RNAO’sResponsetoBill41:PatientsFirstAct,2016SubmissiontotheStandingCommitteeonLegislativeAssemblyNovember23,2016

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TableofContents

SummaryofRecommendations......................................................................................................2

AboutBill41....................................................................................................................................4

RNAOOfferingSolutions.................................................................................................................4

TheIssues........................................................................................................................................6

AnalysisofBill41.............................................................................................................................6

DefinitionofHealthServiceProvider..........................................................................................6

HealthEquity...............................................................................................................................7

HealthPromotion........................................................................................................................8

RoleofLHINsinProvidingandManagingService.......................................................................8

HealthSystemOversight.............................................................................................................9

PatientandFamilyCouncils........................................................................................................9

DevelopmentofSub-Regions....................................................................................................10

HealthProfessionalAdvisoryCouncils......................................................................................10

TransferofCCACs......................................................................................................................10

OntarioAssociationofCommunityCareAccessCentres(OACCAC).........................................11

HealthQualityOntario..............................................................................................................12

SupportServices.......................................................................................................................12

Conclusion.....................................................................................................................................12

AppendixA–RNAO’sModelforHealthSystemEffectiveness.....................................................14

AppendixB–RNAO’sEnhancingCommunityCareforOntariansModel.....................................15

References.....................................................................................................................................16

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SummaryofRecommendations Recommendation#1:Advanceanintegratedhealthsystemthatisanchoredinprimarycare.Amendsection1(3)toincludeallofprimarycare,publichealthunits,homehealth-careandsupportserviceprovidersashealthserviceproviders(HSP).Recommendation#2:Replace"healthdisparities"insection4(2)with“healthinequities”andadoptHealthQualityOntario'sdefinitionsof"healthequity"and"healthinequity”asoutlinedinitsIncomeandHealthReport.Recommendation#3:AddthefollowingLHINobject:Advancehealthpromotionanddiseasepreventionthroughleadershipinplanning,fundingandmonitoringhealthpromotionservicesthataddressthebroaddeterminantsofhealthandsupportcommunitydevelopment.Recommendation#4:RemoveallprovisionsthatwouldpositionLHINsasdeliveringand/ormanaginghealthservicedelivery.Instead,empowerHSPsandfocusthescopeofLHINsonwholesystemplanning,integration,fundingallocation,monitoringandaccountabilityfunctions.Recommendation#5:Amendsection19(2)byremovingtheexemptionofpublichospitalsfromreceivingLHINdirectives.Recommendation#6:EstablishpatientandfamilyadvisorycommitteeswithinLHINsandamendthebilltorequirethattheyreflectthediversityofthecommunitybeingserved.Furthermore,amendsection41torequiretheministrytoestablishapatientandfamilyadvisorycouncil.Recommendation#7:Amendsection12byexplicitlyclarifyingthattheobjectsofthesub-regionsareplanning,fundingandintegratingservices;notimposingbarriers,unnecessarynewbureaucracyand/ornewgovernancelayers.Recommendation#8:Mandatetri-partiteleadershipmodelsincorporatingmedicine,nursingandoneotherregulatedhealthprofessionwithineachLHIN.Recommendation#9:FullydissolveCCACsandproducetruehealthsystemtransformationbypreventingtheautomatictransferofallCCACfunctions,processesandresourcestotheLHINs.Recommendation#10:Locatethenearly4,100careco-ordinators(currentlyinCCACs)withinprimarycareasthesectoriseagerandready.Recommendation#11:Amendsection30toremovetherequirementthatOACCACemployeesbeautomaticallytransferredtoanewsharedservicescorporation.Recommendation#12:Amendsection37torequireHQOtoseektheadviceofthepublicandhealthproviderswhenformulatingadviceonthefundingofhealthservicesandmedicaldevices.

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Recommendation#13:RemoveSection40(1)andprovideadequatepublicfundingforcommunitysupportservices.

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TheRegisteredNurses’AssociationofOntario(RNAO)istheprofessionalassociationrepresentingregisterednurses(RN),nursepractitioners(NP)andnursingstudentsinallsettingsandrolesacrossOntario.RNAOextendsitsgratitudetothestandingcommitteefortheopportunitytoreviewBill41: PatientsFirstAct,2016andofferrecommendationstoenhanceit.

AboutBill41

Bill41wasintroducedbytheMinisterofHealthandLong-TermCareonOctober20toamend20differentstatutes,includingtheLocalHealthSystemIntegrationAct,2006(LHSIA)andtheHomeCareandCommunityServicesAct,1994.Asimilarbill(210)wasintroducedinJune,however,itdidnotadvancebeyondfirstreadingbecausethelegislaturewasprorogued.

