Indigenous and Northern Affairs Committee on May 31st, 2018

[The Chair, Liberal, MaryAnn Mihychuk]

Welcome, everybody. We are here on a study on long-term care. You're at the indigenous and northern affairs committee of Canada. We're sorry that we're late. We had a vote, which means that we were delayed.

Pursuant to Standing Order 108(2), we are doing a study of long-term care on reserve.

Before we get started, I want to always point out that we're on the unceded territory of the Algonquin people, and that it's an important piece of recognizing the truth and working toward reconciliation.

I understand, Chief Maracle, that you're going to be leading and doing the presentation. Go ahead. You have 10 minutes.

You may need a little bit of extra time, I understand.

Go ahead.

[Chief R. Donald Maracle, Chief, Band No. 38, Mohawks of the Bay of Quinte]

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.

[Graham Mecredy, Senior Health Analyst, Senior Epidemiologist, Institute for Clinical Evaluative Sciences (ICES), Chiefs of Ontario]

Thanks, Don.

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.

[Chief R. Donald Maracle]

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.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you.

Questioning opens with MP Mike Bossio.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Thank you so much, Chief Maracle and Grand Chief Abram, for being here today. We really appreciate this testimony.

These are exactly the kind of data points and information we need, which will greatly help to inform this report and indigenous services moving forward on the need for long-term care.

Chief, when Minister Philpott, you, I, and other representatives of the Mohawks of the Bay of Quinte met this past winter, we discussed long-term care. Facilities was a component of our conversation, along with many others, but it was a central component of that.

For the purpose of the committee and this report, can you please outline the unique challenges and considerations our study should include when looking at long-term care facilities in first nations communities?

[Chief R. Donald Maracle]

I don't understand your question, Mike.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

We know there are a lot of long-term care needs that exist within society, but what are some of the unique challenges that you see within your own community around those needs and the delivery and fulfillment of those needs?

[Chief R. Donald Maracle]

I handed out some information. On the back page, you'll see a report that's addressed to the regional chief, Isadore Day. It's on Canada's letterhead.

In the Ontario region, there's a unique situation regarding capital. If you turn to the third page, you will see that Ontario has 22% of the indigenous population living on reserves, yet they only received 14.5% of the overall funding. Oftentimes, because of the larger populations on reserves in Ontario and the chronic underfunding of INAC programs, a lot of the capital money that's available gets diverted into O and M expenditures, which makes the capital budget to build new structures very limited.

There have to be measures taken by the Government of Canada to correct this situation that affects the Ontario region. There have been discussions with the associate regional director general, Anne Scotton, and with the headquarters staff. The minister, Jane Philpott, is aware of it. We're just waiting for some corrective action to be taken to address this situation that has plagued Ontario for decades with this chronic, unfair funding allocation to the indigenous communities in Ontario.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

What I wanted to allude to, as well, is that the Mohawks of the Bay of Quinte itself it is quite representative of the overall need that exists for long-term care. Maybe what you could do is give us a snapshot of the need for the Mohawks of the Bay of Quinte and how that is reflective of the overall need for indigenous communities.

[Chief R. Donald Maracle]

I'd like to turn you to another page that I handed out. There's a letter there from our nurse, Gloria George, and she estimates that 37 members.... They have currently 60 members who receive home and community care, so that would represent about 60 households. There are more than 1,200 households in our community. In addition to that, we have about 2,200 of the 10,000 members who live on the reserve. Within the periphery of the reserve, there are about 3,000 members who live within a short commuting distance of the reserve, and if the services are available in the community, they expect to receive those services because they're members of the band.

Actually, the federal government encourages us to treat all of our members equally. They may have grown up on the reserve and had to move off the reserve because of the lack of housing or to get a job, but when they retire a lot of them do come home, and so there's always a lot of pressure to find housing and long-term care. As you can see in the report, there are a number of people who are on a waiting list for housing at the elders lodge. Many people are frail and can't find affordable housing because of limited incomes. There's also a shortage in the municipalities of affordable housing around the Mohawk reserve, and just about every reserve in Ontario. I know the national government has recognized that there has to be help given to the municipalities to deal with the issue of affordable housing across the country.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

I see this list you have. A total of 66 people are on the waiting list right now.

[Chief R. Donald Maracle]

That's just for housing, but of those, probably a lot of those would need long-term care.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Exactly, and that's what I was going to get at.

