Health Committee on Oct. 17th, 2011

[The Chair, Conservative, Joy Smith]

Good afternoon. Could I please call the committee to order?

We're doing something a little different today that is--kind of--a first of its kind. From the Canadian Geriatrics Society, we have with us Dr. Frank Molnar, who will be doing a powerpoint presentation. I know that Dr. Molnar is very aware that this presentation has to be within the parameters of the time I've set out. That is very important.

If you'll bear with us, we thought it might be set up prior to the committee, but they're still trying to work out some technical things. We will just need to have some patience.

We're very pleased that, pursuant to Standing Order 108(2), we're studying chronic diseases related to aging. The committee has acknowledged that our demographic is an aging demographic.

We are so pleased to welcome all of you to this committee today to give us some knowledge and some insight, some very important insight.

We have with us, from the Canadian Medical Association, Dr. Haggie, who is the president. Welcome, Dr. Haggie. I welcome Dr. Ricketts as well.

From the Canadian Chiropractic Association, we have Dr. Eleanor White and Dr. Tucker. Welcome.

From the Canadian Nurses Association, we have with us Ms. Barb Mildon, president-elect, and Mr. Don Wildfong, nurse adviser, policy and leadership.

Of course we have Dr. Frank Molnar here as well.

We're very pleased that you're here.

Dr. Molnar, I am going to leave you till the end to allow for everything to be set up.

We're going to begin with the Canadian Chiropractic Association and Dr. Eleanor White and Dr. John Tucker.

You have a ten-minute presentation. When I turn on the light, you'll know that you have about a minute left to wind down. Please begin.

[Dr. Eleanor White, President, Canadian Chiropractic Association]

Madam Chair and members of the Standing Committee on Health, Madam Clerk, and colleagues, thank you for inviting us here today to have the opportunity to be with you again.

The issue of chronic disease related to aging is both serious and growing. More than 90% of adults over the age of 65 report suffering from at least one chronic disease. Notably, most risk factors for chronic disease, and particularly those related to aging, are often preventable. The Canadian Chiropractic Association believes that preventative health care for all ages is the key to halting or attenuating the advance of chronic disease and promoting health for all Canadians.

We have two fundamental recommendations. First is to implement progressive public education programs targeting vulnerable populations. That includes promoting active self-care to encourage all Canadians and communities to take responsibility for their own health. Second is to support collaborative approaches among public health organizations, health care providers, governments, and for-profit and non-profit sectors. These measures taken together would have a profound beneficial effect on health care, and would address chronic disease and health funding issues across Canada.

The effects of unhealthy lifestyle choices are most visible in older adults. However, the development of chronic disease begins much earlier, often during youth. Accordingly, the prevention of disease and promotion of health must take a population-based approach covering the full spectrum of ages, ethnicities, and socio-economic demographic sectors. It's never too late or too early to invest in promoting healthy lifestyle choices.

Research is fundamental to addressing the issue of chronic disease related to aging. Research informs treatment and preventative measures, and guides public education initiatives. The Canadian Chiropractic Research Foundation is the chiropractic profession's primary research-funding organization. It also allocates funds and develops opportunities. In partnership with the CIHR, the CCRF has established the chiropractic research chairs and professorships in universities across Canada. Many of these positions devote time and effort to the study of chronic diseases related to aging, and the treatment of age-related conditions. Such research informs practitioners on best practices available and clinical guidelines, and in turn promotes better care for patients.

Public health workers produce a number of valuable resources to help Canadians live better and healthier lives. However, many programs are time-limited and have restricted resources that see them falter after only a few years. The use of health care providers as educators might be one way to substantially change the public health programs and augment them. For example, the CCA has developed a number of educational resources for use by Canadian chiropractors and the public to promote physical activity and prevention of injury. We've listed three. One is in the area of brain injury prevention. The CCA has partnered with ThinkFirst Canada to promote the brain day program among elementary school children in Nunavut. The brain day program educates youth about the importance of injury prevention, in the hope that these approaches will also be translated to the community at large.

