Veterans Affairs Committee on June 7th, 2012

[The Chair, Conservative, Greg Kerr]

I'll call the meeting to order. I know it's a challenging thing to do.

As I explained, we do have a vote pending. We will try to get the three presentations in before we go. It's a 30-minute bell. If the members are in agreement, we don't mind staying a few minutes into the bells to make sure we get the presentations. Then, we'll break for the bells, and we'll come back and we'll finish the question and answer session.

Welcome, on behalf of the committee. As you are well aware, we're studying transformation initiatives at Veterans Affairs. We're getting some good input, and we certainly welcome yours today. We have 10 minutes for each organization.

I think we're starting with McMaster University, Nancy Murray, with the case management program.

If you'd like to start now, please go ahead.

[Nancy Murray, Instructor, Case Management Program, McMaster University]

Thank you, Mr. Kerr and the session organizers, for inviting me as a representative of McMaster University, Hamilton, Ontario, to briefly address today's topic on case management.

I would like to commend you on your study of transformation Initiatives at Veterans Affairs Canada, which includes your five themes—reducing complexity, overhauling service delivery, strengthening partnerships, sustaining the new Veterans Charter of October 2011, and adapting to changing demographics—all of which look as if they're very client-focused and will require the element of case management.

In light of this and as a focus for today's session, I would like to provide my comments under four sections: first, history; second, the McMaster University case management program; third, examples of home care—they're interspersed throughout the presentation—and finally, research.

In terms of history, case management in homes began in England in 1601 under social welfare legislation. In the United States, case management rehabilitation programs were started in the 20th century. George Welch is considered the father of U.S. modern case management, and really, the focus was controlling the spiralling costs of health care.

In 2000, approximately 68% of an estimated 80,000 case managers in the U.S.A. worked in insurance and rehabilitation, so 32% worked someplace else. The genius of case management is its extraordinary flexibility and endurance, under the premise that case management provides an individual with the opportunity to reach her optimum level of wellness, functional capacity, and living arrangements. Case management is a collaborative, client-driven process that focuses on quality health care and social support, through the effective and efficient use of resources.

Case management achieves client wellness, wholeness, and autonomy through respect, communication, advocacy, service identification, coordination, integrated planning, reflective evaluation, and research-based approaches.

Catherine Mullahy, one of the champions of case management several years ago, described case management as the only profession that looks at the gestalt. Certainly at McMaster University we take the focus it needs.

McMaster University's certificate program offers an online program to all parts of Canada. We have students from British Columbia, the east coast, the Northwest Territories, and outside Canada. There are five core courses, and they are completed in five years.

We begin with topics such as history: background, definitions. We focus on the legislation and regulations, which look at where the case manager works, such as B.C, the Northwest Territories, or Ontario. We add items of interest such as the Drummond report, where they spoke of case management and the systems navigators, and that all regions should have that quarterback.

The standards of practice, the competencies, roles, functions, processes, and reflective practice are other areas of case management. The CCAC offers as an example the electronic tools, scores, and algorithms that give an assessment of case management with key outcome indicators in order for the case manager to provide care in the home including: nursing, personal support, physiotherapy, OT, speech-language pathology, social work, nutritional counselling, and medical supplies and equipment.

They also have things such as medication reviews for the elderly in terms of risk management and safety. The case managers are considered the care connectors; they match clients in need with primary care providers. We look closely at the models of case management—and there are many—and we go through those details. A more recent example is an integrated and intensive model that the CCACs are looking at, which looks at clients who are high-complex or “chronic community-independent short-stay”. The model includes a high-risk need with fewer clients per case manager.

They also have an integrated client-care project, a multi-year initiative that looks at specific populations including: wound care, palliative care, frail seniors, chronic disease management, and medically complex children. The model is the work of Michael Porter from Harvard, and it looks at value-based care with coordination, integration, and specialization as the key features.

Other things they have are the rapid-response nurse, who is very solution-focused, for those who need attention and are complex in their transitioning from hospital to home.

Along with the models, we also teach the topologies of case management. One of the key ones that is featured is the problem-based topology. Again, in terms of the application, they are using that as a model in CCACs with integrated intensive models, along with a populated-based focus, which looks at seniors, child and youth, and palliative.

Other topics we include in our program are the elements of personhood, which is such an important feature in terms of individuality, wholeness, and integrity; and ethical issues in terms of ethical dilemmas, decision-making; and ethical, legal, and financial issues in case management. We view cultural competencies in looking at adequate health and social services without facing any discrimination.

The impact of mental health issues is another area. We see in many of the CCACs in Ontario, if the client has a primary diagnosis of mental health issues, that is assigned to a specialized case manager because of the complexity of that care. We do mention things, such as the Mental Health Commission of Canada's introduction of Changing Directions, Changing Lives, the first mental health strategy for Canada.

Other areas we focus on are the social determinants of health and their application in terms of case management; collaboration between sectors—public health, primary care, community care—and systems thinking and navigation. Because case management is a dynamic process, case managers act as a systems navigator, facilitator, in trying to balance the provision of services to produce optimal health, independence, client satisfaction, and fiscal responsibility.

I'd like to end with research. We do offer another course linking case management to policy, education, and evidence-based research to influence policy and program development. We encourage case managers to continue their professional development and to familiarize themselves with best practice and its application.

The most recent study being done is regarding case management. You can have all the tools, algorithms, and scores in the world, but when you are looking at teams and working together in an integrated specialized way, you have to have that excellent skill, that expert case manager. The study is a qualitative, phenomenological research that looks at the experience of experienced case managers. It's called “The Nature of Insight: Case Management”. It will be completed this summer.

Thank you.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Murray. I'm not even going to ask you what “phenomenological” means. Maybe someone will ask about it in the round of questioning.

I appreciate that. Thank you.

Now I understand we have the National Case Management Network of Canada, Joan Park and Ruth Anne Campbell.

We're going to start your 10 minutes, please.

[Joan Park, President, National Case Management Network of Canada]

Thank you, Mr. Chair.

