Indigenous and Northern Affairs Committee on Sept. 26th, 2018

[The Chair, Liberal, MaryAnn Mihychuk]

I call the meeting to order. Welcome, everybody.

It's a lovely fall day in Ottawa. We're very grateful that you came all the way to our committee. We are on the unceded territory of the Algonquin people. Canada is in a process of truth and reconciliation. This committee, in particular, always recognizes that for both the location and the broader meaning.

Pursuant to Standing Order 108(2), we are conducting a study of long-term care on reserve. We have with us a delegation of three who are going to spend 10 minutes with their presentation, and then we'll have an opportunity to do questions from the MPs, both on the Liberal and the opposition side.

Anybody who wishes to start, please go ahead.

Robin, welcome to our committee.

[Robin Decontie, Director, Kitigan Zibi Health and Social Services, Kitigan Zibi Anishinabeg First Nation]

Thank you.

First I'd like to acknowledge my ancestors of this land, the Algonquin Anishinabeg first peoples.

My name is Robin Decontie. I'm the director for Kitigan Zibi health and social services.

I was born and raised in Kitigan Zibi. I left home for 10 years to pursue my education, to then return to work for our community health centre over the past 20 years in different capacities. I'm now the director of our combined approach of health and social services programs. We've been a transferred health services community since 1989, and we're categorized as a high-functioning, low-risk administration community under ISC.

I'm also a member of the board of directors of the First Nations of Quebec and Labrador Health and Social Services Commission. Hence, I have some insight into what challenges there are on a regional basis as well.

With that in mind, today I offer you a community perspective of our challenges in delivering on-reserve long-term care and potential solutions to these issues. We're a community that believes in doing the work for our own people, by our own people. We believe in capacity-building. Policy-level changes impact good practice at the community level; therefore, I'm honoured to be here today to engage in this important topic of long-term care on reserves and I thank you all for this opportunity.

I'll describe challenges to long-term care on reserve and present some solutions for thought.

The major issue we're facing in many areas of service delivery is medicare delegation to the provinces and the associated jurisdiction issues.

Our community members are dependent on the provincial medicare system for our long-term medicare needs, as all Canadians are. We are dependent on our medicare system for our illness and health care. ISC is not a medicare authority in Canada and delegates these authorities to the provinces via the Indian health policy of 1979. This dependence creates issues when we try to work with the provincial medicare system for, one, uniform communication with first nations liaisons positions to facilitate better access to provincial medicare; two, proper health service delivery practice supervision; and three, planning for chronic disease service delivery and health planning.

Concerning uniform communication with first nations liaisons positions within the medicare system, Quebec's provincial ministry of health and social services liaisons within regional health boards do not have a standardized way of communicating and networking with on-reserve first nations providers in their province. We are dependent on each other to provide care to those needing long-term care on reserve, from womb to tomb. There needs to be a better way for on-reserve service providers to communicate with regional health boards in Quebec that would improve the health services access problems we are experiencing in communities.

For example, I have with me a document entitled “Portrait of the Situation for English-speaking First Nations: Accessing Health and Social Services in English in the Province of Quebec”, from the Coalition of English-Speaking First Nations Communities in Quebec. The portrait identifies the need for provincial boards to have a clearer role and responsibility for first nation liaison agents of the health system to work in partnership with on-reserve health services for long-term care. This is one example of an access issues study.

The solution is to obligate the ministry of health boards throughout the provincial ISC services to mandate a standardized first nations liaison that will meet the needs of communicating with first nations on-reserve care systems to allow for greater access to provincial services on reserve. There needs to be an obligation from the ministry of health and social services of the province to their own provincial medicare system to have a solid, standardized liaison practice from one regional health board to the next, to communicate and work in partnership with first nations communities to improve access to their medicare system.

I have this report. It's translated. It's bilingual.

Regarding proper health service delivery practice supervision, currently there are administrative obstacles with the ISC intermediate resource home facilities. These homes are for semi-autonomous people on reserve. This population will eventually have a growing need for care as their independence continues to diminish. A legal opinion that Quebec first nation intermediate resource homes indicated that non-certified ISC-funded homes on reserve are running an illegal practice of care that can be subject to heavy fines from the province if the province wishes to pursue our homes' care activity.

I have a copy of this opinion in English, if you wish me to submit it as well.

This means that the group homes on reserve in Quebec are providing services beyond the ISC levels 1 and 2 care because there is a growing need for these services with our aging populations. In so doing, we are working against provincial medicare law. There needs to be a congruent way to evaluate autonomy of the human condition between the ISC assisted living service and the provincial medicare system. Currently there is no provision to obligate the provincial medicare system to work with the on-reserve service provider to determine definitive levels of care that a client may need.

