Indigenous and Northern Affairs Committee on May 31st, 2018

[Chief R. Donald Maracle]

In terms of the non-insured health benefits program administered by Canada, they know the types of medications people are on and what kinds of health issues are out there. They would have data in terms of the health profile of first nations people by reserve, by age group.

I think in the South East LHINs there are 5,000 people on a waiting list. Some of them are chronic placements with no place to go. We know that 3,000 of our members live within close commuting distance to the reserve because of the lack of housing, so I would expect that a significant number of those people who are on the waiting list are our members.

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

You don't actually have that data, do you?

[Chief R. Donald Maracle]

We don't have it. There is nobody who collects that data by band number.

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

In a perfect world, what data points would you like to see? What data points do you think would truly reflect the need that exists for long-term care?

[Chief R. Donald Maracle]

I think what we need to understand, Mike, is that when you get a licence from the Ministry of Health for long-term care, the beds have to be made available to people in Ontario who need them because they're subsidized publicly. We can prioritize our own members and other first nations first, but if there are beds available, they have to make them available to anybody who needs them because it's publicly funded. That's how all of the beds on first nations reserves.... With Joel's, they have a number of non-natives who live in the Oneida long-term care facility, and it's the same with the other ones. Ours would be no different.

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

Mr. Bouchard.

[Bernard Bouchard]

I was just going to say that I think, from this report, that we can lower the age group now. We can start looking at that kind of data and see how many people are 55 and over who may require this. When the Province of Ontario made their assessment for 20,000 beds, they chose that 75-plus number. Now we're just starting to understand that we have to go lower.

The question is, what is the number we should be looking at to gather information? I think 55 years is a reasonable number, so it wouldn't be that difficult to accumulate that information.

The important point here, though, is that a lot of the first nations are invisible. They're in the hospitals. They're living at home, at risk. Maybe the family is taking care of them, but we don't know what's going on until there is a crisis. I think it's quite frankly under-reported. We would probably need more beds than we are asking for.

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

I guess that's what I'm trying to get at, because you have on-reserve, off-reserve people in homes, and families living together in homes where the families are taking care of their elders. Is it almost a case where the province assigned that number, but it was a number they took out of the air and said that sounded about right?

[Bernard Bouchard]

If we look at the last 14 years, we see that it shows that the waiting list has not diminished. With all the good work that's done in home care, all the good work that's done with the LHIN, and all the the things that keep people in their own homes, we can see that over 14 years it has not reduced significantly the number of people who are waiting.

I operate a long-term care facility and I have a two-year waiting list near Ottawa. People come in and they can't get in. I think with first nations they're even more invisible, and they have less money, so when those rooms do become available, those private and semi-private rooms—and that's 60% of the licence—they won't have access to those beds.

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

Finally, Mr. Mecredy, I know you're the epidemiologist. In an ideal world, what kinds of data points would you like to see that you would feel would be giving real data that is truly representative of the need?

[Graham Mecredy]

I think we're starting to get at it a bit with what we showed, that the aging population is more frail and more likely to have chronic conditions. That starts to get at the need.

Really, though, we don't have data on the number of people who would be applying if those spots were available, and what the wait-list would be looking like. We don't really have access to that sort of data, so I think improvements in that area would go a long way.

[Chief R. Donald Maracle]

Mike, a few years ago we built a 25-unit apartment building for seniors. Everybody said, “Who will live there?” There's a waiting list of 11 on that, with political lobbying of the council to put somebody out so they can live there.

The other point I wanted to make was that timing is critical in this proposal because Ontario has offered a 128-bed licence to our community. There certainly is a need in the South East LHINs. We know 3,000 of our members live in that area, and 2,200 on the reserve.

We have to get on with planning and getting it designed and built by 2022 to keep the provincial financial commitment there. Right now we need to go ahead with the planning of it and to realize...on the $12 million from the province.

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

What is the barrier that you see to being able to fulfill this project at the end of the day?

[Chief R. Donald Maracle]

Capital funding from the federal government.

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

How much capital funding would that require?

[Chief R. Donald Maracle]

Fifteen million dollars.

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

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

That's a good way to wrap up.

Thank you very much for coming out to our standing committee. We appreciate it. Your report was very interesting, and with a lot of statistics. That's very helpful. Thank you very much. Merci beaucoup. Meegwetch.

We'll suspend for a couple of minutes, and we have another panel that's coming forward.

[The Chair, Liberal, MaryAnn Mihychuk]

Welcome to our committee. We're looking at long-term care. Thank you for coming forward and presenting and taking the day to come to Ottawa.

We're going to start with Grand Chief Abram Benedict. You can go ahead. You have approximately 10 minutes. After that, we'll do a round of questioning from the MPs.

[Grand Chief Abram Benedict, Grand Chief, Mohawk Government, Mohawk Council of Akwesasne]

Good afternoon. Sekoh. I bring greetings on behalf of the Mohawk Council of Akwasasne and the community of Akwasasne.

I'm Grand Chief Abram Benedict. I'm joined today by Keith Leclaire, our Director of Health.