Our fit-in-15 program, developed in consultation with the Public Health Agency of Canada, promotes a progressive introduction of physical activity into one's daily routine. The program is based on the concept that fitting in at least 15 minutes of physical activity a day can lead to the development of the habit to exercise and the motivation to increase daily physical activity. Adults who are physically active are shown to significantly decrease their risk of diabetes, heart disease, and some forms of cancer.

Older adults are at risk due to falls. Falling among seniors is one of the leading causes of disability and morbidity. It is estimated that senior fall-related injuries in Canada cost over $2.8 billion per year. In response to this, the CCA has developed a program that we call “Best Foot Forward”. It's a campaign targeted specifically at Canadian seniors. The campaign provides practical strategies on how to prevent falls at home, and how to promote balance and strength on a daily basis. The program has been widely disseminated, used, and shared with our partners. All of the self-help materials are available at no cost on the CCA website.

Our organization believes that specific targeted approaches are needed for subgroups of the population, including veterans, first nations, aboriginal populations, Royal Canadian Mounted Police, and Canadian Forces. These groups should be provided with the full continuum of care, including integrated service delivery, to better prevent occupational chronic conditions and chronic disease.

Partnership and collaboration are key to a prevention and reduction strategy. The task at hand must be embraced by primary contact health care providers, support workers, and the federal, provincial, and territorial governments, as well as non-profit and private sectors so that the promotion of a common consistent message on healthy living strategies will have a more meaningful and significant impact when embraced by all sectors.

Canadian chiropractors can help alleviate the burden of chronic disease among seniors by providing care and co-management to patients. The early detection of dysfunction and immediate treatment of common musculoskeletal complaints have been shown to decrease the probability of chronic pain. Studies have demonstrated that chiropractic care for patients presenting with low back pain decreases the utilization of diagnostic testing, reduces the rate of hospitalization and back surgeries, and lowers overall costs and prescriptions, including NSAIDs and opioids. Qualitative benefits include improved quality of care and quality of life for patients treated within an integrative model.

Many communities, particularly in remote areas across Canada, are requesting greater access to care, patient choice in service delivery, and the implementation of preventive health measures. Canadian chiropractors are part of the solution to these requests.

A progressive transition from an acute care model of health to a preventive model can help seniors maintain good health, resulting in independence and improved quality of life. CCA believes that Canadian chiropractors must play an important role in the promotion of healthy aging and the prevention of chronic disease, including musculoskeletal conditions. The inclusion of all health care providers and patients in this dialogue will deliver more innovative and sustainable solutions. Maintaining independence and quality of life for seniors in Canada is an important goal that impacts both the sustainability of the health care system and the fabric of our society.

The Canadian Chiropractic Association recommends that dealing with the present and growing challenge of chronic diseases related to aging be based on a public health, prevention, and wellness model where there are incentives for stakeholders and individuals to assume a greater degree of responsibility for health care outcomes. We believe that public education combined with strong support for multi-sectoral partnerships and interdisciplinary collaboration will yield the best results.

Thank you to the committee for the opportunity to contribute to the dialogue on chronic diseases and aging.

[The Chair, Conservative, Joy Smith]

Thank you so very much.

You still have three minutes. Are you doing the whole presentation, Dr. White?

[Dr. Eleanor White]

Those were our introductory remarks. I'll be glad to answer anything in the question period.

[The Chair, Conservative, Joy Smith]

Well, we'll do it in due time, when it's time. There are two of you here and you have three minutes left, so I wondered whether there were some more comments you wanted to make.

[Dr. Eleanor White]

I'm sure John will contribute later.

[The Chair, Conservative, Joy Smith]

Okay.

Now we'll go to the Canadian Medical Association.

Dr. Haggie, will you be doing the presentation? Okay, thank you. We look forward to it.

