Indigenous and Northern Affairs Committee on May 24th, 2018

[The Chair, Liberal, MaryAnn Mihychuk]

Welcome, everybody, to the indigenous and northern affairs committee of the 42nd Parliament, first session. Today is meeting number 109, and pursuant to Standing Order 108(2), we're in the study of long-term care on reserve.

Before we get started we always recognize that we're on the unceded territory of the Algonquin people here in Ottawa. It's an important step for us to reflect on that even if it's momentary, as we're in a process of understanding the truth and moving towards reconciliation.

The committee is thrilled to have you. You're at the beginning of a new study on long-term care. We hope it's a short study and very effective on long-term care, which we need in many communities. We will be receiving presentations. You have 10 minutes to present, after which we'll go through questions from the members of Parliament, and that will conclude this session. After that, I understand there's the will to have an in camera session on committee business. That's what we're doing at this meeting.

We'll get started with the Department of Indian Affairs and Northern Development. That's a bit confusing, isn't it? Are you the Department of Indigenous Services? They're nodding yes, but you're not officially a separated department until the bill comes. Is that why we have this issue?

[Keith Conn, Acting Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Indian Affairs and Northern Development]

I think so, yes. It's a technicality.

[The Chair, Liberal, MaryAnn Mihychuk]

Welcome, and I'll turn it over to you, Keith. Do you want to lead us through?

[Keith Conn]

Thank you, Madam Chair. Good afternoon.

Thank you for the opportunity to appear before the committee regarding long-term care on reserves. It's obviously an important subject for all communities, Canadians and indigenous peoples alike, in terms of the need for long-term care.

Obviously, elders or seniors are an important aspect in indigenous cultures in terms of knowledge keepers. They also play an integral role in terms of the vitality and well-being of communities writ large, as part of families, in guiding young people and young families, and for the strength of communities and nations. Indigenous peoples turn to their elders as key sources of traditional knowledge, wisdom, and cultural continuity.

I've been told quite clearly, in my travels and in other business meetings with communities and leadership, that first nations individuals and families want to be able to live at home as long as possible, and if and when they require additional supports, to stay in their own communities close to their loved ones. We've heard this time and time again as a common thematic message.

Many first nations individuals, of course, who are no longer able to live at home safely due to complex illnesses or disabilities, must leave their communities to access appropriate housing and care. For those who were previously forced to leave their communities to attend residential schools, in some instances this can be a re-traumatizing experience. That's something we need to think about.

In terms of needs for services, it's important for all of us to keep in mind that the demand for long-term care facility beds is affected by both the number of seniors in a population as well as their overall health status. While the percentage of the on-reserve first nations population over 65 is relatively small, it is growing quickly. By 2016 the proportion had risen to about 28,000 individuals. According to projections, the number of seniors could be more than double by 2036, to almost 75,000 first nations seniors on reserve likely requiring some level of support in terms of housing or assisted living, home and community care, and/or long-term care.

In addition to the increasing numbers of first nations seniors, it is important for us to consider the nature and complexity of the health conditions they face. Compounding the rising size of first nations senior populations, as I mentioned, is the fact that first nations often have more chronic health conditions—as we've all heard, probably, in previous submissions—than non-first nations seniors. By age 60 approximately half of the first nations adults on reserve have been diagnosed with four or more chronic health conditions. My friend and colleague Robin will get into some of that detail.

Our short-term remarks this afternoon will provide you with an overview of the current existing services, along with the continuum of continuing care, the situation in terms of long-term care, and the future opportunities, including current policy development work being led by Indigenous Services Canada.

Before we get deeper into the subject matter, I'd like to clarify for the purpose of the presentation that we're looking at the term “long-term care” to mean “facility-based long-term care”, actually a structure or facility with a team of expertise. It's a term that is used differently across the country, as we can imagine you'll probably hear from different jurisdictions, and territories and provinces. However, we'll use the Canadian Healthcare Association's definition:

Care is provided for people with complex health needs who are unable to remain at home or in a supportive living environment. Health service is typically delivered over an extended period of time to individuals with moderate to extensive functional deficits and/or chronic conditions.

That's the classical, Canadian Health Care Association's definition that's guiding some of our discussions.

The association itself uses the term “continuing care” to define a system comprised of four elements: home care, which is a big area of interest and investment from Indigenous Services Canada's perspective that we are currently in, and Robin could get into some of that detail; community support services; supportive and assisted living; and long-term facility-based care. Continuing care is a system, in our minds, of service delivery encompassing a range of health and social services that address the holistic health, social, and personal care needs of individuals who do not have or who have lost some capacity for self-care.

These integrated services are designed to improve individual functioning and to provide culturally sensitive support and care in the community where possible, through different stages of aging and illness, up to and including palliative and end-of-life care.

Also, for clarity, I think it's important that since the study is on long-term care on reserve, our response will be focused on needs and programs specific to first nations.

Now I will turn this over to my colleague, Nurse Robin Buckland, to provide you with a brief overview on the home and community care program and the assisted living program, which are two major instruments or initiatives that are funded in terms of first nations on reserve.

