: Sekoh sewakwekon
. Good afternoon, everybody. Bonjour.
Thank you to the chair, vice-chairs, and members of the committee for the invitation to present the work of the tripartite working group on first nations long-term care in Ontario.
My name is Donald Maracle. I'm the chief of the Mohawks of the Bay of Quinte, on Tyendinaga Mohawk Territory in southeastern Ontario near Belleville. We have approximately 10,000 members, of whom more than 2,000 live on the territory. As of 2007, we have the ninth largest membership of all first nations in Canada, the third largest in Ontario.
Long-term care is a long-standing priority issue for first nations across Ontario. In fact, I personally participated in a consultation 25 years ago with the Ontario Advisory Council on Senior Citizens, which released its report, entitled Denied too long: The needs and concerns of seniors living in first nations communities in Ontario, in 1993.
The advisory council highlighted at that time the lack of long-term care for first nations seniors and recommended increasing the availability of long-term care for first nations communities. The fact of the matter is that, while the provincial and federal governments have made significant investments in long-term care housing and health services since these recommendations were made, many of the concerns raised by first nations communities remain the same.
Like all Ontarians, first nations individuals and families want their loved ones to be able to live at home as long as possible and, when and if required, want additional supports to stay in their communities close to their loved ones. Currently in Ontario and across Canada, the vast majority of first nations communities do not have long-term care homes or adequate seniors housing options in their own communities.
Many first nations individuals who are no longer able to live at home safely must leave their communities to access appropriate housing and care. For those who previously were forced to leave their communities to attend the residential schools, this can be a re-traumatizing experience. While there are a small number of long-term care homes operated by first nations—four in total in Ontario—that provide culturally safe care in first nations communities, the vast majority of first nations residents do not have access to services in their own language, access to the land, traditional cultural activities, or traditional food.
It is important to note that the issues go beyond a lack of long-term care homes alone, and exist within the context of disproportionately high rates of poverty, chronic disease, and core housing needs in first nations communities.
Also, we know that long-term care may not always be the most appropriate or economical solution, depending on a community's needs. Improving access to services such as home and community care, assisted living, and supportive housing availability can often delay or alleviate the need for long-term care.
In June 2017, Grand Council Chief Patrick Madahbee, who's the chair of our chief's committee on health, other first nations leaders, and I met with senior officials from the Ontario Ministry of Health and Long-Term Care, Indigenous Services Canada, and Canada Mortgage and Housing Corporation. Together we committed to forming a tripartite working group on first nations long-term care. Chiefs and assembly passed a resolution to nominate representatives from each of the provincial-territorial organizations—Nishnawbe Aski Nation, the Union of Ontario Indians, the Association of Iroquois and Allied Indians, the Grand Council Treaty #3—the Independent First Nations Alliance, and the Six Nations to the working group.
As housing and health services are delivered to first nations communities and individuals by a variety of departments across jurisdictions, in fact, that jurisdictional ambiguity is one of the key challenges for first nations. We want to be sure that we have the right government representatives at the table. Additional government departments subsequently joined or attended meetings. Our meetings included Ontario's Ministry of Housing and Ministry of Infrastructure and Infrastructure Canada.
The mandate of the tripartite working group was to examine first nations' access to long-term care and other seniors housing and care options, and to make recommendations to both levels of government on opportunities for improvements to services and programming.
Over the past several months, our tripartite working group on first nations long-term care has met several times and we've shared our knowledge, research, and data to understand the health and housing landscape for first nations in Ontario. Our final report, which I'm sharing with you today, contains extensive data analysis, which reveals serious population health needs for first nations across the province, as well as service gaps. It also identifies key priorities for first nations and makes a series of recommendations for improvement.
I will now summarize these elements for the committee, beginning with first nations social determinants of health. First nations people in Ontario face significantly poorer health outcomes than those of the general population, including shorter life expectancy, a higher prevalence of chronic disease, and mental health and addictions issues that result from ongoing discrimination and a legacy of intergenerational trauma.
First nations individuals and communities in Ontario often face barriers to accessing health care due to fractured jurisdictional service delivery, limited cultural safety services, racial discrimination, and geography, which contribute to poor health outcomes.