MinisterHoskinsindicatesthatBill41:“Ifpassed…wouldhelpustobuilda[health]systemthatbestmeetstheneedsofOntarians,asystemthatclosesthegapsthatexistandonethatwouldhelpbringhealthcareservicestothepeoplewhotrulyneedthemmost.Asystemthatbestmeetstheneedsofpatientsinanequitablewayisonethatistrulypopulation-focusedanddeeplyintegratedatthelocallevel.Todothat,weneedstronglocalhealthsystemplanningandstrongmanagement.”1

Bill41aroseoutofadiscussionpaperissuedbyMinisterHoskinsinDecember20152andRNAOwascreditedforinformingitsdevelopment.3

RNAOOfferingSolutionsNursingisthelargestregulatedhealthworkforceinCanadaandisconsistentlyregardedasthemosttrustedprofessionamongmembersofthepublic.4Therearenearly98,500RNsandNPsworkinginOntario.5RNsandNPsarepresentinallreachesoftheprovinceandhealthsystem.Theyareoftendescribedastheeyesandearsofthesystemandareintimatelyfamiliarwithwhatisworkingandwheregapsexist.RNAOisproudtobeatrustedhealthsystempartnerthatissolutions-focusedandhasproducedamodeltoachievehealthsystemeffectiveness(AppendixA).ThemodelhasinformedanumberofpolicyoutputsfocusedontransformingOntario’shealthsystem,including(butnotlimitedto)thefollowing:

• PrimarySolutionsforPrimaryCare:6In2012,RNAOledaprovincialtaskforcerepresentativeofleadingsystemstakeholders.Thepurposewastoidentifywaystofullyutilizethecompetencies,knowledgeandskillsofprimarycarenursestofacilitatetimelyaccesstoqualityprimarycare.Thetaskforcewasboldandvisionaryinrecommending:“Identify[ing]areasofstructuralduplicationandwork[ing]towardbettersystemintegrationbyimprovinglinkagesacrossallsectorsandmovingcarecoordinationtoprimarycare.”

• EnhancingCommunityCareforOntarians(ECCO):7In2012,RNAOreleasedthegroundbreakingECCOmodeltobuildarobustfoundationforcommunitycareand

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improveintegrationbetweenallhealthsectors(AppendixB).AsecondversionofECCOwasreleasedin2014toenrichdetailaccompanyingthepolicyproposal.RNAOwasthefirstorganizationtorecommendasinglehealthsystemplanner/funder–theLocalHealthIntegrationNetworks(LHIN);whileanchoringthehealthsysteminprimarycareandeliminatingCommunityCareAccessCentres(CCAC)asstructuralentities.

• ReviewoftheLocalHealthSystemIntegrationAct:8In2014,RNAOpresentedtotheStandingCommitteeonSocialPolicywhenitreviewedtheLHSIA.RNAOusedtheECCOmodeltodeliveralegislativeproposalthatstrengthenshealthservicedeliveryinOntario.Specifically,RNAOcalledforagreateremphasisonhealthequityandtheengagementofmarginalizedgroups;amendingthedefinitionofhealthserviceproviders(HSP)toincludeallhealthorganizations/providers;andtransitioningtheplanning/fundingfunctionsofCCACstoLHINs–thusmakingtheLHINsresponsibleforwholesystemplanning,integration,fundingallocation,monitoringandaccountabilityfunctionsatthelocallevel.

• ResponsetoPatientsFirstDiscussionPaper:9Inearly2016,RNAOrespondedto

MinisterHoskins’discussionpaperonstrengtheningpatient-centredhealthcareinOntario.RNAOcontinuedtourgetheministertoenableLHINstoplan,integrate,fund,monitorandbeultimatelyaccountableforlocalhealthsystemperformance,whilestronglycautioningagainstLHINsprovidingservicedeliveryand/ormanagement.RNAOre-iterateditscallfortheeliminationofCCACsasstructuralentitiesandreaffirmeditsinsistencetorelocatethenearly4,100careco-ordinatorscurrentlyinCCACstoprimarycare.

• MindtheSafetyGapinHealthSystemTransformation:10InMay2016,RNAOreleased

theresultsofaninvestigationintotherelationshipbetweenMinister’sHoskinspatientsfirstagendaandnursinghumanresourcetrends.Theconclusionisthattrendsinnursingskillmixandorganizationalmodelsofnursingcaredeliveryruncountertothegovernment’sgoalsforthehealthsystem.Thisconclusionmaythwarteffortstopositivelytransformthesystem.RNAOmadeeightrecommendations:

o TheMinistryofHealthandLong-TermCare(MOHLTC)developaprovincialevidence-basedinterprofessionalHHRplantoalignpopulationhealthneedsandthefullandexpandedscopesofpracticeofallregulatedhealthprofessionswithsystempriorities;

o TheMOHLTCandLHINsissueamoratoriumonnursingskillmixchangesuntilacomprehensiveinterprofessionalHHRplaniscompleted;

o LHINsmandatetheuseoforganizationalmodelsofnursingcaredeliverythatadvancecarecontinuityandavoidfragmentedcare;

o TheMOHLTClegislateanall-RNnursingworkforceinacutecareeffectivewithintwoyearsfortertiary,quaternaryandcancercentres(GroupAandD)andwithinfiveyearsforlargecommunityhospitals(GroupB);

o LHINsrequirethatallfirsthomehealth-carevisitsbecompletedbyanRN;o TheMOHLTC,LHINsandemployerseliminateallbarriers,andenableNPsto

practisetofullscope,including:prescribingcontrolledsubstances;actingasmostresponsibleprovider(MRP)inallsectors;implementingtheirlegislatedauthoritytoadmit,treat,transferanddischargehospitalin-patients;andutilizingfullytheNP-anaesthesiaroleinclusiveofintra-operativecare;

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o TheMOHLTClegislateminimumstaffingstandardsinLTChomes:oneattendingNPper120residents,20percentRNs,25percentRPNsand55percentpersonalsupportworkers;and

o LHINslocatethenearly4,100careco-ordinators(currentlyinCCACs)withinprimarycaretoprovidehealthsystemcareco-ordinationandnavigation,whicharecorefunctionsofinterprofessionalprimarycare.

