Do You Support Changes in Provincial Policy That Would Enable Nurse

Do you support changes in provincial policy that would enable nurse practitioners (NP) to work to their full scope of practice, thereby increasing access to health care in Ontario?

Time and time again we continue to hear that Ontarians have limited access to health services. One important measure to address this issue is to enable NPs to work to their full scope of practice.

What is an NP? NPs are registered nurses who have advanced knowledge and education, and a broader scope of practice.1 NPs are registered with the College of Nurses of Ontario (CNO) under four specialty categories: primary care; adult; paediatric; and anaesthesia.2 3 NPs work in all health care settings including: public health, primary care, hospitals, rehabilitation, home care, and long- term care.

For more than four decades, NPs have delivered high quality patient care to meet the needs of Ontarians.4 Evidence collected over the last fifty years conclusively shows the positive value and impact NPs have on patient care and health system outcomes.5 6

NPs in Ontario In response to RNAO’s robust evidence-based advocacy to expand the role of NPs, Ontario was a trailblazer in the evolution of the NP role. Specifically:  26 NP-led clinics providing primary care have been established across Ontario7  NPs in Ontario were the first in Canada to be granted the authority to admit, treat, transfer and discharge hospital in-patients8  The province has committed to fund 75 attending NPs in long-term care homes of which 49 are already in place.9

These are tremendous advances for NPs in Ontario. However, we now lag behind the rest of the country. There are several practice, policy, regulatory, and legislative gaps in NP scope of practice that hinder access and prevent NPs from providing comprehensive care.

Practice and policy barriers An RNAO-led survey of senior nurse leaders in Ontario’s hospitals found that while 70 per cent of responding organizations had NPs treating patients, only 41 per cent were discharging patients and just four per cent were admitting patients. The reasons cited as main barriers to the full

utilization of NPs in hospitals included: physician concerns; budget limitations; and organizational policies.

Examples include employers limiting NPs’ duties by not enabling them to act as the most responsible provider (MRP) in hospitals and some primary care settings, as well as not fully utilizing NPs’ anesthesia role. This negatively impacts timely access to quality care. Vulnerable populations are particularly affected, including persons struggling with mental health, those suffering with addictions, transgendered persons, and people at the end-of-life.

It is urgent that all roadblocks to NP full scope of practice be eliminated to enable timely access, better patient flow, enhanced services, and improved health outcomes for Ontarians.10 The failure to promote the advancement of the NP role within the health system is incompatible with other Canadian jurisdictions and with Ontario’s goal of ‘Putting Patients First.’ Extensive evidence on the value of NPs demonstrates that fully utilizing NPs results in improved quality of care, patient outcomes and patient experience. In addition outcomes show health system improvements and cost-effectiveness. RNAO’s Nurse Practitioner Utilization Toolkit is a key resource to assist organizations in optimizing NP utilization. 11

Regulatory and legislative barriers RNAO calls for the immediate removal of legislative and regulatory barriers that hinder NPs from working to their full scope of practice, and participating fully as vital members of our health system to achieve the goals of the “Patients First: Action Plan for Health Care”.12 These include the following:

1. Grant NPs the ability to perform point-of-care testing Recent amendments were made to the Ontario Drug Benefit Act authorizing the Ministry of Health and Long-Term Care to fund non-drug therapeutic substances listed in the formulary, such as blood glucose test strips and nutritional products, when prescribed by an NP or other authorized prescriber. While RNAO welcomes these legislative changes, regulatory barriers still remain. NPs are authorized to order laboratory tests as appropriate for patient care through regulations under the Laboratory and Specimen Collection Centre Licensing Act, 1990, however, NPs are not authorized to perform or order point-of-care tests, such as a urinalysis dip or pregnancy test. NPs must use medical directives13 for these tests, which are restrictive, risky, and time consuming. It is both cost-effective and more efficient to perform point-of-care testing that produces test results on-the-spot. It is well within NP competency to order, perform, and interpret point-of-care testing. RNAO urges an immediate change to the regulation in order to grant NPs this authority.

The story of Raymond demonstrates the importance of allowing NPs to perform point-of-care testing.

Raymond is an NP in a busy urban family health team. His patient – a 15-year-old teenage girl – has come to see him to get a pregnancy test. After performing the procedure herself, she hands the urine sample to Raymond and asks him for the results. Although Raymond is capable of testing the urine via dip stick and interpreting the results, he has to send the sample to the lab to be tested. His patient anxiously waits for hours for the results. If Raymond and other NPs are able to perform point-of-care testing, patients will get timely results and interventions without having to wait unnecessarily.

2. Grant NPs the ability to order electrocardiograms (ECG) in all situations NPs are only authorized to order ECGs in non-urgent situations. This distinction between urgent and non-urgent situations is incomprehensible. In order to increase timely access to necessary care, NPs should be given authority to order this test in all situations, especially those that are urgent. The current gap leads to decreased access to a necessary test for clients in critical situations, and creates the need for inefficient medical directives that delay urgently needed client care. We urge the government to immediately remove this senseless restriction.

3. Authorize NPs to order all diagnostic imaging NPs can only order x-rays itemized on a fixed list and do not have authority to order beyond this list. As a result, tests that are necessary to provide comprehensive primary care are excluded. For example, NPs should have the authority to order bone mineral density (BMD) tests which are routinely used to screen for osteoporosis. NPs are central to advancing timely access to quality care and their current inability to order all x-rays, Computed Tomography (CT) scans, and Magnetic Resonance Imaging (MRI), limits their capacity to provide comprehensive care, timely access, and hampers health system effectiveness. RNAO urges that NPs be immediately authorized to order all x-rays, CT scans, and MRIs.

Eliminating barriers for NPs to order necessary tests, medications and procedures will enhance timely access to quality care for Ontarians in institutional and community settings, and advance health system effectiveness. This will also help meet the goals outlined in the Minister of Health and Long-Term Care’s current Patients First: Action Plan for Health Care,14 which aims to promote access to high-quality care by qualified health professionals and the best use of resources.

4. Expand NPs’ authority to certify a death RNAO continues to advocate for expanding nurse practitioners’ (NP) authority to certify a death beyond the current eligibility criteria and calls for corresponding changes to Regulation 1094 (General) under the Vital Statistics Act to include NPs. This will ensure the dignity of deceased persons and support the well-being of their loved ones. It also ensures that the regulation keeps pace with the significant evolution in NP utilization in Ontario as NPs are now serving as most responsible provider (MRP) across all sectors, including as attending NPs in long-term care homes.

5. Authorize NPs to complete legal forms for mental health services At present, Section 15 of the Mental Health Act authorizes a physician to complete 7 forms related to mental health services (See Appendix A). These include forms (1-5) related to bringing someone to a psychiatric facility, keeping them there and discharging them. There are also 2 forms (14 and 28) which control access to a patient’s clinical records.

Given that NPs often serve as entry-points to the health system, restricting the ability to initiate legal forms for mental health services to physicians presents a significant safety hazard. For example, at present, if a client who appears to be suffering from a mental illness presents to an NP indicating he/she is at risk of harming himself/herself or someone else, the NP is severely limited in their response. They would need to locate a physician in a timely manner to initiate a Form 1 – Application for Psychiatric Assessment, which is not always possible. This leads to undue risk for the patient and potentially for others. While waiting for a physician, the patient, who may be in a compromised state of mind, is able to leave on his or her own free will. Alternatively, an NP could appear before a justice of the peace to seek a Form 2; however, this is time intensive and incredibly unrealistic when a patient is in immediate distress.

Authorizing NPs to initiate legal forms for mental health services aligns with the evolution of the health system and the NP role. It promotes the public interest, improves access to greatly needed care and is consistent with the scope of practice that NPs already have. It will increase safety for individuals, families, and communities.

 Allow NPs to perform point-of-care testing.

 Grant NPs the ability to order electrocardiograms (ECG) in all situations.

 Authorize NPs to order all diagnostic imaging.

 Expand NPs authority to certify a death.

 Authorize NPs to complete Forms 1, 2, 3, 4, 5, 14 and 28 for mental health services under the Mental Health Act.

Appendix A

The following table outlines the legal forms for mental health services, under the Mental Health Act, which are presently restricted to physicians.

Legal Form Description Form 1 – Application for Psychiatric Used to bring someone to a psychiatry facility for an Assessment assessment if the individual is at serious risk of harm to themselves or others. Form 2 – Order for Examination Used under the same conditions as the Form 1 but is issued by a justice of the peace. Form 3 – Certificate of Involuntary Used to admit a person to a psychiatric facility against his Admission or her will for up to two weeks. Form 4 – Certificate of Renewal Used when a physician determines that the person must remain in a psychiatric facility involuntarily for another month or longer as determined based on assessment. Form 5 – Change to Voluntary Determines that the patient does not need to be kept Status involuntarily any longer and is also used to end a Form 3 or a Form 4 before it expires. Form 14 – Consent to the Used when a patient wants to give another person the Disclosure, Transmittal or permission to see or get a copy of their clinical record. Examination of a Clinical Record Form 28 – Request to Examine or to Used when a patient wants to get a copy of their own Copy Clinical Record clinical record.

References:

1 College of Nurses of Ontario (CNO). (2016). Nurse practitioners. Retrieved from http://www.cno.org/en/learn- about-standards-guidelines/educational-tools/nurse-practitioners/.

2 CNO. (2017). Membership totals at a glance. Retrieved from http://www.cno.org/en/what-is-cno/nursing- demographics/membership-totals-at-a-glance/.

3 The College of Nurses of Ontario has the authority to register NPs in anaesthesia, but to date there are no registrants in this category.

4 Government of Canada. (2007). Nursing issues: Primary health care nurse practitioners. Retrieved from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/nursing/nursing-issues- primary-health-care-nurse-practitioners.html.

5 Ibid.

6 Registered Nurses’ Association of Ontario. (2015). Nurse practitioner utilization toolkit. Retrieved from http://nptoolkit.rnao.ca/.

7 Registered Nurses’ Association of Ontario. (2011). Increasing access to primary care through nurse practitioner-led clinics. Retrieved from http://rnao.ca/policy/briefing-notes/increasing-access-primary-care-through-nurse- practitioner-led-clinics.

8 Registered Nurses’ Association of Ontario. (2016). Press release: Mind the safety gap in health system transformation: RNAO issues recommendations to ensure patients come first. Retrieved from http://rnao.ca/news/media-releases/2016/05/09/mind-safety-gap-health-system-transformation-rnao-issues- recommendati.

9 Registered Nurses’ Association of Ontario. (2015). Press release: Attending nurse practitioners will improve care for seniors in long-term care. Retrieved from http://rnao.ca/news/media-releases/2015/09/24/attending-nurse- practitioners-will-improve-care-seniors-long-term-car.

10 Registered Nurses’ Association of Ontario. (2016). Mind the safety gap in health system transformation: Reclaiming the role of the RN. Retrieved from http://rnao.ca/sites/rnao-ca/files/HR_REPORT_May11.pdf.

11 Registered Nurses’ Association of Ontario. (2015). Nurse practitioner utilization toolkit. Retrieved from http://nptoolkit.rnao.ca/.

12 Ministry of Health and Long-Term Care. (2015). Patients First: Action Plan for Health Care. Retrieved from http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_patientsfirst.pdf.

13 A medical directive is a written order by an NP or physician and may be implemented for a number of clients when specific conditions are met and when specific circumstances exist. Source: CNO. (2014). Directives. Practice guideline. Retrieved from http://www.cno.org/globalassets/docs/prac/41019_medicaldirectives.pdf.

14 Ontario Ministry of Health and Long-Term Care. (2016). Patients first: Action plan for health care. Retrieved from http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/.

Will you support improving patient health outcomes and safety by mandating that:  Any new nursing hires in tertiary, quaternary, and cancer care hospitals be RNs  All first home care assessments be conducted by an RN

Will you demand that health-care organizations use professional nursing care models?

This is why In May 2016, RNAO released a policy report entitled Mind the safety gap in health system transformation: Reclaiming the role of the RN, on the health human resources necessary to achieve health system transformation.1 The report’s conclusion is that trends in critical areas run counter to the Ontario government’s goals for the health system transformation and putting ‘Patients First’, specifically:  nursing skill mix in acute care, home care and long-term care is being diluted; and  organizational models of nursing care delivery advance fragmentation of care provision instead of care continuity.

Ontario needs more RNs Ontario has the lowest RN-to-population ratio in Canada.2 The Canadian Institute for Health Information (CIHI) figures show the province has only 703 RNs per 100,000 people compared to an average of 839 per 100,000 people in the rest of Canada.3 At the same time, the ratio of RPNs-to-population continues to increase.

RNs are often a patient’s first point of contact with the health system and they are present in every health service delivery setting. Poll after poll shows that RNs enjoy the highest public trust compared to other occupations.4 In addition, studies conclusively show that employing RNs improves health and financial outcomes.5 And yet, the Ontario government continues to enable the replacement of RNs with lesser qualified health care workers. This comes at a time when patient complexity is increasing. This practice is misguided and puts patient safety and outcomes at risk.

RN SHARE OF ONTARIO NURSING EMPLOYMENT

RPN SHARE OF ONTARIO NURSING EMPLOYMENT

RN effectiveness The largest ever publically available database of 70 years of research into RN effectiveness released in 2017, shows that using RNs results in improved clinical and financial outcomes.6

Higher levels of care from RNs result in fewer deaths, pressure ulcers, pneumonia and other pulmonary events, sepsis and infections, upper gastrointestinal bleeds, cardiac arrests, falls, and medication errors. 7 8 9 10 11 12 13 14 15 16

POSITIVE CLINICAL/PATIENT OUTCOMES

POSITIVE FINANCIAL OUTCOMES

In addition, patient outcomes improve when RNs provide direct care instead of assuming only a supervisory role.17 A higher proportion of RNs is also linked to shorter lengths of stay in hospital, and improved organizational effectiveness.18 19 20

POSITIVE ORGANIZATIONAL AND NURSE OUTCOMES

We need to have the right nurse in the right place

The College of Nurses of Ontario (CNO) indicates that the determination of nursing skill mix focuses on three factors: the client, the nurse, and the environment. These factors have an impact on decision-making related to care-provider assignment or which nursing category to match with patients’/clients’ or residents’ needs depending on complexity, predictability, and risk of negative outcomes. More complex patients, with less predictability and less stable environments should be cared for by RNs. Less complex patients, with predictability and a stable environment may be cared for by RPNs.21 Despite our warnings of the negative impact of RN replacement and risky assignments, RNAO continues to hear of these trends across the province in various health-care settings and sectors. RNAO is not sitting idly by as RN replacement is Fig. 1. Optimizing Ontario’s Nursing Workforce 34

occurring and functional models of nursing care delivery are re-emerging. We have issued multiple Action Alerts; calling on nurses, other health professionals and the public to respond. Despite the 24,300 responses, no action has been taken by government. RNAO is calling on the Ontario government to mandate that any new nursing hires in tertiary, quaternary, and cancer care centres be RNs with a long-term goal of having an all RN-workforce within these settings and within five years for large community hospitals. These centres are designed to provide care specifically to persons with high degrees of complexity and instability. Diluting RN care in these settings is risky to patient safety and outcomes.

The complexity and prevalence of patients receiving home care has also increased as patients are being discharged earlier from hospital.22 The practice of home care nursing is complex, requiring a diverse knowledge base to manage patient care across the lifespan.23 During the initial visit, the complexity and stability of the patient is often unknown.24 It is critical that all first home health- care visits be provided by an RN because they are best suited to perform a comprehensive assessment and develop a care plan that ensures a patient’s complex needs are met safely in their homes.25

Models of nursing care

RNAO believes that a nursing human resources strategy is not as simple as increasing the number of staff. It is about effectively matching human resources with the needs of patients.26 It is imperative that nurses are fully engaged in the evolution of the health system to ensure service delivery remains person- and family-centred and of high quality.27 This can only be accomplished through evidence-based practice and policy that includes: the appropriate number of RN staff; full and expanded scope of practice utilization; robust interprofessional practice; effective organizational models of nursing care delivery; the appropriate skill mix; and evidence based clinical practice.

The replacement of RNs with less qualified providers often goes hand-in-hand with implementing organizational models of nursing care delivery that fragment patient care. These models focus on parceling out patient care into a series of tasks to be completed. This practice, known as “functional nursing”, was abandoned in the 1970s due to its detrimental impact on patient experience and outcomes, and it has now been rebranded as “team nursing”. Functional models of nursing care view nursing as a broad set of tasks (e.g. medication administration, dressing changes, baths, and vital signs) that can a be carried out by a variety of workers (e.g. RNs developing care plans, RPNs performing vital signs, and PSWs giving baths).28 Fragmenting patient care based on tasks results in miscommunication and errors, as the care provider is focused on the task at hand rather than connecting all aspects of care to form a complete picture of the person’s health thereby being able to intervene in a timely manner when necessary. Implementation of these models is often motivated by short-sighted attempts to save money and control local health-care spending by placing greater reliance on cheaper staff to

deliver nursing services. Functional or task-oriented nursing is criticized for not recognizing clients as individuals and devaluing aspects of psychosocial care.29

In contrast, primary nursing or total patient care models assign individual patients to the most appropriate nurse (RN or RPN) who acts as their primary nurse throughout the entire care process, providing all aspects of nursing care. This model facilitates comprehensive care of clients and is linked to improved patient outcomes as the nurse is better able to detect threats to patient safety and intervene promptly to avoid adverse events.30

Primary nursing is associated with improved outcomes for patients, nurses, and work environments when implemented through a supportive culture.31 When nurses practise in primary nursing models, they have more autonomy, increased accountability for the care they provide, and improved clinical decision-making skills.32 Evidence indicates that models of primary nursing are less costly for organizations than team-based models due to the decrease in administrative and supervisory activities.33 34

 Government mandate that any new nursing hires in tertiary, quaternary, and cancer care centres be RNs with a long-term goal of having an all RN-workforce within these settings and within five years for large community hospitals.