[Dr. John Haggie, President, Canadian Medical Association]

Thank you very much for the invitation, members of the committee.

The Canadian Medical Association wishes to commend the House of Commons Standing Committee on Health for undertaking this study of the issue of chronic diseases related to aging. It is a timely issue, since the first members of the baby boom generation turn 65 this year. It's predicted that by 2031, a quarter of Canada's population will be 65 or older.

Though chronic disease is not exclusive to seniors, its prevalence does rise with age. According to Statistics Canada, about 74% of Canadians over 65 have at least one chronic condition, such as diabetes, high blood pressure, arthritis, or depression, and nearly 25% have three or more. The proportion is higher among people 85 years and over.

What are the causes of chronic disease? There are many. Some of them are rooted in unhealthy behaviour—smoking, poor nutrition, and in particular a lack of physical activity. This latter concerns physicians particularly because of the rising obesity rate in Canada. Obesity increases one's risk of developing chronic diseases later in life.

But there's more to chronic disease than simply unhealthy behaviour. It's also affected by a person's biological and genetic makeup as well as by his or her social environment. Lower income and educational levels, poor housing, and social isolation, which is a greater problem for seniors than for other populations, are each associated with poorer health status.

Now the good news. Chronic disease is not an inevitable consequence of aging. We can delay the onset of chronic disease and perhaps even reduce the risk that it will occur at all. The conditions of patients who do have existing chronic disease can often be controlled through appropriate health care and disease management, so they can continue to lead active and independent lives. Thus, the CMA supports initiatives promoting healthy aging, which the Public Health Agency of Canada defines as the process of optimizing opportunities for physical, mental, and social health as people age.

Healthy lifestyles should be encouraged at any age. For example, the Canadian physical activity guidelines, which the CMA supports, recommend that people 65 or older accumulate at least 2.5 hours per week of aerobic activity such as walking, swimming, or cycling. Experts believe that healthy aging will compress a person's period of illness and disability into a shorter period just prior to death, enabling a longer period of healthy, independent, and fulfilling life.

For those who are already affected with chronic diseases, treatment and management is long term and can be very complex. People with diabetes, for example, need a continuous, ongoing program to monitor their blood sugar levels and maintain them at an appropriate level. People with arthritis or mobility problems may require regular physical therapy. For the patient, chronic disease means long-term management that's much more complicated than simply taking antibiotics for an infection. People with two or more chronic conditions may be consulting a different specialist for each as well as seeking support from nurse counsellors, dieticians, pharmacists, occupational therapists, social workers, or other health professionals.

Often, management requires medication. The majority of Canadians over 65 take at least one prescription drug, and nearly 15% are on five drugs or more, which increases the possibility, for example, that two of these drugs could interact negatively with each other to produce unpleasant and possibly serious side effects.

Long-term complex chronic disease care is in fact the new paradigm in our health care system. About 80% of the care now provided in the United States is for chronic diseases, and there's no reason to believe Canada is greatly different. Hence, it's worth considering what form, ideally, a comprehensive program of chronic disease management should take for patients of any age. The CMA believes it should include the four following elements.

First is access to a primary care provider who has responsibility for the overall care of the patient. For more than 30 million Canadians, that primary care provider is a family physician. Family physicians who have established long-standing professional relationships with their patients can better understand their needs and preferences. They can build a relationship of trust so that patients are comfortable in discussing frankly how they want to treat their condition—for example, whether to take medications for depression or to seek counselling with a therapist. The family physician can also serve as a coordinator of the care delivered by other providers.

This leads to our second recommended element, which is that of collaborative and coordinated care. The CMA believes that given the number of providers who may be involved in the care of chronic diseases, the health care system should encourage the creation of interdisciplinary teams, or at a minimum enable a high level of communication and coordination among and between individual practitioners and providers. We believe that all governments should support interdisciplinary primary care practices, such as the family health networks in Ontario, or the primary care networks in Alberta, which bring a variety of different health professionals and their expertise into one practice setting--a medical home, if you like.

