Welcome, everybody, to the indigenous and northern affairs committee of the 42nd Parliament, first session. Today is meeting number 109, and pursuant to Standing Order 108(2), we're in the study of long-term care on reserve.
Before we get started we always recognize that we're on the unceded territory of the Algonquin people here in Ottawa. It's an important step for us to reflect on that even if it's momentary, as we're in a process of understanding the truth and moving towards reconciliation.
The committee is thrilled to have you. You're at the beginning of a new study on long-term care. We hope it's a short study and very effective on long-term care, which we need in many communities. We will be receiving presentations. You have 10 minutes to present, after which we'll go through questions from the members of Parliament, and that will conclude this session. After that, I understand there's the will to have an in camera session on committee business. That's what we're doing at this meeting.
We'll get started with the Department of Indian Affairs and Northern Development. That's a bit confusing, isn't it? Are you the Department of Indigenous Services? They're nodding yes, but you're not officially a separated department until the bill comes. Is that why we have this issue?
Thank you, Madam Chair. Good afternoon.
Thank you for the opportunity to appear before the committee regarding long-term care on reserves. It's obviously an important subject for all communities, Canadians and indigenous peoples alike, in terms of the need for long-term care.
Obviously, elders or seniors are an important aspect in indigenous cultures in terms of knowledge keepers. They also play an integral role in terms of the vitality and well-being of communities writ large, as part of families, in guiding young people and young families, and for the strength of communities and nations. Indigenous peoples turn to their elders as key sources of traditional knowledge, wisdom, and cultural continuity.
I've been told quite clearly, in my travels and in other business meetings with communities and leadership, that first nations individuals and families want to be able to live at home as long as possible, and if and when they require additional supports, to stay in their own communities close to their loved ones. We've heard this time and time again as a common thematic message.
Many first nations individuals, of course, who are no longer able to live at home safely due to complex illnesses or disabilities, must leave their communities to access appropriate housing and care. For those who were previously forced to leave their communities to attend residential schools, in some instances this can be a re-traumatizing experience. That's something we need to think about.
In terms of needs for services, it's important for all of us to keep in mind that the demand for long-term care facility beds is affected by both the number of seniors in a population as well as their overall health status. While the percentage of the on-reserve first nations population over 65 is relatively small, it is growing quickly. By 2016 the proportion had risen to about 28,000 individuals. According to projections, the number of seniors could be more than double by 2036, to almost 75,000 first nations seniors on reserve likely requiring some level of support in terms of housing or assisted living, home and community care, and/or long-term care.
In addition to the increasing numbers of first nations seniors, it is important for us to consider the nature and complexity of the health conditions they face. Compounding the rising size of first nations senior populations, as I mentioned, is the fact that first nations often have more chronic health conditions—as we've all heard, probably, in previous submissions—than non-first nations seniors. By age 60 approximately half of the first nations adults on reserve have been diagnosed with four or more chronic health conditions. My friend and colleague Robin will get into some of that detail.
Our short-term remarks this afternoon will provide you with an overview of the current existing services, along with the continuum of continuing care, the situation in terms of long-term care, and the future opportunities, including current policy development work being led by Indigenous Services Canada.
Before we get deeper into the subject matter, I'd like to clarify for the purpose of the presentation that we're looking at the term “long-term care” to mean “facility-based long-term care”, actually a structure or facility with a team of expertise. It's a term that is used differently across the country, as we can imagine you'll probably hear from different jurisdictions, and territories and provinces. However, we'll use the Canadian Healthcare Association's definition:
||Care is provided for people with complex health needs who are unable to remain at home or in a supportive living environment. Health service is typically delivered over an extended period of time to individuals with moderate to extensive functional deficits and/or chronic conditions.
That's the classical, Canadian Health Care Association's definition that's guiding some of our discussions.
The association itself uses the term “continuing care” to define a system comprised of four elements: home care, which is a big area of interest and investment from Indigenous Services Canada's perspective that we are currently in, and Robin could get into some of that detail; community support services; supportive and assisted living; and long-term facility-based care. Continuing care is a system, in our minds, of service delivery encompassing a range of health and social services that address the holistic health, social, and personal care needs of individuals who do not have or who have lost some capacity for self-care.