Today we're going to describe to you our health services and how we have identified ways to enhance service coordination for the delivery of services to our community. Using culture as a foundation, we employ a strength-based community approach, combining traditional and western-based health options as an integrated health system. For this reason, we are a modern first nation community offering health services based on promoting Akwasasne's cultural strength.

Our community—the map is up here for you to see—is about an hour south of here, on the international border between Canada, the United States. We're a jurisdictionally unique community and an international border community, with half of our community residing in Canada in the provinces of Quebec and Ontario, and the other half in the United States, in upstate New York. This map lays that out a bit. The islands on the northern side, which are grey, and the mainland, are the jurisdiction of the Mohawk Council. The blue, with the red and the blue lines, is the New York state component.

The Mohawk Council is the governing body of the Canadian portion of Akwasasne. My membership is approximately 12,500. The Mohawk Council, as an organization, has eight departments, and about 800 full-time employees—upwards of 1,000 between part-time and full-time—delivering about $100 million in services, in partnership with the federal government predominantly, as well as the provincial governments.

The unique setting creates many challenges in providing services and programs, because we have to work—specifically around today's presentation—within the health requirements of two provinces, but yet one community. In addition, our community of Akwasasne is geographically landlocked by the St. Lawrence River, separated from the Canada mainland, as well as the United States. The three districts which the Mohawk Council services—Cornwall Island, Tsi Snaihne, as well as Kanatakon, which is also known as St. Regis village in Tsi Snaihne—are all under the jurisdiction of the Mohawk Council of Akwasasne.

We also have the added burden of having to report to the CBSA, which is located in the city of Cornwall, before returning to the district of Kawehnoke, which is Cornwall Island in the province of Ontario. This port of entry is the tenth busiest, with approximately two million vehicles crossing annually, with 70% of the traffic being Mohawks of Akwasasne. I reiterate that: 70%. When we look at border-crossing communities across the nation, there is no other community that has 70% of the traffic crossing the border daily, and 70% of that traffic being indigenous peoples. There's a huge difference here, when we talk about border communities and people trafficking all the time. Nowhere else in this country will you find the same people crossing predominantly across that international border all day, every day.

Despite this, the MCA has diligently worked to minimize the impacts of the border on the daily lives of our community by negotiating special arrangements for areas like emergency services. We also utilize a political protocol with Canada, to call Canada and the provinces to a table to discuss solutions to jurisdictional challenges that our community faces. This also includes the health care area.

Akwasasne delivers indigenous services similar to what other first nations communities offer. I must highlight that for the past 20 years we have run our own ambulance services funded by Ontario, Quebec, and ourselves, delivering ambulance services to our community. For the past 22 years, we have been in full control of our Akwasasne non-insured health benefits program, which is normally administered now by Indigenous Services, but formerly by Health Canada. For the past 25 years, we have operated Tsiionkwanonhso:te, a 50-bed long-term care facility licensed and supported by the Ontario Ministry of Health. For the past 23 years, we have operated Iakhihsohtha, a 30-bed care facility in Akwasasne within the Quebec district. We operate four medical clinics across Akwasasne. We operate a fully functional traditional medicine program, and we provide a 30-day rural health work placement for medical students from McGill and Ottawa universities, which incorporates work with our traditional healers.

One of the things that we heavily promote is our partnerships with the federal government, municipal governments, private businesses, and institutions such as colleges and our universities.

The entire Mohawk Council of Akwesasne Department of Health is accredited under the auspices of Accreditation Canada, meeting the highest Canadian quality standards of health services. This is something we're extremely proud of.

In short, our services have evolved into a truly integrated health system, using our culture and values to guide western health-related sciences in program delivery. This is done through exclusive use of our traditional language, traditional medicine, and traditional ceremonies.

I'll now turn it over to our director of health, Keith, to go over a bit more of the programming that we deliver.

[Keith Leclaire, Director of Health, Mohawk Council of Akwesasne]

[Witness speaks in Mohawk]

I'm very proud to be here, and I'd like to share with you our long-term care concerns.

First of all, from Akwesasne's perspective, we understand fully well that the Canadian health care system is fragmented—some provincial stuff, some federal stuff. However, it is our responsibility in Akwesasne to make sense of the different multi-jurisdictional issues, to find solutions, and to meet with the appropriate entities to make that a reality.

Indigenous Services provides support at the federal level, with Ontario health and the réseau de la santé Québec offering support at their levels. Almost half of our community is served with OHIP for insured services, and the other half is served with RAMQ for insured services from the Quebec side.

I think you have had a good chance to see what's on the map over there. Short and sweet, we have roughly 12,500, as Grand Chief Benedict has said. We're pretty well split up, with about a 45-55 split between the Ontario and Quebec groups.

However these multi-jurisdictional issues for Akwesasne have created challenges in providing seamless secondary and tertiary health services. When we provide outside of Akwesasne, Ontario, we have to come up to Cornwall, and we have to go in for tertiary services to Ontario, basically Ottawa. On the Quebec side, we have to go to a smaller community, Barrie Hospital, which is located in Ormstown, Quebec, about 45 minutes away, and for tertiary services, we have to go to Montreal. These are samples of where we are.

