Health Committee on Oct. 31st, 2011

[The Chair, Conservative, Joy Smith]

I call the committee to order.

I'm Joy Smith, the chair of this committee. I'd like to welcome our witnesses. We're very pleased to have all of you here today. I think there's a little information that wasn't given to you. You understand that today is Halloween and the guests traditionally bring the treats for all the members. Don't let that worry you. This being a health committee, they have to be healthy treats...just kidding.

[Voices]

Oh, oh!

[The Chair, Conservative, Joy Smith]

But I do have to say that we will be right on time today because we have a lot of mums and dads around this table who want to have the opportunity to take their children out trick-or-treating. The little people really enjoy that, so we'll be right on time.

We're very pleased that you're here for this very important study of chronic diseases related to aging. It's something that this committee has taken very seriously, and we want to be able to gather as much information as we can from all of you.

I want to welcome Suzanne Garon, who is here via video conference.

[Suzanne Garon, Principal Investigator, Research Centre on Aging, University of Sherbrooke, As an Individual]

Thank you. I am going to speak in French.

[The Chair, Conservative, Joy Smith]

That is trés bon. There's my French. I have three kids who speak it very well, but unfortunately their mum keeps trying to learn and never gets the time to do it consistently. That's a problem. I love the language. Please speak in French. We have translation here.

We also have with us, from the Canadian Pharmacists Association, Jeff Poston, the executive director, and Phil Emberley, director of pharmacy innovation.

Welcome. We're very glad you're here.

We have, from the National Initiative for the Care of the Elderly, Dr. Sandra Hirst, executive board member.

Welcome.

On the translating research in elder care project, we have two people who are going to be speaking about a project together, I understand.

We have 10 minutes, so you'll each have five to do that.

As individuals, we have with us Dr. Carole Estabrooks, professor, Faculty of Nursing, University of Alberta--my sister is a nurse, so I appreciate all the good work you folks do--and Dr. Dorothy Pringle, professor emeritus, from the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

Welcome.

We will begin with each organization giving their 10-minute presentation.

Madame Garon, please.

[Suzanne Garon]

Thank you for receiving me. I am very pleased to be here today.

I would like to tell you about the Age-Friendly Cities Project, or Villes amies des aînés in French. It is an international project that has received Canada’s full support from the very beginning. More specifically the Public Health Agency of Canada has played a crucial role since the project was in its infancy. The first stage went from 2005 to 2007.

I handed out a short document. The project resulted in research being done in almost 33 cities in 22 different countries, including Sherbrooke. So we were involved. This enabled the World Health Organization to establish some broad parameters for dialogue and development on several themes related to our aging population and to explain how we can make our cities more suited to, and more liveable for, seniors.

This was a first experience for Quebec and I was still working with my colleague Marie Beaulieu at the time. With the research team that I am leading at the moment, we have developed a participation model for seniors, built around the broad parameters set by the World Health Organization. One of the parameters is active aging, which is built on three major pillars: health, safety and participation.

We feel that a framework of analysis has to include a holistic approach to health and that those three components contribute to better health.

I would like to draw your attention to what we call social participation. Social participation has a major impact on seniors' health. All studies show that seniors who are active and feel they contribute to society are in better health objectively, meaning it is a proven fact. They also feel—their subjective health—that their health has improved. This reduces morbidity and mortality in addition to increasing their feeling of well-being and satisfaction.

It is also scientifically proven that participation greatly reduces depression and symptoms of depression. This plays a role in keeping cognitive decline in check and in reducing the feeling of being in pain. It increases muscle strength and physical performance, while reducing the need for home support services.

For all those reasons, it is important to have age-friendly cities with appropriate facilities so that our seniors can take their rightful place and be full-time participants.

Together with seniors, we have started a project designed for them based on those principles. As a result, our seniors can act as decision makers since they are involved in every step of the project, including the assessment in their communities and their cities. They determine the process, identify what doesn't work and what could be improved. In addition, the seniors committee plays an active role up to when the project is implemented through an action plan. The seniors are even also invited to participate in finding solutions at that stage. So they are not just waiting for services, but they also have a say in those services. They become people who contribute to their communities through their associations and their involvement in the research stage. The seniors help to form control groups in which they are both participants and analysts at the same time.