TheIssuesRNAObelievesthatpeoplevalueOntario’spublicly-fundedandnot-for-profithealthsystem.Thatbeingsaid,thereareopportunitiestoimproveitbytackling:

• Risinghealthexpendituresandinsufficientfederalhealthtransfers;11,12• Shiftingdemographicsandrisingcarecomplexity;13• Delaysandinequitableaccesstotimelyhealthservices;14,15,16• Lackofemphasisonupstreampreventativemeasures;17• Ineffectivecaretransitionsandlackofco-ordination;18• Variationinthequalityandsafetyofcare.19

Thesechallengesarenotinsurmountable.Byincorporatingthevitalenhancementsoutlinedinthissubmission,Bill41hasthepotentialtoaddressthesegaps.However,RNAO’sbiggestconcernisthatleftas-is,Bill41willperpetuatecurrentsystemlimitations,albeitunderadifferentfaçade.Instead,Bill41couldrepresentauniquemomentinhistorytotransitionandtransformthehealthsystem.RNAOisalarmedthatwhiletheECCOmodeliscreditedashavinginformedBill41,thereareanumberofshortcomingsinthebillthatdonotalignwiththeECCOmodel.Asastapleofintegrationprocess,iscriticalthatbothhealthstructuresandservicedeliverymodelsbeadequatelyaddressedinthegovernment’spatientsfirsttransformationagenda.

AnalysisofBill41

DefinitionofHealthServiceProviderSection1(3)ofBill41seekstoexpandthedefinitionofaHSPunderLHISA.However,itismissing:mostprimarycareorganizations,publichealthunitsandhomehealth-careprovidersdeliveringpurchasedcommunityservices.Effectivehealthsystemintegrationwillnotoccurunlessthereisasinglebody--LHINs--thatiscapableofmakingplanningandfundingdecisionsthatconsiderthehealthsystemasawhole.Otherwise,thereisasignificantriskofperpetuatingexistingsystemlimitations,includingsiloeddecision-makingthatwilltranslateintofragmentationforOntarians.RNAOisbeingjoinedbyagrowingnumberofsystemstakeholdersinassertingthatprimarycaremustbethefoundationanchoringOntario’shealthsystem.20WhileitisencouragingthatBill41classifiesinterprofessionalprimarycareorganizationsasHSPs,theseorganizationsstillprovidehealthservicestoonlyaportionofthepublic(~25percent).Therefore,RNAOassertsthatLHINs

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shouldbeempoweredtooverseetheplanning,contractmanagement,fundingandperformanceofallprimarycareentities.Otherwise,thewayLHINsapproachplanningforprimarycarewillbeinconsistentandwillnotleadtoastrongprimarycarefoundationwhichisfoundationaltohighperforminghealthsystems.21,22,23Thebilldoesseektostrengthentheroleofpublichealthunitsinsupportingplanning,fundingandservicedelivery.However,RNAOisconcernedthattheprovisionsinthebillareinsufficienttoadequatelyadvanceapopulation-healthplanningapproachinOntario.Forexample,sections9and39(1)requiretheleadershipofLHINsandpublichealthunitsto“engage”onanongoingbasis.Thisisavagueexpectationwithno“teeth,”noclearparametersandnoexpectedoutcomes.ForRNAO,publichealthunitsmustassumealeadingroleinadvancinghealthequity.Theyareexpertsinupstreamhealthpromotionanddiseaseprevention,aswellasanalyzingpopulationhealthneedsanddeliveringcommunityengagement.PositioningpublichealthunitswithintheLHINmandate,acknowledgingimplementationconsiderations,24willbetteralignpublichealthwiththerestofthesystem,andcanstimulateabroaderreachofhealthpromotionprinciplesinothersectors.RNAObelievesthatthiscanonlyhappenifpublichealthunitsaredesignatedasHSPs.OneofthedistinctionsbetweenBill41anditspredecessorBill210isthatitincludesaprovisionthatexplicitlyexcludeshomehealth-careprovidersfromthedefinitionofaHSPwhendeliveringacommunityservicepurchasedbytheLHIN.ItisunclearhowLHINswillbecapableofadvancingtheminister’sdesiretobuildcommunitycarecapacity,iftheseserviceprovidersareexcludedfrombeingHSPs?Instead,thecurrentapproachwillbeperpetuatedwherebyservicesarepurchasedfromalargerosterofproviders,leadingtoaninefficientuseofprocurementresourcesandinstabilityinthesector.Instead,RNAOurgesLHINstoserveasfundersofaccreditedhomehealth-careandsupportserviceorganizationsthatdeliveracontinuumofservicesandreformthefundingrelationshipfromaper-visitbasistopredictablefundingbasketsthatfollowevidence-basedpathwaysandleverageproviderautonomy.Thiswillassistinstabilizingthesectorandmakeitmoreperson-centredbyincorporatingarangeofinterventions,includinghealthpromotion.Recommendation#1:Advanceanintegratedhealthsystemthatisanchoredinprimarycare.Amendsection1(3)toincludeallofprimarycare,publichealthunits,homehealth-careandsupportserviceprovidersasHSPs.