For virtually all of the social determinants of health, first nations in Ontario fare disproportionately worse than other Ontarians.
First nations incomes—at household and individual level—are substantially lower than the general population's. On average, the after-tax income of first nations people is 72% of the average income of all Ontario residents, $9,191 less, on average. The prevalence of low income after tax was nearly 70% greater in the provincial indigenous population than in the Ontario population as a whole, as well as in the 65 and older group.
Many communities lack basic infrastructure to ensure a safe drinking water supply. As of January 31, 2018, there were 60 long-term drinking water advisories affecting 28 first nations in Ontario. I think it's now 50. This may severely impact the health services that can be delivered in a community, such as dialysis, that require a safe water supply.
Lack of an adequate supply of safe and affordable housing—meaning the houses meet the minimum health and safety standards and the residents are able to afford the occupancy costs—in many first nations communities has tremendous health impacts and often leads to housing insecurity for families and seniors.
Mould growth in houses is a significant issue in many communities, and there are more house fires on-reserve, with a house fire death rate 10 times greater than that for the rest of Canada. According to CMHC's definition of inadequate and unsuitable housing, 34.6% of housing on first nations reserves is considered inadequate and 14.8% unsuitable.
Based on the social determinants of health, you would expect that first nations health needs would be more acute than the general population's. This is precisely what we found.
The tripartite working group was formulated to access new data produced in partnership with the Chiefs of Ontario and the Institute for Clinical and Evaluative Sciences.
The first nations aging study examined frailty in first nations populations. It found, as we know from our own communities, that first nations adults experience higher rates of frailty and chronic disease at a much younger age than the general population.
Approximately one quarter (26%) of first nations adults aged 45-54 are considered “frail”. The sharp rise in frailty happens in much younger age groups in first nations populations compared to the general population. It happens 25 to 30 years earlier in first nations on-reserve.
This has tremendous implications for the need for health services such as long-term care.
I would now ask Graham Mecredy, senior epidemiologist at the Institute for Clinical and Evaluative Sciences, to present some of the key findings of the first nations aging study in more detail.
I'm just going to go ahead and run through three slides here, with a couple of figures of the results that we found.
We start with some basic demographic information. This information comes from the IRS, which is the Indian registry system. It's basically a census of all registered and status first nations people in Ontario. This shows that as you increase in age, there are fewer people, which is to be expected, but the interesting part of this graph is the proportion of those living on and off reserve. That proportion is increasing as you increase in age. Looking at the 45 to 54 age group, it's around 32%, and that increases all the way up to about 40% in the highest age group.
The next figure here is what Don alluded to earlier. It talks about frailty in first nations people. The information for this comes from a different source. It comes from the regional health survey, which is a representative sample of on-reserve first nations individuals across the province. We looked at a list of 16 different frailty indicators that people were asked on the survey—things like self-perceived health, BMI, and vision loss. There's a list in the appendix of the report if you want to see it in its entirety.
Basically, anyone who had over five of those 16 conditions was considered to be frail. If someone had three to five, they were pretty frail. One or two was not that big an issue, as they were not considered to be frail. The easiest way to look at this figure is to look at that bottom section in each age group, the dark blue bar. That shows that as you increase in age groups, the proportion of people who are frail living in first nations communities is increasing dramatically. It increases all the way up to the age of about 65, where it reaches 50%.
That is a huge number. To compare it to the general Ontario population, we pulled in data from the CCHS, which is the Canadian community health survey, represented by those red squares on the last two bars there. We didn't have information for all the age ranges, just the older people. Looking again at the 65-year-old age group, only 16% of the general Ontario population in that age group is considered to be frail, compared to 50%, as I stated, on first nations reserves. Obviously that's a huge discrepancy.
As Don mentioned, people living on first nations reserves are becoming frail much earlier than the general population. If you look at the 16% and compare it to the comparable number in first nations, you have to go all the way back to the age of 35. It's a 25- or 30-year difference that we're seeing in the development of that frailty, so it's a big difference.
The last slide here is looking at the percentages of people who have two or more chronic conditions. This comes, again, from the IRS. We have a list of 18 different chronic conditions. Again, that list of 18 is in the appendix of the report, so you can look at that. It includes things like asthma, diabetes, and cancer—serious diseases. We looked among the first nations population, both on and off reserve, at how many people had at least two or more of those conditions across the age groups.