Widespread use of electronic health records can facilitate information sharing and communication among providers. There should be a smooth process for referral, for example, from family physician to specialist, or from family physician to physiotherapist. The CMA is working with other medical stakeholders to create a referral process toolkit that governments, health care organizations, and practitioners can use to support the development of more effective and efficient referral systems.

The patient may also need non-medical support services to help cope with disability related to chronic disease. For example, a person with arthritis who wants to remain at home may need to have grab bars, ramps, or stairs installed there. Ideally, a coordinated system of chronic disease management would also include referral to those who could provide these services.

The third necessary element is support for informal caregivers. These people are the unsung heroes of elder care. An estimated four million Canadians are providing informal, uncompensated, unpaid care to family members or friends. About one quarter of these caregivers are themselves over 65 years of age. Their burden can be a heavy one in terms of time and expense. Stress and isolation are very common among caregivers.

The federal government has taken steps to provide much-needed support to informal caregivers. The most recent federal budget, for example, increased the amount of its caregiver tax credit. We recommend that government build on these actions to provide a solid network of support, financial and otherwise, to informal caregivers.

The fourth and final element is improving access to necessary services. Only physician and hospital services are covered through the Canada Health Act, and many other services are not. All provinces have a pharmacare program for people over 65, but coverage varies widely between provinces, and many--particularly those with lower incomes--find it difficult to pay for their necessary medication. Seniors who do not have post-retirement benefit plans--and these are the majority--also need to pay out of pocket for dental care, physiotherapy, mental health care, and other needed supports.

We recommend that all levels of government explore adjusting the basket of services provided through public funding to make sure that it reflects the needs of the growing number of Canadians burdened by chronic disease. In particular, we recommend that the federal government negotiate a cost-shared program of comprehensive prescription drug coverage with the provincial and territorial governments.

In conclusion, the CMA believes that the committee is wise to consider how we might reduce the impact, on individual patients, the health care system, and society, of chronic disease related to aging. Chronic disease management is a complex problem that warrants close attention, as it is now the dominant form of health care in Canada. We look forward to the committee's deliberations.

Thank you for this opportunity.

[The Chair, Conservative, Joy Smith]

Dr. Haggie, thank you for your very insightful comments. Indeed, your presentation reflects some of the goals and objectives that we have as a committee, so thank you very much for reiterating that.

We'll now go to the Canadian Nurses Association and Ms. Barb Mildon.

[Barb Mildon, President-elect, Canadian Nurses Association]

Good afternoon.

On behalf of Canada's 250,000 registered nurses, thank you for the opportunity to speak to the important issue of chronic disease related to aging. CNA will be sending you a brief on this subject containing key recommendations and supporting evidence, but today I will focus on a few main points.

Canada needs a national strategy on healthy aging that includes chronic disease prevention and management, a strategy anchored in team-based care and enhanced access to primary care and community-based supports, particularly for older Canadians, who are more susceptible to chronic diseases and their related complications.

Chronic diseases are the major cause of death in Canada, and their treatment represents a $90 billion annual cost to our economy, accounting for 67% of all direct health care costs. Given that many of these diseases can be prevented or lessened, investments in this area will save health dollars, improve quality of life, and save lives. CNA therefore urges the federal government to lead a healthy aging strategy that emphasizes chronic disease prevention and management.

A comprehensive pan-Canadian healthy aging strategy should be multi-faceted and include measures to foster health promotion and early detection of disease, keep people in their homes longer, support formal and informal caregivers, address the determinants of health, and facilitate better access to health services, including appropriate end-of-life care.

Multiple chronic diseases, not age, are the main driver of health system use by seniors. Multiple chronic conditions require expensive treatments, complex care management, and represent a considerable burden for individuals and their families. For example, health professionals regularly deal with the compounded effects of obesity, type-2 diabetes, and high blood pressure. What's especially alarming is that this is a cluster of conditions that is increasingly common among younger and younger Canadians. We need to act now to reverse this alarming trend.