As is normal, we face these jurisdictional challenges daily. We search for solutions, using innovative approaches and partnerships to resolve the jurisdictional issues we face.

Long-term solutions require a community, strength-based approach, and basically we're doing that. Our community has strengths that afford prioritizing our services to meet the needs of our community members. Our strength is in our ability to prioritize those services. In addition to our community approaches, we offer you a portrait of opportunities within the current system that we hope you will be able to listen to and give some thought to some of our reflections.

The first point we want to tie in is on infrastructure. Akwesasne recommends that you examine the support for maintaining existing resources that are now under community control. This hasn't been considered very well up to now. Akwesasne's long-term care facility is Tsiionkwanonhso:te, and in medical terms that's a level 4 care service. Tsiionkwanonhso:te, by the way, means “our house” in our language, and that's just what it is. It's not an institution; it's an extended part of our community.

Our level 1 and 2 care service is Iakhihsohtha, which means “the home of our grandparents”. We've operated both of these, as Chief Benedict has said, for more than 20 years. Our concern right now is that these two care facilities require infrastructure improvements and support to continue providing the quality services that we give.

Right now, I think long-term care requires long-term support for infrastructure, given the fact that our long-term care facility is actually funded by the province, yet it is located in a first nation territory under federal government jurisdiction.

Due to the federal-provincial divisions of authority, we require your support to seek solutions as we talk about more large capital investments. If we want to continue providing long-term quality care for our people, we need to make sure we have the infrastructure and the buildings that are sufficient to meet the codes.

We are unable to access capital and infrastructure enhancements right now, and I think that's a point we want to make sure you consider in the writing of your report. Please look at this as an issue.

Also, what we're looking at now is prevention. One of the things that our health services, like all of those across Canada, needs to focus on more is the preventative aspects of long-term care.

I think most of the time we're here talking about what the needs are for the facilities, but I'd like your assistance in recommending some departmental support to assist in capturing evidence-based data to show our success, especially in prevention support activities.

I've asked a number of times, and the reply I keep getting back is that it's a bit too complicated. You can get back information on an annual basis about how many people came to a facility, how many people are there, but, in fact, when we start talking about prevention, that isn't done over a three-year or a five-year period. It's done over 10 years, or over decades. One weakness in the system here is that we have to look at how we can support the challenge to get better evidence-based information on this.

What I'm really tying in here is that a prevention type of evaluation is longitudinal in nature and it takes time. As we know, Canada is facing an aging population overall, and we all need to be innovative. I think that's one of the areas we should be looking at, looking outside the box.

Also, Akwesasne has better services provision than do most other first nations across Canada, and we offer you this advice: There will be gaps in service levels in the long term.

Right now your definition under the federal classification system for institutional care, which is found within the National Assisted Living Program Guidelines 2018-2019, delineates service responsibility between Health Canada, FNIHB, and the previous DIAND under the assisted living program. Right now, I expect modifications of this classification system, with greater community-based participation, and, in fact, we at Akwesasne are prepared to assist you with any technical revisions to make sure that does happen.

Our biggest concern also is for the mental health and mental wellness of our elders. There needs to be consideration to enhancing programs that impact mental wellness for our elders given our size and districts in Akwesasne. As you can see, we're spread out. The reality is that it is difficult for long-term care clients to socialize.

The last point we are really trying to tie in here is that we have to ensure there is an acknowledgement of volunteerism. Most of the time a lot of our activities that are going on are adult care, day care services, and meals on wheels, and a lot of times we have a lot of individuals who are providing mental health support. In reality, what we need to do is to make sure we have recognition through your recommendations to support and enhance volunteerism at our community level.

With that in mind, I'll pass it back to Chief Benedict.

[The Chair, Liberal, MaryAnn Mihychuk]

I think we have run out of time for this presentation, but we will dive into it with questions and we—

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

Why don't we let the chief finish, Chair, if you don't mind. He has just one quick comment.

[Grand Chief Abram Benedict]

Very quickly, I just want to wrap up what the director has said. I just want to reiterate that jointly Akwesasne, as one of the few communities that have beds existing now, has a vested interest in the work you are doing. With what we have said today, with the service delivery model we have, which we have delivered for a long time, I think we can partner together and learn from our challenges and learn from our successes. We are a large progressive community that is in a very unique situation, in that we are spread over an international line, and we deliver culturally appropriate services in the provinces of Quebec and Ontario. Our organization is made up predominantly of our own people who deliver these services daily to meet the needs of our community, and I know that we have very similar goals in mind here.

We are here to bring a message to you that we're prepared to work with you to develop your report, to make recommendations, to see that we ensure that we are meeting the needs of all first nations and Canadians across this country.

In closing, I do invite all of you, as I have in the past, to visit our community, which is about one hour south of here. Don't forget to bring your status card or passport.

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

That's a valid status card.

The questioning moves first to MP Will Amos.