 All first home health-care visits be provided by an RN.

 Professional models of nursing care that advance care continuity and avoid care fragmentation (primary or total patient care) be required across all sectors of the health system.

References:

1 RNAO. (2016). Mind the safety gap in health system transformation: Reclaiming the role of the RN. Retrieved from http://rnao.ca/sites/rnao-ca/files/HR_REPORT_May11.pdf.

2 RNAO. (2017). RNAO says latest nursing stats reveal Ontario’s RN workforce continues to decline. Retrieved from http://rnao.ca/news/media-releases/2017/06/01/RN-workforce-decline.

3 RNAO. (2017). RNAO says latest nursing stats reveal Ontario’s RN workforce continues to decline. Retrieved from http://rnao.ca/news/media-releases/2017/06/01/RN-workforce-decline.

4 Gallup. (2015). Honesty/ethics in professions. Retrieved from http://www.gallup.com/poll/1654/honesty-ethics- professions.aspx.

5 Registered Nurses’ Association of Ontario (RNAO). (2017). 70 years of RN effectiveness. Retrieved from http://rnao.ca/bpg/initiatives/RNEffectiveness.

6 RNAO. (2017). 70 years of RN effectiveness. Retrieved from http://rnao.ca/bpg/initiatives/RNEffectiveness.

7 West, G., Patrician, PA. & Loan, L. (2012). Staffing matters – every shift. American Journal of Nursing, 112(12), 22-27.

8 Needleman, J., Buerhaus, P., Mattke, S., Stewart, M. & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. The New England Journal of Medicine, 346(22), 1715-1722.

9 Glance, LG., Dick, AW., Osler, TM., Mukamel, DB., Li, Y. & Stone, PW. (2012). The association between nurse staffing and hospital outcomes in injured patients. BMC Health Services Research, 12, 247.

10 Kane, RL., Shamliyan, TA., Mueller, C., Duval, S. & Wilt, TJ. (2007). The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Medical Care, 45(12), 1195-1204.

11 Twigg, D., Duffield, C., Bremner, A., Rapley, P. & Finn, J. (2012). Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: A retrospective study. Journal of Advanced Nursing, 68(12), 2710-2718.

12 Aiken, LH., Sloane, DM., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kozka, M., Lesaffre, E., McHugh, MD., Moreno-Casbas, MT., Rafferty, AM., Schwendimann, R., Scott, RA., TIshelman, C., van Achterberg, T. & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830.

13 Cho, E., Sloane, DM., Kim, E., Kim, S., Choi, M., Yoo, IY., Lee, HS. & Aiken, LH. (2015). Effects of nurse staffing, work environments, and education on patient mortality: An observational study. International Journal of Nursing Studies, 52(2), 535-542.

14 Estabrooks, CA., Midodzi, WK., Cummings, GG., Ricker, KL. & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 74-84.

15 Kutney-Lee, A., Sloane, DM. & Aiken, LH. (2013). An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Affairs, 32(3), 579-586.

16 Frith, K., Anderson, EF., Fan, T. & Fong, E. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economic$, 30, 288-294.

17 Alenius, LS., Tishelman, C., Runesdotter, S. & Lindqvist, R. (2014). Staffing and resource adequacy strongly related to RNs' assessment of patient safety: A national study of RNs working in acute-care hospitals in Sweden. BMJ Quality and Safety, 23 (3), epub.

18 Harless, DW. & Mark, BA. (2010). Nurse staffing and quality of care with direct measurement of inpatient staffing. Medical Care, 48(7), 659-663.

19 Dubois, C., D’amour, D., Tchouaket, E., Clarke, S., Rivard, M. & Blais, R. (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care, 25(2), 110-117.

20 Patrician, PA., Pryor, E., Fridman, M. & Loan, L. (2011). Needlestick injuries among nursing staff: Association with shift-level staffing. American Journal of Infection Control, 39(6), 477-482.

21 College of Nurses of Ontario (2014). RN and RPN practice: The client, the nurse and the environment. Practice guideline. Retrieved from http://www.cno.org/globalassets/docs/prac/41062.pdf.

22 Home Care Ontario & OCSA Nursing Practice Council. (2017). Optimizing nursing in Ontario’s renewed home care system. Retrieved from http://homecareontario.ca/docs/default-source/position-papers/optimizing-nursing-in- ontario-home-care-ontario-ocsa-final-july-2017.pdf?sfvrsn=4.

23 Home Care Ontario & OCSA Nursing Practice Council. (2017). Optimizing nursing in Ontario’s renewed home care system. Retrieved from http://homecareontario.ca/docs/default-source/position-papers/optimizing-nursing-in- ontario-home-care-ontario-ocsa-final-july-2017.pdf?sfvrsn=4.

24 RNAO. (2016). Mind the safety gap in health system transformation: Reclaiming the role of the RN. Retrieved from http://rnao.ca/sites/rnao-ca/files/HR_REPORT_May11.pdf.

25 RNAO. (2016). Mind the safety gap in health system transformation: Reclaiming the role of the RN. Retrieved from http://rnao.ca/sites/rnao-ca/files/HR_REPORT_May11.pdf.

26 Bylone, M. (2010). Appropriate staffing: more than just numbers. AACN Advanced Critical Care, 21(1), 21-3.

27 McBride, S., Delaney, JM. & Tietze, M. (2012). Health information technology and nursing. American Journal of Nursing, 112(8), 36-42.

28 Dubois, C., D’Amour, D., Tchouaket, E., Clarke, S., Rivard, M. & Blais, R. (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care. 25(2), 110-117.

29 Duffield, C., Roche, M., Diers, D., Catling-Paull, C. & Blay, N. (2010). Staffing, skill mix and the model of care. Journal of Clinical Nursing, 19(15-16), 2242-2251.

30 Dubois, C., D’Amour, D., Tchouaket, E., Clarke, S., Rivard, M. & Blais, R. (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care. 25(2), 110-117.

31 Matila, E., Pitkanen, A., Alanen, S., Lino, K., Luojus, K., Rantanen, A. & Aalto, P. (2014). The effects of the primary nursing care model: A systematic review. Journal of Nursing Care, 3(6), epub.

32 Wolf, GA. & Greenhouse, PK. (2007). Blueprint for design: Creating models that direct change. Journal of Nursing Administration, 37(9), 381-387.

33 Wolf, GA. & Greenhouse, PK. (2007). Blueprint for design: Creating models that direct change. Journal of Nursing Administration, 37(9), 381-387.

34 Dubois, C., D’Amour, D., Tchouaket, E., Clarke, S., Rivard, M. & Blais, R. (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care. 25(2), 110-117.

Ontario’s health system is being transformed. There is great potential to improve access, safety and effectiveness when it comes to health service delivery. Will you support an integrated health system that is anchored in primary care?

Do you agree care co-ordinators and the care co-ordination function should be located in primary care settings so that patient care is more seamless and costly hospital re- admissions can be avoided?

Do you agree that home care agencies, instead of the Local Health Integration Networks (LHIN), should assume responsibility for the allocation of home care services?

Between May and June 2017, the functions of all 14 former Community Care Access Centres (CCAC) transferred over to the 14 LHINs. According to the health minister’s mandate letter, LHINs are now “responsible for creating an integrated service delivery network that includes primary care providers, inter-professional health care teams, hospitals, public health, mental health and addictions and home and community care to ensure a more seamless patient experience”.1 It is critical that health system transformation not end with this change because much more is needed to ensure Ontarians have an effective health system.

Health system anchored in primary care The Ontario Primary Care Council (OPCC), of which RNAO is a founding member, strongly encourages anchoring the health system in primary care. High performing health systems around the world already do this.2 Ontarians need a better integrated health system where primary care is the patient’s main contact with the health system, and where connections are automatically made between different health sectors and providers. There is ample evidence that integrated health systems anchored in primary care deliver the best health outcomes and are the most cost- effective.3 4 5 6

Better integrated and co-ordinated care at all levels will enable Ontarians to live healthier lives. Primary care practitioners provide comprehensive first contact and continuing care to patients.7 Vulnerable populations such as the elderly, people with chronic conditions, severe physical disabilities, developmental or cognitive impairments, and serious mental illnesses and addictions easily fall through the cracks without properly integrated and comprehensive care.8 Those with high-risk and complex conditions would benefit from primary care co-ordinating their care, including chronic disease prevention and management, on an ongoing basis.9

Benefits of care co-ordination in primary care Mrs. Lee, recently diagnosed with end-stage cancer, decided palliative care was the best way to cope with her terminal diagnosis. The oncologist, respectful of Mrs. Lee’s decision, sent her home with medications to manage her pain while a referral to the Local Health Integration Network (LHIN) for palliative care was forwarded to a centralized location. Although oral pain medications were readily available, Mrs. Lee increasingly suffered with cancer-related pain for three weeks while she waited for palliative services to begin. If a LHIN care co-ordinator had been located at Mrs. Lee’s local Community Health Centre, where she sees the nurse practitioner for ongoing primary care, she could have obtained home care services with minimal delay, and her primary care practitioner would be linked in with these services.

Locating care co-ordination and care co-ordinators in primary care settings Now that CCAC functions have been transferred to the LHINs, RNAO wants the government to move forward with their commitment to relocate the 3,100 former CCAC care co-ordinators (this number excludes those working in hospitals) and the care co-ordination function into primary care settings with salary and benefits intact. In the health minister’s 2017 mandate letter, LHINs are expected to “develop and implement a plan with input from primary care providers, patients, caregivers and partners that embeds care co-ordinators and system navigators in primary care to ensure smooth transitions of care between home and community care and other health and social services as required.”10

Moving care co-ordination and care co-ordinators to primary care will expand the reach of primary care practitioners to community care. This shift will facilitate seamless transitions for patients and families, reduce duplication, increase quality of care, facilitate access, and reduce costs.11 Increasing the workforce capacity of primary care will significantly improve primary care’s ability to deliver comprehensive person-centred health services. This will result in improved co-ordination, continuity and transitions, reduce service delays, avoid costly hospital re-admissions, improve overall quality and personal health outcomes, and empower patients and families.12

The majority of care co-ordinators are registered nurses (RN). RNs possess a comprehensive understanding of the health system and a person’s holistic health status, including physical, mental, social, emotional and spiritual needs. Their competencies, knowledge and clinical skills make them naturally suited to function as leaders in the co-ordination of care and navigation of the system. As profiled in RNAO’s Primary Solutions to Primary Care13 and in Enhancing Community Care for Ontarians (ECCO)14, RN-led and primary care-based co-ordination result in positive patient and health system outcomes.

Role of LHINs In addition to planning, integrating, funding, monitoring service, and being ultimately accountable for local health system performance, LHINs are now engaged in direct service provision – a function CCACs previously carried out (e.g. Rapid Response, Mental Health and Addiction, and Palliative Care). It is not effective to fund and monitor a system while also providing direct service. These roles should be shifted into the community.

LHINs must also move away from the former CCAC function of case management brokerage, where home and community service hours are allocated to patients based on recommendations of LHIN staff who then assign these levels to service providers. The functions of service provision and management, including allocations at the patient level, should become the responsibility of Ontario’s 160 third-party service provider organizations that have contracts with the LHINs for provision of home health care services. They would have the best understanding of people’s needs given that they are directly providing care on a regular basis.

The role of the LHINs must be shifted towards allocating funding and service agreement accountability. Furthermore, all contracted home care providers should be required to provide the full spectrum of services to patients, including nursing, personal support, and therapies, in order to eliminate the dysfunctional fragmentation of their care. Having services delivered by one provider ensures continuity of service, better communication with the patient and less opportunity for error.

Public health Public health units (PHU) have expertise in health promotion and disease prevention, as well as in analyzing population health needs and delivering community engagement. That’s why RNAO believes PHUs should assume a leading role to advance health equity by integrating with Ontario’s LHINs. In January 2017, the government of Ontario established the Expert Panel on Public Health to develop recommendations on proposed structural, organizational and governance changes for Ontario’s public health sector in order to achieve an integrated health system, which actively promotes health, reduces health disparities, and improves access to health-care services.15 The expert panel report recommended the existing 36 public health units be reorganized into 14 distinct entities that work closely with their LHIN counterparts to ensure more frequent and effective communication at all levels and better integration of services.16 This will benefit the LHINs’ system planning efforts, since positioning public health units within the LHIN boundaries will better align public health with the rest of the system, and can stimulate a broader reach of health promotion principles in other sectors.

Although this presents an important first step in aligning public health units with the rest of the system, as recommended in RNAO’s Enhancing Community Care for Ontarians (ECCO 2.0) report, including all sectors within the mandate of each LHIN will advance co-ordination and

integration of service to more effectively meet the needs of people as well eliminate duplication of services.17 RNAO believes that geographically aligning public health and the LHINs is insufficient. While it may stimulate collaboration, it will be unsuccessful in facilitating whole system integration and won’t fully extend the health promotion capacity of public health throughout the system. Therefore, as previously expressed, public health units must be encompassed within the LHIN mandate.

 LHINs must follow through with the health minister’s mandate letter requirement that LHIN care co-ordination and care co-ordinators be located in primary care settings. Eighty per cent of care co-ordinators should be located in primary care settings by the summer of 2018.

 LHINs must stop providing direct service. Service provision, management, and allocations should become the responsibility of the LHIN’s contracted service providers, which should be required to provide the full spectrum of home health care services.

 Integrate public health units with Ontario’s LHINs.

References:

1 Ontario Ministry of Health and Long-Term Care (MOHLTC). (2017). Ministry mandate letter to LHINs. Retrieved from http://www.lhins.on.ca/Pan-LHIN%20Content/LHINs%20Accountability.aspx.

2 Ontario Primary Care Council. (2015). Position statement: Care co-ordination in primary care. Retrieved from https://www.afhto.ca/wp-content/uploads/OPCC_Care-Co-ordination-Position.pdf.

3 Wodchis,W., Dixon, A., Anderson, G. & Goodwin, N. (2015). Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis. International Journal of Integrated Care, 15(6).

4 Registered Nurses’ Association of Ontario (RNAO). (2014). Enhancing community care for Ontarians (ECCO) v. 2.0, p25. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_ECCO_2_0.pdf.

5 Starfield, B., Shi, L. & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457-502.

6 Institute for Clinical Evaluative Sciences. (2012). Comparison of primary care models in Ontario by demographics, case mix and emergency department use, 2008/09 to 2009/10. Retrieved from http://www.ices.on.ca/flippublication/ comparison-of-primary-care-models-in-ontario-by-demographics/index.html#7/z.

7 Wodchis,W., Dixon, A., Anderson, G. & Goodwin, N. (2015). Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis. International Journal of Integrated Care, 15(6).

8 Kodner, D. (2012). ECCO- A disruptive health-care innovation whose time has come. Retrieved from http://rnao.ca/sites/rnao-ca/files/Kodner_-_ECCO_-_A_Disruptive_Health-Care_Innovative_Whose_Time_ Has_Come.pdf.

9 Kodner, D. (2012). ECCO- A disruptive health-care innovation whose time has come. Retrieved from http://rnao.ca/sites/rnao-ca/files/Kodner_-_ECCO_-_A_Disruptive_Health-Care_Innovative_Whose_Time_ Has_Come.pdf.

10 MOHLTC. (2017). Ministry mandate letter to LHINs. Retrieved from http://www.lhins.on.ca/Pan-LHIN% 20Content/LHINs%20Accountability.aspx.

11 Ontario Primary Care Council. (2016). Framework for primary care in Ontario. Retrieved from http://www.afhto.ca/wp-content/uploads/OPCC-Framework-for-Primary-Care-2016-01-13.pdf.

12 Ontario Primary Care Council. (2016). Framework for primary care in Ontario. Retrieved from http://www.afhto.ca/wp-content/uploads/OPCC-Framework-for-Primary-Care-2016-01-13.pdf.

13 RNAO. (2012). Primary solutions for primary care. Retrieved from http://rnao.ca/sites/rnao-ca/files/Primary__ Care_Report_2012_0.pdf.

14 RNAO. (2014). Enhancing community care for Ontarians (ECCO) v. 2.0, p25. Retrieved from http://rnao.ca/sites/ rnao-ca/files/RNAO_ECCO_2_0.pdf.

15 Minister’s Expert Panel on Public Health. (2017). Public health within an integrated health system. http://www.health.gov.on.ca/en/common/ministry/publications/reports/public_health_panel_17/expert_panel_report. pdf.

16 Minister’s Expert Panel on Public Health. (2017). Public health within an integrated health system. http://www.health.gov.on.ca/en/common/ministry/publications/reports/public_health_panel_17/expert_panel_report. pdf.

17 Minister’s Expert Panel on Public Health. (2017). Public health within an integrated health system. http://www.health.gov.on.ca/en/common/ministry/publications/reports/public_health_panel_17/expert_panel_report. pdf.

RNAO supports a provincial pharmacare program covering all medically necessary drugs without means testing, user fees or co-payments for Ontarians of all ages. Do you agree with RNAO?

In Ontario, about 2.3 million people cannot afford to visit a dental professional. Will you join RNAO and the Ontario Oral Health Alliance in asking the province to invest $10 million, as a start, to provide oral health care to adults and seniors living with low income across the province?