As you can see, that's increasing with age, as you would expect. One interesting thing, looking at the difference between off-reserve and on-reserve populations, is that it actually appears that the off-reserve have a higher rate of multiple chronic conditions. That increases with age, and you can see the biggest discrepancy in the 75-plus group.
We can't say for sure why that's the case. It could be that people who live off reserve have more frequent interactions with the health care system. The way this data is captured is by people going to the doctor, or going to the hospital or the ED. In order to show up in this data, they have to have access to those services. People who live off reserve are likely closer to those services and can access them more easily, and hence show up more in our data. It's also possible that people who have multiple chronic conditions are more likely to move off reserve to be closer to those services. Again, they would show up disproportionately more in the data because of that.
Aside from that, the main take-away from this is the huge number of people living with multiple chronic conditions. Once you get up to the highest age group, 70% to 80% of people have at least two of these serious conditions. These are people who really require a lot of care.
That's all for me, and I'll send it back to Don to finish the presentation.
Thank you, Graham, for that presentation.
The fact that frailty occurs at a much younger age group in first nations populations compared to the general population points to the need for intensive supports such as home care, assisted living, and long-term care earlier and more often.
As of November 2017, there were 628 long-term care homes in Ontario with 78,943 licensed beds. Of these, only four long-term care homes are located in first nations communities, with a combined capacity of 223 licensed beds, representing less than 1% of long-term care beds in the province. As a matter of fact, it's 0.28.
With regard to health and housing services across the continuum of care, while our working group focused on the need and availability of long-term care for first nations communities and individuals, we also know that long-term care sits alongside continuing care supports that are available. Like all Ontarians, first nations seniors want to live at home as long as they possibly can. Investments in home and community care are available, and availability of congregate living options such as elders homes that provide assisted living or supportive housing may allow more individuals to stay in their homes or community for longer periods.
While retirement homes are an option and often a potential alternative to long-term care for many Ontarians, high poverty rates in first nations communities and the lack of culturally safe and appropriate retirement homes in first nations communities eliminate this private pay option for many first nations seniors.
I also want to mention that first nations communities often have difficulty securing capital financing for health and housing facilities. Even if they have access to operating funding, access to capital funding is complex and jurisdictionally jumbled.
Based on the need and gaps in services, the first nations tripartite working group has identified a number of key priorities and made recommendations to the Ontario and federal governments. The priorities for first nations are improved access to services, improved capital planning and financing, strengthened community decision-making, and improved data collection. In accordance with those priorities, we have the following recommendations.
There should be new long-term care home beds specifically set aside for first nations.
The federal and provincial governments should make new investments across the housing continuum that make the most sense based on community need. Investments should identify and account for additional cost considerations and potential solutions for operational facilities in first nations.
Ontario should examine expanding its existing capital planning grant program to help first nations communities determine what capital investments are required to best meet the health needs of their population.
Canada and Ontario, in partnership with communities, should explore opportunities for innovative and alternative funding arrangements for seniors housing, infrastructure, and capital investments across the continuum, based on the needs of the individual communities, whether that be for long-term care, assisted living, or supportive housing.
Canada and Ontario, in partnership with first nations communities, should establish a mechanism for facilitating the federal-provincial first nations capital planning process. The process should enable a one-window approach for first nations to access the resources they need as opposed to working separately with jurisdictions or individual programs.
Canada and Ontario, in partnership with first nations communities, should improve data collection on first nations seniors' health and access to services in order to fully understand the need and to inform policy-making.
Ontario should work with the long-term care homes sector, human resources sector, and first nations communities to improve culturally appropriate and safe training and to address staffing challenges around delivering services to first nations.
In conclusion, I want to emphasize the pressing need in first nations communities for improved access to housing and health services across the continuum of care. The report we have shared with you today makes the need clear and makes concrete recommendations, which are opportunities to improve the lives of first nations individuals across the province.
There was a news release that the Ontario government has made an investment in additional long-term care beds, 30,000 over 10 years. Five thousand are being allocated now, and 500 of those have already been allocated to first nations communities. The Mohawks of the Bay of Quinte have received 128. There's an indigenous group in Toronto that will receive 128. The rest are being divided up between seven different first nations, but with each tranche of funding, first nations will be a priority because of the long-standing neglect.