Good afternoon. It's an honour to speak with you today about the National Case Management Network of Canada in relation to the work of this Standing Committee on Veterans Affairs.

I've reviewed the evidence presented at the first session, on May 8, as you studied transformation initiatives at Veterans Affairs Canada. I commend VAC on its commitment to improving service for Canada's veterans and their families by building on its greatest strength as a department: employees who care about their work and the people they serve.

I will begin with a brief overview of NCMN. Then I will speak to how a partnership with NCMN can assist Veterans Affairs Canada to have the right people with the right skills in the right places to meet the needs of veterans of all ages; to equip front-line VAC case managers with real-time access to the clinically relevant, evidence-based resources needed to do their jobs; and to connect front-line VAC case managers with case managers across the country who work with clients and families from similar and complementary target populations.

NCMN leads today for tomorrow. In a few short years, NCMN has emerged as a leading national organization that connects, supports, and sustains all providers of case management. The mandate of NCMN is to foster case management providers for the benefit of individual Canadians, their families, supporters, and the Canadian health care system. The mission and vision of NCMN is to promote excellence and professionalism for case management in Canada.

Established in November 2006, NCMN is federally incorporated as a non-profit professional organization that is membership based. Our membership embraces individuals and organizations in every province and territory. It represents diverse health and social service sectors that include academic and educational providers; acute care; community support agencies; the Department of National Defence and the Canadian Forces; disability management; first nations and Inuit health; home and community care; long-term care; mental health; private insurance; regional health authorities; rehabilitation; research; therapy services; Veterans Affairs Canada; and workplace safety and insurance boards.

In 2010, support from Health Canada's health care policy contribution program allowed NCMN to distribute Canadian standards of practice for case management, provide learning resources, and develop a professional association. This established the foundation on which to identify, attract, and prepare highly skilled interdisciplinary health and social service providers of case management. Health Canada's support also allowed for the initiation of the development of a national competency profile and the selection of a competency framework.

NCMN recently signed a second contribution agreement with Health Canada for the project called “Promoting Excellence and Professionalism for Case Management in Canada. Phase II: Core Competencies, Credentialing, and Sustainability”. This funding allows for the development and validation of national core competencies and the selection of a credentialing process to indicate competence in case management. The project also aligns with Health Canada's health human-resource policy framework to optimize Canada's health workforce for the increasingly demanding and complex health care needs of Canadians.

Leading today for tomorrow, NCMN seeks to identify case management best practices to steward these discoveries into meaningful standards of knowledge and to disseminate that knowledge nationwide. VAC members have served on the NCMN board, have contributed to the Canadian standards of practice, and have shared their experience at NCMN's national conferences.

What does NCMN offer to Veterans Affairs Canada? VAC case managers, like case management providers across the country, practise a collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. They support the client's achievement of safe, realistic, and reasonable goals within a complex health, social, and fiscal environment.

VAC case managers, like case management providers across the country, are experts in care coordination and integrated care as communicators, collaborators, navigators, advocates, managers, and professionals.

The work of NCMN aligns with the intent of Veterans Affairs Canada to tighten the focus on case management and ensure that our employees will be supported so they are well equipped to do their jobs. In many ways NCMN addresses Keith Hillier's statement that “we have the right people with the right skills in the right places to meet the needs of veterans of all ages”.

First and foremost, NCMN is building a Canadian case management body of knowledge with its development of both national standards of practice and core competencies. Together the standards and core competencies form a distinct body of knowledge and provide a standard of care. A standard of care communicates the practice, knowledge, skills, and attitudes of case management providers to the many Canadian constituencies, including the health care system, government, commerce, the military, and the general public.

This body of knowledge establishes a foundation for case management providers to acquire the right skills, for educational institutions to develop curriculum, and for workers and employers to create job descriptions and performance appraisals. Secondly, given that practising front-line VAC case managers, like case management providers across the country, have limited time for engagement with educational materials, seminars, conferences, and other events that help to maintain their professional currency, NCMN is able to equip VAC case managers with real-time access to the clinically relevant evidence-based resources needed to do their jobs.

OvidMD is an online tool that allows NCMN members to perform a Google-type search of anything in the medical world. Ovid is an advanced search tool known to university librarians around the world, and access is generally a privilege of large academic and research institutions. OvidMD is a tool recently designed specifically for busy front-line health care providers. NCMN members have commented on its ease of use, functionality, and applicability to self, work colleagues, and clients. A mobile app is about to be released.

Professional Case Management journal is the official journal of NCMN, Case Management Society of America, and the Case Management Society of Australia. PCM is an international, evidence-based, peer reviewed journal with a readership of 13,000. NCMN members receive a hard copy of the journal and online access to journal archives. Each bimonthly publication includes “News from NCMN”. The July-Aug 2011 issue “News from NCMN” reported on the work of a Canadian case manager from the Interior Health Authority in B.C. and was the most read article around the world.

The third benefit NCMN offers to Veterans Affairs Canada is to connect front-line VAC case managers with case managers across the country who work with clients and families from similar and complementary target populations. NCMN members from other sectors are working with individuals and populations that VAC case managers are also working with, including: disability, return-to-work, seniors, child services, chronic illness, and mental health. As VAC clients and families transition from military to civilian life, there is strength in numbers and the benefits of case management increase exponentially when case managers integrate their knowledge, skill, and practice across these spectrums.

NCMN provides an opportunity for case managers to collaborate more closely with their peers in applying evidence and best practice to case management. A membership directory provides them with easy access to colleagues across the country and across sectors, and our national conference gives them the opportunity to meet with colleagues face to face to strengthen bonds and share their work.

NCMN encourages VAC case managers to continue to bring their voice and experience to affect the crucial national conversation on the future of Canadian case management.

With that, Mr. Chair, I would like to thank you and your committee for this time. I've provided an overview of the National Case Management Network of Canada and spoken to how a partnership with NCMN can assist Veterans Affairs Canada to tighten that focus on case management and show VAC case managers, who provide service to your most complex veterans, that they are well supported to make decisions that improve the care of veterans today for tomorrow.