Currently our community services use a provincial assessment tool, which rates autonomy from levels 1 to 15 rather than the 1 to 5 that ISC uses. The ISC criteria of care between levels 2 and 3 is a grey zone, which leads to the home having to provide more services than it should in providing to clients in this grey zone. Hence comes forward the illegal practice of providing more help and care in these homes than we should, according to the province.

With the provision of more long-term helping services in the group homes beyond levels 1 and 2 come nursing services that the professional Order of Nurses of Quebec restricts in these homes. According to Bill 90 of the Quebec health act, nurses are not allowed to practise services in intermediate resource homes that are not certified by the province. Hence, we have inadequate supervision available to us by the provincial medicare system as needed. Nursing licences can be revoked by the Order of Nurses of Quebec if nurses are found practising nursing in group homes that are not certified by the province.

Currently our Kiweda group home, funded by ISC's assisted living program, is not a certified home under the province, but we are accredited by Accreditation Canada. Nonetheless, there is no legal provision in Quebec to secure any nursing services we may need to provide to the client in this home. This has always been a contentious issue for our health care team when deciding what care we can provide on reserve to our own people legally.

Our community mirrors the aging population situation, as in the rest of Canada. More aging people will be needing more care in the future, up until the next generation. Nursing home care, which is currently regulated by the province, will be the next set of residential services that we will need to provide to our community members on reserve. We need to ensure that nursing care licensing and certification processing for these homes is better facilitated between the provincial medicare system and first nations service providers on reserve, so that we can provide long-term care by our own people for our own people.

A solution perhaps is to provide the budget resources for assisted living homes to become certified in a culturally appropriate manner, equal to the province. This would mean infrastructure funding to upgrade our homes to meet provincial certification standards, and changes to scope of practice would need to happen to allow for cultural activity. For example, proper sprinkler systems for fire safety would need to be installed in homes, and certification would be needed to allow wild meats to be eaten in these homes, which is not allowed by current provincial certification. The province should be obligated to allow capacity-building approaches for our own community workers to provide the work for our own people by our own people in certified homes as well.

As well, provide the budget to allow first nation home and community care services to expand their hours of service delivery as needed to help community members remain at home and out of the provincial hospital care system as long as possible.

With regard to planning for chronic disease service delivery and health planning, there are other conditions besides elderly aging that constitute the need for long-term care on reserve. There are emerging concurrent disorders needing long-term care, such as people with mental health disorders and physical disabilities and people with chronic concurrent pain crisis management and addictions.

Those struggling with these mental health conditions concurrently with their physical conditions have very limited capacity for decision-making and are dependent on service provision, because they cannot live on their own. With the onset of the opioid crisis that we're experiencing in North America, we are observing the need for long-term care for community members struggling with addictions to have a place to go to so they don't die young.

[The Chair, Liberal, MaryAnn Mihychuk]

You have 40 seconds

[Robin Decontie]

Forty seconds?

[The Chair, Liberal, MaryAnn Mihychuk]

Yes.

[Robin Decontie]

For solutions, obligate the first nations liaison to configure aggregate public health and medicare data to be accessible for first nations communities to determine what chronic diseases the communities are dealing with, for a better medicare system and better health planning for long-term care.

Here is our conclusion.

Improve the obstacles between the provincial medicare partners and first nations who are capacity-building to provide care for our own people by our own people. Federal funds are disseminated to the province to provide first nation care; therefore, there should be more accountability as to what the province is providing to first nations in medicare.

Provide law changes to the provinces to allow for more jurisdiction and decision-making authority to first nations on-reserve services regarding medicare services development. The province must be open to working with first nations on reserve under federal jurisdiction to create and sustain safe medicare for those communities that are ready to provide medical practice themselves for long-term care.

We are in changing times now. Our community members are becoming more educated in health fields. We need to look at how we can provide better services to our elderly, chronically ill community members, prenatal and postnatal mothers, and children with chronic care needs.

Currently the province is able to deny service delivery on reserve due to our communities being under federal jurisdiction. It's observable, and data is available proving our province is not understanding that we do not have jurisdiction over medicare in our communities. They have been redirecting our people back to services on the reserve because we live on federal lands. There needs to be an obligation for the provincial medicare system to work in partnership—not simply to discard the responsibility—with on-reserve service delivery providers to create, sustain, and practise medicare in our communities, for those communities that are ready to take on that challenge.

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you.

We were a bit lenient on the time because, of course, we have one delegation. I hope members understand.

We have a new member of our committee. MP Robillard has joined us. He will be opening the questions in this round.

[Don Rusnak, Thunder Bay—Rainy River, Lib.]

No, sorry, Madam Chair. This is just a question. Do we only have one presentation?

[The Chair, Liberal, MaryAnn Mihychuk]

I thought it was one. Oh, I should have cut you off. Now I'm sorry.

Okay, you guys can fight it out. I don't know. I'm sorry for the misunderstanding.