UNIVERSAL PHARMACARE

A matter of rights Access to conditions that permit health, including access to health care, are universal human rights.1 Foundational human rights documents that enshrine the right to health include the constitution of the World Health Organization (WHO) (1946),2 the Universal Declaration of Human Rights (1948),3 and the International Covenant on Economic, Social, and Cultural Rights (1966).4 The WHO has long recognized access to essential medications as a part of the right to health5 6 and in 2007, acknowledged that "the greatest burden of oral diseases lies on disadvantaged and poor populations."7

Drug coverage in Canada Shockingly, these rights have yet to be realized in Canada. Every developed country with a universal health care system across the globe provides universal coverage of prescription drugs except for Canada.8 Most Canadians do not have access to public drug coverage, and the absence of common purchasing of pharmacare means that we face some of the highest drug prices in the developed world. Canadians pay about 35 per cent more than the median for countries in the Organization for Economic Co-operation and Development (OECD),9 and Canada has the highest per capita drug expenditure in the OECD after the U.S.10 This puts the squeeze on everyone: the public, employers and government. It is thus not surprising that public drug spending in Ontario had risen to 9.2 per cent of the health budget in 2016 – up from 1.2 per cent in 1975.11

In the absence of a national pharmacare program, many Ontarians rely on a patchwork of existing public drug plans,12 while the rest have to pay personally or obtain private insurance. Currently, the Ontario Drug Benefit Program covers seniors, people receiving social assistance, and participants in the Ontario Disability Support Program, while the Trillium Drug Program

subsidizes those whose drug costs are high relative to their income.13 14 15 Ontario also offers a number of smaller programs that address specific drug needs.16 In 2016, 40.3 per cent of Ontario prescription expenditures were covered by the provincial government, 1.1 per cent by the federal government, and 0.5 per cent by the Workplace Safety and Insurance Board. The other 58.2 per cent17 was paid by private insurers and out-of-pocket by the public.18

The lack of pharmacare today forces those who are living with low or modest incomes without access to adequate drug coverage to either go without medication, pay out-of-pocket instead of purchasing other life necessities such as food, or go into debt.19 20 Law et al., writing in the Canadian Medical Association Journal, found that one in ten Canadians receiving prescriptions reported they did not adhere to them because of the cost of their medications.21 A 2015 Angus Reid survey found that in the past year, 23 per cent of respondents reported they, or another member of their household, did not take drugs as prescribed due to cost.22 Numerous international studies have also confirmed the health consequences of cost-related prescription non-adherence.23 24 25 26 27 28

Inability to pay for medications can have fatal consequences for people with diabetes. In Ontario, insufficient drug coverage has been a factor in thousands of avoidable deaths among Ontarians with diabetes under the age of 65. Mortality rates drop when people with lower incomes living with diabetes reach 65 because their medication is then covered under the Ontario Drug Benefit program (ODB).29 30 Even at that, the ODB could do better: “Syringes and other diabetic supplies, such as lancets, glucometers, eyeglasses, dentures, hearing aids or compression stockings are not covered by the ODB.”31 While pharmacare would benefit all Ontarians, research shows it is particularly important for people with lower incomes, no matter what their health conditions.32 33 34 35 36 37 38

Advantages of pharmacare RNAO has long advocated for a national pharmacare program.39 40 41 RNAO had hoped discussions around a national Health Accord would include pharmacare, but so far that has not happened. It is thus fitting for Ontario to lead with its own provincial plan, the way it did when strengthening the Canada Pension Plan.42

RNAO agrees with the overarching principle that "all Canadians deserve equitable access to safe, cost-effective, and appropriately prescribed medicines at a fair and affordable cost to patients and society as a whole."43 Pharmacare has the potential to help realize this principle by meeting four key policy goals:  Access: universal access to necessary medicines  Fairness: fair distribution of prescription drug costs  Safety: safe and appropriate prescribing, and  Value for money: maximum health benefits per dollar spent44

Savings to individuals, families, businesses, and the health care system from pharmacare would come from:  reduced administrative, marketing and regulatory costs due to a single-payer system  more effective, evidence-informed prescribing  use of purchasing power to reduce drug prices  more efficient use of health system resources (uninsured services tend to be underused because of affordability concerns, which leads to an increased risk of costly health complications)

Cost savings of pharmacare Potential savings for Canadians from pharmacare are significant. Gagnon and Hébert estimate $10.7 billion in annual savings (or 42.8 per cent of total Canadian spending on prescription pharmaceuticals).45 A 2015 Canadian Medical Association Journal article estimated the expected savings at $7.3 billion.46 While those estimates would not be as high for a provincial pharmacare program in Ontario, savings would nonetheless be substantial.

Evidence-based prescribing It is critical that a provincial pharmacare program have an evidence-based formulary and guidance be provided on optimal prescribing.47 48 This would pool information on safety, effectiveness and cost, and would be important when dealing with the growing pool of drugs targeted at rare diseases. In these cases, the evidence is based on very small samples and manufacturers supply the studies while exerting strong lobbying pressure for coverage of very expensive drugs.49

Support for pharmacare An impressive list of organizations is calling for a national pharmacare program, including: RNAO,50 51 the Canadian Federation of Nurses Unions,52 53 Canadian Nurses Association,54 Canadian Doctors for Medicare,55 56 Canadian Medical Association,57 Standing Senate Committee on Social Affairs, Science and Technology,58 Canadian Health Coalition,59 60 61 and Canadian Association of Retired Persons62 63 (see the appendix for more endorsing organizations).

There are also several active campaigns for a national pharmacare program, including the Campaign for National Drug Coverage, of which RNAO is a founding member (and including more than 90 endorsing organizations64),65 and the campaign for a National Public Drug Plan.66 Newspapers such as the Toronto Star have also called for a national pharmacare program that goes beyond a mere national bulk-buying arrangement.67

Members of the public have expressed strong support for a universal pharmacare program, as indicated in the table below:

Pharmacare polling Date Company Issue Support May Support universal public drug plan for all necessary prescription EKOS68 78% 2013 drugs Support pharmacare in Canada 91% July Angus 2015 Reid69 70 Support adding prescription drugs to medicare coverage 87%

Strongly or somewhat strongly support implementing a national May Environics71 pharmacare program providing universal access to prescription 91.4% 2017 drugs for all Canadians. May Forum Approve of Ontario government plan to provide free 56% 2017 Research72 prescriptions to those under 25.

Prior to the April 2017 provincial pharmacare announcement, the province had also been championing national pharmacare. Health Minister Dr. Eric Hoskins wrote op-eds calling for a national program,73 74 and has been working with his health minister counterparts in other jurisdictions to that same end.75

The federal and provincial terrain After the October 2015 election, the federal political context changed and pharmacare advocates looked to Ottawa for leadership on this issue. In January 2016, federal and provincial/territorial health ministers met in Vancouver to lay the groundwork for a new Health Accord, and they promised to work together on drug policy.76 In 2016-17, the federal House of Commons Standing Committee on Health held hearings on the development of a national pharmacare program,77 and concluded that it was time to implement a pharmacare program that would provide universal access to essential medications, without means testing, user fees or co- payments. Unfortunately, the federal government needs a bigger push than anticipated. Health Minister Jane Philpott has stated “that her mandate, as far as it concerns drug prices and availability, is limited to getting better deals within the status quo.”78

Recent developments In the spring of 2017, two Ontario parties – Liberals and NDP – offered competing pharmacare strategies. The Liberals’ pharmacare plan, which was announced as part of their 2017 budget, 79 , will cover the full costs of all 4,40080 prescription drugs covered under the ODB program for children and youth under age 25, with no co-payments or deductibles.81 While this is an excellent

start towards universal pharmacare, it would result in a three-tiered program with free medication for those under 25; coverage with deductibles and co-payments for those on ODSP, OW and seniors; and no coverage (other than private insurance) for the remainder of Ontarians from 25 and 64. The Liberals announced they would invest $465 million in pharmacare, with the program starting Jan. 1, 2018.82 The proposed NDP plan83 84 would cover the “most common and essential 125 drugs” for all Ontarians, but this is only a fraction of the 4,400 medications covered under the Ontario Drug Benefit (ODB) program. The NDP plan would cap co-payments at the level currently available under the ODB program.85 The NDP said independent experts would develop the list of covered drugs, and that it would expand over time. They also indicated the program will cost $475 million, and could be fully implemented by 2020.86

RNAO welcomes both announcements as steps forward, and is calling for a plan that incorporates the best features of each: pharmacare for the entire population with full coverage and no co-payments or deductibles of all prescription drugs currently listed under ODB. Should Ontario adopt such a program, there is strong potential for ripple effects across the country.87 Canada needs leadership to move toward the national plan that everyone wants,88 and taking this step in Ontario could be the necessary push.

 Proceed with a universal, single-payer pharmacare program in Ontario covering all medically necessary drugs and associated products,89 with no means testing, co-payments or deductibles. This will deliver equity, compliance with prescriptions and the efficiency of a single-payer system.90 91

INVESTING IN ORAL HEALTH SERVICES FOR ADULTS AND SENIORS LIVING WITH LOW INCOME

Ontario's registered nurses, nurse practitioners, and nursing students know that oral health is a critical component of overall health and well-being.92 The problem is that about 2.3 million Ontarians or 17 per cent of the province's population cannot afford to visit a dentist or dental hygienist.93 This includes people who are living in low income because of precarious or low-paying jobs, adults receiving Ontario Works (OW), and Ontario Disability Support Program (ODSP) recipients who are eligible for public dental benefits, but are often refused treatment by dental providers due to the low level of public compensation. Those suffering from pain and infection are forced to turn to more costly and less effective health services. In 2015, there

were nearly 61,000 visits to emergency rooms for dental problems at a cost to the system of at least $31 million.94 In 2014, there were almost 222,000 documented visits to physicians for oral health problems at a cost of $7.5 million.95 Instead of spending this money on visits to health providers who often do not specialize in dentistry,96 97 these resources would be better spent on public dental services for adults and seniors in need.

The 2014 provincial budget committed to extending public dental programs to adults living with low income by 2025, but this promise needs to be delivered more quickly. Evidence of the inequities in oral health and in access to oral health services is well documented, and these issues need to be urgently addressed both as consequences and causes of poverty in our province.98 99 100

RNAO endorsed the Ontario Oral Health Alliance's recommendation that the province invest $10 million to support the first phase of a public program to provide oral health care to adults and seniors across the province living with low income.101 This funding should be allocated to maximize use of existing public investments in dental clinic infrastructure in Community Health Centres, Aboriginal Health Access Centres, and Public Health Units.102

Addressing the oral health needs of Ontarians will have physical, mental, and social benefits, and allow people to live with health, dignity, and hope.

 Invest $10 million to support the first phase of a public program to provide oral health

care to adults and seniors living with low income across the province.

References:

1 Registered Nurses' Association of Ontario (RNAO). (2010). Creating vibrant communities: RNAO's challenge to Ontario's political parties, p3. Retrieved from http://rnao.ca/sites/rnao-ca/files/CVC_Technical_Backgrounder.pdf.

2 World Health Organization (WHO). (2017). Constitution of WHO: principles. Retrieved from http://www.who.int/about/mission/en/.

3 United Nations. (n.d.). Universal Declaration of Human Rights. Retrieved from http://www.ohchr.org/EN/UDHR/ Documents/UDHR_Translations/eng.pdf.

4 United Nations Human Rights Office of the High Commissioner. (2017). International Covenant on Economic, Social and Cultural Rights. Retrieved from http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx.

5 WHO. (2017). Access to essential medicines as a part of the right to health. Retrieved from http://www.who.int/medicines/areas/human_rights/en/.

6 WHO. (2014). Access to essential medicine. Geneva: World Health Assembly. WHA67.22, Retrieved from http://apps.who.int/medicinedocs/documents/s21453en/s21453en.pdf.

7 WHO. (2007). Oral health: action plan for promotion and integrated disease prevention. Retrieved from http://apps.who.int/gb/archive/pdf_files/WHA60/A60_16-en.pdf.

8 Morgan, S., Martin, D., Gagnon, M., Mintzes, B., Daw, J. & Lexchin, J. (2015). Pharmacare 2020: The future of drug coverage in Canada. Retrieved from http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_ in_Canada.pdf.

9 Gagnon, MA. (2016). Further information regarding the implementation of a national pharmacare program. Submitted to the House of Commons Standing Committee on Health. Retrieved from http://www.parl.gc.ca/Content/ HOC/Committee/421/HESA/Brief/BR8201423/br-external/CarletonUniversity-Gagnon-9341046-2016-04-18-e.pdf.

10 Gagnon, MA. (2016). Further information regarding the implementation of a national pharmacare program. Submitted to the House of Commons Standing Committee on Health. Retrieved from http://www.parl.gc.ca/Content/ HOC/Committee/421/HESA/Brief/BR8201423/br-external/CarletonUniversity-Gagnon-9341046-2016-04-18-e.pdf.

11 Canadian Institute for Health Information. (2016). National Health Expenditure Trends, 1975 to 2016. Table D.4.6.2: Provincial Government Health Expenditure, by Use of Funds, Ontario, 1975 to 2016 -- Current Dollars.

12 Government of Canada. (2017). Provincial and territorial drug benefit programs. Retrieved from https://www.canada.ca/en/health-canada/services/health-care-system/pharmaceuticals/access-insurance-coverage- prescription-medicines/provincial-territorial-public-drug-benefit-programs.html.

13 Government of Ontario. (2016). Get help with high prescription drug prices. Retrieved from https://www.ontario.ca/page/get-help-high-prescription-drug-costs.

14 Government of Ontario. (2013). A guide to understanding Ontario's drug programs. Retrieved from http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-S46850E-87~15/$File/014- S46850E-87.pdf.

15 Newman, J. (2013). Pharmacare: What is publicly funded in Ontario. Retrieved from http://povertyfreeontario.blogspot.ca/2013/08/pharmacare-what-is-publicly-funded-in.html.

16 Ontario Ministry of Health and Long-Term Care (MOHLTC). (2016). What drug programs does Ontario offer? http://www.health.gov.on.ca/en/public/programs/drugs/programs/programs.aspx.

17 Canadian Institute for Health Information. (2016). Op. cit. Table G.6.2: Expenditure on Drugs by Type as a Share of Total Drugs Expenditures, Ontario, 1985 to 2016. Percentage calculated by RNAO. CIHI suppresses provincial- level data on private insurance payments, so we don’t know the breakdown between out-of-pocket expenses and private insurance.

18 Canadian Institute for Health Information. (2016). Op. Cit. Table G.14.2 Expenditure on Drugs by Type as a Share of Total Drugs Expenditures, Canada, 1985 to 2016. Percentage calculated by RNAO.

19 Levy, H. (2015). Income, poverty, and material hardship among older Americans. The Russell Sage Foundation Journal of the Social Sciences, 1(1), 55-77.

20 Heisler, M., Wagner, T. & Piette, J. (2005). Patient strategies to cope with high prescription medication costs: Who is cutting back on necessities, increasing debt, or underusing medications? Journal of Behavioural Medicine. 28(1), 43-51.

21 Law, MR., Chen, L, Dhalla, IA., Heard, D. & Morgan, S. (2012). The effect of cost on adherence to prescription medications in Canada. Canadian Medical Association Journal, 184(3). 297-302.

22Angus Reid Institute. (2015). Prescription drug access and affordability an issue for nearly a quarter of all Canadian households. Retrieved from http://angusreid.org/prescription-drugs-canada/.

23 Piette JD., Heisler, M. & Wagner, TH. (2004). Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care, 27(2), 384-391.

24 Law, MR., Chen, L, Dhalla, IA., Heard, D. & Morgan, S. (2012). The effect of cost on adherence to prescription medications in Canada. Canadian Medical Association Journal, 184(3). 297-302.

25 Heisler M., Choi H., Rosen AB., Vijan, S., Kabeto, M., Langa, KM. & Pietter, JD. (2010). Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. Medical Care, 48(2), 87.

26 Soumerai, SB., Pierre-Jacques, M., Zhang, F., Ross-Degnan, D., Adams, AS., Gurwitz, J., Adler, G. & Safran, DG. (2006). Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the Medicare drug benefit. Archives of Internal Medicine, 166(17), 1829-1835.

27 Briesacher, BA., Gurwitz, JH. & Soumerai, SB. (2007). Patients at-risk for cost-related medication nonadherence: a review of the literature. Journal of General Internal Medicine. 22(5), 864-871.

28 Madden, JM., Graves, AJ., Zhang, F., Adams, AS., Briesacher, BA., Ross-Degnan, D., Gurwitz, JH., Pierre- Jacques, M., Safran, DG., Adler, GS. & Soumerai, SB. (2008). Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D. JAMA, 299(16), 1922-1928.

29 Booth, GL., Feig, DS., Bishara, P., Bhattacharya, O., Lipscomb, LL., Bierman, AS. & Shah, B. (2012). Universal drug coverage and socioeconomic disparities in major diabetes outcomes. Diabetes Care, 35, 2257-2264.

30 Government of Ontario. (2017). Get coverage for prescription drugs. Retrieved from https://www.ontario.ca/page/ get-coverage-prescription-drugs.

31 Government of Ontario. (2017). Get coverage for prescription drugs. Retrieved from https://www.ontario.ca/page/ get-coverage-prescription-drugs.

32 Law, MR., Chen, L, Dhalla, IA., Heard, D. & Morgan, S. (2012). The effect of cost on adherence to prescription medications in Canada. Canadian Medical Association Journal, 184(3). 297-302.

33 Heisler M., Choi H., Rosen AB., Vijan, S., Kabeto, M., Langa, KM. & Pietter, JD. (2010). Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. Medical Care, 48(2), 87.

34 Agardh, E., Allebeck, P., Hallqvist, J., Moradi, T. & Sidorchuk, A. (2011). Type 2 diabetes incidence and socioeconomic position: a systematic review and meta-analysis. International Journal of Epidemiology, 40, 804–818.