As expected, the areas of focus at the World Health Organization are the major determinants of health. Each of those eight areas—outdoor spaces, transportation, housing, social participation, respect, inclusion, employment and civic participation, whether in the context of community support or communication as a way to be heard—is taken into account. For each of them, projects have been set up in our cities.

There is a key aspect. In Quebec, we have carried out dozens of projects. In some pilot projects, we have had over 450 people involved. For the projects currently underway, the model has been set up in the same way. We have seven pilot projects in 316 different communities. We also have committees in charge of pilot projects and of the control groups made up of seniors. One of the themes connected to the major determinants of health I just mentioned is obviously housing, having a home. That is a crucial finding.

I would like to share some of the things that came up. One of them is the importance of having housing conditions that work for seniors and that can help them stay in their homes for as long as possible so that they can be socially active without depending on services. For that to happen, adapted, adaptable and affordable housing is a must, since not everyone can afford to live in expensive homes.

I will quickly go on with my presentation. In order for aging to take place at home, it is also important to have access to local services. Those include groceries, leisure activities, health services, as well as a safe environment that is walkable or that has good public transit. Home support services for daily activities and seasonal work must also be set up.

There are 316 communities involved in Quebec. In Canada, over 500 cities are currently setting up those types of projects. The Quebec model is based on five years. The World Health Organization adopted the model as having three stages: assessment, action plan and implementation. Everything gets seniors involved in projects that are designed for them. Canada also uses that model. Seniors are at the heart of it. This initiative brought a new way of working together for various housing and health partners who, in most cases, did not know each other. It also makes knowledge transfer possible in terms of research. Research data are collected a number of times. The transfer is done between our research team at the Research Centre on Aging at the Université de Sherbrooke and non-profit organizations that administer and work with each of the cities in order to implement the model.

So, we went from seven pilot projects to 316 towns in very little time. That funding comes from Quebec's department for families and seniors, the ministère de la Famille et des Aînés du Québec. According to our minister, Ms. Blais, that is a social investment. That is basically all I have to say about Quebec.

Things are also going very well in Canada. With the help of the Public Health Agency of Canada, several provinces have moved on to the implementation phase. Three provinces are extremely active: Manitoba, which also has a centre for aging research; and British Columbia and Nova Scotia, which have been involved from the beginning and still are.

Internationally, our team and Canada play a key role as a global leader. Most researchers who developed the model are part of the World Health Organization's foundation. Together with my French and European colleagues, I am currently working on creating a francophone subgroup that will be ready next June.

I have used all my floor time, right?

[The Chair, Conservative, Joy Smith]

Thank you very much, Madame Garon. That was very interesting.

We'll now go to the Canadian Pharmacists Association, to Mr. Jeff Poston, please.

[Dr. Jeff Poston, Executive Director, Canadian Pharmacists Association]

Thank you, Madam Chair, and thank you to the committee for the invitation to present today.

My name is Jeff Poston, and I'm the executive director of the Canadian Pharmacists Association. With me is Dr. Phil Emberley, CPhA's director of pharmacy innovation. We are the national association representing pharmacists in all areas of practice. CPhA is also Canada's largest publisher of drug and therapeutic information for health care professionals. We provide evidence-based information to support doctors, nurses, and other health care practitioners in clinical decision making.

By 2021, the population of Canadian seniors is expected to reach 6.7 million. Currently, 74% of Canadians aged 65 or older are taking at least one medication. In 2008 over 75% reported having at least one of eleven chronic diseases, which included cancer, chronic pain, diabetes, heart disease, and depression.

Additionally, we spend about $833 per person per annum on drugs, making us one of the highest spenders among OECD countries. Maintaining affordability and obtaining value for money are key challenges. Evidence also tells us that elderly people are more likely to experience drug-related problems and adverse reactions to drugs. This is as a result of being on one or more medications due to a number of chronic diseases, and to the diminished capacity of the body to handle drugs as we age. Chronic disease also poses challenges in younger people, particularly with respect to continuation and adherence to drug therapy.