We'll have the second presentation, please.

[Sharon Rudderham, Director of Health, Eskasoni First Nation]

I'll just introduce myself. My name is Sharon Rudderham and I'm the health director of Eskasoni First Nation.

Eskasoni is the largest first nation or Mi'kmaq community east of Montreal, in Nova Scotia. It has a population of 4,500 people. Half of our population, about 2,200, are young people in our community, so we have a significant youth population.

As you know, I'm here today to talk about long-term care and the needs related to it. We know that the impacts of the Indian residential school system have created an unwillingness by our people to access long-term care services outside of our communities. They prefer for services to be provided within our communities.

We've been working collaboratively with the Province of Nova Scotia in trying to resolve what we believe to be discriminatory policies that exclude provision of care to first nations people within Nova Scotia.

I also want to reference in my presentation—and I'm not sure if you're aware—that when the Health Council of Canada did a research study in 2012 and surveyed aboriginal people across this country, they found that aboriginal people feel fearful, powerless, and discriminated against, and have little trust in the public health system as it exists outside of our first nations communities.

I want to reference some data specific to our communities here in Nova Scotia. This data comes from what's called the Nova Scotia First Nations Client Linkage Registry. It's a unique identifier that allows first nations to extract data from provincial data sources. This was done through an agreement with our provincial government and our first nations communities.

Death before the age of 75 is considered premature. Between 2004 and 2013, 80% of deaths in our first nations communities were considered premature in comparison to the rate for Nova Scotia, which was only 30% premature deaths.

As you all know, the rates of diabetes are significant in our communities, with the rate almost double or triple the provincial diabetes rates.

I know we have limited time. I have some statistics. I'm referencing the importance and need around chronic disease management and the supports that we need to have in place and in process within our communities to support our population affected by these diseases.

Looking at heart attacks and heart failure, within our first nations communities the median age of someone who has a heart attack is 56. In Nova Scotia, the average age is 69. For heart failure, the average age was 67 years compared to 78 years for Nova Scotia overall.

You're probably wondering where I'm going with this. It's to give you an example of the need and the differences that exist between aboriginal and non-aboriginal communities. We do have a young population in our communities, but we have higher rates of chronic disease and disability that are being created because of these high rates of chronic disease.

We have small numbers around Alzheimer's and dementia, but when we look at the premature death rate that exists, if 80% of the people in our communities die before the age of 75, people are not getting diagnosed and not reaching those ages in the same manner that the entire country is reaching those ages and filling our long-term care facilities.

[Stephen Parsons, General Manager, Eskasoni Corporate Division]

My name is Steve Parsons. I am the general manager of Eskasoni corporate services. My job in this whole team concept is to help negotiate with the province, on behalf of the band, for a long-term care facility.

It is important for members to understand that we're the model for Nova Scotia and that we could potentially be the model for the country. There's no such mechanism, no such long-term care, in the province of Nova Scotia as it exists today. One of the reasons this is a priority of the chief and council is that we do have a population of elders who need this care. We have had elders staying in existing non-first nations long-term care facilities, and they're struggling. Members need to understand that they want to come back to their communities because of cultural differences and language differences.

Take palliative care. Death in first nations communities is different from death in non-native communities. Palliative care is very important. When somebody is dying in our community, they are supported by family. When they go to our regional hospitals, the staff get inundated because they can't handle the number of people coming in to support the person who's dying. These people are dying in long-term care facilities and they want to be able to live in their communities. There is no mechanism in place when you go, and because people don't understand the language, they're fearful of it. Therefore, they stop going to the non-aboriginal homes. The support then can't be there.

We're currently negotiating with the Province of Nova Scotia. The fact that they have recognized and are negotiating a 48-bed facility for our community.... It's not just for our community. We've created a model that is for all Mi’kmaq in Nova Scotia. There are approximately 15,000 first nations people in Nova Scotia.

We have submitted our presentation for your reading at bedtime, or whenever you want to do it. We're creating a model that reflects the need of the community. We even went so far as to pre-empt this by training 10 continuing care workers in our community three years before we started the negotiation. Why? These are employment opportunities for our young people—which we have—who can participate in employment opportunities and give back to their people in a setting and in a service that we can provide ourselves.

We know that the negotiations are provincial, but there is a role for the federal government. The role is to help with capital infrastructure. These things aren't cheap to build. You all come from communities where infrastructure is built. Infrastructure is the primary focus. You can't have a home to provide the service unless you have a home.

We have three full-time doctors in our community. A natural progression in our community is from primary care to long-term care. In a lot of first nations communities today, there is a housing opportunity. Elders are living with large-sized families, and the level of care that they need is not there. We have 400 people in our community who require home care. The natural progression for these people is that they end up in a long-term care facility. Right now in Nova Scotia—I know it's a provincial issue—we have a waiting list not only in our region but in our province. There are 3,500 Nova Scotians right now on a waiting list for a home. Identifiably, the need is there.