An example of success can be found in the Complex Chronic Disease Clinic in Calgary, Alberta, where an interprofessional team has reduced hospital admissions through an integrated approach to care. Registered nurses, nurse practitioners, physicians, and pharmacists are collaborating to address medical, social, lifestyle, and other factors that affect health outcomes. This comprehensive chronic disease management model reduced the total number of hospital admissions by 24% and the total length of hospital stay by 51%.

Of course, the ultimate goal is to reach patients and families and give them the supports and tools they need before multiple chronic conditions develop. Health screening, early detection, and access to the right interventions early on can help patients to better manage initial risk factors and conditions, increasing their chances of preventing and reducing the severity of the occurrence.

As we age, the likelihood of developing chronic conditions increases. For too many of our seniors, however, interventions come too late. For example, when hypertension is undetected or not well managed an individual is at greater risk of establishing a stroke and/or advanced cardiac disease. When a health crisis hits, it often triggers the all-too-common chain of events involving ambulance transfer to an emergency room, hospital admission, prolonged hospital stay, and rehabilitation. This situation illustrates the serious consequences of insufficient community and home care services in Canada. All too often, home care services are time-limited and focused on post-hospital recovery versus ongoing chronic disease management. This gap in service is likely familiar to many in this room.

Thus, CNA's second recommendation is that the federal government support primary care reform with a particular focus on home- and community-based services, emphasizing interprofessional collaborative teams. There is a desperate need to bolster community-based health services such as primary care, ambulatory care, and home care to improve the health of our nation.

Far too many Canadians visit our emergency departments or are hospitalized for health conditions that could and should be managed in the community. There are excellent examples of primary care models that should be more widely implemented. These include community health centres, family health teams, and nurse-practitioner-led interprofessional clinics. These models fully harness the expertise of health professionals so that Canadians have access to the right care at the right time and in the right place, thus helping to reduce barriers to accessing needed services.

Primary care initiatives that ensure earlier and more consistent access to care lead to straightforward, low-cost, easier-to-manage interventions. As registered nurses, we know this territory well. A simple example is community-based or mobile foot care clinics that provide timely support for lifestyle and behaviour changes that result in early detection of serious foot diseases that may lead to the need for amputation for people with diabetes. A foot clinic may not be the most glamourous example, but it represents a tangible, community-oriented service that demonstrates the benefit of addressing minor complications early, before they snowball into personal catastrophes.

We know that prevention diverts health care costs away from far costlier acute care interventions down the road. Optimizing the health and wellness of Canadians requires that care be brought closer to home, to the very heart of our communities.

We need to think and act differently to expand the implementation of new approaches such as mobile health clinics, after-hours services, home visits, and community outreach programs that are publicly funded and not for profit.

In one such approach, teams of mobile emergency nurses responded to non-urgent calls from long-term-care homes. A recent study in Toronto demonstrated that these teams were effective and able to provide the necessary care for 78% of the residents they visited, who would have otherwise been sent to emergency rooms for treatment. The cost of these mobile visits is 21% less than the cost of having those same needs addressed in the emergency room.

Let me once again stress that now is the time for a national strategy on healthy aging. CNA's vision for this strategy is one that enhances timely access to primary care, harnesses the effectiveness of interprofessional collaborative teams, brings care closer to homes and communities, and provides the appropriate range of community-based supports necessary to adequately prevent and manage chronic disease.

Chronic disease is indeed an alarming and growing concern, in every part of our country and around the world. As discussions on the next federal, provincial, and territorial health accord ramp up, we must take the opportunity to confront this pan-Canadian epidemic in a more strategic way. Indeed, registered nurses and other health care providers play an integral role in preventing and managing chronic disease throughout the entire continuum of care. Greater benefits to the health of individuals and enhanced health system sustainability can be realized by a healthy aging strategy that emphasizes chronic disease prevention and management and is enabled by primary care reform.