Pharmacists are the medication experts in the health care system. Today, pharmacists receive at least five years of university education, including training in patient care settings. Recently, most provinces have passed legislation that provides pharmacists with a degree of prescriptive authority, which allows them to change a patient's drug therapy to improve patient outcomes. This is obviously done in collaboration with the patient's physician and other members of the health care team. I shall say more about collaborative care later.

Given such legislative change, pharmacists, as both medication experts and the most accessible health care professionals, are ideally positioned to assist in delivering services to the aging population. Pharmacists can play a significant role in chronic disease management by providing comprehensive medication management. This involves critically assessing patients and their medication regimen for appropriateness, effectiveness, safety, and convenience; identifying any problems that may exist with drug therapy; and developing a plan to fix them. This plan has to be shared with the patients' other health care providers, and then pharmacists must follow up with the patients to make sure that desired outcomes are achieved.

Research has demonstrated that such services save money and help patients. An estimate by the Ontario Pharmacists' Association reported that expanded scope services would save $72.4 million a year in health care in Ontario in one year alone. In a large U.S. study, pharmacist-led medication management services provided a return on investment of $1.29 for each dollar invested. Furthermore, over 95% of surveyed patients agreed or strongly agreed that their overall health and well-being had improved as a result of these services.

In addition to the new legislation, pharmacists are also working in new collaborative models of practice, such as family health teams. Studies have shown that pharmacists in such teams can play a key role in managing diseases such as high blood pressure, raised cholesterol, asthma, and other chronic conditions. Improving drug therapy through collaboration leads to fewer emergency room and physician visits, and thus allows for potential health care savings. As we go forward, ensuring a pharmacist presence in inter-professional health care settings is an important component of the care that we need for our aging population.

In June 2010, this committee, in its report dealing with health human resources, offered several recommendations aimed at enhancing inter-professional collaborative care, including the pursuit of greater collaborative care for federally served populations. We would support these recommendations, and suggest that the committee may consider repeating these recommendations in its final report.

Investment in electronic health records and e-prescribing systems is also necessary to support collaborative care and improvements in the continuity of care.

We are encouraged to see provinces beginning to fund new pharmacy services. For example, in Ontario, the government is paying pharmacists to help patients quit smoking and to optimize drug therapy for patients on multiple medications, those receiving home care, and patients with diabetes. Pharmacists are also funded to review patients' drug treatments in Quebec, Saskatchewan, and Nova Scotia. British Columbia is currently funding a pilot study.

We recommend that the federal government explore funding of pharmacist medication management services as part of federal employee health care programs and for clients of the Federal Healthcare Partnership and the first nations and Inuit health branch.

The federal government already has a number of programs and investments in place to address chronic disease and aging, such as the federal tobacco control strategy and the Canadian diabetes strategy. We've worked closely with the government to provide programs to develop pharmacy services and improve patient outcomes with respect to smoking cessation and diabetes management. CPhA would encourage the government to continue to strengthen its support for those programs.

The accessibility of pharmacists in the community setting also positions them well to play a major role in the early detection and prevention of disease. This involves screening for diseases such as raised blood pressure, the provision of immunizations, smoking cessation, and promoting wellness and healthy lifestyles. Recognizing the potential for pharmacists to provide vaccination services, governments in British Columbia, Alberta, New Brunswick, Manitoba, and Nova Scotia have passed legislation to enable pharmacists to perform such services. These developments allow Canada to be able to better respond to public health challenges.

Research has shown that pharmacy-based screening programs reduce hospital admissions. As an example, a large Canadian study published this year showed that pharmacy-based blood pressure screening programs in 39 communities in Ontario resulted in a 9% reduction in hospital admissions for heart attack and heart failure in patients 65 and older.

As we move toward the renewal of the 2004 health accord, CPhA would urge governments to make health promotion and disease prevention a cornerstone of the new accord in 2014, particularly as we believe this will be a reflection of the needs of the aging population.