Thank you.

[The Chair, Conservative, Greg Kerr]

Thank you very much, Ms. Park. I'm sure there will be questions flowing, after a bit.

We are now certainly very pleased to have the Canadian Peacekeeping Veterans Association as our final presenters of the day.

Mr. Kokkonen, Mr. Gollner, and Mr. Eggenberger, I understand you're going to split your time.

[Ray Kokkonen, National President, Canadian Peacekeeping Veterans Association]

That's correct.

[The Chair, Conservative, Greg Kerr]

Please proceed. Thank you.

[Ray Kokkonen]

Mr. Chair, committee members, ladies and gentlemen, my name is Ray Kokkonen. I'm the national president of the Canadian Peacekeeping Veterans Association, or CPVA. I sit as a member of the Veterans Affairs Canada stakeholders committee.

With me today is Brigadier-General Larry Gollner, retired, the patron of CPVA. Larry sits on the veterans ombudsman's advisory council now, and also served as a member of the new Veterans Charter advisory group. Colonel John Eggenberger, retired, is our vice-president of research. John has a doctorate in educational psychology from the University of Calgary. His main field of endeavour has been personnel applied research, making him an ideal VP of research.

Thank you for this opportunity to appear and to share our views. You have our written presentation. We do not intend to read it. However, we would like to offer some verbal supplements to the different sections, if I have your permission to do that, sir.

[The Chair, Conservative, Greg Kerr]

Absolutely.

[Ray Kokkonen]

Then I would like to proceed with Larry Gollner giving some comments on paragraphs two and three.

[Brigadier-General, Retired) Joseph E. L. Gollner (Patron, Canadian Peacekeeping Veterans Association]

Mr. Chair, ladies and gentlemen, I want to focus on the spirit of our association.

Ours is first and foremost a veterans association that strives to support and sustain our members and all Canadian veterans. We are veterans who help other veterans, pure and simple.

We work cooperatively with other veterans associations and Veterans Affairs. We understand that cooperation is far more productive than confrontation. However, on occasion we have vigorously contested Veterans Affairs policies and practices, especially when we believe that the spirit of existing legislation is being diluted by bureaucrats who pay more attention to detail than to the spirit and the principles of the legislation.

Some of our fellow citizens do not understand that veterans legislation, our legislation, both the Pension Act and the new Veterans Charter, is based on Parliament's clearly defined understanding of service to Canada, an understanding that is predicated on the fact that those who serve in Canada's armed forces do so with an unlimited liability clause in place, and further, that its members are obligated by law to obey legal orders. Canada has acknowledged in legislation that it has a duty to provide care to its fallen, to its wounded, injured, sick, and aged veterans and their families so that they can live with dignity.

The mandate of Veterans Affairs is to provide for Canadian veterans, which it does very well, although frequently the service is not publicly recognized. To that end, last year CPVA created a national award program to recognize individual and collective groups of Veterans Affairs staff who do outstanding service for Canada's veterans. This program is ongoing and reflects the spirit of our association.

Thank you, Mr. Chair.

[The Chair, Conservative, Greg Kerr]

Thank you very much.

I would just point out that we started the proceedings by saying the bells would go. I mentioned it to the committee, and the committee seemed to agree that we would continue with the presentations and then break.

That's why the light is flashing, in case you folks are wondering.

[Colonel, Retired) John Eggenberger (Vice-President, Research, Canadian Peacekeeping Veterans Association]

So there's no fire in the building.

[The Chair, Conservative, Greg Kerr]

You won't be interrupted. Please, carry on.

[Col John Eggenberger]

All right. Thank you very much.

I have been reliably informed that I have less than three minutes of conversation, so I'll try to make it go smoothly.

The transformation of Veterans Affairs Canada calls for changes in organizational structure. We three, among all veterans who have worked in large headquarters, can attest to the confusion between organizational units that inevitably ensues when changes are made.

Realizing that Veterans Affairs Canada has included this issue in their risk analysis methods, we still wish to place on record our concern that particular care be focused on assuring that there would not be a loss of communication between Veterans Affairs Canada and veterans, especially those veterans who are not Internet-savvy but depend upon snail mail or telephone.

Thank you.

How did I do?

[The Chair, Conservative, Greg Kerr]

That was way too brief. You were just getting warmed up.

If that covers all your comments from your group, you've set a record for brevity.

[Ray Kokkonen]

Actually, Mr. Chair, I get to do a wrap-up.

[The Chair, Conservative, Greg Kerr]

You are smooth. Please, carry on.

[Ray Kokkonen]

I'd like to then carry on with other issues that are not necessarily part of the transformation but that impact on the shape of the transformation. The first of those, which has been a long-time irritant for all modern-day veterans, is long-term health care for modern-day veterans. I simply want to say that there is patent unfairness in the fact that one section of veterans gets preferential treatment over another section of veterans. I'll leave it at that.

The next point is the Veterans Affairs Canada personnel cuts. We sent a joint letter, with the Gulf War veterans and the NATO veterans organizations, to the Prime Minister expressing our strong concerns about the budget cuts to Veterans Affairs Canada. We cannot fathom how you can cut several hundred people from an organization that serves veterans without reducing the quality of service to the veterans.

The last one is, if I may say, the recommendations of this standing committee, coupled with the recommendations of the new Veterans Charter advisory group, which you endorsed and added to. Those need to be implemented right away. There is no question. The Veterans Affairs Canada stakeholders committee, in fact, passed three motions for immediate implementation, and this was one of the ones that was discussed.

As John has said, we are generally satisfied with the transformation process and the reasons it's happening. However, we have a concern that it's such a huge thing. And as we were discussing earlier, a wheel can come off somewhere and have disastrous effects, at least for a period of time, for many veterans.

Our recommendation is that you, as part of this legislative body, as the Standing Committee on Veterans Affairs, publicly monitor this transformation to make sure that the wheel doesn't come off and hurt veterans.