Thank you, again, for the opportunity to speak with you today.

[The Chair, Conservative, Joy Smith]

Thank you very much.

My sister is a nurse, and she often sounds just like you: practical, down-to-earth, and with some very insightful ideas. Thank you so much.

Well, Dr. Molnar, we have some technical challenges here. I have seen your chronic diseases overview, and I understand everyone has a copy of it. We are looking forward to your presentation. We will follow along, then.

Thank you so much for the preparation you have put into this.

[Dr. Frank Molnar, Secretary-Treasurer, Member of the Executive, Canadian Geriatrics Society]

I work in health care, so I am used to technology not working.

[The Chair, Conservative, Joy Smith]

There you go.

[Dr. Frank Molnar]

Thank you for inviting me to speak on behalf of the Canadian Geriatrics Society.

When I was putting this together, I had to think long and hard about the focus I should take. I think the most important thing for the society is for us to bring forward the critical diseases that need to be included in any study of aging and any study of chronic disease.

The most important disease, from a geriatric perspective, is one that's often not considered a chronic disease. It's dementia. Dementia in many forms is considered the grandfather or the godfather of chronic disease. It's one that has the largest impact on health care and the largest impact on alternative level of care, and yet it's often marginalized. It's not found in our health care plans. I know that almost none of our regional health authorities in Ontario have included dementia care as part of their plans. It has a huge impact, but it seems to be peripheralized very often.

How common are Alzheimer's and related dementias? I would invite you to look at the Rising Tide: The Impact of Dementia on Canadian Society document at the Alzheimer Society of Canada website. It shows that we now have about half a million people in this country with dementia. That really underestimates the impact on Canadian society, because each of those persons with dementia has a caregiver or may have two or three caregivers, all of whom are at risk of anxiety disorders, depression, or caregiver burnout. So in fact if we look at how many people are impacted by dementia, it's probably one million to two million Canadians. The numbers are really huge, and there are about 100,000 new diagnoses every year, or one every five minutes.

It's highly prevalent. It's also very expensive. You can look at the cost breakdown. Right now it's costing us about $15 billion, and that's rising quickly. Once again, I would invite you to look at the Rising Tide report to see the methodology of that economic analysis, but the scale of the numbers is probably very correct.

So it's a prevalent disease, and it's an expensive disease. How does that make it any different from heart failure, from COPD, or from diabetes? There are two distinct differences with dementia. One is what we call the dementia domino effect. Many people can go along quite well managing their heart failure, their chronic lung disease, or their diabetes until they develop cognitive issues. Once dementia starts to be weaved into the mix, you start seeing loss of control of their heart failure, their COPD, or their diabetes. It spins out of control very quickly, they end up in hospital, they're stabilized, they're discharged, and they end up back in hospital. They go through a cycle with the health care professionals not really recognizing the underlying foundational problem that has caused destabilization. Many people have referred to having two or three chronic diseases at the same time. Certainly hospitals struggle with that. But once you mix dementia into the equation, hospitals really fall down and they really have great difficulty in managing dementia. That's been my clinical experience over 20 years and the clinical experience of dozens and dozens of geriatricians.

Does the data really support that? We do have a report from CIHI, the Canadian Institute for Health Information, and I've included two key pages from the CIHI report. If you want the full report, I do have some copies in French and English with me.

CIHI says that the main diagnosis driving alternate level of care, or ALC, rates in Canada is dementia. Diagnosed dementia is related to one-third, or 33%, of cases of ALC. I think that's a huge underestimate, because working in the hospital, many—if not most—cases of dementia are unrecognized. So if you really did a study and drilled down and asked how many people who are listed as requiring alternate level of care truly have dementia, I would not be surprised to see 50% or 60%. It's really the driving diagnosis for the destabilization of multiple chronic diseases and for our ALC crisis.