HealthEquityGiventheinternational,25national,26andprovincial27evidenceoftheimportanceofimprovinghealthequityanddecreasinghealthinequities,RNAOwelcomessection4(2)inthebill.Astheterm"healthdisparities"isusedmorecommonlyintheUnitedStatesandhasbeencriticizedforbeinglessprecise,28"healthinequities"isthepreferredtermusedbyCanada'sNationalCollaboratingCentreforDeterminantsofHealth(NCCDH).29Robustdefinitionsfor"health

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equity"and"healthinequity"consistentwiththeNCCDH30andusageinotherCanadianjurisdictions31shouldbeincludedsuchasthoseusedbyHealthQualityOntario:

"Healthequityistheidealstateinwhichallpeopleareabletoreachtheirfullhealthpotentialandreceivehigh-qualitycarethatisfairandappropriatefromeachperson'sperspective,nomatterwheretheylive,whotheyareorwhattheyhave."32"Healthinequityisaninequalitythatisanunfair,avoidable,systematicdisadvantage."33

Recommendation#2:Replace"healthdisparities"insection4(2)with“healthinequities”andadoptHealthQualityOntario'sdefinitionsof"healthequity"and"healthinequity”asoutlinedinitsIncomeandHealthReport.

HealthPromotionAchievingthebestpossiblehealthoutcomesrequiresnotonlyarobusthealth-caresystemtopatchpeopleupwhenillnessstrikes,butalsodemandsrobustattentiontopreventingillnessinthefirstplace.Somesystemstakeholdershaveidentifiedlimitationswiththeframingofthebillas“patientsfirst”becauseitfocusesonillness-basedtreatments.34Theoldadageanounceofpreventionisworthapoundofcureholdstrue.ItisnecessaryforLHINstobestrongchampionsofhealthpromotionanddiseasepreventiontoimprovepopulationhealthandensurethesustainabilityofthehealth-caresystem.Bill41couldbenefitfromthisexplicitrecognition.Recommendation#3:AddthefollowingLHINobject:Advancehealthpromotionanddiseasepreventionthroughleadershipinplanning,fundingandmonitoringhealthpromotionservicesthataddressthebroaddeterminantsofhealthandsupportcommunitydevelopment.35

RoleofLHINsinProvidingandManagingServiceAnumberofprovisionswithinBill41,includingSection4(3)andPartVII.1,positiontheLHINasaprovider/managerofhealthservices.RNAOprofoundlydisagreeswithsucharole.AscapturedinRNAO'sECCOreport,themosteffectiveroleoftheLHINistoplan,integrate,fund,monitorandbeultimatelyaccountableforlocalhealthsystemperformance.ItwouldbeineffectiveforLHINstoengageindirectserviceprovision.Itischallengingto“row”and“steer”atthesametime.RNAOurgeslegislatorsnottoperpetuatetheexistinglimitationsofCCACsbyhavingLHINsactasacasemanagementbrokeragethatallocateshoursofservicetoOntariansbasedonacommandandcontrolapproachperSection28.5(4)ofBill41.Rather,serviceprovisionandthemanagementofservice,includingserviceallocationatthepatientlevel,shouldbethefocusofhealthprovidersthathavethebestunderstandingofpatientneed.Recommendation#4:RemoveallprovisionsthatwouldpositionLHINsasdeliveringand/ormanaginghealthservicedelivery.Instead,empowerHSPsandfocusthescopeofLHINsonwholesystemplanning,integration,fundingallocation,monitoringandaccountabilityfunctions.

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HealthSystemOversightBill41enablestheMinisterofHealthandLong-TermCaretoissueoperationalandpolicydirectivestoLHINs;appointaninvestigatortoassessthemanagementandadministrationofaLHINandrecommendthatcabinetappointmentaLHINsupervisor,allwheninthepublicinterest.ItwouldalsoauthorizeLHINstodothesameforhealthserviceproviders.RNAOsupportsthisauthority,inprinciple,whenitiswithinthepublicinterest.Itisimportanttoconsiderthatwhiletheministerofhealthandcabinetaredemocraticallyelectedpublicofficials,LHINCEOsarenot.Therefore,aclearthresholdwithparametersisneededtospecifywhenLHINCEOscanexercisethisauthority;alongwithatransparent,clearandconsistentprocessthatmustbefollowed.TheMinisterofHealthandLong-TermCaremustretainultimateauthorityandaccountabilityfortheoperationofOntario’shealthsystem.RNAOisconcernedthatBill41excludespublichospitalsfrombeingsubjecttoLHINdirectives.ThisisadeparturefromBill210andRNAOisunclearwhythechangewasmadeandhowitalignswiththepublicinterest?Instead,onlytheministercanissueadirectivetoapublichospitalboardpersection46(2)ofthebill.Recently,RNAOhasseenfirsthandveryconcerninghealthhumanresourcedecisionsbeingmadeinpublichospitalsthatputpatientsatrisk.Incircumstanceswherethepublicinterestisadverselyimpacted,itisessentialthatLHINs–inadditiontothehealthminister--havetimelyauthoritytoissuedirectivestohospitals.Section19(4)ofBill41alsospecifiesthatLHINdirectivescannotcompelaHSPthatisareligiousorganizationtoprovideaservicethatiscontrarytothereligionrelatedtotheorganization.WhileRNAOsupportsreligiousfreedomaspartoftheCanadianCharterofRightsandFreedoms,itisstillessentialthattheseorganizationseffectivelyreferpatientsseekingimpactedservicestoanalternateorganizationandthatLHINsplantoensurethereisequitableaccesstoallservicesforpatients.Recommendation#5:Amendsection19(2)byremovingtheexemptionofpublichospitalsfromreceivingLHINdirectives.