35 Bierman, AS. (Ed.). (2010). Project for an Ontario Women’s Health Evidence-Based Report. Retrieved from https://www.ices.on.ca/Publications/Atlases-and-Reports/2012/POWER-Study.

36 Brown, AF., Ettner, SL., Piette, J., Weinberger, M., Gregg, E,., Shapiro, MF., Karter, AJ., Safford, M., Waitzfelder, B., Prata, PA. & Beckles, GL. (2004). Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiologic Reviews, 26(1), 63-77.

37 Saydah, S. & Lochner, K. (2010). Socioeconomic status and risk of diabetes-related mortality in the U.S. Public Health Reports, 125(3), 377-388.

38 Kwan, J., Razzaq, A., Leiter, LA., Lillie, D. & Hux, JE. (2008). Low socioeconomic status and absence of supplemental health insurance as barriers to diabetes care access and utilization. Canadian Journal of Diabetes, 32, 174-181.

39 RNAO. (2001). Ontario registered nurses speak out for Medicare: Protect, preserve and strengthen submission to the Commission on the Future of Health Care in Canada. Retrieved from http://rnao.ca/sites/rnao-ca/files/storage/ related/702_RNAO_romanow_submission.pdf.

40 RNAO. (2002). RNAO response to the Romanow Commission Report. Retrieved from http://rnao.ca/sites/rnao- ca/files/storage/related/698_Final_Romanow_response.pdf.

41 RNAO. (2016). Nurses call for national pharmacare program: RNAO submission to the Standing Committee on Health. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_Submission_on_a_National_Pharmacare_Program_ FINAL_1_0.pdf.

42 Benzie, R. & Ferguson, R. (2016, June 21). Wynne says CPP deal means no need for Ontario pension plan. Toronto Star. Retrieved from https://www.thestar.com/news/queenspark/2016/06/21/wynne-says-cpp-deal-means-no-need-for- ontario-pension-plan.html.

43 Morgan, S., Martin, D., Gagnon, M., Mintzes, B., Daw, J. & Lexchin, J. (2015). Pharmacare 2020: The future of drug coverage in Canada, p4. Retrieved from http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_ in_Canada.pdf.

44 Morgan, S., Martin, D., Gagnon, M., Mintzes, B., Daw, J. & Lexchin, J. (2015). Pharmacare 2020: The future of drug coverage in Canada, p6. Retrieved from http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_ in_Canada.pdf.

45 Gagnon, M. & Hébert, G. (2010). The economic case for universal pharmacare, p10. Retrieved from https://s3.amazonaws.com/policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2010/09/ Universal_Pharmacare.pdf.

46 Morgan, SG., Law, M., Daw, JR., Abraham, L. & Marin, D. (2015). Estimated cost of universal public coverage of prescription drugs in Canada. Canadian Medical Association Journal, 187(7), 401.

47 The CMA defines optimal prescribing as “the prescription of a medication that is: the most clinically appropriate for the patient’s condition; safe and effective; part of a comprehensive treatment plan; and the most cost-effective available to best meet the patient’s needs.” Source: Canadian Medical Association. (2016). National pharmacare in Canada: Getting there from here: Submission to the House of Commons Standing Committee on Health, p9. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/Brief/BR8354361/br- external/CanadianMedicalAssociation-e.pdf.

48 Health Quality Ontario notes: “A good pharmacare plan would focus not just on providing coverage to the entire population but also on improving the quality of prescribing. The development of a good pharmacare program would require ongoing evaluation and refinement.” Source: Health Quality Ontario. (2016). To the members of the Standing Committee on Health, p3. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/ Brief/BR8214743/br-external/HealthQualityOntario-Dhalla-2016-04-20-e.pdf.

49 Herder, M. (2016). House of Commons’ Standing Committee on Health: Development of a national pharmacare program. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/Brief/BR8254292/br- external/DalhousieUniversity-Herder-2016-05-04-e.pdf.

50 RNAO. (2010). RNAO says economic analysis shows Canada can't afford not to have pharmacare. Retrieved from http://rnao.ca/news/media-releases/RNAO-says-economic-analysis-shows-Canada-cant-afford-not-to-have- pharmacare.

51 RNAO. (2016). Nurses call for national pharmacare program: RNAO submission to the Standing Committee on Health. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_Submission_on_a_National_Pharmacare_Program_ FINAL_1_0.pdf.

52 Canadian Federation of Nurses Unions. (2011). A national pharmacare strategy. Retrieved from http://www.nsnu.ca/site/media/nsnu/Pharmacare.pdf.

53 Silas, L. (2016). Submission from the Canadian Federation of Nurses Unions to the House of Commons Standing Committee on Health regarding the development of a national pharmacare program. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/Brief/BR8400664/br- external/CanadianFederationOfNursesUnions-e.pdf.

54 Canadian Nurses Association. (2016). Pan-Canadian pharmaceutical strategy: Recommendations to improve access to affordable prescription medications: Brief prepared for the House of Commons Standing Committee on Health. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/Brief/BR8289787/br- external/CanadianNursesAssociation-e.pdf.

55 Canadian Doctors for Medicare. (2013). RX: National pharmacare. http://www.canadiandoctorsformedicare.ca/ images/2013-07-21_CoF_Pharma_.pdf.

56 Canadian Doctors for Medicare. (2016). Statement by Monika Dutt, Chair, Canadian Doctors for Medicare for the House of Commons’ Standing Committee on Health (HESA) regarding the development of a national pharmacare program. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/HESA/Brief/ BR8362704/br-external/CanadianDoctorsForMedicare-e.pdf.

57 “Recommendation # 7: The CMA recommends that the federal government, in consultation with the provincial and territorial governments, health care providers, the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies”. Source: Canadian Medical Association. (2013). Healthier generations for a prosperous economy: Canadian Medical Association 2013-2014 pre-budget consultation submission to the Standing Committee on Finance, p4. Retrieved from https://www.cma.ca/Assets/assets-library/document/en/advocacy/Pre-Budget- Submission-2013-2014_en.pdf.

58 “Recommendation 28: That the federal government work with the provinces and territories to develop a national pharmacare program based on the principles of universal and equitable access for all Canadians; improved safety and appropriate use; cost controls to ensure value for money and sustainability; including a national catastrophic drug-coverage program and a national formulary.” Source: Standing Senate Committee on Social Affairs, Science and Technology. (2012). Time for transformative change: A review of the 2004 Health Accord, p xviii. Retrieved from http://www.parl.gc.ca/content/sen/committee/411/soci/rep/rep07mar12-e.pdf.

59 Canadian Health Coalition. (2017). National public drug plan. Retrieved from http://healthcoalition.ca/national- public-drug-plan/.

60 Canadian Health Coalition. (2017). Canada needs a national public drug plan for all. Retrieved from.http://healthcoalition.ca/wp-content/uploads/2017/02/2017-One-Pager-NPDP.pdf.

61 Canadian Health Coalition. (2016). Brief to HESA for the Study of the Development of a National Pharmacare Program: A national public drug plan for all. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/421/ HESA/Brief/BR8290924/br-external/CanadianHealthCoalition-2016-05-16-e.pdf.

62 Canadian Association of Retired Persons. (2013). Canada needs pharmacare. Retrieved from http://www.carp.ca/ 2013/06/28/canada-needs-pharmacare/.

63 Canadian Association of Retired Persons. (2010). CARP pharmacare report. Retrieved from http://www.carp.ca/ 2010/10/07/carp-pharmacare-report/.

64 Campaign for National Drug Coverage. (2016). Supporters: Organizations endorsing the Campaign for National Drug Coverage. Retrieved from http://campaign4nationaldrugcoverage.ca/who-we-are/supporters/.

65 Campaign for National Drug Coverage. (2015). Retrieved from http://campaign4nationaldrugcoverage.ca/.

66 Canadian Health Coalition. (2017). National public drug plan. Retrieved from http://healthcoalition.ca/national- public-drug-plan/.

67 Anon. (2016, January 18). Bulk-buying is fine but pharmacare should be the real goal: Editorial. Toronto Star. Retrieved from http://www.thestar.com/opinion/editorials/2016/01/18/bulk-buying-is-fine-but-pharmacare-should- be-the-real-goal-editorial.html.

68 EKOS. (2013). Canadian views on prescription drug coverage. Retrieved from http://www.ekospolitics.com/wp- content/uploads/press_release_may_22_2013.pdf.

69 Angus Reid Institute. (2015). Prescription drug access and affordability an issue for nearly a quarter of all Canadian households. Retrieved from http://angusreid.org/prescription-drugs-canada/.

70 Kurl, S. (2016). Briefing note to: House of Commons’ Standing Committee on Health: Canadian public opinion regarding a national pharmacare program. Retrieved from http://www.parl.gc.ca/Content/HOC/Committee/ 421/HESA/Brief/BR8352162/br-external/AngusReidInstitute-e.pdf.

71 Council of Canadians. (2017). New council of Canadians poll shows 91% want Liberals to implement pharmacare. Retrieved from https://canadians.org/blog/new-council-canadians-poll-shows-91-want-liberals- implement-pharmacare.

72 Forum Research Inc. (2017). Majority Approve of Liberal Pharmacare Plan. Retrieved from http://poll.forumresearch.com/data/a11b4399-f60a-4dbc-9fff-4e61cd2efa9bOntario%20Pharmacare.pdf.

73 Hoskins, E. (2014, December 15). Eric Hoskins: The time for national pharmacare has come. Toronto Star. Retrieved from http://www.thestar.com/opinion/commentary/2014/12/15/eric_hoskins_the_time_for_national_ pharmacare_has_come.html.

74 Hoskins, E. (2014, October 14). Why Canada needs a national pharmacare program. Globe and Mail. Retrieved from http://www.theglobeandmail.com/globe-debate/why-canada-needs-a-national-pharmacare-program/ article21086014/.

75 Hepburn, B. (2016, April 23). Eric Hoskins’ quiet campaign for pharmacare: Hepburn. Toronto Star. Retrieved from https://www.thestar.com/opinion/commentary/2016/04/23/eric-hoskins-quiet-campaign-for-pharmacare- hepburn.html.

76 BC Gov News. (2016). Statement of the Federal-Provincial-Territorial Ministers of Health. Retrieved from https://news.gov.bc.ca/releases/2016HLTH0004-000070.

77 Parliament of Canada Standing Committee on Health. (2016). Development of a national pharmacare program. Retrieved from http://www.parl.gc.ca/Committees/en/HESA/StudyActivity?studyActivityId=8837577.

78 Delacourt, S. (2017, May 5). Drugs and Trudeau government a combustible mix: Delacourt. Toronto Star. Retrieved from https://www.thestar.com/news/insight/2017/05/05/drugs-and-trudeau-government-a-combustible- mix-delacourt.html.

79 Ontario Ministry of Finance. (2017). Ontario to provide free prescription drugs for children and youth. Retrieved from https://news.ontario.ca/mof/en/2017/04/ontario-to-provide-free-prescription-drugs-for-children-and- youth.html.

80 MOHLTC. (2017). Which drugs do the programs pay for? Retrieved from http://www.health.gov.on.ca/en/ public/programs/drugs/funded.aspx.

81 Sousa, C. (2017). 2017 Ontario budget : A stronger, healthier Ontario p5. Retrieved from http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/budget2017.pdf.

82 Ontario Office of the Premier. (2017). Free prescription medications for children and youth through OHIP+. Retrieved from https://news.ontario.ca/opo/en/2017/04/free-prescription-medications-for-children-and-youth- through-ohip.html.

83 Ontario NDP. (2017). Horwath reveals details of her universal pharmacare plan. Retrieved from http://www.ontariondp.ca/horwath_reveals_details_of_her_universal_pharmacare_plan.

84 Ontario NDP. (2017). Pharmacare for everyone. Retrieved from http://act.ontariondp.ca/sites/default/files/ pharmacare-for-everyone-web.pdf.

85 Ontario NDP. (2017). Pharmacare for everyone. Retrieved from http://act.ontariondp.ca/sites/default/files/ pharmacare-for-everyone-web.pdf.

86 Ontario NDP. (2017). Horwath reveals details of her universal pharmacare plan. Retrieved from http://www.ontariondp.ca/horwath_reveals_details_of_her_universal_pharmacare_plan.

87 McGrath, JM. (2017, May 3). Liberal pharmacare plan may start a nationwide trend. TVO. Retrieved from http://tvo.org/article/current-affairs/the-next-ontario/liberal-pharmacare-plan-may-start-a-nationwide-trend.

88 Morgan, S. & Boothe, K. (2016). Universal prescription drug coverage in Canada: Long-promised yet undelivered. Healthcare Management Forum, 29(6), 247-254.

89 Ontario already covers a range of associated products under its current Ontario Drug Benefit program, including prescribed over-the-counter drugs, essential, prescribed nutrition products that are the sole source of nutrition, allergy shots, Epipens, and diabetic testing strips. Source: Government of Ontario. (2017). Get coverage for prescription drugs. Retrieved from https://www.ontario.ca/page/get-coverage-prescription-drugs .

90 Morgan, SG., Daw, JR. & Law, MR. (2014). Are income-based public drug benefit programs fit for an aging population? IRPP Study 50. Retrieved from http://irpp.org/wp-content/uploads/2014/12/study-no50.pdf.

91 Fuller access would be obtained by going beyond coverage under the Ontario Drug Benefit (ODB) program. For example, “[s]yringes and other diabetic supplies, such as lancets, glucometers, eyeglasses, dentures, hearing aids or compression stockings are not covered by the ODB.” Source: Government of Ontario. (2017). Get coverage for prescription drugs. Retrieved from https://www.ontario.ca/page/get-coverage-prescription-drugs.

92 RNAO. (2008). Oral health: Nursing assessment and intervention. Retrieved from http://rnao.ca/bpg/guidelines/ oral-health-nursing-assessment-and-intervention.

93 Association of Ontario Health Centres. (n.d.). Take action on oral health. Retrieved from http://www.aohc.org/oralhealth.

94 Association of Ontario Health Centres. (2017). Lack of access to dental care: Facts and figures on visits to emergency rooms and physicians for dental problems in Ontario. Retrieved from https://www.aohc.org/sites/default/ files/documents/Information%20on%20ER%20and%20DR%20visits%20for%20dental%20problems%20- %20Jan%202017.docx.

95 Association of Ontario Health Centres. (2017). Lack of access to dental care: Facts and figures on visits to emergency rooms and physicians for dental problems in Ontario. Retrieved from https://www.aohc.org/sites/default/ files/documents/Information%20on%20ER%20and%20DR%20visits%20for%20dental%20problems%20- %20Jan%202017.docx.

96 Sheikh, H. (2017, February 21). Prescription from ER doctor: expand public dental programs. Toronto Star. Retrieved from https://www.thestar.com/opinion/commentary/2017/02/21/prescription-from-er-doctor-expand- public-dental-programs.html.

97 Smith, J. (2017, February 28). Lack of oral care leads to needless pain. Toronto Star. Retrieved from https://www.thestar.com/opinion/letters_to_the_editors/2017/02/28/lack-of-oral-care-leads-to-needless-pain.html.

98 King, A. (2012). Oral health--More than just cavities: A report by Ontario's Chief Medical Officer of Health, p17. Retrieved from http://www.health.gov.on.ca/en/common/ministry/publications/reports/oral_health/oral_health.pdf.

99 Sadeghi, L., Manson, H. & Quiñonez, C. (2012). Report on access to dental care and oral health inequalities in Ontario. Retrieved from http://www.publichealthontario.ca/en/eRepository/Dental_OralHealth_Inequalities_ Ontario_2012.pdf.

100 Canadian Academy of Health Sciences. (2014). Improving access to oral health care for vulnerable people living in Canada. Retrieved from http://www.cahs-acss.ca/wp-content/uploads/2014/09/Access_to_Oral_ Care_FINAL_REPORT_EN.pdf.

101 Ontario Oral Health Alliance. (2016). 2017 Ontario budget submission from the Ontario Oral Health Alliance, p5. Retrieved from https://www.aohc.org/sites/default/files/documents/2016-12-07%20Budget%20Submission% 20ONtario%20Oral%20Health%20Alliance.pdf.

102 Ontario Oral Health Alliance. (2016). 2017 Ontario budget submission from the Ontario Oral Health Alliance, p5. Retrieved from https://www.aohc.org/sites/default/files/documents/2016-12-07%20Budget%20Submission% 20ONtario%20Oral%20Health%20Alliance.pdf.

Do you agree that Ontarians should have ownership and control of their own personal health records and that this information should be electronic and portable between health- care settings?

Will you support implementing mandatory electronic medical records in all primary care settings?

A key component of person-centred care is to put patients – and, in cases where patients consent, their family and/or caregivers1 – in control of their own health records. This will allow them to make informed decisions and manage their health care.2 The evidence shows that patients are more satisfied, more informed, and more engaged in their care if they have access to their health information.3 4

Current state of health records Currently, technologies and some Ontario laws support patients being able to view their own health information. The Personal Health Information Protection Act,5 passed in 2004, gives patients the right to see their own health information. However, this is an onerous and potentially expensive process.6 The records provided to patients are typically photocopies of patient charts. This format can be confusing for a non-medical professional to understand. If patients wish to access their imaging results, they often need to request and pay for CDs, which can be inconvenient and costly. It is unacceptable that, in 2017, Ontario relies on antiquated methods to share information with patients.