So any study of chronic diseases and aging that goes forward really, in our opinion, has to include dementia as a central component.

What opportunities are there? I'll throw out a few. I've talked to a few colleagues and we've discussed this at the Canadian Geriatrics Society. Certainly down the road we should look at models in other countries where they have dementia networks. We do have dementia networks in Canada; they're voluntary networks. People like me pay to be part of it. We support it with our own money. We should think about making those networks formalized and accountable to the Canadian public so they can organize dementia care and so they can link with other chronic diseases. As I said, it's that interplay between diseases.

Surprisingly, I presented to our department of endocrinology, and none of the diabetes specialists were aware that diabetes is a risk factor for dementia, and one of the first signs of dementia is inability to use your insulin. They didn't realize there was that interplay. And we've heard that before, that the specialties are not communicating, are not integrated. So any study of chronic disease really has to look at that integration of different chronic diseases.

As far as other things we can look at, national dementia strategies have been applied in other countries, and I'd certainly look at those models. Dementia should be included in any study that goes forward. That's message one.

I have a second message, and it has been brought forward already. We really have to take a long, hard look at community care. When you look at the cause of the hospital crises--the bed gridlock, the ALC crisis--the main cause is not what's happening in hospital. Hospitals and long-term-care institutions bear some of the responsibility, but we have a community care system that is not integrated and does not communicate. It is not strong enough to keep people out of the hospital, so it overflows into the acute care system. The acute care system, our most expensive site of care, becomes the default setting for all of these care issues, and it is not set up to deal with multiple chronic conditions or dementia. There are very few specialists in dementia working in the acute care system. If we want to fix the system and study chronic care, we have to look at how the system interacts with chronic disease.

Another issue is long-term care. There are problems in long-term care, but once again they are related to community care. Some studies out there indicate that 20% to 30% of people do not need to be in long-term care. I have some issue with the methodology of those studies. I have formal research training, and some of the methodology can be challenged. But when I talk to directors of long-term care they say that 20% to 25% of people probably don't need to be there any more. They had an illness that required prolonged recovery and they recovered and became better. They'd already sold their house and had nowhere to go, so the nursing home was their new home.

Other people enter long-term care or nursing homes because they cannot afford residences. Essentially, we're punishing low-income seniors by forcing them to go into long-term-care institutions prematurely, instead of finding alternate sites where they can live. In essence, for these people with chronic diseases who require care, we need subsidized residences rather than long-term care or nursing homes.

This does not just penalize low-income seniors; we are all paying the price. They are living in long-term-care beds or nursing home beds that are desperately required by acute care hospitals. This is one of the reasons we have a backup of patient flow going to long-term care, ALC crises, hospital bed gridlock, and emergency departments that are full. We have people in long-term care who do not need to be there. If as a society we gave them proper care, they would be in subsidized residences and we would not have to build as many nursing homes as people say we need. We need to build more, but not as many.

What can we do in the community? This is getting into your expertise, not mine. I'm a simple doctor--even worse, I'm a teaching doctor--but you guys can take it or leave it.

[The Chair, Conservative, Joy Smith]

We'll take it.

[Dr. Frank Molnar]

There's an army of senior volunteers out there. Do we have tax credits for volunteers? I don't know. Certainly that's something. Can you find a way to engage that army of senior volunteers to help in the health care system? You're already giving some tax credits to people who are caregiving, but we have to look at how much support we can give to caregivers. Are they still allowed to contribute to CPP while they're doing the caregiving role?

If someone has multiple chronic diseases and a family member is not taking time to care for them, they will end up in hospital. That is almost guaranteed. So as other people have said, you really have to look at caregiver support. We've talked about tax incentives, but that doesn't really help low-income seniors. Think about other incentives that could bring low-income seniors into the volunteer pool.

We've talked about mobility and falls, and those are other huge issues. We really need to look at exercise programs that prevent de-conditioning. There's a lot of literature out there on programs that prevent de-conditioning and falls. Then we have to look at incentives to bring seniors into those programs. We can't just build them; we have to entice people to come in.