I'd like to touch briefly on the Canadian Pharmacists Association's role as a publisher of drug and therapeutics information. Our online service, e-Therapeutics+, provides doctors, nurses, and pharmacists with an up-to-date, evidence-based source of drug and therapeutics information that helps them make better decisions to support improved patient outcomes.

CPhA would like to work with Health Canada and Canada Health Infoway to increase point-of-care access to this resource through integration in electronic health record applications, including e-prescribing.

In conclusion, pharmacists have a key role to play in managing and minimizing the impact of chronic diseases on Canada's elderly. By working to help strengthen that role, either unilaterally in partnership with the provinces and territories or with pharmacists themselves, the federal government can play a lead role in helping Canadian seniors access the quality care they rightfully deserve.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you very much. That was a very insightful presentation.

Now we'll go to the National Initiative for the Care of the Elderly, with Dr. Sandra Hirst.

[Dr. Sandra Hirst, Executive Board Member, National Initiative for the Care of the Elderly]

Thank you, Madam Chair.

I offer my apologies for not bringing either carrot snacks or apple wedges, but I'm not sure they would have fit in my briefcase.

As context, the National Initiative for the Care of the Elderly was established about five years ago through funding from the national Centres of Excellence. It brings together geriatricians, health care professionals from nursing, social work, and other disciplines. Since its initial establishment, it has now grown to more than 2,000 members and includes lawyers, police officers, and a variety of other individuals committed to promoting the health and well-being of older adults.

My own background is that of a registered nurse working primarily in long-term care, with an adjunct appointment in home care, so these comments are influenced by my perspective.

I would like to address my remarks specific to aging, older adults, and the presence of chronic disease in the format of key messages. I am sure that with the number of witnesses you have called and are calling, you are well aware of the increased presence of chronic disease in Canada and of the supporting statistical data.

Key message number one is that aging is a lifelong process. In Canada, older adults are typically described as all men and women aged 65 years and over. This large and growing population is a highly diverse group, reflecting different values, educational levels, socio-economic status, and the presence of varying chronic conditions, all of which, again, influence health status in the broadest perspective of the term.

Women and men experience aging in different ways and thus experience the presence of chronic disease and its management in different ways. There are significant differences between life at age 65 and life at age 75 or 85. Aging may reflect varying levels of independence and dependence--again, influenced by the presence of chronic disease.

The majority of older Canadians, more than 90%, live primarily independently in the community and want to remain there. Thus the term “aging in place” is well known and is used in resource planning and service delivery activities. But perhaps we should be considering aging in the right place with the right resources.

I would also point out that today's generation of older adults will not be the senior generation of tomorrow, and policy-makers and service deliverers both need to address this reality, because this will affect how we respond to the presence of chronic disease.

Key message number two is that chronic disease is not a corequisite of growing older. While the presence of chronic disease does increase with age, aging and chronic disease should not be perceived as inseparable twins.

Chronic diseases are the result of a complex web of causation, including genetics, gender, environment, and lifestyle factors. Modifiable risk factors, such as unhealthy diet--which is why I would suggest the carrot snacks--physical inactivity, and tobacco use, in combination with the non-modifiable factors of age and heredity, explain the majority of most chronic diseases in older adults.

The increasing presence of chronic disease and the increasing numbers of older Canadians, especially those over the age of 80, is well documented. Supporting healthy aging will promote a healthy and active population, consequently helping to reduce or delay the presence of chronic disease and the need for health care services.

Key message number three is that chronicity is associated with poor health and disability for some older adults. Poor health and disability in old age are largely a consequence of chronic diseases and conditions; for example, deterioration in vision and hearing, or a reduced sense of balance coupled with injuries due to falls.

The World Health Organization has recently pushed non-communicable diseases up its health care agenda, and WHO has focused on four chronic conditions: cardiovascular disease, diabetes, cancer, and chronic respiratory disease. These are responsible for premature mortality. They also focus on four risk factors: smoking, harmful alcohol use, lack of physical activity, and high-salt, high-fat diets.