Thank you. We're grateful for this opportunity. That finishes our presentation.

[The Chair, Conservative, Greg Kerr]

Are you sure?

[Ray Kokkonen]

Yes, sir.

[The Chair, Conservative, Greg Kerr]

I don't want to cut you off.

Thank you very much for that.

What we're going to do is suspend until the vote is finished. We'll reconvene here, so relax.

We're suspended until the vote is finished. Thank you.

[The Chair, Conservative, Greg Kerr]

I call the meeting back to order.

Thank you very much for your patience. We all survived the vote, one way or another, and we're back in business here.

We'll go right to the question round. We'll start with Mr. Stoffer, for five minutes.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you, Mr. Chair.

Thank you, all of you, very much for coming today.

First, to Joan and Nancy, we hear from DVA that they're working towards the figure of 40 clients per case manager. I notice that you didn't give any figures for the optimum number. Obviously some clients are a lot more work in terms of involvement, and others are fairly straightforward.

Do you have, in your research, what the optimal number of clients should be per case manager?

[Joan Park]

You're the researcher, Nancy.

[Nancy Murray]

Thank you very much for your question.

It depends upon the model and the complexity of the client. In Ontario, for example, you have case managers who are dealing with, in generalist caseloads, over 100, and in specialty caseloads, perhaps 80. In the intensive models that they are using, I know that one region is looking at 60 clients per case manager. There are others looking at 30 per case manager.

In the intensive integrated model, that one case manager then has 30 teams to work with, because each client has their own set of particular professionals that she'll be working with.

So 30 is what they're looking at trying as the optimal. There is no research that I know of in Canada that actually speaks to that specifically.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you.

Ray, in your organization, the advisory group of the various veterans organizations made 18 recommendations, I believe, to the department, and you asked them to expedite those recommendations as soon as possible. Have you heard back from the department or the minister on if and when any of those recommendations would be accepted, and when they would happen?

[Ray Kokkonen]

We haven't had any information back.

Incidentally, the 18 recommendations, the most recent made by this committee, were not part of the motions that were passed in the stakeholders committee.

In fact, Mr. Chair, perhaps I could summarize the motions that were passed by the stakeholders: that the VAC fully implement the recommendations of the NVC advisory group as endorsed and complemented by the Standing Committee on Veterans Affairs; that VAC fully implement the recommendations of the Gerontological Advisory Council report; and that the recommendations of the special needs advisory group be incorporated in the federal government's full implementation of the NVC advisory group report.

Those were the motions.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

So it's fair to say you haven't heard back officially from the department on that yet.

[Ray Kokkonen]

Nothing yet.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Okay.

And I do thank you as well...my final question for you is regarding the concerns of long-term health care benefits for modern-day veterans.

As you know, World War II and Korean overseas veterans who have a disability will have access to, for example, Camp Hill, the Perley, Colonel Belcher, and Ste. Anne’s, obviously before the transfer, but the modern-day veterans, people such as yourselves, may not. I know in Nova Scotia they're quite concerned about that in terms of what the additional costs will be to the province in that regard.

Have you done any estimates yourself in terms of research of what it may cost the provinces if indeed they have to pick up that long-term health care for modern-day veterans in the future?

[Ray Kokkonen]

No, we don't really have the capability for that kind of research.

I know that the NATO Veterans Organization has produced some numbers in those terms, but I'm not even sure what they've done.

But no, we have not.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you very much.

Thank you all very much for coming.

[The Chair, Conservative, Greg Kerr]

Thank you, Mr. Stoffer, for being so efficient. That's excellent. Thank you very much.

Mr. Chisu, for five minutes.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Thank you very much, Mr. Chair.

Thank you very much for showing up at our committee.

I have a question for Ms. Nancy Murray about the core body of knowledge.

As I understand it, this case management course you're offering at McMaster University is establishing the academic requirement, let's say, for a case manager. You're outlining an academic requirement for the case manager.

I'm just telling you this because I was the vice-president of Professional Engineers Ontario, and I have some knowledge about professional bodies.

[Nancy Murray]

Right.

The course that McMaster University offers is a certificate course. It offers five core courses that need to be completed in five years.

In order to be eligible to take the program, generally you either have to have an undergrad degree completed or have some kind of certificate or be working in an appropriate related environment and make an application that way.

It's a certificate program, so it's not a degree.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

It's not a degree, but it's establishing the basis. For example, can this individual who has completed your course be a member of the National Case Management Network of Canada?

[Nancy Murray]

That's not a requirement. No, our certificate program is not a requirement for being a member of the case managers network.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Okay, so that's where I am going. What is your requirement as to academics for your professional association? Because I understand, Ms. Park, that you've incorporated this association. It's a professional association, so you've probably established standards for the professional association and have academic requirements, and probably you also eventually will have an experience requirement.

[Joan Park]

The road of credentialing is probably the path we're going down, right?

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Yes.

[Joan Park]

We've established standards of practice and are currently working on core competencies, all with the intent of identifying a credentialing process. As for who would want a credentialing process, maybe an employer, or maybe an individual. That's the process we're going down....

As for being a member of our network, anyone who supports our mandate to promote excellence and professionalism in case management can be a member of our network.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

My question is this: how are you verifying competency? Because if you are a professional association, you need to have standards of competencies, and I understand that you are a Canadian organization.

[Joan Park]

That's correct.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

What about relations with the provinces, which usually license health professionals and other professionals. In the health professions act, there were 21 health professions under the umbrella of the health professionals....

[Joan Park]

Case management today is not a profession. Case management is a process, and it's a role. It is not a profession. In my day job, I'm a nurse at St. Michael's as a case manager, so I am a professional nurse.

I am a regulated health professional in that regard, but there are many people practising case management, some who are regulated health professionals and some who are not. It's a reason for this national network to begin establishing standards of practice—core competencies—to lead to either a voluntary credentialing process or a legislated credentialing process.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

So my question was related because you were speaking about the professional associations.

[Joan Park]

That's correct.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

I just wanted to have some clarification on that.