We're saying that we could be the model for Nova Scotia first nations Mi'kmaq. We could provide that service in our community no differently than we do for alcohol and drugs for Nova Scotia Mi'kmaq. We do that out of our community. We're a large and progressive community. We want to be able to do this in conjunction with federal and provincial help and our own community chief and council.

We're willing to finance this. The need is there. We've costed it out, and we have an operating partner. We know we can't do this ourselves. We have an operating partner agreement with Shannex, the largest operator in Atlantic Canada for long-term care facilities. Their name is in our report. Shannex provides services for thousands in Atlantic Canada right now.

We knew we couldn't do it ourselves. We don't have the expertise or the capacity. We married that up with a joint venture. We have a management contract for a term. We want to get our people up to those administrative jobs. We have nurses and PCWs in our community today. What we're trying to do is take it to the next level and provide the services beyond “A”, which is there. The band did a feasibility study that cost $30,000. Why? We needed to understand the proper scope of the province.

We made a pitch to our provincial government to be a partner, in a per diem per day of 48 beds: If these beds are not filled by all first nations people, we're willing to help out the present waiting list. Empty beds don't pay the per diems that you need to operate. We set this up so that this is not a burden on the band and it's not subsidized by the band annually. It has to run on its own operationally. That's why we went out and got a partner—to create those opportunities, provide the service, and create the jobs for young people that are desperately needed as well.

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

Very good.

Now I'll do a rewind and invite MP Robillard to start off the questioning.

[Yves Robillard, Marc-Aurèle-Fortin, Lib.]

Thank you.

I will ask my questions in French.

First of all, I would like to thank everyone for being here today.

My first question is for Robin Decontie.

Could you describe the specific needs of the various age groups requiring long-term care in your community?

[Robin Decontie]

Approximately 25% of our community membership will be over the age of 65 within the next five years. There's a growing aging population, which will subside perhaps in the generation after that. It's been referred to as the baby boomer generation, the set of elderly population that will be needing long-term care, but that's for aging purposes. There are other people and other patients in our community needing long-term care for other issues than just aging, as I mentioned quickly in my presentation, needing long-term care for chronic disease and chronic illness. We would like to get that population addressed as well. We would like to offer service delivery for them as well.

[Yves Robillard]

Thank you.

My next question is for Stephen Parsons or Sharon Rudderhan.

In 2014, your community informed the provincial government that it wanted to build a long-term care facility. What steps could the federal government take to further coordinate its funding process with that of the provinces?

[Stephen Parsons]

As to the long-term care process right now, we have no other choice but to work through the process of standardization with the province as far as homes are concerned. The province basically had to sign off on everything from the management agreement to the staffing levels to the operations—the whole gamut. There's really no role, as we're told by the province as it relates to....

The province has the authority to grant a licence. Our goal is to garnish that licence for 20 years. In order to finance such a project, we need per diems based on our model for 20 years. Our project is shovel-ready. Yes, we go through the process of acquiring the licence, signing off on permits and so on and so forth with every department within the government from environment to agriculture and so on. That will take its course. This is territory where we've never been. No first nations in the province have gone down this road; we're the first.

We've had communications with the Minister's department, and we've had communications with our local MP. The role of the federal government here, knowing that decision-making process has been turned over to the province to administer, would be to help support that through a partnership not only in working with provincial counterparts, but at the end of the day we feel that the federal role here is one that could help establish the home. Whether a committee and/or the federal Department of Health wants to go back and engage with the province, I can't shed any light on that, on how to improve that, because I don't know that. I know that we've created a model. There's a role for the federal government and there's a role for the provincial government. That's why we're here hoping to encourage our MPs who are sitting on this committee to talk.

I want to back up just for a second. It really brings to light what members need to understand. I have a lot of friends who work in long-term care as staff. Not knowing the first nations, not understanding them, not knowing their traditions or their culture is really a sin. It's somewhat degrading when families of first nations go to visit their elders in homes and the staff say, “Oh my God, here they come again.” You really need to understand that. Picture your own family going into a home. It's inevitable that people, when they get elderly, need services. That's what governments do. That's what we all do collectively; we provide for that. Imagine families coming in from Eskasoni, and the staff says, “Oh my God, here they come again.” That's worrisome.

[Sharon Rudderham]

It's discriminatory.

[Yves Robillard]

Thank you.

I will give the floor to my colleagues.

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

I have a few very quick questions.

Right now you're looking at a facility with how many rooms?

[Stephen Parsons]

It's a 48-room long-term care facility.

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

How many jobs does that create?

[Stephen Parsons]

It creates 74, to be exact.

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

Would it be open to both indigenous and non-indigenous people?

[Stephen Parsons]

We're training people as we go.

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

No, I mean the residents.