I'd like to address your point.
Normally for long-term care, we think of about an hour's radius as being acceptable, but in first nations, if you look at the facilities, there are only four that exist. You might have to go seven hours away, and so the chances of your having interaction with your family are very minimal. It's a lot different than going to Smiths Falls to go into a long-term care facility. I'm working with the Moose Cree First Nation, and it's 1,200 miles. If your senior leaves that community, you're not going to be visiting.
In Ontario, because there's such a lack of long-term care for first nations, they've had to travel all over the place. When the person does move, if it's an older couple, for example, and the husband can't drive, he's not visiting anymore. There are a lot more complications. If you're in an urban setting, that's one thing, but for most first nations, they're looking at being spread out quite a bit.
I don't think the same argument works in that case. That's why we need to support our first nations facilities.
Good afternoon. Sekoh
. I bring greetings on behalf of the Mohawk Council of Akwasasne and the community of Akwasasne.
I'm Grand Chief Abram Benedict. I'm joined today by Keith Leclaire, our Director of Health.
Today we're going to describe to you our health services and how we have identified ways to enhance service coordination for the delivery of services to our community. Using culture as a foundation, we employ a strength-based community approach, combining traditional and western-based health options as an integrated health system. For this reason, we are a modern first nation community offering health services based on promoting Akwasasne's cultural strength.
Our community—the map is up here for you to see—is about an hour south of here, on the international border between Canada, the United States. We're a jurisdictionally unique community and an international border community, with half of our community residing in Canada in the provinces of Quebec and Ontario, and the other half in the United States, in upstate New York. This map lays that out a bit. The islands on the northern side, which are grey, and the mainland, are the jurisdiction of the Mohawk Council. The blue, with the red and the blue lines, is the New York state component.
The Mohawk Council is the governing body of the Canadian portion of Akwasasne. My membership is approximately 12,500. The Mohawk Council, as an organization, has eight departments, and about 800 full-time employees—upwards of 1,000 between part-time and full-time—delivering about $100 million in services, in partnership with the federal government predominantly, as well as the provincial governments.
The unique setting creates many challenges in providing services and programs, because we have to work—specifically around today's presentation—within the health requirements of two provinces, but yet one community. In addition, our community of Akwasasne is geographically landlocked by the St. Lawrence River, separated from the Canada mainland, as well as the United States. The three districts which the Mohawk Council services—Cornwall Island, Tsi Snaihne, as well as Kanatakon, which is also known as St. Regis village in Tsi Snaihne—are all under the jurisdiction of the Mohawk Council of Akwasasne.
We also have the added burden of having to report to the CBSA, which is located in the city of Cornwall, before returning to the district of Kawehnoke, which is Cornwall Island in the province of Ontario. This port of entry is the tenth busiest, with approximately two million vehicles crossing annually, with 70% of the traffic being Mohawks of Akwasasne. I reiterate that: 70%. When we look at border-crossing communities across the nation, there is no other community that has 70% of the traffic crossing the border daily, and 70% of that traffic being indigenous peoples. There's a huge difference here, when we talk about border communities and people trafficking all the time. Nowhere else in this country will you find the same people crossing predominantly across that international border all day, every day.
Despite this, the MCA has diligently worked to minimize the impacts of the border on the daily lives of our community by negotiating special arrangements for areas like emergency services. We also utilize a political protocol with Canada, to call Canada and the provinces to a table to discuss solutions to jurisdictional challenges that our community faces. This also includes the health care area.
Akwasasne delivers indigenous services similar to what other first nations communities offer. I must highlight that for the past 20 years we have run our own ambulance services funded by Ontario, Quebec, and ourselves, delivering ambulance services to our community. For the past 22 years, we have been in full control of our Akwasasne non-insured health benefits program, which is normally administered now by Indigenous Services, but formerly by Health Canada. For the past 25 years, we have operated Tsiionkwanonhso:te, a 50-bed long-term care facility licensed and supported by the Ontario Ministry of Health. For the past 23 years, we have operated Iakhihsohtha, a 30-bed care facility in Akwasasne within the Quebec district. We operate four medical clinics across Akwasasne. We operate a fully functional traditional medicine program, and we provide a 30-day rural health work placement for medical students from McGill and Ottawa universities, which incorporates work with our traditional healers.