[Joan Park]

Yes.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

So you probably are going towards that...?

[Joan Park]

Yes, we had that conversation. I had a webinar yesterday, so we had that discussion. Are we a profession? What are the elements of a profession? One of the elements is having research. Do we have outcomes that show the benefit of this? Nancy is one of the researchers, but we're not an established profession today as we speak.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Okay.

Do you have a code of ethics?

[Joan Park]

That's the next question I've entertained today.... If you have a standard of practice and you have core competencies, of course the next step would be a code of ethics.

I'll have to go back to Health Canada—no.... But yes, the next piece to come would be a code of ethics. Then you begin to become a profession.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Yes, exactly. I was asking this because I belonged to the College of Medical Radiation Technologists. I established at that time the code of ethics, which was not—

[Joan Park]

That's correct. Also, there's a difference between a college and a profession, because I get that question too. Is NCMN going after a college? That's a whole other level of regulations.

[The Chair, Conservative, Greg Kerr]

Okay. That's it for the first round. Thank you very much.

We'll now go to Mr. Casey for five minutes.

[Sean Casey, Liberal, Charlottetown, PE]

Thank you, Mr. Chairman.

I'll go to Mr. Gollner first, please.

Sir, I was interested in a couple of the topics you raised. With regard to the new Veterans Charter advisory group, you indicated that your organization was involved with that. The advisory group had some recommendations with respect to the new Veterans Charter. I wonder if you could just inform the committee about the recommendations that were made by your group and what happened to them.

[BGen Joseph E.L. Gollner]

Mr. Chair, Mr. Casey, I was not part of the advisory group. When the new Veterans Charter was first passed by Parliament, a group of us were brought in to advise the minister and senior staff from veterans associations across the country. We helped draft the regulations.

To be quite frank, at that time many of the warts that have continued to trouble the new Veterans Charter were already known and defined, and were certainly clearly understood by Veterans Affairs. However, the legislation had been passed, and that's what they were dealing with, not what they would have liked to have been dealing with.

The group that I was working with was well aware of some of the shortfalls and complications, best illustrated, probably, by the problems between the Canadian Forces insurance program, PSHCP, and Veterans Affairs pensions, which have come to light of late.

But no, I was not in that latter group that studied for three years, Mr. Casey.

[Sean Casey, Liberal, Charlottetown, PE]

Okay.

You also referenced an award to Veterans Affairs Canada employees. Is that an award that's granted by your organization?

[BGen Joseph E.L. Gollner]

It is an initiative of the Canadian Peacekeeping Veterans Association. Lots of people throw slings, deservedly sometimes, at Veterans Affairs, but we feel that there's a host of very good people in Veterans Affairs who work hard and do a good job. Often they're at the coal face, dealing with veterans on a one-to-one basis.

We felt that their good service should be recognized. We read in the media about how they frequently were being trashed collectively, so we instituted this award at two levels. With the national award, our chapters across the country put in recommendations, and at our AGM we debate and select. We have our criteria, and someone is picked, or else a group is picked. Last year it was Ms. Bridget Preston, who is the director of Veterans Affairs Canada on Vancouver Island. She and her merry band have about 14,000 candidates. They do an unbelievably good job for most of the folks. This year we are in the process of selecting another organization at the national level.

Each of our chapters across the country, from Vancouver Island to Newfoundland, also has the capability to identify someone at a local level and say, “Those folks are really doing a good job. Let's give them an award.” The award takes the form of a scroll. Then an appropriate plaque is made up and presented at some public event.

As happened last year in Victoria, the lieutenant governor of the province presented Ms. Preston her award. There was lots of media coverage and one thing and another, and deservedly so.

[Sean Casey, Liberal, Charlottetown, PE]

Thank you.

Mr. Eggenberger, you talked about the fact that there are still a good number of people who kind of prefer direct face-to-face contact, as opposed to the electronic mode that seems to have overtaken society.

Are you aware, sir, of the plans within the department for the closure of district offices?

[Col John Eggenberger]

Not district offices; I'm aware of the downsizing, right-sizing, transformation process, as I spoke of briefly. We're all very much aware of that.

Whenever you reduce the number of people around, you're going to reduce the number of capabilities to discuss matters with veterans.

As an aside, often there are veterans who view Veterans Affairs Canada, and anybody in government, with a good deal of suspicion. It's just the nature of some of the people. So the more they're able to speak with a person, the better off they are. Anything the department can do to encourage the capability to have a warm voice at the end of the phone would be very much appreciated.

[The Chair, Conservative, Greg Kerr]

Thank you very much. We are over time.

We now go to Mr. Lizon, for five minutes, please.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you very much, Mr. Chair.

And thank you to all the witnesses for coming here to the committee. Thank you for your great work.

My first question is to Madam Murray from McMaster University.

You described the courses you offer for case managers. Do you offer specific training that would apply to those who work for Veterans Affairs to address veterans' needs? How do you address that, or do you address it at all in your courses ?

[Nancy Murray]

As I mentioned our students are from all across Canada and beyond, from all sectors of the health and social service environments.

I personally haven't had an individual who has worked for Veterans Affairs, but we would make sure the program would meet their needs. We'd look at it in terms of the laws. We'd look at the context of their work and look at their environment. We'd make sure it wasn't just a make-work project but a real application of their knowledge in areas they wanted to study and were interested in, to promote it that way, so that at the end of the program they would have learned something.

That would be in each of the five courses, not just one. There would be a real extension of knowledge and an enhancement of their understanding relative to their area of work.

We make an effort to make sure it really fits their needs in their region, in their province, and in the context of the work they do. There is application that way.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you very much.

Now I'll go to the National Case Management Network.

If I may ask, you said you are a not-for-profit federal corporation. You have been around for six years. Who are your members? What's the membership?

[Joan Park]

We're small but mighty is what we say. We number 500. We represent every province and every territory, as I said, and every sector that I was speaking about. Our current membership comes from the 16 sectors across the health and social services.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Are they individual members or are they organizations?