Some patients desire and require access to their health records for continuity of care. Ontario legislation only requires that patient records be kept for 10 years (and in the case of children, 10 years after they turn 18).7 This is a significant issue for people with chronic conditions who need access to their full medical history – not just the past 10 years.8

In most cases, patients’ health records belong to their health-care provider and patients cannot make notes in their charts. Patients and the public, including members of RNAO’s Public and Patient Engagement Advisory Council (PPE Council),9 want access to their own health information. They want to be able to exchange information, including viewing and monitoring their medical records and adding their comments in their own personal health records. For instance, a patient who routinely self-monitors some aspect of their health such as blood glucose levels may wish to store their day-to-day self-monitoring results electronically so that they are easily accessible at future health appointments. With the emergence of electronic health and medical records, this is now possible to implement.

RNAO's best practice guidelines provide evidence that e-health solutions can advance health- care delivery.10 Canadians recognize the importance of e-health as well: 96 per cent of Canadians believe it is important for health records to be kept electronically so that they can be easily transferred within the system.11

Types of electronic health records

The electronic health record (EHR) is a longitudinal, systematic record of clinically relevant information, created from information drawn from multiple data sources. It is capable of being shared across different health-care settings.

The electronic medical record (EMR) is a digital version of a paper chart that contains a patient’s medical and clinical data gathered from one provider organization (e.g., physician’s office, family health team). It is not easily shared with providers outside of that organization.

The electronic personal health record (PHR) is controlled by patients. It can integrate information from a variety of sources (e.g., medical records from multiple health-care providers and patients), and helps patients securely store and monitor their own health information. A PHR will include all or some information from an electronic medical record or electronic health record, but it is separate from, and not a replacement of, the records of any health-care provider.

Ontario is pursing two strategies for electronic record-keeping: the EHR and the EMR. Ontario’s EHR system is the provincial electronic health information system developed and maintained by eHealth Ontario to enable health provider organizations to collect, use, and disclose personal health information for the purpose of providing or assisting in the provision of health care. It is not currently accessible by patients.12

Ontario has also made significant progress in advancing the use of EMR systems. According to OntarioMD,13 almost 11 million Ontarians, which represents approximately 79 per cent of the population, already have an EMR through one of the 14,000 providers using EMRs in Ontario.14 While the provincial EHR system has one record for each patient, multiple EMRs may coexist for patients that have seen multiple primary care providers.

There are 17 different OntarioMD-certified EMR systems available. These approved EMR systems interface with two important health data repositories – the Health Report Manager (HRM) and the Ontario Laboratories Information System (OLIS) – to create a comprehensive record of health information. The HRM electronically sends hospital and diagnostic imaging reports directly into a patient’s chart within the provider’s EMR.15 The OLIS is a system that electronically connects laboratories, hospitals, and providers to facilitate the exchange of lab test orders and results.16 This means that primary care physicians, nurse practitioners, and specialists with access to a certified EMR offering can receive patient data that has been electronically collected outside of their practices.

Flow of information to provider EMR

HRM (imaging) Provider EMR OLIS (lab results)

The emergence of EHR and EMR systems are important advances in collating and making information more accessible to providers. However, these were not designed with patients as end users and are not systems with which patients can interact.

Introducing the Personal Health Records RNAO is calling for e-health solutions that are specifically tailored to what patients and family caregivers want and need. Specifically, all patients in Ontario should have the option to access an electronic PHR, which will give them more control over their personal health information. They would otherwise only be able to obtain this information through expensive and time-consuming release-of-information processes. This information typically includes all, or a portion of, their primary care provider-maintained EMR. It can also include information from other health-care providers, such as a discharge summary, and the patients themselves.

Patients are the custodians of their information in a PHR and exert control over it, for instance by deciding with whom to share their information. Research shows that patients rate ‘access to their personal health information’ as the most important feature of a PHR.17

PHRs have many capabilities and benefits. Specifically:

 Patients can use their PHR to view information, such as test results and verifying that all information is accurate.

 Most PHRs have advanced capabilities through which patients can manage and participate in their own health care, such as entering and tracking blood pressure readings or requesting routine prescription refills.18 19

 Patients can share PHRs with any provider involved in their care. In this way, PHRs can create a more efficient and safe system by enhancing the flow of information and care co- ordination among different health-care providers.20 When providers can see all of a patient’s health information, they are less likely to duplicate tests or make medication errors. Patients will not have to repeat their health history at every point of contact. As a result, providers can focus on delivering care, instead of retrieving information.

 PHRs can also facilitate communication between patient and health-care providers.21 Many PHRs have capabilities for direct, secure communication between patients and providers to communicate test results, or ask quick questions to clarify a treatment plan.22 This opens lines of communication and can improve the patient-provider relationship.

 Much of what patients do for their health happens outside clinical settings. The tracking functions of PHRs support self-management of health, and this information can easily be shared with relevant providers.

Province-wide use of PHRs will enhance the patient experience for Ontarians by making our system more patient-centered. PHRs support patient decision-making by facilitating access to patients’ own health information.23 When patients are empowered in this way, they can take greater control of their own health.24 Patients, families and caregivers can have more informed discussions with their doctors,25 26 and enhance their confidence in managing their health.

Tethered Personal Health Records model PHRs take one of two forms. Standalone PHRs require patients to fill in and maintain information themselves, usually through an Internet-based service. Standalone PHRs are useful to store, organize and share health information with providers. The drawbacks of the standalone PHR model are that patients manually enter all of the data. Reliability is dependent on patient memory and scope of knowledge. It is also not a complete record of all relevant health information.

Integrated, ‘tethered’ PHRs are linked to a specific provider’s EMR system. The majority of information in the tethered PHR is automatically drawn directly from the primary care provider’s pre-existing EMR. Patients can access and add to their records through a patient-facing, Internet- based portal.27 28

Given the key role that primary care providers play in managing their patients’ health, the most appropriate and feasible PHR system is one that is tethered to providers’ EMR systems. OntarioMD-certified EMRs are an enabling structure as they interface with HRM and OLIS data repositories to provide a comprehensive set of health information.

Examples of promising practices In Ontario, adoption of PHRs is being driven at the institutional and organizational levels. One of the most successful examples of an electronic PHR system in Ontario is MyChart, an initiative of Sunnybrook Health Sciences Centre. It was designed specifically for patient use and allows patients to view their test results, clinical reports, and discharge reports, as well as request and schedule appointments, submit consultation assessment forms, and see pertinent medical information like allergies and conditions. MyChart also includes a section where patients can enter their own information – they can record symptoms or keep track of other factors that could have an effect on their health or course of treatment. Patients can share their health records with anyone that they choose (i.e., family caregivers, other health-care providers).29 Launched in 2006 as one of Canada’s first PHR solutions, MyChart has 152,000 users with approximately 45,000 system logins every month.30 Patient survey results indicate almost all patients agree that access to their health information via MyChart has improved their patient experience (91 per cent of respondents), and that MyChart helps them self-manage their own or a family member’s health (94 per cent).31

Nova Scotia introduced a two-year, province-wide PHR pilot project in 2012 whereby a web- based PHR system was selected for use across the province that would interface with whichever pre-approved EMR system participating primary care providers had chosen. Patients involved in the pilot could view information in their PHR, like test results and specialist reports, and also log their own information for their provider to see.32 More than 30 primary care providers and over 6,000 patients were involved in the pilot project. Reviews were very positive, with 99 per cent of patients saying they wanted to continue to receive their results online, and 100 per cent of doctors saying that sharing test results online was valuable or extremely valuable to patients. The majority of respondents said they felt more involved in their care (77 per cent) and that the project had made a positive difference to them in managing their health (85 per cent).33

Principles for Personal Health Records systems RNAO recommends using the following principles to guide the development of a PHR system for Ontario:  Patient-controlled – the PHR is viewable and editable by patients

 Trustworthy – personal health information is accurate, up-to-date, secure, and private

 Comprehensive – integrates information from patients, EMRs, and clinical reports from all health sectors (including hospitals, community, diagnostic imaging, labs, and pharmacy)

 Accessible  Real-time updates  Available at all times, from any location34

 No out-of-pocket expenses  Tutorials provided to make PHR easy to use for all who choose to

 Publicly-funded and administered

 Rigorously evaluated, with results transparently shared

 Mandate the availability of PHRs to patients, to provide increased access to medical care information and encourage their participation in health-care decision-making. Patients, families, caregivers, RNs, NPs, and other health-care providers must be consulted in the development of a provincial PHR plan so that it reflects what patients need and want.

 Mandate the use of EMR systems in all primary care settings in Ontario, as a complementary and enabling step to the development of a provincial PHR system.

References:

1 A caregiver is a person who takes on an unpaid caring role for someone who needs help because of a physical or cognitive condition, an injury, or a chronic life-limiting illness. Definition retrieved from Carers Canada at http://www.carerscanada.ca/carer-facts/.

2 Archer, N., Fevrier-Thomas, U., Lokker, C., McKibbon, K.A. & Straus, S.E. (2011). Personal health records: a scoping review. Journal of the American Medical Informatics Association, 18, 515-522.

3 Nazi, KM., Turvey, CL., Klein, DM., Hogan, TP. & Woods, SS. (2015). VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. Journal of the American Medical Informatics Association, 22, 380.

4 Curtis, J., Cheng, S., Rose, K. & Tsai, O. (2011). Promoting adoption, usability, and research for personal health records in Canada: The MyChart experience. Healthcare Management Forum, 24, 149.

5 Personal Health Information Protection Act, 2004. S.O. 2004, c. 3, Schedule A.

6 Gagnon, M-P., Payne-Gagnon, J., Breton, E., Fortin, J-P., Khoury, L., Dolovich, L., Price, D., Wiljer, D., Bartlett, G. & Archer, N. (2016). Adoption of electronic personal health records in Canada: perceptions of stakeholders. International Journal of Health Policy Management, 5(7), 425-433.

7 O. Reg. 114/94, s. 19.

8 Recent media has highlighted the challenges this poses for children with chronic conditions, such as congenital heart disease. Their medical records as they age can become incomplete, missing vital information about childhood surgeries and their earliest conditions, all of which is essential for their continued care. Source: Rushowy, K. (2017, July 28). Medical record of sick kids should be kept for life, group urges. Toronto Star. Retrieved from https://www.thestar.com/news/queenspark/2017/07/28/medical-records-of-sick-kids-should-be-kept-for-life-group- urges.html.

9 Registered Nurses’ Association of Ontario (RNAO). (n.d.) Patient and public engagement. Retrieved from http://rnao.ca/about/PPE.

10 RNAO. (2017). Adopting eHealth solutions: Implementation strategies. Retrieved from http://rnao.ca/sites/rnao ca/files/bpg/Adopting_eHealth_Solutions_WEB_FINAL.pdf.

11 Canada Health Infoway. (2016). Connecting patients for better health: 2016. Retrieved from https://www.infoway-inforoute.ca/en/component/edocman/3152-connecting-patients-for-better-health-2016/view- document?Itemid=101.

12 eHealth Ontario. (n.d.). Accessing your EHR. Retrieved from http://www.ehealthontario.on.ca/en/ehr/accessing- your-ehr.

13 OntarioMD. (2017). From foundation to integration. Annual report 2016 – 2017. Retrieved from https://www.ontariomd.ca/documents/annual%20report%202017.pdf.

14 This uptake is not surprising, given that investments in e-health in Ontario have focused on core infrastructure projects (e.g., the provincial EHR system) and the adoption of EMRs.

15 OntarioMD. (2017). EMR HRM 4.3 requirements. Retrieved from https://www.ontariomd.ca/pages/ specifications-current-.aspx.

16 OntarioMD. (2017). EMR OLIS 4.3 requirements. Retrieved from https://www.ontariomd.ca/pages/specifications- current-.aspx.

17 Kerns, JW., Krist, AH., Longo, DR., Kuzel, AJ. & Woolf, SJ. (2013). How patients want to engage with their personal health record: A qualitative study. BMJ Open, 3, e002931.

18 Gagnon, M-P., Payne-Gagnon, J., Breton, E., Fortin, J-P., Khoury, L., Dolovich, L., Price, D., Wiljer, D., Bartlett, G. & Archer, N. (2016). Adoption of electronic personal health records in Canada: perceptions of stakeholders. International Journal of Health Policy Management, 5(7), 425-433.

19 Jackson, C. & Bradley, R. (2014). A new approach: Patient portals for primary intervention. University of Ottawa Journal of Medicine, 4(2), 16-18.

20 Usher, S., Jayabarathan, A., Russell, M. & Mosher, D. (n.d.). Personal health records in primary care: One province takes steps to make sure they’re available. Retrieved from https://www.healthinnovationforum.org/ article/personal-health-records-in-primary-care/.

21 Kerns, JW., Krist, AH., Longo, DR., Kuzel, AJ.& Woolf, SJ. (2013). How patients want to engage with their personal health record: A qualitative study. BMJ Open, 3, e002931.

22 Hansen, C., Christensen, KL. & Ertmann, R. (2014). Patients and general practitioners have different approaches to e-mail consultations. Danish Medical Journal, 61(6), A4863.

23 Davis, S., Roudsari, A. & Courtney, K. (2017). Designing personal health record technology for shared decision making. In F. Lau, J. Bartle-Clar, G. Bliss, E. Borycki, K. Courtney & A. Kuo (Eds.), Building capacity for health informatics in the future (pp75-80).

24 Archer, N., Fevrier-Thomas, U., Lokker, C., McKibbon, K.A. & Straus, S.E. (2011). Personal health records: a scoping review. Journal of the American Medical Informatics Association, 18, 515-522.

25 Lester, M., Boateng, S., Studeny, J. & Coustasse, A. (2016). Personal health records: Beneficial or burdensome for patients and healthcare providers? Perspectives in Health Information Management, 13(Spring).

26 Group Health Centre. (2016). Connecting patients for better health 2016: 2016 myCARE benefits evaluation and final report. Retrieved from https://www.infoway-inforoute.ca/en/component/edocman/2954-group-health-centre-s- mycare-benefits-evaluation-plan/view-document?Itemid=0.

27 Vydra, TP., Cuaresma, E., Kretovics, M. & Bose-Brill, S. (2015). Diffusion and use of tethered personal health records in primary care. Perspectives in Health Information Management, 12(Spring), 1c.

28 Archer, N., Fevrier-Thomas, U., Lokker, C., McKibbon, K.A. & Straus, S.E. (2011). Personal health records: a scoping review. Journal of the American Medical Informatics Association, 18, 515-522.

29 Sunnybrook Health Sciences Centre. (n.d.). MyChart. Retrieved from http://sunnybrook.ca/content/?page= mychartlogin-learnmore.

30 Sunnybrook Health Sciences Centre. (2016). MyChart PHR Program. Retrieved from http://imaginenationchallenge.ca/wp-content/uploads/2017/02/MyChart.pdf.

31 Sunnybrook Health Sciences Centre. (2016). MyChart PHR Program. Retrieved from http://imaginenationchallenge.ca/wp-content/uploads/2017/02/MyChart.pdf.

32 Usher, S., Jayabarathan, A., Russell, M. & Mosher, D. (n.d.) Personal health records in primary care: One province takes steps to make sure they’re available. Retrieved from https://www.healthinnovationforum.org/ article/personal-health-records-in-primary-care/.

33 Stylus Consulting. (2014). Nova Scotia personal health record demonstration project benefits evaluation report. Retrieved from https://www.infoway-inforoute.ca/en/component/edocman/1995-nova-scotia-personal-health-record- demonstration-project-benefits-evaluation-report/view-document?Itemid=0.

34 The increased mobility of patients and care providers requires that electronic PHRs can be accessed anytime, anywhere – ideally through a web-based application.

Will you join RNAO’s call to transform funding models in long-term care (LTC) homes to improve resident care?

Can we count on you to support minimum staffing levels in LTC homes so that residents can live safely and with dignity?

RNAO has long advocated that every senior in Ontario must have the opportunity to live with dignity in an environment that fully meets their needs.1 2 3 4 5 This evidence-based advocacy is in line with the fundamental principles of the Long-Term Care Homes Act, 2007,6 which asserts that a LTC facility must provide its residents with a secure, safe, and comfortable home.

About LTC in Ontario  LTC homes provide accommodation and care for people – primarily seniors – with long-term health and/or cognitive disabilities. In LTC facilities, residents have 24-hour access to nursing and personal care as well as assistance with activities of daily living.

 Ontario spends about $4 billion – almost eight per cent of the overall health budget – each year on LTC.7 There are 627 LTC homes in the province with more than 78,000 beds in total, comprised of a mix of public, private for-profit, private not-for-profit, and other (e.g., religious) providers.8 Facilities receive most of their funding from government. Currently, Ontario’s LTC homes operate at 99 per cent capacity.

 The Long-Term Care Homes Act, 2007 (LTCHA) is the single legislative authority for safeguarding residents’ rights, improving quality of care, and improving accountability in LTC homes.

 Of all direct care staff in LTC, 26 per cent is regulated nursing staff. RNs account for nine per cent of this 26 per cent, and RPNs for the remaining 17 per cent. Other regulated professionals include nutritionists, social workers, and physiotherapists, who together account for eight per cent of all direct care staff. The remaining 65 per cent of direct care is delivered by unregulated staff.9

 Under regulations in the LTCHA, homes are required to implement evidence-based practices to provide quality care for residents.10 11 RNAO has best practice guidelines (BPGs) that address each of the mandatory programs that LTC homes are required to implement, including prevention of falls and fall injuries in the older adult; promoting continence using prompted voiding; prevention of constipation in the older adult population; assessment and management of pain; and various guidelines for skin and wound care. RNAO has numerous additional BPGs relevant to the sector,

including alternative approaches to the use of restraints; preventing and addressing abuse and neglect of older adults; and delirium, dementia, and depression in older adults.