The bottom line for us is that the weak link in the health care system is really community care. I agree 100% that we have to look at health promotion and prevention measures. However, we have to recognize that people eventually become ill, and then we need to have a community care system that is strong enough and integrated enough to keep them out of hospital. Right now we don't. We have a bunch of community care silos that compete for money. They do not cooperate or collaborate, and they have no accountability. There is really no connection between community care and acute care. So we have to look at the system itself. If you do research, it will have to look at the entire system design.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Molnar. We appreciate so much all your insightful comments.

We'll now go to questions and answers, and we'll have seven minutes per person.

We'll start with Madam Quach.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

Good afternoon. I would like to thank everyone for providing us with very relevant information. I have a number of questions. I will start with my questions for the Canadian Chiropractic Association.

You are saying that we must focus on preventive care to help people be in better shape and healthier. Do you have an estimate of how many more chiropractors would be needed to cater to the aging population and provide more appropriate care?

Can I ask all of my questions?

[The Chair, Conservative, Joy Smith]

No. Perhaps we'll take that one first.

Who would like to take that question?

Ms. Mildon.

[Barb Mildon]

My apologies. I am so sorry. I didn't have my interpretation working properly and didn't understand the question.

[The Chair, Conservative, Joy Smith]

Could you repeat the question, Ms. Quach, please?

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

My question is for the Canadian Chiropractic Association.

You were talking about preventive measures and about implementing education and care programs. Is there an estimate of how many more chiropractors should be in the system to provide more effective care to people in order to prevent chronic disease?

[The Chair, Conservative, Joy Smith]

Dr. White, would you like to try that?

[Dr. Eleanor White]

I'd like to start with an appreciation of the question. You finished your question with how could we prevent chronic disease. I'd like to first make clear that as one of the primary care practices, it would always be a collaborative approach.

We've all spoken to essentially the same topics. The common points have been collaboration; having a medical home, or a health home; integrated services and research; and primary care reform. So taking those points into account and answering your question, I would suggest that we don't perhaps need any further numbers of chiropractors to assist in the job. What we need is better access to the patients and them to us.

We also need to disseminate information in a manner that is much more imaginative. For every practitioner who is successful in his or her office, whether it is medical, psychiatric, chiropractic.... For nurse practitioners, the problem is time management. To educate patients on what they may need to know is no longer always possible to do, need to need. Often you can. Often extra time is set up. But we have to be much more imaginative in how we deliver material.

First, I would think, is that material is consistent, not only within a profession but inter- and intra-professional. Second, the use of social media, of having things on our websites, of having things on Facebook, is very appropriate.

I'd like to suggest another small program that might be of use, particularly to a federal audience. All our patients now come to us with what they have read on the Internet: I have such and such a condition. I have read this. Is it of use? I'm aging. I have a husband with such and such, or a mother. How do I deal with this? So they're researching information.

The federal health minister has brought the importance of clinical guidelines to mind, and so have the provincial premiers. Those guidelines are currently geared toward practitioners finding treatment for chronic disease as one of many things. Perhaps what the federal government could do very well is take those clinical guidelines and turn them on their sides and find an adjudicated, authorized manner of taking the successful approaches to treating a disease and make that accessible to people for self-care.

If you have diabetes and you look online to see what you can do, instead of finding some sort of approach that you wonder about in terms of validity or usefulness or safety, have an authorized report so that when you look at diabetes you would see this is what the following practitioners all do--they have been shown, through the research, to be effective to the following degree, particularly when done in conjunction with so and so's approach.

We know that all our patients are doing a lot of self-care. I think we have a role. If we all do our clinical guidelines properly, and compare them and find common points on the side instead of silos, we could serve in a capacity that way as well as our treatment and education of patients in the office.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Quach.

You have a minute and a half for your next question and answer.