[Joan Park]

They are individuals and organizations but primarily individuals. There are more and more organizations. Our largest member organizations in Ontario are the community care access centres. For a second year, the Toronto Central CCAC renewed membership in NCMN for 200 of its front-line case managers. We find more and more employers are providing this membership to their front line.

In January our board made a strategic decision to reduce membership to $100 annually with the intent of making it affordable for everybody who's practising case management across the country.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Now I have a question that can go to both of you, maybe separately.

What's your involvement in Veterans Affairs' issues? Do you work in collaboration with Veterans Affairs Canada? How do you help in the specific issues we face?

[Joan Park]

First of all, that's why they sit on our board. So as a national board representing case management across the country, there is a representative from VAC on our board.

They sat with us when we wrote our Canadian standards of practice, so that when we speak to those standards, they apply to that sector of VAC.

Yesterday I had a cross-country webinar at lunchtime. Forty people called in from across the country. There were a couple of front-line VAC case managers on that call who said.... And I asked if I could speak to Ms. Irwin from Vancouver, a VAC case manager, who said that when she got off the phone she was going to take the slide show to her superiors and tell them that they needed to be members of this network and this OvidMD, this clinical tool. She said she could type in PTSD and mental health, and see how all of that works together and have real information to apply for herself and her patients.

Does that answer your question?

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Yes.

Is there an answer from the university side?

[Nancy Murray]

I don't have any particular involvement, unless a student would come.... But in terms of the transformation initiatives, I can see how valuable our course would be in terms of the learning and the application, so the best is yet to come.

[The Chair, Conservative, Greg Kerr]

Thank you very much. That's your five minutes.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Really?

[The Chair, Conservative, Greg Kerr]

Does it seem any longer than four? No...?

Ms. Mathyssen, for five minutes, please.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you very much, Mr. Chair.

Thank you very much for being here.

I have a number of questions, but I wanted to focus in on what Mr. Kokkonen and I think Mr. Eggenberger said in regard to concerns. I think you used the word “irritant”. Coming back to Mr. Stoffer's question, you talk about those who served under the understanding of “unlimited liability”, and you say that, in return, Canada “has a duty to provide [appropriate] care to its wounded, injured, sick, and aged veterans”.

This pertains to the fact that they are indeed closing long-term care beds for veterans. The World War II and Korean veterans are disappearing, and those beds are gone. We keep hearing over and over again that all is well, and that it's fine that this care is transferred down to the province. My question is, though, is this the obligation of the province or does the federal government have a real role that it should be playing instead of downloading to the provinces?

[Col John Eggenberger]

Who did you want to answer that?

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Either one of you—or both, actually.

[Ray Kokkonen]

I think I can start here with the simple statement that the people of Canada have an obligation to the veterans of Canada. I don't need to go any deeper. Now, how the people of Canada decide to pay that obligation or to fulfill that obligation, that's what our government looks after.

We're an apolitical organization.

[Col John Eggenberger]

That suits me.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Okay.

So the people of Canada need to direct their government to fulfill those obligations as they see fit.

[Ray Kokkonen]

Well, not exactly. The obligation is on the people of Canada, and the thing that drives Canada is our government. It's the government's obligation, then, to fulfill that obligation of the Canadian people towards its veterans.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Okay.

You also expressed a concern in regard to the cuts to personnel at Veterans Affairs. What are those specific concerns? What do you see happening as a result of those cuts?

[BGen Joseph E.L. Gollner]

Madam, we know that in aggregate terms 800 people are going to disappear from Veterans Affairs—550 involved in the transformation and 250 subsequently—but behind it all is a Treasury Board study, the Coulter report, which was done in 2010. We have been trying desperately to find out what it contains. We don't know. It triggered the transformation process. We were told that it's cabinet secret.... We don't have any basis for what triggered this or where the focus of that study was, but the study was done by a federal ministry, and that started the process.

That was done in 2010. We have heard various comments by our minister, but we don't have any substance and really can't say that they're cutting 15 people here or 20 there. You heard the presentation on May 8 that talked about the various sleight-of-hand operations, but as for what's the overall plan, we don't know.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

In terms of losing those personnel, there's no sense of how the ministry, the department, would conduct its business. Is that a concern or not?

[BGen Joseph E.L. Gollner]

It's certainly a concern, because wherever there's doubt, there's always concern. With the scale of the transformation and Veterans Affairs going from 4,000 to 3,200, that's a pretty dramatic change, and the veterans population is not going to change that radically in the next three years.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you very much.

In fact one of the things we heard from the ombudsman was that there will be an increased demand. So many folks are coming back from Afghanistan, and of course, there are the peacekeepers who haven't even accessed the system yet. There's no sense of what needs they will place on Veterans Affairs and the services involved.

To either Ms. Murray or Ms. Park, you made mention of the fact that case managers would have 30 teams to deal with. Could you explain that? It sounds like a huge workload.

[Nancy Murray]

Overwhelming, yes; and that's why in complex cases, where clients are in great need and at high risk, they want to reduce the numbers.

My comment was that if one case manager manages 30 clients, in that sense, she still has to work with an individual team with each individual client. So one client might have a PT or OT nurse on it, another might have a social worker, or a speech pathologist. Each team would be different people with different areas. And because they are not in the same geographic area—it's a population-based approach—each case manager would have a team from a variety of professionals.

So that's what I mean. It is one case manager working with 30 clients, but each client is separately attended to in terms of the service plan and the interdisciplinary team that she works with.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

So it could be a lot to deal with—

[The Chair, Conservative, Greg Kerr]

Thank you very much.

We're a minute and a half over your time. I try to be generous, as you know.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you. I know you are indeed generous.

[The Chair, Conservative, Greg Kerr]

Mr. Lobb, please, for five.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Well, speaking as someone who sits besides him, his generosity is sometimes sporadic—nonetheless, it's generosity from time to time.

[The Chair, Conservative, Greg Kerr]

Is this “single out the chair” day?