LTC has not adapted to meet the increased needs of today’s resident population Ontario’s population is rapidly aging. Experts estimate the number of seniors aged 75 and older will double within the next 20 years.12 Without dramatic system changes, there will be a shortfall of 48,000 LTC beds over the next five years.13

The needs of LTC residents are also changing. Compared to previous generations, residents in LTC homes today have increasingly complex care needs. For instance, nearly all residents have multiple chronic conditions (e.g., heart disease, diabetes, arthritis).14 This is partly due to changes to LTC admission criteria in 2010 that required new residents to have high or very high physical and cognitive challenges to qualify for admission.15 It is also an outcome of the provincial direction for home care that has resulted in more complex seniors being cared for at home. In the past, many of these individuals would have been in LTC. As a result, seniors who are older, frailer, and have the greatest needs are the ones being admitted to LTC homes today, and thus acuity in the LTC population continues to increase.16

About 90 per cent of LTC residents have cognitive impairment, including dementia,17 and about 80 per cent of residents with dementia have behavioural symptoms, including aggressive or severely aggressive behaviour.18

The complexity of LTC residents has increased to rival that of patients in alternative level of care (ALC) beds in hospitals, or complex continuing care (CCC). But funding for LTC is significantly less. This needs to change.

Funding for LTC homes in Ontario

The Ministry of Health and Long-Term Care (MOHLTC) funds LTC homes in Ontario on a level-of care (LOC) per diem basis within four spending envelopes, as follows:

Base LOC per diem funding (as of July 1, 2017):19 Funding envelope LOC per diem Nursing and personal care $96.26 (variable) (includes direct care staff and care supplies) Program and support services $9.60 Raw food $9.00

Other accommodations $55.28

Total $170.14

All LTC home beds receive the same base per diem funding for all funding envelopes, except nursing and personal care (NPC). Under the NPC envelope, per diem funding is adjusted based on resident complexity and care needs, identified by an indicator called the “case-mix index” (CMI) – a measure of relative patient acuity levels in a LTC home.20 Case-mix classification uses formulas to cluster residents into clinically similar groups that reflect the relative costs of services and supports that individual residents, with different needs, are likely to use. Funding is also dependent on the LTC home’s occupancy rate.

Funding and staffing must change to keep LTC residents safe Despite the growing incidence of responsive behaviours (a term used to describe the behavioural and psychological symptoms of dementia)21 and an increasingly complex LTC population, funding and staffing standards have not changed. It is thus not surprising that we are hearing increased reports of violence in LTC homes.22 23 24 25 26 Adequate funding and staffing must be put in place to safeguard nursing homes’ vulnerable residents. Every LTC home in the province strives to provide the highest level of quality care to its residents. However, the reality is that finite resources and complex resident conditions are straining the current system.

It is shocking that the only legislated LTC staffing requirements in Ontario are a vague instruction for care “to meet the assessed needs of residents”27 and a minimum requirement of one registered nurse (RN) on duty at all times.28 Currently, there is no legislated minimum staffing ratio (the number of nursing home staff members compared to the number of residents), and no requirements related to how much care residents receive on a daily basis (“paid hours of care per resident per day”, or PHPRD).29 Most residents in Ontario receive just over three hours of care each day,30 even though a target staffing level of 4.0 PHPRD was a major recommendation from a 2008 MOHLTC-commissioned review,31 and was recently introduced to the Ontario legislature through a private member’s bill.32 Why is it that child care in Ontario has rigid care requirements under the Child Care and Early Years Act, 2014,33 but care for vulnerable seniors is left up to LTC home operators?

Funding in LTC penalizes quality improvement practices LTC funding models are severely flawed and must be transformed and modernized. Under existing funding structure, there is a financial disincentive to improve patient outcomes. As a result, funding and services have failed to keep pace with residents’ increasing care needs, and retroactive data determines current funding levels.

1. Disincentive to improve patient outcomes: When evidence-based practices are implemented and resident problems are prevented or resolved, resident acuity decreases.

While this is good for residents, the home’s CMI correspondingly falls and funding in future years is decreased. In other words, the unintended negative consequence of improving resident outcomes is that LTC homes are financially penalized. This financial penalty is a disincentive to improve patient outcomes.

2. Increased complexity and prevention not accurately funded: Funding is not provided for activities or conditions that are not captured in the resident assessment tool,34 including some preventative interventions. For example, if a resident is incontinent, funding is provided for incontinence care and supplies, but funding is not provided for the staff hours required to implement prompted toileting at regular intervals to reduce the frequency of incontinence. Similarly, the highest level of funding that can currently be provided for the responsive behaviours of residents with dementia is inadequate to cover the most costly and time-consuming interventions that are required for residents displaying severe or very severe aggressive behaviours.

3. Retroactive data used to determine current funding: LTC homes receive funding based on retroactive data. For example, funding for 2017-18 is based on the case-mix data that was submitted at the end of the four quarters in 2015-16. Consequently, funding is always outdated. It does not take into account the rapidly increasing complexity of residents, and is often inadequate to care for the immediate resident acuity.

LTC funding lessons from Alberta Alberta uses an approach to LTC funding that can be adapted to the Ontario context to mitigate the current unintended disincentive. Alberta's Patient/Care-Based Funding (PCBF) matches funding to the needs of residents, similar to how funding adjustments are made under Ontario’s nursing and personal care envelope.

In addition to the overall PCBF provided to Albertan LTC homes, there is also quality incentive funding (QIF). This is an annual allotment that is calculated separately from the overall PCBF amount to provide incentives for improving the quality of care.35 For instance, quality incentive submission criteria in past years have included achieving target immunization rates for staff and residents.

RNAO proposes that a resident outcomes improvement fund be put in place in Ontario’s LTC system to offset any funding losses that are correlated with improvements in patient outcomes.

LTC needs the right mix of staff to keep residents safe and healthy In Ontario, LTC staff includes RNs, registered practical nurses (RPN), personal support workers (PSW), nurse practitioners (NP), allied health professionals (e.g., physical and occupational therapists, dieticians), and other employees (e.g., staff in housekeeping and food services). Each is trained to a different educational level and skill set.

Despite the best efforts of care providers, the needs of LTC residents are not being met due to inadequate staffing resources, inappropriate skill mix, and limited access to RNs. According to the College of Nurses of Ontario (CNO), the determination to use an RN or RPN should depend on three factors: the client, the nurse (or, in the case of LTC, other care providers like PSWs), and the environment.36 More complex patients with less predictability and less stability should be cared for by RNs, whereas residents with less acuity and more predictability should be cared for by RPNs or PSWs, as appropriate.

The evidence is clear that RNs improve the quality of care in LTC homes. Research demonstrates that increasing RN staffing ratios in LTC homes reduces the probability of hospitalizations and associated health system costs, increases rates of discharge to home, improves client outcomes (e.g., fewer pressure ulcers, fewer urinary tract infections, lower urinary catheter use, lower restraint use, fewer falls), and reduces mortality.37 38 39 40 41 42 43

In recent years, there has been a marked increase in the share of nursing and personal care employment held by RPNs and PSWs in Ontario’s LTC homes.44 This is troubling when compared to the trend of increasing complexity of LTC home residents, for whom RNs are best suited to care.

RN replacement in LTC is concerning, as it compromises the LTC home’s ability to care for the complex needs of residents. It may also place greater burden on other parts of the health system. For example, if one resident's care needs are beyond the scope of an RPN, and the home has inadequate RN staffing, this resident will be transferred to hospital, causing unnecessary disruption for the resident and increasing the burden of care and costs on the acute care sector.45

While RPNs and other care providers play important roles in LTC, it is critical to match skill mix to resident needs. RNAO’s preferred model of care delivery in LTC homes would include NPs, RNs, and RPNs working to their full scope of practice with assistance from PSWs. Each resident would be assigned to one primary nurse provider, with RNs assigned total nursing care for complex and/or unstable residents with unpredictable outcomes. The assigned provider would take responsibility for all of the assigned resident’s care needs on a continuous basis. This type of staffing model provides continuity of care and caregiver and would result in substantive improvements to resident outcomes and the broader health system.

Mandated RN staffing levels in LTC Specific regulation in Ontario stipulates that one RN, who is both an employee of the LTC home and part of the home’s nursing staff, must be on duty and present in the home at all times.46 This number is the same for all LTC homes despite varying sizes. The average number of residents in a nursing home in Ontario is 124. Thus the current staffing requirements translate to an average of just one RN for every 124 LTC residents. This is compounded for larger homes, which can legally employ as few as one RN for upwards of 400 residents.

Untapped potential of attending NPs in LTC All LTC homes must ensure that either a physician or an RN in the extended class (NP) “attend regularly at the home” to provide assessment and other clinical services, and be on-call.47 NPs are RNs with advanced education and decision-making skills, and a broadened scope of practice.48

RNAO successfully advocated for creating the attending NP role in LTC, with the goals of ensuring resident care needs were met on site in a timely manner, and providing continuity of care by allowing NPs and residents to develop long-term therapeutic relationships. Unlike attending physicians who typically visit LTC homes on a weekly or bi-weekly basis, attending NPs are intended to be based in their respective LTC homes full-time. The attending NP has the overall responsibility for managing and co-ordinating resident care in their respective LTC home. NPs can also play an important role in LTC through early detection and treatment of medical complications,49 50 treating chronic conditions, and dedicating time for health promotion, thereby reducing the need for hospitalization of LTC residents.51

To date, the MOHLTC has announced funding for 75 attending NP in LTC positions, and filled the first 49 of these positions. As described in the MOHLTC’s role description, 70 per cent of an attending NP’s time is supposed to be spent on direct resident care, with the stipulation that funding was only to be used for NPs to carry out the role.52 53

Unfortunately, the intended goals of attending NPs in LTC have not been realized. NPs are not being used to their full scope, as intended by the MOHLTC initiative. For instance, NPs have been used for administrative tasks instead of patient care. Many of the NPs were hired into these roles as independent contractors instead of employees and receive lower salaries than specified in the ministry’s funding policy. This has resulted in difficulty attracting qualified candidates for the role.

Funding  Review and transform funding models in LTC to support improved resident care. o In particular, consider putting resident improvement funding in place to encourage and enable – rather than penalize – improvements in resident outcomes.

 Support the use of evidence-based practices in LTC homes to promote and sustain improvements in resident health and well-being. o Incentivize LTC homes to proactively implement RNAO BPGs to meet legislative requirements.54

o Mandate the use of relevant RNAO BPGs when homes are found non-compliant after MOHLTC inspections. This would be similar to the approach Ontario has taken with

the Quality Based Procedures in hospitals.55

Skill mix and staffing levels  Legislate minimum staffing and skill mix standards in LTC, accompanied by the necessary funding to support this change. o We urge no less than one attending NP for every 120 residents, and a staff mix consisting of 20 per cent RNs, 25 per cent RPNs, and 55 per cent PSWs. This ratio would guarantee all LTC residents receive care when they need it from the most appropriate provider.

Attending NPs in LTC  Increase the number of funded positions in LTC to a minimum of one attending NP per 120 residents. o These attending NPs must serve as primary care providers and practise to their full scope, as expressed in the role description provided in the MOHLTC Attending Nurse Practitioners in Long-Term Care Initiative Funding Policy.

 Develop and implement an accountability framework to hold Local Health Integration Networks (LHIN) and LTC homes accountable for hiring attending NPs in the manner specified by the MOHLTC role description and funding policy.

References:

1 Grinspun, D. (2002). Making elder health a priority for the political agenda. Executive Director’s dispatch with Doris Grinspun. Registered Nurse Journal, 14(6), 7.

2 Registered Nurses’ Association of Ontario (RNAO). (2012). Submission to the Government of Ontario’s Seniors Care Strategy. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAOs_Submission_to_the_Government_of_ Ontarios_Seniors_Care_Strategy_-_Sept._6.pdf.

3 RNAO. (2011). Strengthening client centred care in long-term care. Retrieved from http://rnao.ca/sites/rnao- ca/files/Position_Statement_LTC_client_centred_care.pdf.

4 RNAO. (2007). Staffing and care standards for long-term care homes: Submission to the Ministry of Health and Long-Term Care. Retrieved from http://rnao.ca/sites/rnao-ca/files/storage/related/3163_RNAO_submission_to_ MOHLTC_--_Staffing_and_Care_Standards_in_LTC_-_Dec_21_20071.pdf.

5 Development and implementation of clinical practice guidelines in the area of elder care has been one of five top priorities of RNAO’s Best Practice Guideline Program since its inception. RNAO has supported the uptake of clinical practice guidelines relevant to elder care, including: falls prevention, alternative approaches to the use of restraints, continence and constipation, prevention and management of elder abuse, pressure ulcer prevention and management, dementia, and chronic disease management. For more information, see http://rnao.ca/bpg.

6 Long-Term Care Homes Act, 2007, S.O. 2007, c. 8.

7 Ontario Long-Term Care Association (OLTCA). (2016). This is long-term care 2016. Retrieved from http://www.oltca.com/OLTCA/Documents/Reports/TILTC2016.pdf.

8 Data collated by RNAO from http://publicreporting.ltchomes.net/en-ca/default.aspx.

9 Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS). (2015). The need is now: Addressing understaffing in long-term care - provincial budget submission. Retrieved from https://www.middlesex.ca/council/2015/january/27/C%207%20-%20CW%20Info%20-%20Jan%2027%20- %20OANHSS2015ProvincialBudgetSubmission.pdf.

10 O. Reg. 79/10, s. 30.

11 O. Reg. 79/10, s. 48.

12 Canadian Institute for Health Information (CIHI). (2017). Seniors in transition: Exploring pathways across the care continuum. Retrieved from https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017- en.pdf.

13 OANHSS. (2017). Meeting seniors’ needs now. OANHSS 2017-18 provincial spending priorities. Retrieved from http://www.advantageontario.ca/AAO/Content/Resources/Advantage_Ontario/Position_Papers_Submissions.aspx

14 OLTCA (2017). Building better long-term care: Priorities to keep Ontario from failing its seniors. Retrieved from http://www.oltca.com/OLTCA/Documents/Reports/2017OLTCABudgetSubmission.pdf.

15 OLTCA. (2016). This is long-term care 2016. Retrieved from http://www.oltca.com/OLTCA/Documents/ Reports/TILTC2016.pdf.

16 OANHSS. (2016). Improving seniors’ services in Ontario. OANHSS position paper on capacity planning and development. Retrieved from https://www.pshsa.ca/wp-content/uploads/2016/06/OANHSS-Capacity-Planning.pdf.

17 OANHSS. (2016). Improving seniors’ services in Ontario. OANHSS position paper on capacity planning and development. Retrieved from https://www.pshsa.ca/wp-content/uploads/2016/06/OANHSS-Capacity-Planning.pdf.

18 OANHSS. (2016). Ensuring the care is there. Meeting the needs of Ontario’s long-term care residents 2016-17 provincial budget priorities. Retrieved from https://muskoka.civicweb.net/document/27441.

19 Ontario Ministry of Health and Long-Term Care (MOHLTC). (2017). Policy: LTCH level-of-care per diem funding policy. Retrieved from http://www.health.gov.on.ca/en/public/programs/ltc/docs/level_of_care_per_ diem_funding.pdf.

20 Residents are assessed on admission, if there is a significant change in their status, and on a regular quarterly basis, using the Resident Assessment Instrument – Minimum Data Set (RAI-MDS). This assessment puts the resident into a clinically similar group. These groups are believed to consume a similar set of resources and, by extension, have similar costs. Each group is associated with a CMI, which is a relative measure of the expected resource consumption intensity of any group. Source: Costa, AP., Poss, JW. & McKillop, I. (2015). Contemplating case mix: A primer on case mix classification and management. Healthcare Management Forum, 28(1), 12.

More information about case-mix systems used to allocate resources is available from CIHI at https://www.cihi.ca/ en/submit-data-and-view-standards/methodologies-and-decision-support-tools/case-mix.

21 Responsive behaviours is a term to describe the behavioural and psychological symptoms of dementia, which includes, to varying levels of severity, changes in mood, delusions, apathy, agitation, wandering, calling out, repetitive questioning, and sexual disinhibition. Source: RNAO. (2016). Delirium, dementia, and depression in older adults: Assessment and care (2nd ed.). Retrieved from http://rnao.ca/sites/rnao- ca/files/bpg/RNAO_Delirium_Dementia_Depression_Older_Adults_Assessment_and_Care.pdf.

22 Anon. (2017, May 16). Grey matters: Mistreatment and abuse of patients in long-term care homes is anything but rare. National Post. Retrieved from http://nationalpost.com/news/canada/grey-matters-mistreatment-and-abuse-of- patients-in-long-term-care-homes-is-anything-but-rare/wcm/b1ac28f5-2473-4014-b22d-92076a8804ef.

23 Helmer, A. (2017, July 27). Union calls long-term care violence ‘tragic symptom of a care system in crisis’. Ottawa Citizen. Retrieved from http://ottawacitizen.com/news/local-news/union-calls-long-term-care-violence- tragic-symptom-of-a-care-system-in-crisis.

24 Fraser, L. (2017, January 31). 82-year-old faces manslaughter charge in the death of fellow long-term care resident. CBC News. Retrieved from http://www.cbc.ca/news/canada/toronto/senior-manslaughter-long-term-care- death-1.3960786.

25 Anon. (2016, January 5). Wave of dementia behind 12 homicides has Ontario nursing homes pleading for help from province. National Post. Retrieved from http://nationalpost.com/news/canada/wave-of-dementia-behind-12- homicides-has-ontario-nursing-homes-pleading-for-help/wcm/a9780387-df1b-41a6-9be4-69f918b3d2b4.

26 Geriatric and Long Term Care Review Committee. (2016). 2015 annual report. Retrieved from http://www.mcscs.jus.gov.on.ca/sites/default/files/content/mcscs/docs/GLTRC%202015%20annual%20report%20E NGLISH.pdf.