These integrated services are designed to improve individual functioning and to provide culturally sensitive support and care in the community where possible, through different stages of aging and illness, up to and including palliative and end-of-life care.
Also, for clarity, I think it's important that since the study is on long-term care on reserve, our response will be focused on needs and programs specific to first nations.
Now I will turn this over to my colleague, Nurse Robin Buckland, to provide you with a brief overview on the home and community care program and the assisted living program, which are two major instruments or initiatives that are funded in terms of first nations on reserve.
Great. Thank you, Keith. I'd like to thank the committee for the opportunity to come here to speak about long-term care. We're quite excited about the fact that the committee is studying this issue, so we are hoping that we are going to be helpful in the remarks that we offer today.
I'll jump right into our home and community care program.
The first nations and Inuit home and community care program was launched in 1999. It's delivered in first nation and Inuit communities right across the country. In terms of first nation communities, it's actually available in 96% of the communities. The services are delivered based on a needs assessment that is done, and there's a range of services that are offered through the home care program to help people who are living with acute, chronic, and complex health issues, so that they can remain in their homes.
The program has a number of key elements that must be delivered in the communities. It's delivered predominantly by RNs, licenced practical nurses, and home health workers. In 2013-14, over two million hours of service were provided to approximately 35,000 clients across 686 first nation and Inuit communities.
While the home care program is to be universal and accessible, there are gaps. The gaps include only being available from Monday to Friday from 9:00 to 5:00. You can imagine a senior living at home requiring services. They might need something after 5:00 at night. That is certainly a demand and a gap.
Like provincial programs, the home and community care program does place limits on the amount of service and the number of hours that are provided to clients. Another gap that we saw prior to budget 2017 was in terms of what were previously called “allied services”, such as physiotherapy and occupational therapy. Typically, communities did not have funding to provide those services. Fortunately, with budget 2017, we saw an investment of $184.6 million over five years in the program. This is quite significant. Communities will work hard to use these dollars to increase the services that they're offering in their communities, increase the number of hours, and offer some of those additional services such as physiotherapy and palliative care.
Brenda is going to talk to us quickly about the assisted living program that she is responsible for.
Thank you, committee members, for inviting me to provide comments here as well.
In addition to the services provided through the department's home and community care program, there are also services available through the assisted living program. These services fall within the range of non-medical supports, things such as housekeeping, homemaking, etc. This is a $110 million per year program that has three components: in-home care, adult foster care, and institutional care.
Eligible individuals may receive in-home care services—as I mentioned, light housekeeping, homemaking etc.—and other activities to help them maintain their functional independence within their home. In 2016-17 about 9,600 individuals benefited from the in-home care program component of the the assisted living program.
Adult foster care is a type of service that is also available. It provides supervision and care to individuals who are unable to live independently because of either physical or cognitive disabilities. These are individuals who do not require 24-hour continuous nursing or medical care. In 2016-17, 118 individuals participated in the adult foster care component of the assisted living program.
The institutional care component of the program helps to subsidize the facility copayment fees related to room and board for those within an institutional environment, long-term care facility, or personal care home, either on or off reserve. In 2016-17, some 830 individuals benefited from the institutional care component of this program.
It's important to note that this program really functions like an income support program, in that it is available to those individuals who cannot pay for institutional care or in-home care supports themselves. It very much mirrors what provinces and territories do with respect to in-home care and institutional services.
As well as not having the financial means, individuals must also not have any available family members who can provide the service to them. It's thus very limited in the scope of its application.
Sure. Thanks for the question.
Long-term care is a new issue for us at ISC to be looking at. We probably will not have all the answers. We're just exploring long-term care ourselves. Recognizing that this is a gap in the services available to first nations on reserve, we're beginning to explore the issue as well.
What I might say, and I suspect some of the committee members may know this, is that long-term care varies quite significantly right across the country. It's not an insured service under the Canada Health Act, so provinces deliver it in different ways in different provinces. Even within provinces there are variations.