[Voices]

Oh, oh!

[The Chair, Conservative, Greg Kerr]

Carry on, please.

[Ben Lobb, Conservative, Huron—Bruce, ON]

The first question I have for our gentlemen today is with regard to page 2, paragraph 5.3, which talks about the Veterans Affairs committee report. I believe this is a report from last Parliament, which I believe was the review of the new Veterans Charter. “A Timely Tune-up”, I think it was called.

You indicate that there are 18 recommendations from the report that you'd like to see implemented. Do you have them prioritized, by chance? Are they in their top three or five?

[Ray Kokkonen]

The recommendations about which we are speaking here are the most recent ones that this committee made. The report came out in May of this year. Those are the ones I'm referring to.

We have not prioritized those in any way.

[Ben Lobb, Conservative, Huron—Bruce, ON]

So you're speaking specifically from the May report—

[Ray Kokkonen]

I'm speaking more to the previous recommendations that were made.

[Ben Lobb, Conservative, Huron—Bruce, ON]

That's what I mean. This came from last year, the previous Parliament's recommendations.

[Ray Kokkonen]

Yes.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Okay. Good. So we're on the same page with what we're talking about.

[Ray Kokkonen]

I threw in the other 18, because after reading them, we decided they were pretty good recommendations.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Fair enough. It's just that, the way it read, I wanted to make sure we were clear on that.

Of those, have you had the chance or the time to prioritize those or put them in some semblance or fashion that the department may be able to take them on in bite-size chunks? Or have you had that opportunity yet?

[Ray Kokkonen]

In the previous incarnation of the stakeholders committee, the Veterans Affairs Canada advisory committee, there was an attempt to put priorities on those various recommendations, but it did not go through. It was decided that they're all equally important and must all be implemented. There was a lot of discussion. It would have been a decision in principle, if we had set a priority on some of them.

So the collective decision was no prioritization.

[Ben Lobb, Conservative, Huron—Bruce, ON]

That's fair enough.

To Ms. Murray, I appreciate your presentation. I'm just wondering, when we look at case management, obviously there have been some changes at Veterans Affairs in regard to, I guess, empowering case managers to make some proactive decisions that will create some great outcomes for veterans of all ages.

What else do you see coming down the pipeline in the future that will provide case managers even better opportunities for better outcomes?

[Nancy Murray]

Well, currently what is promoted are the assessment tools—the electronic tools that give you scores or outputs that are indicators of where the client is in terms of risk, need, and possible care issues. That could be a possibility.

Also, common electronic records that can be shared would be another helpful opportunity for Veterans Affairs, if they don't have them. It's very helpful if someone in one region or another can share records. That type of thing is very helpful.

Also very helpful are teams that think in the same way and work in an interdisciplinary fashion with common client-focused and client-centric goals.

So some of the five themes that you have outlined in your transformation initiatives really speak to the value of case managers, of face-to-face assessment, and of looking at supporting the clients from their point of view and within their context.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Okay.

Mr. Kokkonen, you've presented your paper here and have obviously had time to observe the pillars of transformation. You've seen this take shape over time as far as transformation goes.

Of everything you have seen in the past, maybe, of what you see in the present, and of what has already been laid out for future opportunities in regard to transformation, if you were going to critique it or provide more input to Veterans Affairs, what would you like to see? Is there anything? I know that you've mentioned long-term health, but beyond that, is there anything else you would like to see in this report that would be helpful to Veterans Affairs?

[Ray Kokkonen]

I think the addressing of the shortcomings and the flaws in the new Veterans Charter is an absolute. That has to be done. They talk about “sustaining the new Veterans Charter”. Now, I'm not exactly sure how that fits in with correcting the flaws, but if you're asking for a sort of priority statement on this, that would be it on my part.

[The Chair, Conservative, Greg Kerr]

Thank you very much for that.

Now we'll go to Mr. Storseth for five minutes, please.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

Thank you very much, honourable Chairman.

Thank you very much to the witnesses. I'd like to thank you for coming.

Once again, it's always good to talk to you and your organization, Mr. Kokkonen. I think you guys have some very valuable input for this transformation initiative study that we have going on.

Ms. Murray, I'd like to talk to you—and perhaps to Ms. Park as well—about where you see the future of case management going. It's a broad question, but it's one that I'll narrow down in a minute.

[Joan Park]

It's the future—it's what's required for the health care system across Canada as we all age, as we all live with chronic illness, and as we survive catastrophic injuries. That is not a health care situation that is solved in a period of time or an episode of time. So all of us, moving forward.... My screen saver sometimes says, “Not everybody needs case management, but they need their care managed”. More and more of the population will need case management because of mental illness coming on board, as well as physical illness.

I was at the Health Council of Canada on Monday for the announcement of their progress report on health care. I said that they should interview front-line case managers, because they would hear about where the system is a problem and where the health care provider is a problem.

Dr. Kitts, who chaired that report, said that he had just come back from the U.S., where they spend a lot of money on trying to find solutions for their system. He asked Massachusetts General and Brigham Young what they had done and what they had spent the most money on that was bringing in the most value for the future, and their answer was case management.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

That's excellent.

So can you explain to me, then, your vision of what the role would be for somebody who is not yet a veteran, but who is in the process of transferring out of the Department of National Defence and the Canadian Forces into the role of a veteran? What would you see the ideal role of the case manager being in that situation? Also, how many case managers should the individual have in such a situation?

[Joan Park]

I was talking to somebody in this room earlier about having too many case managers.

Case management starts with an assessment. It's a very holistic assessment of what that individual client's needs, wants, and even dreams are for living a fruitful and productive life. It's based on that critical assessment, which is different from a nursing assessment versus an OT assessment. It's an all-inclusive assessment of their health and social needs. I think that's where case management's strength lies, in pulling together the health care and the social service needs of an individual client.