One of the things that we heavily promote is our partnerships with the federal government, municipal governments, private businesses, and institutions such as colleges and our universities.
The entire Mohawk Council of Akwesasne Department of Health is accredited under the auspices of Accreditation Canada, meeting the highest Canadian quality standards of health services. This is something we're extremely proud of.
In short, our services have evolved into a truly integrated health system, using our culture and values to guide western health-related sciences in program delivery. This is done through exclusive use of our traditional language, traditional medicine, and traditional ceremonies.
I'll now turn it over to our director of health, Keith, to go over a bit more of the programming that we deliver.
[Witness speaks in Mohawk]
I'm very proud to be here, and I'd like to share with you our long-term care concerns.
First of all, from Akwesasne's perspective, we understand fully well that the Canadian health care system is fragmented—some provincial stuff, some federal stuff. However, it is our responsibility in Akwesasne to make sense of the different multi-jurisdictional issues, to find solutions, and to meet with the appropriate entities to make that a reality.
Indigenous Services provides support at the federal level, with Ontario health and the réseau de la santé Québec offering support at their levels. Almost half of our community is served with OHIP for insured services, and the other half is served with RAMQ for insured services from the Quebec side.
I think you have had a good chance to see what's on the map over there. Short and sweet, we have roughly 12,500, as Grand Chief Benedict has said. We're pretty well split up, with about a 45-55 split between the Ontario and Quebec groups.
However these multi-jurisdictional issues for Akwesasne have created challenges in providing seamless secondary and tertiary health services. When we provide outside of Akwesasne, Ontario, we have to come up to Cornwall, and we have to go in for tertiary services to Ontario, basically Ottawa. On the Quebec side, we have to go to a smaller community, Barrie Hospital, which is located in Ormstown, Quebec, about 45 minutes away, and for tertiary services, we have to go to Montreal. These are samples of where we are.
As is normal, we face these jurisdictional challenges daily. We search for solutions, using innovative approaches and partnerships to resolve the jurisdictional issues we face.
Long-term solutions require a community, strength-based approach, and basically we're doing that. Our community has strengths that afford prioritizing our services to meet the needs of our community members. Our strength is in our ability to prioritize those services. In addition to our community approaches, we offer you a portrait of opportunities within the current system that we hope you will be able to listen to and give some thought to some of our reflections.
The first point we want to tie in is on infrastructure. Akwesasne recommends that you examine the support for maintaining existing resources that are now under community control. This hasn't been considered very well up to now. Akwesasne's long-term care facility is Tsiionkwanonhso:te, and in medical terms that's a level 4 care service. Tsiionkwanonhso:te, by the way, means “our house” in our language, and that's just what it is. It's not an institution; it's an extended part of our community.
Our level 1 and 2 care service is Iakhihsohtha, which means “the home of our grandparents”. We've operated both of these, as Chief Benedict has said, for more than 20 years. Our concern right now is that these two care facilities require infrastructure improvements and support to continue providing the quality services that we give.
Right now, I think long-term care requires long-term support for infrastructure, given the fact that our long-term care facility is actually funded by the province, yet it is located in a first nation territory under federal government jurisdiction.
Due to the federal-provincial divisions of authority, we require your support to seek solutions as we talk about more large capital investments. If we want to continue providing long-term quality care for our people, we need to make sure we have the infrastructure and the buildings that are sufficient to meet the codes.
We are unable to access capital and infrastructure enhancements right now, and I think that's a point we want to make sure you consider in the writing of your report. Please look at this as an issue.
Also, what we're looking at now is prevention. One of the things that our health services, like all of those across Canada, needs to focus on more is the preventative aspects of long-term care.
I think most of the time we're here talking about what the needs are for the facilities, but I'd like your assistance in recommending some departmental support to assist in capturing evidence-based data to show our success, especially in prevention support activities.
I've asked a number of times, and the reply I keep getting back is that it's a bit too complicated. You can get back information on an annual basis about how many people came to a facility, how many people are there, but, in fact, when we start talking about prevention, that isn't done over a three-year or a five-year period. It's done over 10 years, or over decades. One weakness in the system here is that we have to look at how we can support the challenge to get better evidence-based information on this.