Mr. Bouchard.

[Bernard Bouchard, Associate, Assured Consulting, Mohawks of the Bay of Quinte]

I was going to mention that in the area of the South East LHIN, there are 5,210 people waiting for long-term care. In Ontario, we know that over the last 14 years we haven't seen a decrease at all in the waiting list. It's actually grown. While the government has announced new beds, and that's welcome news for everyone, there are still over 3,200 people who are eligible for long-term care and can't find a bed to go to. For first nations seniors, many of them can't afford the preferred venue, which is semi-private or private. Often what happens is if you can afford a private room, you can get into the facility much quicker. For first nations seniors living on reserve, their income is so low they're the ones who end up being stuck in the hospital or living at home at risk. We see that the system is not really addressing those issues, and that's why we hear every day about the bad things that are happening in long-term care as well as the hospitals and emergency wards being jammed. For first nations seniors, they don't have the income. They can't access the publicly funded system for private and semi-private rooms so they have to wait for what they call “basic accommodation”. Seventy per cent of all the seniors, of the 30,000 in Ontario, can only afford basic accommodation. That's one of the problems.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Would you say a big part of it, as well, is that they could be overshadowed because of the massive demographic bulge that's happening with our aging society within Canada? That's the reverse of what's happening within indigenous communities. There are so many more younger individuals. We're having an exponential growth of youth within indigenous communities, but it's the absolute opposite in—

[Bernard Bouchard]

When the Province of Ontario brought in 20,000 beds in 1998, they based it on the formula of people aged 75-plus. At that time, when we looked at the first nations groups in 2006, we saw that the average age was about 10 years younger. What this report demonstrates is that it's even younger than that. We could even look at 55 as being a group that could need long-term care, but you're right; we normally think of long-term care being for somebody 75 and over.

[The Chair, Liberal, MaryAnn Mihychuk]

The questioning now goes to MP Arnold Viersen.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Thank you to our guests for being here today.

Do you want to finish that thought?

[Bernard Bouchard]

No, I'm fine.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

I'm not sure what the real thrust of this is. We didn't come to this study because we saw a major problem; we just wanted to understand it.

Particularly where I'm from in northern Alberta, there isn't really this on-reserve, off-reserve issue. The nearest town ends up being where you end up living in a long-term care facility.

What's interesting is that, reserve or non-reserve, folks are just frustrated about the fact that they have to leave their community and go 100 kilometres down the road to live in a long-term care facility.

I was wondering, from your perspective, where you're at. Is that an issue, as well?

[Chief R. Donald Maracle]

On the issue of the 78,000 licensed long-term care beds in Ontario, 50% of them have to be redeveloped, or they will lose their licence. If they lose their licence, it's going to make the shortage of beds all the more chronic.

In addition to that, 50% of those beds are for basic rate. If first nations don't have other pensions, other than the old age pension and the guaranteed income supplement, they don't qualify. They don't have enough income to be able to afford to go there. Then, coupled with the alarming increase and the waiting lists, the way it's growing for long-term care....

In the South East LHIN there is a 99.2% occupancy rate, which means that people have to wait until someone dies to free up a bed. The South East LHIN has the most severe chronic waiting list of all the homes, but all of the homes in Ontario have chronic long waiting lists, sometimes up to two years. Both the Canadian government and the Province of Ontario are supposed to be committed to looking after the well-being of the citizens of this country. There is a responsibility on both governments to address this need, which cries out for some immediate attention.

When the Province of Ontario looked at it, they recognized that there was long-standing neglect of first nations investment in long-term care or housing options. That's why the whole file is so dismal.

We are here today to ask the federal government for some capital investments in housing and long-term care and to partner with the Province of Ontario and the first nations communities to address this.

[Bernard Bouchard]

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.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

One of the issues we run across all the time—where I'm from anyway—is that we can build the facility, but getting people to work in it is a whole other story. Have you had any experience in that field?

I'm worried a little bit. Talking about licensed facilities, sometimes what the government does is just lower licensing requirements, and then we get more facilities.

[Chief R. Donald Maracle]

The Mohawks of the Bay of Quinte have an excellent track record with the First Nations Technical Institute, partnering with colleges and universities to provide training programs so people get the appropriate job qualifications. We would use that model there. There's plenty of money for employment and training for the skills that are definitely needed everywhere in Ontario. There will be plenty of opportunity to get jobs in those fields.