Robin.

[Robin Buckland, Executive Director, Office of Primary Health Care, First Nations and Inuit Health Branch, Department of Indian Affairs and Northern Development]

Great. Thank you, Keith. I'd like to thank the committee for the opportunity to come here to speak about long-term care. We're quite excited about the fact that the committee is studying this issue, so we are hoping that we are going to be helpful in the remarks that we offer today.

I'll jump right into our home and community care program.

The first nations and Inuit home and community care program was launched in 1999. It's delivered in first nation and Inuit communities right across the country. In terms of first nation communities, it's actually available in 96% of the communities. The services are delivered based on a needs assessment that is done, and there's a range of services that are offered through the home care program to help people who are living with acute, chronic, and complex health issues, so that they can remain in their homes.

The program has a number of key elements that must be delivered in the communities. It's delivered predominantly by RNs, licenced practical nurses, and home health workers. In 2013-14, over two million hours of service were provided to approximately 35,000 clients across 686 first nation and Inuit communities.

While the home care program is to be universal and accessible, there are gaps. The gaps include only being available from Monday to Friday from 9:00 to 5:00. You can imagine a senior living at home requiring services. They might need something after 5:00 at night. That is certainly a demand and a gap.

Like provincial programs, the home and community care program does place limits on the amount of service and the number of hours that are provided to clients. Another gap that we saw prior to budget 2017 was in terms of what were previously called “allied services”, such as physiotherapy and occupational therapy. Typically, communities did not have funding to provide those services. Fortunately, with budget 2017, we saw an investment of $184.6 million over five years in the program. This is quite significant. Communities will work hard to use these dollars to increase the services that they're offering in their communities, increase the number of hours, and offer some of those additional services such as physiotherapy and palliative care.

Brenda is going to talk to us quickly about the assisted living program that she is responsible for.

[Brenda Shestowsky, Senior Director, Social Policy and Programs Branch, Education and Social Development Programs and Partnerships Sector, Department of Indian Affairs and Northern Development]

Thanks, Robin.

Thank you, committee members, for inviting me to provide comments here as well.

In addition to the services provided through the department's home and community care program, there are also services available through the assisted living program. These services fall within the range of non-medical supports, things such as housekeeping, homemaking, etc. This is a $110 million per year program that has three components: in-home care, adult foster care, and institutional care.

Eligible individuals may receive in-home care services—as I mentioned, light housekeeping, homemaking etc.—and other activities to help them maintain their functional independence within their home. In 2016-17 about 9,600 individuals benefited from the in-home care program component of the the assisted living program.

Adult foster care is a type of service that is also available. It provides supervision and care to individuals who are unable to live independently because of either physical or cognitive disabilities. These are individuals who do not require 24-hour continuous nursing or medical care. In 2016-17, 118 individuals participated in the adult foster care component of the assisted living program.

The institutional care component of the program helps to subsidize the facility copayment fees related to room and board for those within an institutional environment, long-term care facility, or personal care home, either on or off reserve. In 2016-17, some 830 individuals benefited from the institutional care component of this program.

It's important to note that this program really functions like an income support program, in that it is available to those individuals who cannot pay for institutional care or in-home care supports themselves. It very much mirrors what provinces and territories do with respect to in-home care and institutional services.

As well as not having the financial means, individuals must also not have any available family members who can provide the service to them. It's thus very limited in the scope of its application.

Robin.

[Robin Buckland]

Recognizing the time, I will just very quickly speak about some work that we're doing in long-term care.

We're currently exploring the issue of long-term care as well. With the home care program and the assisted living program we cover a number of things, but long-term care has been identified as a gap. We too are therefore going to be looking at it and considering what the potential policy options could be.

[The Chair, Liberal, MaryAnn Mihychuk]

Good. Thank you.

Questioning first moves to MP Will Amos.

[William Amos, Liberal, Pontiac, QC]

Thank you to our hard-working civil servants who come before us today to introduce what is for many but not all of us a new topic, and not something that we all know a lot about. I represent indigenous communities and I must confess that I don't know what the nature of long-term care is in, for example, the community of Kitigan Zibi. It makes me reflect also upon the nature of local consultations that I need to have in relation to this study.

Could you spend a bit of time describing for us the variability of the various long-term care services? You've gone into a couple of areas. I think most of us would expect that it can vary significantly community by community. I don't have a sense of how the variation occurs. For a community of 300 people it might look one way. For a community of 1,000 or 1,500, it might look another way.

If you could flesh that out a bit, I'd appreciate it.

[Robin Buckland]

Sure. Thanks for the question.

Long-term care is a new issue for us at ISC to be looking at. We probably will not have all the answers. We're just exploring long-term care ourselves. Recognizing that this is a gap in the services available to first nations on reserve, we're beginning to explore the issue as well.

What I might say, and I suspect some of the committee members may know this, is that long-term care varies quite significantly right across the country. It's not an insured service under the Canada Health Act, so provinces deliver it in different ways in different provinces. Even within provinces there are variations.