27 Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 8(1) Every licensee of a long-term care home shall ensure that there is, (a) an organized program of nursing services for the home to meet the assessed needs of the residents; and (b) an organized program of personal support services for the home to meet the assessed needs of the residents.

28 Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 8 (3) Every licensee of a long-term care home shall ensure that at least one registered nurse who is both an employee of the licensee and a member of the regular nursing staff of the home is on duty and present in the home at all times, except as provided for in the regulations.

29 The previous standard of 2.25 hours of personal and nursing care per resident per day was repealed in 1996.

30 OANHSS. (2017). Meeting seniors’ needs now. OANHSS 2017-18 provincial spending priorities. Retrieved from http://www.advantageontario.ca/AAO/Content/Resources/Advantage_Ontario/Position_Papers_Submissions.aspx.

31 Sharkey, S. (2008). People caring for people: Impacting the quality of life and care of residents of long term care homes. Toronto: MOHTLC.

32 Bill 188, Time to Care Act (Long-Term Care Homes Amendment, Minimum Standard of Daily Care), 2016, seeks to amend the LTCHA to establish a minimum standard of daily care through which long-term care homes will provide residents with at least four hours a day of nursing and personal support services (4.0 hours averaged across residents). It received its first reading in April 2016.

33 The Child Care and Early Years Act, 2014, S.O. 2014, c. 11, Sched. 1, sets out the rules governing child care in Ontario. This includes, among other restrictions and standards, setting a ratio for the maximum number of children that a child care centre or home child care provider can care for (e.g., minimum ratio of three staff to ten children younger than 18 months for licensed child care centres; maximum six children under the age of thirteen for a licensed home child care provider).

34 For RAI-MDS “… what counts is what is measured”. This means that important data is often missing, namely contextual data that may provide more insight into the care required for a particular measurement. The tool also doesn’t recognize the time that providers spend on more relational care. Source: Armstrong, H., Daly, T. & Choiniere, JA. (2016). The case of RAI-MDS in Canadian long-term care homes. Journal of Canadian Studies, 50(2), 348.

35 Alberta Health Services. (2015). Patient/care-based funding long-term care. User summary. Retrieved from http://www.albertahealthservices.ca/assets/info/pf/if-pf-cc-patient-based-care-ltc-summary.pdf.

36 College of Nurses of Ontario. (2014). RN and RPN practice: The client, the nurse and the environment. Practice guideline. Retrieved from http://www.cno.org/globalassets/docs/prac/41062.pdf.

37 Dellefield, ME., Castle, NG., McGilton, KS. & Spilsbury, K. (2015). The relationship between registered nurses and nursing home quality: an integrative review. Nursing Economic$, 33(2), 95.

38 McGregor, M., Murphy, JM., Poss, JW., McGrail, KM., Kuramoto, L., Huang, H-C. & Bryan, S. (2015). 24/7 registered nurse staffing coverage in Saskatchewan nursing homes and acute hospital use. Canadian Journal on Aging, 34(4), 492.

39 Spilsbury, K., Hewitt, C., Stirk, L. & Bowman, C. (2011). The relationship between nursing staffing and quality of care in nursing homes: a systematic review. International Journal of Nursing Studies, 48(6), 732.

40 Kim, H., Harrington, C. & Greene, W. (2009). Registered nurse staffing mix and quality of care in nursing homes: A longitudinal analysis. The Gerontologist, 49(1), 81-90.

41 Horn, S. (2008). The business case for nursing in long-term care. Policy, Politics & Nursing Practice, 9(2), 88.

42 Collier, E. & Harrington, C. (2008). Staffing characteristics, turnover rates, and quality of resident care in nursing facilities. Research in Gerontological Nursing, 1(3), 157-170.

43 Lhang, N., Unruh, L., Liu, R. & Wan, T. (2006). Minimum nurse staffing ratios for nursing homes. Nursing Economic, 24(2), 78-93.

44 RNAO. (2016). Mind the safety gap in health system transformation: Reclaiming the role of the RN. Retrieved from http://rnao.ca/sites/rnao-ca/files/HR_REPORT_May11.pdf.

45 Harrington, C., Schnelle, JF., McGregor, M. & Simmons, SF. (2016). The need for higher minimum staffing standards in U.S. nursing homes. Health Services Insights, 9, 13.

46Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 8.

47O. Reg. 79/10, s. 82.

48 College of Nurses of Ontario. (2016). Nurse practitioners. Retrieved from http://www.cno.org/en/learn-about- standards-guidelines/educational-tools/nurse-practitioners/.

49 Intrator, O., Zinn, J. & Mor, V. (2004). Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. Journal of the American Geriatrics Society, 52, 1730-1736.

50 Allen, L., Mihalovic, S. & Narveson, G. (2000). Successful protocol-based practitioner management of warfarin anticoagulation in nursing home patients. Annals of Long-Term Care, 8, 60-71.

51 Burl, J., Bonner, A., Rao, M. & Kahn, A. (1998). Geriatric nurse practitioners in long-term care: demonstration of effectiveness in managed care. Journal of the American Geriatrics Society, 46, 506.

52 MOHLTC. (2015). Policy: Attending nurse practitioners in long-term care homes initiative funding policy. Retrieved from http://www.health.gov.on.ca/en/public/programs/ltc/docs/attending_nps_in_ltch_policy.PDF.

53 MOHLTC. (2017). Attending nurse practitioners in long-term care homes. Recruitment and integration toolkit. Toronto: Author.

54 The use of RNAO’s BPGs is not mandatory; however it is an important resource for the LTC sector and enables improved resident outcomes.

55 Quality-based procedures clinical handbooks outline the evidence and clinical best practice recommendations for specific groups of patient services (e.g., hip fracture, tonsillectomy, chronic kidney disease). The goals of the program are to standardize care and ensure that patients get the right care at the right place and time. Providers (i.e., physicians) receive a standard funding amount on a ‘price times volume’ basis to implement quality-based procedures. Source: MOHLTC. (n.d.). Health system funding reform. Quality-based procedures. Retrieved from http://www.health.gov.on.ca/en/pro/programs/ecfa/funding/hs_funding_qbp.aspx.

Do you support government working in partnership with Indigenous nations to address urgent health needs identified by them such as the ongoing crisis of children and youth suicide?

Will you commit to supporting the transformation of our health system from a colonial approach to an Indigenous-led self-governance model?

Truth and reconciliation After a six-year process of hearing from more than 6,750 survivors of residential schools,1 the Truth and Reconciliation Commission of Canada (TRC) released its 94 calls to action in June 2015.2 3 On August 24, 2015, the Chiefs of Ontario4 and the Government of Ontario5 formally signed a historic political accord6 to guide the government-to-government relationship between First Nations and the province. Ontario's First Nations Health Action Plan was announced on May 25, 2016 to address health inequities and improve access to services, including life promotion and crisis support. The action plan was accompanied by a $222 million commitment over three years followed by ongoing funding of $104.5 million annually.7 8 On May 30, 2016 the Ontario government made a formal apology for the past and continuing harm that generations of systemic abuse has caused to Indigenous communities, families, and individuals.9 At that time, the province also released Ontario's response to the TRC, The Journey Together: Ontario's Commitment to Reconciliation with Indigenous Peoples,10 along with an investment of more than $250 million over three years for action on reconciliation to be developed and evaluated with Indigenous partners.11

Moving from perpetual crisis to Indigenous self-determination in health The legacy of intergenerational trauma from the residential school system, colonialism, and racism has resulted in Indigenous people experiencing tremendous inequities in health and social outcomes. One alarming example is that suicide rates are up to seven times higher for First Nations youth compared with non-Indigenous youth.12 In February 2016, Nishnawbe Aski Nation (NAN) Territory and the Sioux Lookout region declared a health and public health emergency.13 14 15 NAN reported there had been 543 suicides, of all ages, in their territories since 1986.16 From January to July 2017 alone, there were 22 suicides, of which eight were children between the ages of 10 to 15 years.17

On July 24, 2017 NAN Grand Chief Alvin Fiddler ceremonially signed an agreement with the Ontario and federal health ministers to work towards transforming health services in the 49 communities that make up NAN.18 This Charter of Relationship Principles for Nishnawbe Aski Nation Territory is “a concrete sign” of a “renewed multilateral nation to nation relationship.”19

Ontario's Minister of Health and Long-Term Care, Eric Hoskins, acknowledged that “the colonial health system that was set up and currently exists...is not serving First Nations communities well.”20 A joint statement on July 24, 2017 by the provincial Ministers of Indigenous Relations and Reconciliation, Health and Long-Term Care, and Children and Youth Services announced additional actions and funding to address “the youth suicide crisis in northern First Nations (that) is nothing short of a health and social emergency.”21 The government of Ontario made a clear promise:22

Ontario is committed to providing immediate support to First Nations in crisis. However, we feel strongly that emergencies will continue to occur and intensify unless meaningful and dramatic realignment and transformation happens to change the status quo and address the systemic disparities facing Indigenous communities, particularly in northern First Nations. It is not up to First Nations to right the wrongs of colonization. Governments must invest in meaningful and lasting Indigenous-led solutions so communities can heal and young people can have hope for a brighter future.

Statement by Ministers of Indigenous Relations and Reconciliation, Health and Long-Term Care and Children and Youth Services, July 24, 2017

As an ally organization, RNAO is committed to advocating for and supporting Indigenous leadership in health in the spirit of reconciliation and so urges:

 Governments to partner with Indigenous nations to address urgent health needs identified by them such as the ongoing crisis of children and youth suicide

 Transformation of our health system from its colonial approach into an Indigenous-led self-governance model.

References:

1 Truth and Reconciliation Commission of Canada. (2015). TRC releases call to action to begin reconciliation. Retrieved from http://www.trc.ca/websites/trcinstitution/File/TRCReportPressRelease%20(1).pdf.

2 Truth and Reconciliation Commission of Canada. (2015). Truth and Reconciliation Commission of Canada: Calls to action. Retrieved from http://www.trc.ca/websites/trcinstitution/File/2015/Findings/Calls_to_Action_ English2.pdf.

3 Truth and Reconciliation Commission of Canada. TRC final report. Retrieved from http://www.trc.ca/websites/ trcinstitution/index.php?p=890.

4 Chiefs of Ontario. (2015). The political accord. Retrieved from http://www.chiefs-of-ontario.org/node/1168.

5 Ontario Office of the Premier. (2015). First Nations, Ontario sign political accord. Retrieved from https://news.ontario.ca/opo/en/2015/08/first-nations-ontario-sign-political-accord.html.

6 Chiefs of Ontario. (2015). Political accord between First Nations and the Government of Ontario. Retrieved from http://www.chiefs-of-ontario.org/sites/default/files/files/Political%20Accord-FINAL-AUGUST2015.pdf.

7 Ontario Ministry of Health and Long-Term Care (MOHLTC). (2016). Ontario launches $222 million First Nations Health Action Plan. Retrieved from https://news.ontario.ca/mohltc/en/2016/05/ontario-launches-222-million-first- nations-health-action-plan.html.

8 MOHLTC. (2016). Backgrounder: Indigenous health investments to focus on four priority areas. Retrieved from https://news.ontario.ca/mohltc/en/2016/05/indigenous-health-investments-to-focus-on-four-priority-areas.html.

9 Ontario Office of the Premier. (2016). Ontario's commitment to reconciliation with Indigenous peoples. Retrieved from https://news.ontario.ca/opo/en/2016/05/ontarios-commitment-to-reconciliation-with-indigenous-peoples.html.

10 Ministry of Indigenous Relations and Reconciliation. (2016). The journey together: Ontario's commitment to reconciliation with Indigenous Peoples. Retrieved from https://www.ontario.ca/page/journey-together-ontarios- commitment-reconciliation-indigenous-peoples.

11 Ministry of Indigenous Relations and Reconciliation. (2016). The journey together: Ontario's commitment to reconciliation with Indigenous Peoples. Retrieved from https://www.ontario.ca/page/journey-together-ontarios- commitment-reconciliation-indigenous-peoples.

12 Ministry of Indigenous Relations and Reconciliation. (2016). The journey together: Ontario's commitment to reconciliation with Indigenous Peoples, p22. Retrieved from https://www.ontario.ca/page/journey-together-ontarios- commitment-reconciliation-indigenous-peoples.

13 NishnawbeAski Nation. (2016). News release: First Nation leaders declare health and public health emergency. Retrieved from http://www.nan.on.ca/upload/documents/comms-2016-02-24-health-emergency.pdf.

14 NishnawbeAski Nation & Sioux Lookout Area Chiefs Committee on Health. (2016). Declaration of a health and public health emergency in NishnawbeAski Nation (NAN) Territory and the Sioux Lookout Region. Retrieved from http://www.nan.on.ca/upload/documents/comms-2016-02-24declaration-health-emerg.pdf.

15 NishnawbeAski Nation & Sioux Lookout First Nations Health Authority. Backgrounder: Health and public health emergency. Retrieved from http://www.nan.on.ca/upload/documents/comms-2016-02-24-backgrounder-health- eme.pdf.

16 Winter, J. & Talaga, T. (2017, July 17). Suicide crisis meeting to address reducing bureaucracy faced by Indigenous leaders, federal health minister says. Toronto Star. Retrieved from https://www.thestar.com/news/gta/ 2017/07/17/health-ministers-indigenous-leaders-to-meet-over-suicide-crisis-in-northern-ontario.html.

17 Winter, J. & Talaga, T. (2017, July 17). Suicide crisis meeting to address reducing bureaucracy faced by Indigenous leaders, federal health minister says. Toronto Star. Retrieved from https://www.thestar.com/news/gta/ 2017/07/17/health-ministers-indigenous-leaders-to-meet-over-suicide-crisis-in-northern-ontario.html.

18 Ballingall, A. (2017, July 24). Province, feds agree to 'transform' health care for 49 Ontario First Nations. Toronto Star. Retrieved from https://www.thestar.com/news/canada/2017/07/24/doctors-urge-trudeau-to-act-on-escalating- suicide-crisis-in-first-nations-communities.html.

19 Government of Canada, Government of Ontario, & NishnawbeAski Nation on behalf of the First Nations in NAN Territory. (2017). Charter of relationship principles for NishnawbeAski Nation Territory. Retrieved from https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/charter-nan.html.

20 Ballingall, A. (2017, July 24). Province, feds agree to 'transform' health care for 49 Ontario First Nations. Toronto Star. Retrieved from https://www.thestar.com/news/canada/2017/07/24/doctors-urge-trudeau-to-act-on-escalating- suicide-crisis-in-first-nations-communities.html.

21 MOHLTC. (2017). Ontario ministers outline actions to address First Nations youth health and safety crisis. Retrieved from https://news.ontario.ca/mohltc/en/2017/07/ontario-ministers-outline-actions-to-address-first-nations- youth-health-and-safety-crisis.html.

22 MOHLTC. (2017). Ontario ministers outline actions to address First Nations youth health and safety crisis. Retrieved from https://news.ontario.ca/mohltc/en/2017/07/ontario-ministers-outline-actions-to-address-first-nations- youth-health-and-safety-crisis.html.

Do you support increasing investment in affordable housing so that Ontario can address the backlog of existing units in need of repair and create new affordable, accessible housing stock?

Do you support raising the minimum wage to $15 per hour with no exemptions regarding age or sector?

Social determinants of health The conditions in which people are born, grow up, work, live, and age are known as the social determinants of health.1 The reason some people are healthy and others are not is linked to these conditions of daily life as well as the wider set of economic, political, and social systems that drive factors such as: income and its distribution; access to necessities such as food, housing, and health care; employment and working conditions; discrimination and social inclusion.2 3

Nurses know that meaningful action on poverty is critical to sustaining lives, supporting health, and enabling human dignity. That is why Ontario’s registered nurses, (RN), nurse practitioners (NP) and nursing students continue to implore our elected leaders to accelerate action to assist the daily struggles of 1.9 million people in the province living with low income. The most recent Statistics Canada data reports 14.3 per cent of Ontarians (or 1,945,000 persons) meet the low income measure4 after tax (LIM) in 2015.5 This is broken down as 15.8 per cent for those under 18 years; 14.2 per cent for those 18 to 64 years; and 12.5 per cent for Ontarians 65 years and over.6

Progressive public policy can and is making a difference. Ontario's Poverty Reduction Strategy7 with its investment in the Ontario Child Benefit has helped to decrease poverty for Ontarians under 18 years from 18.9 per cent in 2012 to the previously mentioned 15.8 per cent in 2015. That works out to 87,000 fewer children living in poverty over three years. A continuing challenge, recognized by the province itself, is that marginalized populations including people with disabilities, recent immigrants, persons in female lone parent families, Indigenous persons living off-reserve, and unattached individuals had significantly higher poverty rates of 32.6 per cent in 20148 (compared with 13.8 per cent for all Ontarians in 2014.)9

A home, a job, a friend Pat Capponi, well known poverty activist, and one of the founders for Working for Change10 says: “a home, a job, a friend” is all people need to ensure “stability, love, a safe place to live, a

purpose.”11 Paid work should be a pathway out of poverty that covers basic needs, and be sufficient to provide people with the opportunity to participate in the “economic and social fabric of their community”12 as a living wage aspires to do.