The majority of older adults living in the community--about 80%--have at least one chronic condition, and of this group, 33% have three or more chronic conditions, compared with 12% of younger adults. For older adults, diseases such as cancer, cardiovascular disease, and dementia are especially significant. In addition, between 10% and 15% of older adults in the community suffer from depressive symptoms and/or clinical depression, another chronic condition.

Polypharmacy—and in no way, gentlemen, am I even mentioning anything other than polypharmacy—is a recognized health challenge and is often associated with the presence of chronic disease.

A key message is that maintaining independence should be a key objective. Maintaining independence as one grows older should be a key objective of individuals, of the community, and of policy-makers. Dependency is highly related to the presence of chronic conditions and associated pain.

Supporting activities and choices that help older adults delay and manage chronic disease and pain—for example, appropriate physical activity and falls prevention programs—may reduce dependency associated with chronic conditions and ultimately support their ability to live in the community. This would require a shift in priorities away from medical treatment and acute care towards health promotion, disease and injury prevention, healthy aging, and family and community support.

Another key message is that developing and using self-management programs is required. Self-management refers to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, lifestyle management, and emotional management. This is usually a process for the older adult that is done in partnership with a health care professional.

One key component is education. The older adult needs accurate and current information to be able to make informed choices about how to manage his or her chronic disease. We often say that an older adult made an inappropriate or--quote, unquote--stupid choice, but in realty we have to question what information they were given to make an informed decision. There are a number of self-management programs in Canada, the first of which was at the University of Victoria.

Here is another key message. Support for informal care providers is essential. Caregiving--such as support for older adults who are aging with a chronic condition and who may need help with grocery shopping or travel to a doctor's appointment--is largely provided by family members, but these same family members remain largely invisible. They also lack training in or education on the aging process; for example, how to address minor health needs associated with a chronic condition, how to distinguish normal aging changes from dysfunctional ones that may flare up in a chronic condition for their older family member, or how to advocate within the health care system.

Family members provide billions of dollars per year in support, with estimates ranging between $60 billion and $80 billion in support provided by informal care providers. But health care expenditures—for example, loss of time from work by a daughter—can impoverish some families.

However, we need to consider fatigue, caregiver burden, and burnout as challenges faced by family members. We often relate to students in our training programs that they have two patients: they have the older adult and they have the one standing beside the bed, but they are only funded to care for one.

Here is another key message. Social relationships can contribute to quality of life. There is strong evidence that higher levels of social integration are associated with lower morbidity and mortality rates. Higher levels of social integration have been found to provide protective effects against a wide range of physical and mental illnesses.

In one recent U.S. study, loneliness was prospectively associated with increased risk of incident coronary heart disease, after controlling for other multiple factors. A study of older adults in Thailand recently found that social support buffered the impacts of dependency and disability and reduced the risk of depression.

Social participation may be a health-motivating factor for older adults with a chronic condition, one that we need to seriously explore, yet at the same time, transportation challenges—for example, getting to a local bus stop or obtaining a ride with a family member—are serious concerns that may impede social relationships.

Here again is a key message: acute care hospitals are not designed for those with chronic conditions. Acute care hospitals are designed for short-term interventions aimed at curing presenting signs and symptoms. They focus on the presenting health problem and often do not note that the older adult is a whole, with both challenges and strengths associated with personal aging. The presence of older adults who often enter acute care hospitals with pre-existing chronic conditions—for example, hypertension or diabetes—challenges the attitudes of doctors, professional nursing staff, and others.

This is another key message: intervention should start in the early years. Chronic diseases do not come as a birthday gift when one turns 65 years of age. Health promotion education needs to be a clear and mandated thread within all educational programs across the country, starting in the earliest grades.

I would like to thank this committee for hearing our views.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Hirst. That was excellent.

We will now go to the translating research in elder care project.

Dr. Estabrooks, will you be doing the major presentation for this project?

[Dr. Carole Estabrooks, Professor, Faculty of Nursing, University of Alberta; Canada Research Chair in Knowledge Translation, As an Individual]

Yes, and Dr. Pringle will conclude.

[The Chair, Conservative, Joy Smith]

Thank you. You may begin now.