How many case managers does somebody need? It does become problematic to have one, two, or three leading the parade. Sometimes I don't think that's the problem. It is a problem that the client and the case managers have, but it's a problem created by the system, not to help identify who is going to be the collaborative leader. You need a collaborative leader in that case.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

So it is possible that it could be overwhelming for somebody transferring into the role of a new veteran to have two, maybe even three case managers, plus a SISIP adviser, plus an adviser on some of his health matters, plus an adviser on his pension, to sit down with them all.

[Joan Park]

Case management is about coordinating care. That's exactly what you're talking about, so that is the expertise of a case manager, to coordinate that care. It's going to take those roles of heavy communication, heavy collaboration, navigation, and advocating the systems and the other individuals on the team.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

You might not be able to answer this, but what would a reasonable timeframe be for somebody dealing with all this, working with a case manager, to work through the processes?

[Joan Park]

In lots of cases you're not talking about an episode of care that has a start and a stop; you are talking about—I don't want to use the word continuum—a journey, for sure. I think, like any journey—that's what Nancy's referred to—there are times for intensive case management, and there are times when things are going along okay, but you're always on the ready for the next intensive period.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

With the plethora of these systemic case managers that can occur, is it beneficial to have one key point person they know they can go to if there is a situation?

[Joan Park]

Absolutely.

[Brian Storseth, Conservative, Westlock—St. Paul, AB]

Thank you for your time.

[The Chair, Conservative, Greg Kerr]

Thank you very much.

That's the end of round one. We appreciate that.

We're only going to have time for two, and we're going to have to jam them in. Ms. Morin, we're going to have four minutes for you, please.

[Marie-Claude Morin, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you.

Hi, everybody. It's nice to meet you. I want to offer you my apologies because my English is not very good. I will ask my question in French because it's easier for me to ask questions in my native language.

My first question is for Ms. Murray or the National Case Management Network of Canada representatives. You can decide who is better suited to answer.

I would like to know how your training ensures that case managers make the right decisions. If a negative determination is made by mistake, a whole administrative and legal process is required to correct that one bad decision by a case manager.

How does your training limit the inconvenience that might be caused to veterans when the wrong decision is made or prevent such situations in the first place?

[Nancy Murray]

In terms of training, you have to look at a long process. You have to look at an orientation that would give them the overview. They would have to be trained properly in terms of the tools that they use. As well, there would be a mentorship program. Case management is very complex and novices grow in their work to become professionals and experts. It's best to have some mentorship arrangement. I have taught those tools. Those tools are separate and distinct from the certificate program that we offer. In terms of enhancing their practice, that would come with more understanding of what the profession is.

You asked about mistakes and issues in terms of decision-making. Again, if there is mentorship and support for the case manager who is learning, it's the same as in any new job or profession. You meet indicators of success as you move along. It's a long process. Similar to what Joan mentioned earlier, it is a long and complex process. To understand and to be experienced that way, and to be able to look at the gestalt and understand the big systems, and how it applies does take time to learn.

It's the same as in any profession. There are no guarantees. Hopefully, it's the support that you get in that mentorship program.

[Joan Park]

For me to help with that decision-making, it is the strength of networking. That's why we are called a network. Anybody in his or her job gains experience from networking with mentors, as Nancy's talking about, and with others. When we started writing our standards of practice, we held a round table of 40 people across the country. VAC case managers and rehab case managers told their stories. We had the same issues. There is so much we can learn from each other a lot more quickly than trying to find the answer in a book.

[Nancy Murray]

One final point is the research that's being done. “The Nature of Insight” looks at exactly that. There is the novice and the expert, and there are differences. It is a continuum of learning.

[The Chair, Conservative, Greg Kerr]

Thank you very much. We allowed it to go a minute over because of the technical difficulties, but that is the end of the time.

We're over five minutes, so, Mr. Trottier, you have whatever time is left, which will be very brief.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

That's okay.

Thank you, Mr. Chair.

You're doing a very good job today.

Thank you, witnesses, for coming in today.

I want to talk briefly about productivity. When you talk about case management, what's getting behind a lot of that is productivity, being able to do more with less. What goes into productivity are systems, to be sure, but there are procedures, and what you mentioned, the idea of networking among interdisciplinary teams and sharing know-how. In fact, it's the history of human progress. If you think about 150 years ago, over 90% of the population was engaged in agriculture. Now it's less than 2%, and yet we produce more and more food. It's the same thing for manufacturing. In medicine, cardiologists can treat many more patients than they could 20, 30, or 40 years ago, because of all the know-how that has spread around the world, and also because of increased use of technology.

If you think about case management, what does that mean in terms of the ability of case managers to do more, in terms of their output, but also of a higher quality, with a greater consistency, and better customer service? Can you describe how that applies?

Then, if we have some time, I'd like to hear from our veterans how they might see that from their end, as clients.

[Joan Park]

I think it is building that body of knowledge. We are a relatively new field. We're not as old as medicine, but we can learn from those examples. By building that body of knowledge and working together and sharing resources, that's how we're going to work smarter, not necessarily work harder. We're going to have to share the knowledge that we have. That's going to be the trajectory that gets us to making smart decisions.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

To our veterans, thank you for coming in, and thank you for all your service.

From a client point of view, somebody who has worked with case managers or heard stories of people who have worked with case managers, what do you see in case management compared to 10 or 20 years ago? How does that affect the service and the amount of service you're able to receive?

[Ray Kokkonen]

This is rather an awkward question for me. I am not a client of VAC.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

No, but you talk to people who might receive those services, right? Are there any stories?

[The Chair, Conservative, Greg Kerr]

It will have to be very brief, please. We're just about on the clock.

[Ray Kokkonen]

Would you state that question again?

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

What's the impact of case management on the ability for—

[Ray Kokkonen]

From what I've listened to—just to give you a short answer—I think it's positive. I think a complete study of that particular science is what's required. It may solve some of the problems that VAC has with client interface.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

Okay.

Thank you very much.

[The Chair, Conservative, Greg Kerr]

Thank you.

We are at the end of our time today. Thank you for your patience in light of what happened upstairs.

To all the witnesses, thank you for coming.

The meeting is adjourned.