When it comes to long-term care facilities on reserve, we have—and this is more the purview of Brenda—very few facilities. I think the number of facilities across the country is....
Recently I've been fortunate enough to participate in a tripartite discussion with the Chiefs of Ontario, with leadership from across the province of Ontario, and the Ministry of Health and Long-Term Care to develop some ideas and options around partnering and the monetization of long-term care facilities.
As we know, for example, in Ontario they are responsible for the licensing of long-term care bed spaces and the operations of the facilities, but they are not there for the capitalization process. I wouldn't call it a debate but more of a spirit of co-operation to look at various strategies and options. In Ontario, for example, there are 30,000 people on waiting lists in the province alone. A chunk of that is probably related to first nations looking for long-term care spaces.
In other jurisdictions I'm not aware of any debate. It rests, in my mind, largely on the provincial or territorial government's mandate for the administration of long-term care facilities.
In some cases there has been some modelling and partnership development and co-funding facilities. I could say that we have some research in that area, but I wouldn't necessarily categorize it as a debate. It's just where we can partner, where we can collaborate, which is part of the energy I'm sensing in British Columbia, Nova Scotia, and Ontario. Other jurisdictions may vary.
That's a great question. The larger discussion on new fiscal relationships with indigenous communities, first nation communities across the country is opportune in terms of looking, for example, at a 10-year grant in terms of a funding relationship. The grant would provide a certain level of flexibility, I must say, in terms of planning, monetization of partnerships with the private sector or the province around looking at the facility needs that the community would define as a priority.
I think we are at the early days of that discussion, but we're certainly looking forward to our target, as was publicly announced, to have at least 100 recipients in a grant-like arrangement for a 10-year period. That would definitely look at responding to community needs based on what their priorities are as defined by the community and the leadership.
Optimistically I could say that this creates a window to actually do some innovation in terms of partnership development or securing funding from other sources that could build actual infrastructure. We're limited at this time. We have a policy constraint, as we speak. We will also, of course, work with what we have in terms of capital funding for health facilities, nursing stations, treatment facilities, etc.
Thank you for that question.
Jordan's principle definitely applies to first nations children living on or off reserve. We've worked quite hard, as I'm sure you're aware, to increase access for children to services and to fill gaps when we see gaps.
For the time being, Jordan's principle applies to kids, but I think we can think of it in a similar way, in terms of there being a gap and our wanting to close the gap. We're working very hard to improve the outcomes, for example, for first nations seniors living on reserve, so that health outcomes are similar to those for other Canadians.
In my mind, Jordan's principle is a useful way of looking at it—let's look to fill the gaps and reduce the gaps—but Jordan's principle per se applies to kids. We are, however, definitely working hard to look at the issue and to figure out what the potential solutions could be so that we can close the gap.
I'll take a crack at that. Thank you for the question.
From my experience in listening and working with a number of communities across the country around the issue of long-term seniors care, I think it's safe to say, and a number of them have also said, that depending on the size of the communities and the location, it's not feasible to have a long-term care facility in each and every community, obviously. Where there is critical mass, it might make sense.
For example, in Ontario—and I hate to use Ontario as an example continually, but it's my experience—Wikwemikong is a large community on Manitoulin Island. Also, Six Nations obviously has a sizeable population. Oneida has a really wonderful facility, with both indigenous and non-indigenous patients, as does Akwesasne, of course. They have the critical mass to have the business case to have a facility in those communities. There might be others.
From what I'm gathering, people want to look at different options and modalities—a hub and spoke model, for example.
Think of Sioux Lookout, for example. There is a high population of northern indigenous Oji-Cree community members in and out of Sioux Lookout, or living there. At least they would have more accessibility if they had a long-term care facility, which is what they're promoting right now. The Town of Sioux Lookout, the Sioux Lookout First Nations Health Authority, and a number of the chiefs have been looking at a model that could serve northwestern Ontario.
I think it will have to be nimble and will have to be innovative in terms of different approaches for rural and remote communities. It's the issue of accessibility, however. We have many fly-in communities and not everybody can afford the air flight.