[Dr. Carole Estabrooks]

Thank you, Madam Chair, and my thanks to the committee members.

Canadians are living longer and are healthier than ever before. Some of us, however, will develop the chronic disease of Alzheimer's or another age-related dementia. Even though we will be able to stay in our homes or communities longer than in previous years, sooner or later our care needs will overwhelm our families and communities and we will be moved to a nursing home, where we will spend the last few years or months of our lives. In 2038, we expect that one million Canadians will have Alzheimer's or a similar age-related disease. Three-quarters of those are expected to die in a nursing home.

Dementia is a progressive disease of unrelenting losses. There are losses of memory and of the ability to manage one's affairs and to recognize family members. Ultimately, there is the loss of the ability to perform the most basic activities of daily life: feeding, walking, talking, swallowing, going to the toilet. There is no cure.

Because many of us cannot imagine what it is like to live in a nursing home, I would ask you to imagine for a moment an experience we are each all too familiar with: flying, and not the Ottawa-Toronto or Ottawa-Montreal junket, but a flight from Ottawa to Sydney, Australia.

The organization of everyday life in a nursing home can be likened to the organization of everyday life in an airplane.

You have no choice of who you sit beside, and there's a risk that the seatmate may smell, slurp food, chatter endlessly, or refuse to participate in even occasional exchanges of pleasantries. You have to stuff your few allowable personal belongings away so they do not encroach on your neighbour or the aisle. You eat on the schedule imposed by the airline, not when you are hungry--assuming you're fed, of course--and moreover, you have little choice over what you eat. You have to use and wait for communal facilities such as bathrooms, and you can't get to the toilet when needed because there is a cart in the aisle or the seat-belt sign is displayed. Television sets are turned on regardless of your interest in watching them. You have to wear a restraint to protect against the rare possibility of injury. There is nothing to do and nowhere to go.

Notably, the quality of service can also depend on your ability to pay. As airline travellers, we put up with these temporary constraints on our space and autonomy because the trade-off is that it gets us to where we want to go.

We then might ask, “What is the trade-off for residents of nursing homes?” These old people who live and die in nursing homes do not contribute any longer, as they did in their youth and middle adulthood. They do not teach, or police, or doctor, or nurse. They do not build, renovate, act, or govern, or swim, ski, or run like the wind any longer. They no longer vote. They are Rita Hayworth and Ronald Reagan, Norman Rockwell and Tommy Dorsey, and Winston Churchill and Margaret Thatcher. More importantly, they are our mothers, fathers, sisters, brothers, husbands, and wives, and sometimes they will be us.

We care tenderly, and with all of our knowledge and skill, for our frail and vulnerable premature newborns. We place them in some of the most high-tech and expensive facilities in the country: neonatal intensive care units. We think nothing of doing this, believing that a life to be lived is precious and with inherent value. At the other end of life, however, we place our frail and vulnerable old people in nursing homes, the least expensive and least knowledge-driven environment in which care is delivered in Canada, raising questions about the value Canadians place on a life that has been lived and has built the country.

We can tell you a lot about what is wrong with nursing homes in Canada and with the services we do and do not provide to seniors: the ill-designed and fragmented residential system that fails to provide effective, efficient, and compassionate care for frail, vulnerable older adults; the mounting evidence in provincial, national, and international reports of poor quality of care and poor quality of life for institutionalized elderly; and the reduced quality of work life for their care providers.

Rather than go through these, however, we think it might be helpful to highlight how some of these things can be improved.

I will start by saying that we would endorse anything that will keep older Canadians out of nursing homes as long as possible, in their own homes and communities, although not at the expense of the health and well-being of their family caregivers at home. But we cannot dodge the nursing home reality or the fact that some 80% of caregivers are unregulated, with little or no training. Nor can we dodge the fact that the residential long-term care sector has the lowest proportion of funding of any sector in which health care is provided, the fewest numbers of researchers, and the lowest rates of research funding.

Nursing homes are a segregated part of our system that few of us know much about. We simply don't give them much thought until a loved one needs one. They are one of the few settings where we have not completed de-institutionalization.