When it comes to long-term care facilities on reserve, we have—and this is more the purview of Brenda—very few facilities. I think the number of facilities across the country is....

[Brenda Shestowsky]

There are 29 facilities across the country that actually receive funding through the assisted living program, but there are many more facilities that are own-sourced through first nation communities themselves. I believe there is a total of 53 that we are aware of, and there are more and more demands for development of communities on the reserves.

[William Amos, Liberal, Pontiac, QC]

What is the perspective of indigenous services, of the department, around the federal government's jurisdiction and role in the provision of long-term services? Is it debated? To the extent that there are debates, where are those discussion points or debate points to be found?

[Keith Conn]

Recently I've been fortunate enough to participate in a tripartite discussion with the Chiefs of Ontario, with leadership from across the province of Ontario, and the Ministry of Health and Long-Term Care to develop some ideas and options around partnering and the monetization of long-term care facilities.

As we know, for example, in Ontario they are responsible for the licensing of long-term care bed spaces and the operations of the facilities, but they are not there for the capitalization process. I wouldn't call it a debate but more of a spirit of co-operation to look at various strategies and options. In Ontario, for example, there are 30,000 people on waiting lists in the province alone. A chunk of that is probably related to first nations looking for long-term care spaces.

In other jurisdictions I'm not aware of any debate. It rests, in my mind, largely on the provincial or territorial government's mandate for the administration of long-term care facilities.

In some cases there has been some modelling and partnership development and co-funding facilities. I could say that we have some research in that area, but I wouldn't necessarily categorize it as a debate. It's just where we can partner, where we can collaborate, which is part of the energy I'm sensing in British Columbia, Nova Scotia, and Ontario. Other jurisdictions may vary.

[William Amos, Liberal, Pontiac, QC]

When I speak to Chief Jean Guy Whiteduck, in Kitigan Zibi, he regularly comments to me that what he and his community are really hoping for is a much greater degree of autonomy in terms of lump sum transfers over to this community so that programming, whether it's health or education, policing, what have you, can be taken care of by them without getting the okay from the department. Is that same kind of discussion going to repeat itself if the federal government engages and takes a hard look at long-term care?

Is this something that should be community-driven as opposed to department-driven?

[Keith Conn]

That's a great question. The larger discussion on new fiscal relationships with indigenous communities, first nation communities across the country is opportune in terms of looking, for example, at a 10-year grant in terms of a funding relationship. The grant would provide a certain level of flexibility, I must say, in terms of planning, monetization of partnerships with the private sector or the province around looking at the facility needs that the community would define as a priority.

I think we are at the early days of that discussion, but we're certainly looking forward to our target, as was publicly announced, to have at least 100 recipients in a grant-like arrangement for a 10-year period. That would definitely look at responding to community needs based on what their priorities are as defined by the community and the leadership.

Optimistically I could say that this creates a window to actually do some innovation in terms of partnership development or securing funding from other sources that could build actual infrastructure. We're limited at this time. We have a policy constraint, as we speak. We will also, of course, work with what we have in terms of capital funding for health facilities, nursing stations, treatment facilities, etc.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you.

[Keith Conn]

There's a large need.

[The Chair, Liberal, MaryAnn Mihychuk]

Questioning now goes to Cathy McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

I was surprised to hear that 50 long-term care facilities have been established. I'm wondering whether you could provide to our analysts a couple of the names, because I think that to hear from them directly would be important to understanding what their challenges and opportunities are. That would be, I think, a great help.

[Brenda Shestowsky]

Definitely we can provide that information.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

Having lived and worked in rural communities, I have witnessed the difficulties of people in their last years—husbands and wives being separated as one has to go to a home and the other has to manage that. I can remember one gentleman taking a train once a week to visit his wife of 50-some years. It is really difficult, because often of distance.

I think a lot of effort was put into adaptation of the home to keep people home as long as possible. What kind of budget is distributed to communities to support such things as wheelchair ramps and bars? Do you have formal programs and processes in place to support that work in communities?

[Brenda Shestowsky]

Some of the funding comes through other areas within the department. Infrastructure programming makes available some funding for home renovation.

Within the assisted living program itself, what we provide funding for is related to the services that individuals can access, such as homemaking services, etc. There really is no renovation portion of the program.

Through the non-insured health benefit program there are also supports that can be accessed. Wheelchairs, for example, and other devices can be made available to support individuals' independence.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

If someone's mother is coming home and is now wheelchair-bound, how are they going to get the wheelchair ramp or get the bars in? The band office may or may not have the funding to do those things.

[Keith Conn]

The individuals who are wheelchair-bound would be provided a discharge plan for accessing appropriate equipment and supplies.

Ramp access is usually left to the local government, to determine how it can address accessibility to the home. Ramps are usually built with band funds in the community. When there's a shortage of band funds, then a request is provided to the first nations infrastructure fund plan at Indigenous Services Canada to support some of that work.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

If, for example, someone has to relocate outside the community into a provincially licensed facility, to what degree does your branch cover the costs of that program?