Thank you, Madam Chair.
Thank you, witnesses, for being here.
I want to start with talking a bit about this idea of institutional care in terms of level 3 or level 4 long-term care. What has been the determined threshold for the size of a community, numbers wise, that it would take to sustain a facility like that?
Normally, I know in New Brunswick, which is where I'm from, you need to have a population centre of 4,000 to 5,000 people with an outlying population to support a facility of that size. What is that number that you think will work, and then how does that look? Is it a combined facility that takes into account assisted living and then level 3 care and level 4 care as a total overarching approach to end-of-life care, or is it different conceptual models that will work within a community or group of communities? How do you see that?
I'm really concerned about the viability of building facilities. It's great if communities can afford to build the facilities on their own. I know there are some communities that have chosen to do so, but just because they've chosen to do so doesn't mean it's necessarily a viable option. Of course, in New Brunswick, we have the exact opposite problem. Except for indigenous communities, we have a declining population. We're building for the top of the bell curve knowing full well that 15 to 20 years from now, the older of our long-term care facilities are actually going to be decommissioned or turned into something else because we just won't have the population we need to sustain them. Could you just speak on that?
I'll do a quick thing, and then Robin can do it. That's very interesting.
The viability in my humble estimation.... For example, the long-term care facility in Oneida in southwestern Ontario has a mixed model, i.e., it is long-term care living, assisted living, and level 3 and 4 institutional care. They have a mixed portfolio, if you will use that term, to make it viable and sustainable.
I think the same principle applies to the other facilities I mentioned earlier. It's mixed. It's not all level 3 or 4. That just doesn't make sense for that population locally, but there is also a catchment area that they're trying to serve. Obviously they'll need to look at the diverse needs within that catchment area to make it viable and sustainable, and it has worked obviously for a number of years. But again, those are exceptional, high-population communities. I think we need to look at some variations in approaches for sure.
I wanted to touch on something quickly that MP McLeod had mentioned earlier around accessibility and the idea of keeping people in their homes as long as they so choose.
I know my family had that opportunity. My grandmother wished to stay in her own home as long as possible, and she was able to do that for about five additional years by making a few simple upgrades to her home. One thing that we've talked a lot about in this committee is housing on reserve and how we should be building housing on reserve with accessibility in mind, so at the very least a minimum of visitable housing. This is the idea that every home that's constructed meets the criteria to have zero-barrier access, wider doorways and hallways, and a ground level washroom facility so that we can plan for the future and allow people to stay in their homes.
I'm wondering if that's something you feel should be taken into consideration and how that could be approached with the communities looking to build housing, because we know that there is a significant need within a lot of communities to build new housing. Maybe it's something that should be suggested or thought about in terms of the long term.
As we alluded to earlier, we have no policy program coverage for long-term care facility construction.
In most cases—perhaps Brenda can speak to it as well—communities have been resourceful in terms of own-source revenues, monetization from the private sector, or other streams of revenue—for example, from the First Nations Finance Authority. They've created the momentum, built the facilities, and then secured the operation and maintenance for running these long-term care facilities from the provinces or territories, generally speaking.
Brenda, I don't know if you have any details.
Basically, yes. We work with our partners in each region and territory to look at the best way of allocating. It is a formula-driven process to ensure that there's some equity across the board. It's also to ensure that for the smaller communities, there's a base with at least one full-time home and community care nurse as opposed to half-time.
To go back to your earlier question, whilst nine to five sounds so black and white and so rigid, I don't think it's the reality in a number of communities. They might start at eight, end at four, or go into the evening, depending on the need. Robin can correct me on this, but I think another aspect that's important to note is that home care nurses work with the families. They work with the daughters and the sons and the aunties to help out on the basic administration of bandage replacements or what have you. It doesn't end at five, per se.
Again, the band determines, with their local health department, what the best regime is. They will adjust and be flexible. Nine to five sounds too “clinical”, or whatever the right word is. I don't think it's the reality in terms of what the communities want and need.
Generally, with the new investments you'll see a lot more mobility and flexibility in terms of design and hours. That's important to note.