However, nursing homes in 2011 are a far cry from those of 10 or 20 years ago. Levels of privacy are better. Restraint use is less. Newer homes and more modern models of care offer more home-like environments, safer access to the outdoors, and better management of pain. We have these glimpses of better ways to make the lives of these older Canadians better, with some pleasure in some of everyday life.

One way we do this, and the reason I believe we were invited, is through applied practical research--in our case, the translating research in elder care program, or TREC. Thus far, TREC has been a good success story, and we think a good model for helping to change this part of the system--good because it is large. It received a $5-million grant from the Canadian Institutes of Health Research, a strong vote of confidence for much-needed work in the area. It includes to date some 40 nursing homes, 3,000 care aides, and 500 regulated health professionals, as well as thousands of resident health records.

This enables us to study the considerable variation across provinces and the variety of conditions in those provinces. We need more large-scale applied health services studies, and those need to be complemented by clinical studies that will show us how to manage problems of mobility, pain, and incontinence, and to create enjoyment in daily life.

In TREC we have been able to identify nursing homes where staff use new knowledge more often and are healthier and less burned out, and thus are able to provide better care. We have also successfully identified strategies to engage and mobilize the front-line care staff to work on and improve care practices and to use new knowledge that will improve quality of daily life and quality of end of life, safety, quality of work life of the care providers, the use of best practices, and support for family and other informal caregivers.

The TREC system does this by helping us to identify key areas for action and key areas of good practice that we should spread, to produce comparative reports so that nursing homes can benchmark, by providing a platform on which we can test the effectiveness of new strategies and programs, and by identifying important areas for additional and future work.

Dr. Pringle.

[Dr. Dorothy Pringle, Professor Emeritus, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, As an Individual]

What actions need to be taken if we are to improve care of the frail elderly living in nursing homes at the end of life? Let us suggest two areas in which we believe the federal government can play a leadership role.

TREC has demonstrated that we need a coordinated, system-level approach that assists in bringing together the many jurisdictions involved in the care of frail and vulnerable older Canadians. The federal government needs to develop, as soon as possible, a long-term care act for community and residential care that parallels the Canada Health Act for acute care and physician coverage.

The act needs to include a long-term care insurance fund, such as has been adopted in many European countries. The act will need to specify standards for quality care, including what constitutes adequate and appropriate staffing. Across the country, the variation in resources available to support long-term care and in the rules governing access to this care is considerable, making it difficult for families to relocate older members in need of community or residential long-term care closer to them.

Secondly, we need to expand the volume of research to inform long-term care, particularly in supporting large-scale studies such as TREC that are expensive to mount and sustain. The threat of a budget cut to CIHR has the potential to constrain the already inadequate level of research--and even shrink it.

Most importantly, the number of researchers devoted to clinical and health services research focused on the older population in long-term care must be increased. This will require an expansion in the graduate and post-doctoral awards needed by students to support their studies.

Without a near-miraculous discovery that will prevent and treat age-related dementia, we are faced with a serious national challenge that will stretch over our lifetimes and those of our children and grandchildren. Even with a dramatic discovery, nursing-home care will be with us for a long time. We need to figure out how we are going to do it well.

Research is important, but it's not sufficient to create the changes needed to appropriately serve frail elderly Canadians with dementia. That will require a willingness of Canadians and their public servants to focus needed and coordinated attention on a group of citizens who once did contribute, but no longer can in the same way, to the nation's productivity, but who, we argue, still contribute to the fabric of Canada.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much. That was a very good presentation.

We'll now go into our session of Qs and As, with seven minutes each. We'll begin with Dr. Morin.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

I want to thank our witnesses for being here today.

My first question is for Mrs. Garon.

You talked a lot about housing needs, especially in the case of low-income seniors. Do you have any suggestions on the financial measures the federal government should take to help with housing for low-income seniors? It could perhaps even invest directly in housing. I would like to know what you think about that.

[Suzanne Garon]

Housing or living at home were key issues for all the focus groups, both in Quebec, as part of pilot projects, and in other parts of Canada or in towns elsewhere in the world. According to the prevailing models in Canada and Quebec, living at home usually means living in an apartment where we have always lived only to spend our last days in a nursing home.