PatientandFamilyCouncilsRNAOisencouragedtoseeBill41requiresLHINstoestablishpatientandfamilyadvisorycommitteesandenablestheministertoestablishapatientandfamilyadvisorycouncil.RNAOfirstcalledforpatientandfamilycouncilsin2012whenitreleasedECCO.Recently,RNAOlauncheditspatientandpublicengagementstrategytoreflectthevoiceofthepublicaspartofbeingatransparent,robustandcollaborativeorganization.36Bill41couldbeenhancedbymandatingthatthecommittees/councilreflectthediversityofthecommunitiesbeingserved.Thebillcouldfurtherbeenhancedtocompeltheministrytooperateapatient-familycouncil,asopposedtoleavingitasanoption.ThisshouldnotbeproblematicgiventhatonOctober26MinisterHoskinsannouncedhisintenttocreatesuchacouncil.37

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Recommendation#6:EstablishpatientandfamilyadvisorycommitteeswithinLHINsandamendthebilltorequirethattheyreflectthediversityofthecommunitybeingserved.Furthermore,amendsection41torequiretheministrytoestablishapatientandfamilyadvisorycouncil.

DevelopmentofSub-RegionsSection12ofBill41createssub-regionswithineachLHINforthepurposeofplanning,fundingandintegratingserviceswithintheseareas.RNAOhasbeeninsupportofthedevelopmentofsub-regionssolongastheyfacilitatehorizontalprimarycareintegrationandimproveservicesforpatientsandnotcreatebarriers,unnecessarynewbureaucracy,ornewgovernancelayers.Itisunclearwhatapproachwillbeusedtoimplementthesub-regions.However,thebillcouldbenefitfromclarityinthisregard.Recommendation#7:Amendsection12byexplicitlyclarifyingthattheobjectsofthesub-regionsareplanning,fundingandintegratingservices;notimposingbarriers,unnecessarynewbureaucracyand/ornewgovernancelayers.

HealthProfessionalAdvisoryCouncilsSection14(2)oftheBillmakesestablishingLHINhealthprofessionaladvisorycommitteesvoluntary,whichisadeparturefromtheircurrentrequirement.Formanyyears,RNAOhasbeenadvocatingforatri-partiteleadershipmodelwithinLHINsthatincludesrepresentationfrommedicine,nursingandoneotherregulatedhealthprofession.38Thismodelchampionsinterprofessionalservicedeliverythroughleadershipandensurestheperspectivesofmultiplehealthprofessionalsisincorporatedintotheplanningandfundingprocess.Moreover,toprovideconsistency,RNAOcallsforthisleadershipmodeltobemandatedwithineachLHIN.Recommendation#8:Mandatetri-partiteleadershipmodelsincorporatingmedicine,nursingandoneotherregulatedhealthprofessionwithineachLHIN.

TransferofCCACsTostrengthentheeffectivenessofhealthservicedeliveryandOntario’shealthsystemasawhole,bothstructuralandservicedeliverychangesareneeded.RNAOwasthefirstorganizationtocallforCCACstobedissolved,beginningin2012withthereleaseofitsECCOreport.MaintainingbothCCACsandLHINsresultsinunnecessarystructuralduplication.Italsoresultsinfragmentation-bydesign-ofservicedelivery.ItseverstheabilityoftheLHINstodeliverwholesystemplanningandallocatefundingbasedondemographicandhealthsystemchanges.RNAO,isalsoconcerned,aswasOntario’sAuditorGeneral,withtheadministrativecostoftheCCACs.39,40,41Furthermore,RNAOhasheardasignificantvolumeofconcernfromhomehealth-careagencies,nurses,andthepublicregardingCCACs’“commandandcontrol”modelofbrokerage.ThecurrentdualityofthesetwoagenciesLHINandCCACs,whilebothimportantintheirfunctions,doesnotenablethedeliveryofperson-centredcare.Theimpetusforchangeisclear.

