly one of the outstanding items that we need to bring to a resolution. I'm sure that the Conservative representative on that subcommittee will present your caucus' views on that point. It certainly is an important topic.
Are there any other items needing the attention of the full committee? If not, a motion to adjourn.
MR. DEWOLFE: So moved.
MR. CHAIRMAN: Would all those in favour of the motion please say Aye. Contrary minded, Nay.
This meeting of the Public Accounts Committee is adjourned.
[The committee adjourned at 9:52 a.m.]