What I'm really tying in here is that a prevention type of evaluation is longitudinal in nature and it takes time. As we know, Canada is facing an aging population overall, and we all need to be innovative. I think that's one of the areas we should be looking at, looking outside the box.
Also, Akwesasne has better services provision than do most other first nations across Canada, and we offer you this advice: There will be gaps in service levels in the long term.
Right now your definition under the federal classification system for institutional care, which is found within the National Assisted Living Program Guidelines 2018-2019, delineates service responsibility between Health Canada, FNIHB, and the previous DIAND under the assisted living program. Right now, I expect modifications of this classification system, with greater community-based participation, and, in fact, we at Akwesasne are prepared to assist you with any technical revisions to make sure that does happen.
Our biggest concern also is for the mental health and mental wellness of our elders. There needs to be consideration to enhancing programs that impact mental wellness for our elders given our size and districts in Akwesasne. As you can see, we're spread out. The reality is that it is difficult for long-term care clients to socialize.
The last point we are really trying to tie in here is that we have to ensure there is an acknowledgement of volunteerism. Most of the time a lot of our activities that are going on are adult care, day care services, and meals on wheels, and a lot of times we have a lot of individuals who are providing mental health support. In reality, what we need to do is to make sure we have recognition through your recommendations to support and enhance volunteerism at our community level.
With that in mind, I'll pass it back to Chief Benedict.
I think that as we know, in all populations statistically, the population continues to grow whether it be indigenous or non-indigenous. As Chief Maracle testified earlier, housing is a huge component to our communities, including our own. From a service delivery perspective, we outlined that the capital needs are huge as well because the facilities we maintain and operate also have aged and continue to age. We need to be able to meet that need and continue to deliver a service that's expected of us, that's required of us, and that our community expects.
As the government starts looking at ways to transform contribution agreements, looking into flexibility, this also applies to the health care sector as well, because sometimes we end up reporting on things that are probably not all that useful anymore.
We talked about data. Our organization is very large, with eight departments and $100 million in services, but it's sometimes difficult to collect all that data together. It's an engine, though, that does exist to be able to do that. I'm looking at supports. I know other communities have them as well. As we look to grow as an organization, we look at innovative ways to be able to pull that data together, to be able to innovate our services, meeting our accountability and transparency requirements of our funding partners as well as our community—which is absolutely important to us—but also having the flexibility that we need in these long-term agreements as well, for sustainability.
Those are some of the high-level concerns. We know that our community continues to press upon us to provide seniors housing as well as facilities, long-term care facilities, whether it be chronic, acute, or just simply living facilities. As we continue to grow as a community, we continue to plan for this. I'll look to add a bit more on the program delivery side, but that really is the high level of where we're going, our vision, as a community and as a service provider to our people as well.
We believe in partnerships. If we have an issue, we are going to identify that issue. We're going to find out the trigger; why is this problem arising? Then we're going to look at the basis: what causes it?
You gave a good example when you described that everybody in Saskatoon was asking for money and they have all these foundations. If I were in your shoes my question to them would be: what do you need the money for? Because you have so many small groups, maybe there is a need to do what we have done in Akwesasne—come together and prioritize the need, and then work on that.
I'm very proud to say that we run ambulances, and the reality is that when we needed a new ambulance, our community came through and provided over $200,000 to be able to purchase a new one and to give the best cardiac monitoring machines to go into each one.
We can sit down as a group, and we can haggle. Sometimes it's longer than days, but once we come up with the priority, we come with one mind.
When I talk about a cultural perspective, as the Mohawks of the Gayanashagowa, we believe we're following what's known as the Great Law of Peace, which indicates there are five main tenets that we have to follow in our daily lives. One is peace: we have to be at peace with ourselves and at peace with others; we have to have respect: respect for ourselves and respect for others; kanikonriio,which means we have to be of good mind and we have to come together because we know we can't solve it, and if we can't, we're going to get stuck, and we're going to be in our own areas; the fourth tenet is being responsible: we know our responsibility and how the other people we're working with have to be responsible; and accountability: every government has it and that is one of our main tenets as well.