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WhileRNAOwelcomesBill41’sintenttodissolveCCACs,thelanguageusedinthebillislimiting.First,RNAOisconcernedthatuseoftheword“may”inSection26isinsufficientanddiscretionaryregardingtheministerissuinganordertodissolveCCACs.Rather,RNAOinsiststhattheword“shall”beused.Second,RNAOisconcernedthebillsimplyseeksto“transfer”theCCACs,includingalloftheirlimitationstotheLHINs;facilitatingamerger.IndeedpartV.1oftheActisnamed“TransferofCommunityCareAccessCorporationstoLocalHealthIntegrationNetworks.”Thereisasignificantriskthatthestatusquowillcontinue,albeitundertheLHINsandwehaveidentifiedanumberofmissedopportunitiesthatmustberectifiedthroughamendmentstothebillandaccompanyingpolicychanges;someofwhichhavealreadybeenaddressedinthissubmission:

A. EnsuringthatLHINsrefrainfromservicedelivery/management.Instead,focusonpolicythatwillre-locatethenearly4,100careco-ordinatorscurrentlyinCCACsintoprimarycare.42Weknowthatnursepractitioner-ledclinics(NPLC),communityhealthcentres(CHC)andaboriginalhealthaccesscentres(AHAC)areeagerandreadytolocatethemontheirpremises.43Thisislikelythesamecaseformanyfamilyhealthteamsandotherpatientenrollmentmodels.Respectingcollectiveagreements,thiscanbedonethroughasecondmentfromtheLHINservingastheemployer.

B. Enableprimarycaretotriggerhomehealth-careservicesandco-ordinatecare

byutilizingthenearly4,100careco-ordinatorsandexistingRNsinthesector.

C. AmendBill41toremovetheelementsofSection26whichwouldresultintheautomatictransitionofallCCACemployeestotheLHIN.RNAOinsiststhatonlycareprovidersinCCACshouldbetransitioned(e.g.careco-ordinators,mentalhealthnursesinschools,nursepractitioners,rapidresponsenurses,etc)andbelocatedinproviderorganizations.LHINsshouldfirstassesstheirexistingmanagement/administrativecapacitytomeetanexpandedmandateandtheninitiateappropriaterecruitmentprocesses.

D. LHINsshouldincludehomehealth-careandsupportserviceprovidersasHSPs.

Accountabilityagreementscanbedevelopedthroughanon-competitiveprocessthatfavorresults-basedqualityandsafety;accreditationstatusandthescopeofservicesbeingoffered.Thegoalshouldbetoensurequality,safe,continuousandconsistentservicesforOntarians.

Recommendation#9:FullydissolveCCACsandproducetruehealthsystemtransformationbypreventingtheautomatictransferofallCCACfunctions,processesandresourcestotheLHINs.Recommendation#10:Locatethenearly4,100careco-ordinators(currentlyinCCACs)withinprimarycare,asthesectoriseagerandready

OntarioAssociationofCommunityCareAccessCentres(OACCAC)RNAOisconcernedwithSection30ofthebillthatessentiallytransfersthefunctionsandemployeesoftheOntarioAssociationofCommunityCareAccessCentres(OACCAC)toanother

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corporation.WhiletheremaybeaneedtoestablishasharedservicescorporationforLHINs,thefocusshouldbeonsharedservicestosupportLHINsinmeetingtheirplanning,fundingandcontractmanagementobligations.Moreover,theLHINsandministrymustfirstassesswhatneedexistsandplananappropriatescopeofwhatthisentityshouldentail.AlthoughRNAOhasgreatrespectfortheemployeesoftheOACCAC,itwouldbeirresponsibletoautomaticallytransferthemtoaneworganizationthatshouldhaveadifferentfunctionfromtheOACCAC.Recommendation#11:Amendsection30toremovetherequirementthatOACCACemployeesbeautomaticallytransferredtoanewsharedservicescorporation.

HealthQualityOntarioHealthQualityOntario(HQO)playsanimportantrolewithinthehealthsystem,includingpromotingevidence-baseddecision-makingatthepolicyandpracticelevelsandmonitoringtheperformanceofOntario’shealthsystem.Giventhattheorganizationprovidestheministerwithimportantadviceonthefundingofhealthservicesandmedicaldevices,itisimperativethattheperspectivesofthepublicandhealthprovidersarecaptured.Currently,theExcellentCareforAllActrequiresengagementofthepublicinformulatingthisadvice.Thisisfantastic,however,itisalsoimportanttoconsidertheperspectivesofhealthproviderswhoareactivelyleadingthedeliveryofhealthservices.Recommendation#12:Amendsection37torequireHQOtoseektheadviceofthepublicandhealthproviderswhenformulatingadviceonthefundingofhealthservicesandmedicaldevices.

SupportServicesSection40(1)ofBill41specifiesthatapprovedhomecareprovidersareabletochargeclientsafeefortheprovisionofhomemakingorcommunitysupportservices.Theprovisionofsupportservicesisacoreelementofpromotinghealth.Often,theavailabilityofsupportservicesmeansthedifferencebetweenbeingabletoremainathomeandbeingtransferredtoacostlyinstitutionalsetting.Thegovernmentindicatesthatitwantstokeeppeoplewellintheircommunitiesforaslongaspossible.Therefore,thereshouldbesufficientfundingprovidedforcommunitysupportservices(includingbasichomemaking)sothatpeoplearenotrequiredtopayoutofpocket.Moreover,theprovisioninthebillisvagueandoffersnoclarificationonwhatisanappropriatechargeanditisimportanttoconsiderthepopulationsthatrequiretheseservicestofunction.Recommendation#13:RemoveSection40(1)andprovideadequatepublicfundingforcommunitysupportservices.