There are several types of apartments, several possible approaches, but it hasn't been thought out. There is not enough research on ways to live at home properly, in a specific environment, and to avoid ending up in some sort of home for seniors. There is a lack of research, but there is also a lack of funding for well-designed social housing that would include units that go beyond option A or B. For the time being, there is nothing between the two. We really need to give this some thought and make services and housing of that type available. We need funding programs for social housing.

I didn't use much time for my presentation because there was an issue with the time indicated on the screen. Therefore, I would like to tell you that, as part of focus groups, we have received written accounts from people from virtually every town. Some of them were telling us that they were 80 years old, and that the pension fund they had contributed to would allow them to live until they turned 86. They were asking what would happen to them if they were to live a healthy life until 90. They said they could not stay in their current apartment that cost $1,000, $1,200 or $1,300 per month.

So, we need to give some serious thought to the living at home issue—which is a social phenomenon—and invest in that area.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much.

My next question is for Mr. Poston.

You talked earlier about the medical health records. You mentioned them briefly. What is your assessment of the work we have been doing in Canada since 2004 with regard to connecting the various pharmacies with the medical health records?

Most importantly, what is the next step for the 2014 accord? What do you, as a member of the Canadian Pharmacists Association, expect will be related to the medical health records in the next health accord?

[Dr. Jeff Poston]

Thanks. I think that's an important question.

The critical thing that we've seen happen to date, I think, is that nearly every country that has taken an expensive top-down approach to try to develop electronic health records has struggled to actually achieve that. If you look at the United Kingdom and Uganda, you'll see that they have spent even more money than Canada has and have made probably only slightly more progress.

I think we do need continued investment. There is a view--I think amongst many people--that we've somehow spent enough money. I think we probably still need some continued investment.

I think we have to encourage more local initiatives. I think we have to look at some of the options that can be developed on a regional basis.

I think we're seeing some changes. For example, eHealth Ontario is moving to trying to develop a very pragmatic, locally funded, local initiative. I think that's probably going to be our best chance in achieving it.

It is going to be critically important, though, that in order to address many of the issues we've heard--for example, long-term care and home care--we are going to have to be able to exchange information and have good sharing of information along the continuum of care. Getting electronic health records right is critically important. I don't think we've found out how to do it yet, and it will probably need some further investment. It needs to be a priority as we move forward.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you.

My next question is for Ms. Pringle.

This comes from your article on interdisciplinary collaboration and primary health care reform:

In addition, the current way physicians are paid works against collaborative interdisciplinary practice in primary care. Innovative reinvestment of health care dollars could support nurse practitioners, nurses, and other health professionals....

What changes would you propose for the 2014 health accord?

[Dr. Dorothy Pringle]

Well, I think we have pretty good evidence from a number of places and a number of different countries that a fee-for-service way of funding health professionals does not encourage interdisciplinary care--and it does not lead to the best possible care, either.

I think that's a huge change, though, because we have a tradition of funding most medical practitioners, although certainly not all of them, and not all of them in primary care. As we move to true primary care as opposed to family practice, I think we're seeing a move away from fee-for-service and other means of remuneration that support well all the health professionals.

I think that's a fundamental change that is needed in order to move us more universally to that.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Pringle

We'll now go to Mr. Gill.

[Parm Gill, Conservative, Brampton—Springdale, ON]

Thank you, Madam Chair.

I'd like to thank the witnesses for being here.

First, to Dr. Hirst, I understand your organization is beginning to develop a tool to help seniors themselves better understand depression and how to treat it. Can you please expand on this project?

[Dr. Sandra Hirst]

We actually already have a tool that we adopted from the Canadian Coalition for Seniors' Mental Health, which is funded by the Public Health Agency of Canada. NICE's focus is to take strong tools that are evidence-based, that are primarily Canadian, and distribute them for all health care practitioners. Because the Canadian Coalition for Seniors' Mental Health has had exceptionally good tools differentiating delirium from depression and dementia, we use their tools.

Am I answering your question, or would you like more details?