Conclusion RNAOispleasedtocontributeitsexpertisetothereviewofBill41–PatientsFirstAct,2016.Thebill,withthepressingamendmentsspecifiedinthissubmission,wouldpositivelytransformOntarians’healthsystem.RNAOisgravelyconcernedthatleftas-is,thebillwoulddolittletoput

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patientsfirst.RNs,NPsandnursingstudents--indeedallnurses--arecallingforauthentictransformation.Welookforwardtoanongoingleadershiproleinhealthservicedeliveryandinbringingaboutgenuineandmuchneededhealthsystemimprovements.Ontariansneedanddeservenoless.

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AppendixA–RNAO’sModelforHealthSystemEffectiveness

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AppendixB–RNAO’sEnhancingCommunityCareforOntariansModel

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References 1LegislativeAssemblyofOntario(2016).HansardforOctober19,2016:http://www.ontla.on.ca/web/house-proceedings/house_detail.do?locale=en&Date=2016-10-19&detailPage=%2Fhouse-proceedings%2Ftranscripts%2Ffiles_html%2F19-OCT-2016_L017.htm&Parl=41&Sess=2#P240_143832MinistryofHealthandLong-TermCare(2016).PatientsFirst:ReportingBackontheProposaltoStregthenPatient-CentredHealthCareinOntario.Retrievedfrom:http://www.health.gov.on.ca/en/news/bulletin/2015/hb_20151217.aspx3MinistryofHealthandLong-TermCare(2015).PatientsFirst.AProposaltoStregthenPatient-CentredHealthCareinOntario.DiscussionPaper.Retrievedfrom:http://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf(seepage9).4Gallup(2015).Honesty/EthicsinProfessions.Retrievedfrom:http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx5RegisteredNurses’AssociationofOntario(2016).NursingWorkforceBackgrounder.Retrievedfrom:http://rnao.ca/sites/rnao-ca/files/Nursing_HR_Backgrounder_June_30.16.1.pdf(withdatafromtheCollegeofNursesofOntario).6RegisteredNurses’AssociationofOntario(2012).PrimarySolutionsforPrimaryCare.Retrievedfrom:http://www.RNAO.ca/primary_care_report7RegisteredNurses’AssociationofOntario(2014).EnhancingCommunityCareforOntarians(ECCO)V2.0.Retrievedfrom:http://www.RNAO.ca/ECCO8RegisteredNurses’AssociationofOntario(2014).SubmissiontotheStandingCommitteeonSocialPolicy–ReviewoftheLocalHealthSystemIntegrationActandRegulations.Retrievedfrom:http://rnao.ca/sites/rnao-ca/files/RNAO_Submission_LHSIA_Review-.pdf9RegisteredNurses’AssociationofOntario(2016).ResponsetotheMinistryofHealthandLong-TermCare’sPatientsFirst:ProposaltoStrengthenPatient-CentredHealthCareinOntario.Retrievedfrom:http://rnao.ca/sites/rnao-ca/files/RNAO_Submission_to_MOHLTC_Patients_First_Discussion_Paper_re_Health_System_Transformation_-_March_2016.pdf10RegisteredNurses`AssociationofOntario(2016).MindtheSafetyGapInHealthSystemTransformation:ReclaimingTheRoleoftheRegisteredNurse.Retrievedfrom:http://www.RNAO.ca/MindTheSafetyGap11CommissionoftheReformofOntario`sPublicServices(2012).Chapter5:Health.Retrievedfrom:http://www.fin.gov.on.ca/en/reformcommission/chapters/ch5.html12RegisteredNurses`AssociationofOntario(2015).WhyHealthMatters:Anurses`guidetothe2015federalelection.Retrievedfrom:http://rnao.ca/sites/rnao-ca/files/Platform_2015_Aug_12.pdf13RegisteredNurses`AssociationofOntario(2016).MindtheSafetyGapInHealthSystemTransformation:ReclaimingTheRoleoftheRegisteredNurse.Retrievedfrom:http://www.RNAO.ca/MindTheSafetyGap14HealthQualityOntario(2016).MeasuringUp2016.Retrievedfrom:http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2016-en.pdf(seeprimarycareaccess)15AuditorGeneralofOntario(2015).AnnualReport–Chapter3:CCACs–CommunityCareAccessCentres–HomeCareProgram.Retrievedfrom:http://www.auditor.on.ca/en/content/annualreports/arreports/en15/3.01en15.pdf16HealthQualityOntario(2016).IncomeandHealth.OpportunitiestoachievehealthequityinOntario.Retrievedfrom:http://www.hqontario.ca/Portals/0/documents/system-performance/health-equity-report-en.pdf17OntarioChronicDiseasePreventionAlliance(2016).MakeOntariotheHealthiestProvince.Pre-BudgetSubmission.Retrievedfrom:http://www.ocdpa.ca/sites/default/files/publications/OCDPA%202016%20Pre-Budget%20Budget%20Submission_1.pdf18RegisteredNurses’AssociationofOntario(2014).EnhancingCommunityCareforOntarians(ECCO)V2.0.Retrievedfrom:http://www.RNAO.ca/ECCO19CanadianInstituteforHealthInformation(2014).YourHealthSystem:http://yourhealthsystem.cihi.ca/

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20OntarioPrimaryCareCouncil(2016).OPCCInitialResponsetoMinister’sPatientsFirstProposal.Retrievedfrom:http://rnao.ca/sites/rnao-ca/files/FINAL_Letter-OPCC-to-Minister-Patients-First-Jan-22-2016.pdf21WorldHealthOrganization(2015).BuildingprimarycareinachangingEurope.Retrievedfrom:http://www.euro.who.int/en/publications/abstracts/building-primary-care-in-a-changing-europe22Schoen,C.etal(2004).Primarycareandhealthsystemperformance:Adults’experiencedinfivecountries.HealthAffairs.(4),487-503.23Baker,R.&Axler,R.(2015).CreatingahighperforminghealthcaresystemforOntario:evidencesupportingstrategicchangesinOntario.Retrievedfrom:https://www.oha.com/News/Documents/OHA%20High%20Performing%20Healthcare%20System%20Paper.pdf 24RegisteredNurses’AssociationofOntario(2014).EnhancingCommunityCareforOntarians(ECCO)V2.0.Retrievedfrom:http://www.RNAO.ca/ECCOseeAppendixCforapublichealthanalysis.25CommissionontheSocialDeterminantsofHealth(2008).Closingthegapinageneration:Healthequitythroughactiononthesocialdeterminantsofhealth.Geneva:WorldHealthOrganization.http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf26ChiefPublicHealthOfficerofCanada(2008).ReportonthestateofpublichealthinCanada2008:Addressinghealthinequalities.Ottawa:PublicHealthAgencyofCanada.http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/index-eng.php27HealthQualityOntario(2016).IncomeandHealth:OpportunitiestoachievehealthequityinOntario.Toronto:Author.http://www.hqontario.ca/Portals/0/documents/system-performance/health-equity-report-en.pdf28Hofrichter,R.&Bhatia,R.(2010).TacklingHealthInequitiesthroughPublicHealthPractice:TheorytoAction.NewYork:OxfordUniversityPress.29NationalCollaboratingCentreforDeterminantsofHealth(2013).Let'sTalk:Healthequity.Antigonish,NS:Author.http://nccdh.ca/images/uploads/Lets_Talk_Health_Equity_English.pdf30NationalCollaboratingCentreforDeterminantsofHealth(2013).Let'sTalk:Healthequity.Antigonish,NS:Author.http://nccdh.ca/images/uploads/Lets_Talk_Health_Equity_English.pdf31AlbertaHealthServices(2011).TowardsanUnderstandingofHealthEquity:AnnotatedGlossary.Edmonton:Author,15.http://www.albertahealthservices.ca/poph/hi-poph-surv-shsa-tpgwg-annotated-glossary.pdf32HealthQualityOntario(2016).IncomeandHealth:OpportunitiestoachievehealthequityinOntario.Toronto:Author,9.33HealthQualityOntario(2016).IncomeandHealth:OpportunitiestoachievehealthequityinOntario.Toronto:Author,9.34AssociationofOntarioHealthCentres(2016).SubmissiontotheStandingCommitteeoftheLegislativeAssemblyregardingBill41–PatientsFirstAct,2016.35AdaptedfromAssociationofOntarioHealthCentres(2016).SubmissiontotheStandingCommitteeoftheLegislativeAssemblyregardingBill41–PatientsFirstAct,2016.36RegisteredNurses’AssociationofOntario(2016).PatientandPublicEngagement.Retrievedfrom:http://rnao.ca/about/PPE37GovernmentofOntario(2016).OntarioEstablishingPatientandFamilyAdvisoryCouncil.Retrievedfrom:https://news.ontario.ca/mohltc/en/2016/10/ontario-establishing-patient-and-family-advisory-council.html 38RegisteredNurses’AssociationofOntario(2012).PrimarySolutionsforPrimaryCare.Retrievedfrom:http://www.RNAO.ca/primary_care_report39AuditorGeneralofOntario(2015).CommunityCareAccessCentres–FinancialOperationsandServiceDelivery.Retrievedfrom:http://www.auditor.on.ca/en/content/specialreports/specialreports/CCACs_en.pdf40AuditorGeneralofOntario(2015).2015AnnualReport–Chapter3,Section3.01CCACs-CommunityCareAccessCentres–HomeCareProgram.Retrievedfrom:http://www.auditor.on.ca/en/content/annualreports/arreports/en15/3.01en15.pdf

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41AuditorGeneralofOntario(2010).2010AnnualReport.Chapter3,Section3.04HomeCareServices.Retrievedfrom:http://www.auditor.on.ca/en/content/annualreports/arreports/en10/304en10.pdf 424,100isbasedondataprovidedbytheMinistryofHealthandLong-TermCaredatedNovember18,2016.43RNAOconductedasurveyofnursepractitioner-ledclinicsinNovember2016.