Affordable, inclusive housing Across Canada in 2014, 12.7 per cent of urban households were in need of affordable housing.13 Ontario was the outlier province with the highest proportion of urban households in need at 16.1 per cent.14 The four communities in the country that had the highest percentage of households in need were in Ontario: Peterborough at 21.8 per cent; Toronto at 19.9 per cent; Kingston at 18.7 per cent; and St. Catharines-Niagara at 17.9 per cent.15

Despite over $4 billion in provincial funding for affordable housing since 2003, wait lists have increased by 45,257 households.16 In 2015, there were 171,360 households across the province waiting for rent-geared-to-income housing.17 The average wait time for applicants housed in 2015 across Ontario was 3.9 years; however, the predicted wait time for recent applicants in high demand regions is 14 years.18 Even women in Toronto who are fleeing from domestic violence (who are put on a special priority list for social housing) have an average wait of 10 months.19 20 This is completely unacceptable. The lack of affordable housing has directly resulted in homelessness ranging from people who are living on the street, in a park or a ravine to those in emergency shelters or categorized as “couch surfers” because they are living with friends.21

It is estimated that there are 35,000 Canadians who are homeless on a given night and at least 235,000 Canadians experience homelessness in a year.22 Mass homelessness in Canada came about because governments stopped investing in affordable housing, structural shifts in the economy lead to more precarious, low-paying jobs, and spending was reduced on health and social supports.23 Over the last 25 years, Canada's population has increased by almost 30 per cent but annual national investment in housing has decreased by over 46 per cent.24 In 1989, the per capita spending on federal housing investments was $115 per Canadian but by 2013, that figure dropped to just over $60 per person (in 2013 dollars).25 To make things even worse, existing social housing is being condemned26 or at risk of being closed27 28 due to neglected repairs of the aging social housing stock.

As RNAO recommended to the Ministry of Municipal Affairs and Housing in 2015 when it was updating the province’s Long-Term Affordable Housing Strategy, one way to reverse this trend is to invest one per cent of the province's budget into affordable housing. The money will help create new affordable housing stock and address the backlog of existing affordable housing units in need of repair.29 In 2014, the Ontario Non-Profit Housing Association calculated that a provincial commitment of $1.3 billion per year, over 10 years (or roughly one per cent of province's annual budget), would be needed to assist households in need of better housing and to help address homelessness.30

The ability to access affordable housing must be extended to every Ontarian who needs it, including people with physical, sensory, cognitive (including developmental) and learning, mental-health, and acquired-brain injury disabilities. Universal design in the built environment is increasingly recognized as a cost-effective, sustainable best practice critical to accessibility and ease of living for everyone as our population ages.31 32 Meanwhile, people looking to buy barrier-free houses find that supply is scarce33 and even progressive developments such as the Toronto’s Regent Park’s 2,083 social housing units and 5,400 market-rate apartments were not designed for people with any type of disability.34

The cost of not having affordable housing and adequate health and social supports can take its toll on individuals, families, and communities. The status quo, which has resulted in high rates of homelessness, also generates high financial costs for society. A recent economic analysis found that the average annual cost of health, social, and criminal justice services per homeless person with mental illness in five Canadian cities averaged $53,144, with Toronto being the highest at $58,972.35 The Mental Health and Addictions Leadership Advisory Council's 2016 recommendations include urging the province to create at least 30,000 units of supportive housing over 10 years for people with mental health and addiction issues.36

Raising the minimum wage to $15 per hour The Ontario government can be credited for introducing Bill 148, Fair Workplaces, Better Jobs Act, 201737 to address issues with the province’s outdated employment and labor laws. With precarious employment as the “new norm”,38 it is critical that employment and labour standards be strengthened and enforced to address social stress across then income spectrum. While RNAO has commented extensively on the need for labour reform,39 40 41 the focus of this backgrounder is to reinforce RNAO's support for Bill 148’s amendment to increase the minimum wage to $14 per hour on January 1, 2018 and to $15 per hour on January 1, 2019 with annual inflation adjustments thereafter.42

Ontario's nominal43 minimum wage in 1965 was $1 an hour, which was 42 per cent of Ontario's average industrial wage.44 There have been gradual increases in the minimum wage except for a nine-year period from 1995 to 2004 when it was frozen at $6.85 per hour and a four-year period from 2010 to 2014 when it stood unchanged at $10.25 per hour.

While the upward nominal minimum wage trend shown in Figure 145 may appear to be positive, the picture is less rosy once adjusted for inflation. Despite productivity gains,46 the real minimum wage in 2017 isn't that much different than the mid-1970.47

Figure 1: Nominal versus Real Ontario Minimum Wage, 1965-2017 $14

$12

$10

$6 Nominal Minimum Wage $4

$2 Minimum Wage Constant 2017$

Jan/65 Jan/67 Jan/69 Jan/71 Jan/73 Jan/75 Jan/77 Jan/79 Jan/81 Jan/83 Jan/85 Jan/87 Jan/89 Jan/91 Jan/93 Jan/95 Jan/97 Jan/99 Jan/01 Jan/03 Jan/05 Jan/07 Jan/09 Jan/11 Jan/13 Jan/15 Jan/17

For comparison purposes, let's consider what workers actually need to get by. As shown in Figure 2, an increasing number of communities48 49 50 51 52 53 in Ontario are calculating the living wage to reflect what a family of four would need to "meet its basic needs, participate in the economic and social fabric of their community, and purchase items that can help them escape marginal subsistence."54 There is a significant mismatch between the living wage and minimum wage, as well as rates for Ontario Works and the Ontario Disability Support Program.

Figure 2: Living Wage Estimates, Selected Communities $19.00 $18.50 $18.00 $17.50 $17.00 $16.50 $16.00 $15.50 $15.00

Public health units across the province continue to document the gap between the cost of nutritious food and shelter in the context of low social assistance rates and precarious, low paid employment. Let's look at the Perez and Smith families,55 for example, who live in Toronto:

Cheryl and Raoul Perez are married with two children – ages 8 and 14. Cheryl has not been able to keep a steady job due to her depression. Raoul works in retail, and earns minimum wage. He brings in $1,950 a month in wages. Their three bedroom apartment is $1,540 per month and does not include hydro. The Perez family must spend 52 per cent of their monthly income on rent and 29 per cent on food. That leaves them $541 each month to cover other basic needs such as transportation, child care, household and personal care items, and clothing.

In comparison, a neighbouring family of four, the Smiths, have an income of $6,689 per month. They spend 25 per cent of their income on rent, 14 per cent of their income on food, and have $3,851 left each month.

Low wages, inadequate social assistance rates, and high shelter costs mean that a significant number of Ontarians go hungry. Put simply, their health is compromised because of food insecurity. According to the Canadian Community Health Survey, there were 594,900 food insecure households in Ontario in 2014.56 Income is the strongest predictor of food insecurity so as can be expected, the probability of food insecurity rises as household income declines.57 Households depending on dangerously low social assistance rates are particularly vulnerable. In 2014, the proportion of households reliant on social assistance who were food insecure in Ontario was 64 per cent.58 Proof that having a job is not a guarantee for being able to get by is that the majority of food insecure households in Canada (62.2 per cent) were reliant on wages from employment.59 In 2014, the proportion of food insecure households reliant on wages and salaries in Ontario was 58.9 per cent.60 Unfortunately, Ontario has not been able to monitor trends in food insecurity since then as the province opted not to include it as part of the Canadian Community Health Survey for 2015 and 2016.61 It is critical that the province be able to track food security as a key determinant of health over time as a means to evaluate the impact of implemented and proposed transformations such as the Ontario Poverty Reduction Strategy,62 Ontario Basic Income Pilot,63 Changing Workplaces Review,64 and a new roadmap for a broader income security system.65

The minimum wage must apply equally without exemptions by age or sector. Ontario is the only province/territory that permits employers to pay a lower minimum wage to young workers.66 In addition, the vast majority of jurisdictions in Canada (except for British Columbia, Ontario, and Quebec) do not allow a lower wage for those who serve liquor.67

 Increase the minimum wage to $14 per hour on January 1, 2018 and to $15 per hour on January 1, 2019 with annual inflation adjustment every year thereafter, without exemptions by age or sector.

 Invest one per cent of Ontario's budget ($1.4 billion)68 to address the backlog of existing affordable housing units in need of repair and to create new affordable housing stock.

 Amend the building code to require that all new multi-unit buildings incorporate the principles of universal design for accessibility and visitability.69

 Create at least 30,000 units of supportive housing for people with mental health and addiction issues over ten years.70

References:

1 World Health Organization (WHO). (2017). Social determinants of health. Retrieved from http://www.who.int/ social_determinants/en/.

2 WHO. (2017). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/.

3 Mikkonen, J. & Raphael, D. (2010). Social determinants of health: The Canadian facts. Retrieved from http://www.thecanadianfacts.org/the_canadian_facts.pdf.

4 "Low income measures (LIMs), are relative measures of low income, set at 50 per cent of adjusted median household income. These measures are categorized according to the number of persons present in the household, reflecting the economies of scale inherent in household size." Source: Statistics Canada. (2017). Low income statistics by age, sex and economic family type, Canada provinces and selected census metropolitan areas, Table 206-0041. Retrieved from http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=2060041.

5 Statistics Canada. (2017). Low income statistics by age, sex and economic family type, Canada provinces and selected census metropolitan areas, Table 206-0041. Retrieved from http://www5.statcan.gc.ca/cansim/ a26?lang=eng&id=2060041.

6 Statistics Canada. (2017). Low income statistics by age, sex and economic family type, Canada provinces and selected census metropolitan areas, Table 206-0041. Retrieved from http://www5.statcan.gc.ca/cansim/ a26?lang=eng&id=2060041.

7 Matthews, D. (2016). Realizing our potential: Ontario's Poverty Reduction Strategy (2014-2019). Retrieved from https://www.ontario.ca/page/realizing-our-potential-ontarios-poverty-reduction-strategy-2014-2019-all.

8 Ballard, C. (2017). Poverty Reduction Strategy (annual report 2016). Retrieved from https://www.ontario.ca/page/ poverty-reduction-strategy-annual-report-2016.

9 Statistics Canada. (2017). Low income statistics by age, sex and economic family type, Canada provinces and selected census metropolitan areas, Table 206-0041. Retrieved from http://www5.statcan.gc.ca/cansim/ a26?lang=eng&id=2060041.

10 Women Speak Out. (2015). History. Retrieved from http://women-speak-out.org/about/history/.

11 Porter, C. (2015, July 1). Pat Capponi's Order of Canada recognizes advocacy for mentally ill. Toronto Star. Retrieved from https://www.thestar.com/news/canada/2015/07/01/pat-capponis-order-of-canada-recognizes- advocacy-for-mentally-ill.html.

12 Tiessen, K. (2015). Making ends meet: Toronto's 2015 living wage, p11. Retrieved from https://www.policyalternatives.ca/publications/reports/making-ends-meet.

13 "A household is said to be in core housing need if its housing falls below at least one of the adequacy, affordability or suitability standards and it would have to spend 30 per cent or more of its total before-tax income to pay the median rent of alternative local housing that is acceptable." Source: Canada Mortgage and Housing

Corporation (CMHC). (2016). 12.7% of urban households were in core housing need in 2014. Retrieved from https://www.cmhc-schl.gc.ca/en/hoficlincl/observer/observer_110.cfm.

14 CMHC. (2016). 12.7% of urban households were in core housing need in 2014. Retrieved from https://www.cmhc-schl.gc.ca/en/hoficlincl/observer/observer_110.cfm.

15 CMHC. (2017). Core housing need remains high in Peterborough and Toronto. Retrieved from https://www.cmhc-schl.gc.ca/en/hoficlincl/observer/observer_129.cfm.

16 Ontario Non-Profit Housing Association (ONPHA). (2015). 2015 Waiting Lists Survey: ONPHA’s report on waiting lists statistics for Ontario, pp7 & 35. Retrieved from http://www.onpha.on.ca/Content/PolicyAndResearch/ Waiting_Lists_2015/Full_Report.aspx.

17 ONPHA. (2016). 2016 Waiting Lists Survey report: ONPHA’s final report on waiting lists statistics for Ontario, p9. Retrieved from http://qc.onpha.on.ca/flipbooks/WaitingListReport/#8.

18 ONPHA. (2016). 2016 Waiting Lists Survey report: ONPHA’s final report on waiting lists statistics for Ontario, p9. Retrieved from http://qc.onpha.on.ca/flipbooks/WaitingListReport/#8.

19 Goffin, P. (2016, September 17). Ontario housing benefit to aid women feeling domestic violence. Toronto Star. Retrieved from https://www.thestar.com/news/canada/2016/09/17/ontario-housing-benefit-to-aid-women-fleeing- domestic-violence.html.

20 Ngabo, G. (2017, August 29). Toronto women's shelter caught off guard by influx of children. Toronto Star. Retrieved from https://www.thestar.com/news/gta/2017/08/29/toronto-womens-shelter-caught-off-guard-by-influx- of-children.html.

21 Gaetz, S., Gulliver, T. & Richter, T. (2014). The state of homelessness in Canada 2014. Retrieved from http://homelesshub.ca/sites/default/files/SOHC2014.pdf.

22 Gaetz, S., Dej, E., Richter, T. & Redman, M. (2016). The state of homelessness in Canada 2016. Retrieved from http://homelesshub.ca/sites/default/files/SOHC16_final_20Oct2016.pdf.

23 Gaetz, S., Dej, E., Richter, T. & Redman, M. (2016). The state of homelessness in Canada 2016. Retrieved from http://homelesshub.ca/sites/default/files/SOHC16_final_20Oct2016.pdf.

24 Gaetz, S., Gulliver, T. & Richter, T. (2014). The state of homelessness in Canada 2014. Retrieved from http://homelesshub.ca/sites/default/files/SOHC2014.pdf.

25 Gaetz, S., Gulliver, T. & Richter, T. (2014). The state of homelessness in Canada 2014. Retrieved from http://homelesshub.ca/sites/default/files/SOHC2014.pdf.

26 Rider, D. (2017, April 19). Toronto Community Housing units set to close despite residents' pleas. Toronto Star. Retrieved from https://www.thestar.com/news/city_hall/2017/04/19/toronto-community-housing-units-set-to-close- despite-residents-pleas.html.

27 Cheung, M. (2016, March 11). Toronto Community Housing: Thousands of units could close due to lack of cash for repairs. CBC. Retrieved from http://www.cbc.ca/news/canada/toronto/subsidized-housing-tch-federal-budget- 1.3487070.

28 Rider, D. (2017, August 24). Tory admits new provincial money for social housing may not stop units being closed. Toronto Star. Retrieved from https://www.thestar.com/news/city_hall/2017/08/24/tory-admits-new- provincial-money-for-social-housing-may-not-stop-units-from-being-closed.html.

29 Registered Nurses' Association of Ontario (RNAO). (2015). RNAO input on long-term affordable housing strategy update. Retrieved from http://rnao.ca/policy/submissions/rnao-input-long-term-affordable-housing-strategy- update.

30 ONPHA. (2014). Big problems need bold solutions: An ambitious model for solving Ontario's most pressing housing needs. Retrieved from https://www.onpha.on.ca/onpha/Content/PolicyAndResearch/Other_Research/ BigProblemsNeedBoldSolutions.aspx.

31 City of Calgary. (2010). Universal design handbook: Building accessible and inclusive environments. Retrieved from http://www.calgary.ca/CSPS/CNS/Documents/universal_design_handbook.pdf.

32 Mace, R. (2016). Universal design in housing. Retrieved from https://www.humancentereddesign.org/resources/ universal-design-housing.

33 Lee-Shanok, P. (2016, December 9). 'More and more people' looking for barrier-free homes, Toronto real estate agent says. CBC. Retrieved from http://www.cbc.ca/news/canada/toronto/hot-real-estate-may-need-to-be-barrier- free-1.3888318.

34 Bozikovic, A. (2016, March 18). Affordable housing must be designed with accessibility in mind. Globe and Mail. Retrieved from https://beta.theglobeandmail.com/life/home-and-garden/architecture/affordable-housing-must- be-designed-with-accessibility-in-mind/article29289685/?ref=http://www.theglobeandmail.com&.

35 Latimer, E., Rabouin, D., Cao, Z. Ly, A., Powell, G., Aubry, T., Distasio, J., Hwang, S., Somers, J., Stergiopoulos, V. & Veldhuizen, S. (2017). Cost of services for homeless people with mental illness in 5 Canadian cities: A large prospective follow-up. CMAJ Open, 5(3), E5760585.

36 Mental Health and Addictions Leadership Advisory Council (MHALAC). (2016). Moving forward: Better mental health means better health. Annual report of Ontario’s Mental Health and Addictions Leadership Advisory Council. Retrieved from http://www.health.gov.on.ca/en/common/ministry/publications/reports/bmhmbh_2016/ moving_forward_2016.pdf.

37 Bill 148, Fair Workplaces, Better Jobs Act, 2017.

38 Mojtehedzadeh, S. (2015, May 21). Precarious work is now the new norm, United Way report says. Toronto Star. Retrieved from http://www.thestar.com/news/gta/2015/05/21/precarious-work-is-now-the-new-norm-united-way- report-says.html.

39 RNAO. (2015). RNAO’s response to the Changing Workplaces review. Retrieved from http://rnao.ca/sites/rnao- ca/files/RNAO_Submission_to_Changing_Workplaces_Review_FINAL_2.pdf.

40 RNAO. (2016). RNAO submission on personal emergency leave. Retrieved from http://rnao.ca/sites/rnao- ca/files/RNAO_submission_on_personal_emergency_leave_-_Aug_31_2016.pdf.

41 RNAO. (2016). RNAO's response to the interim report of the Changing Workplaces Review. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_Response_to_Interim_Report_of_Changing_Workplaces_Review_ FINAL.pdf.

42 RNAO. (2017). RNAO's response to Bill 148: Fair Workplaces, Better Jobs Act, 2017. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_submission_Bill_148_july_21_2017_final.pdf.

43 Nominal minimum wage is the minimum wage in current dollars unadjusted for inflation.

Source: Ministry of Labour. (2014). Section 2: Minimum wage in Ontario: Profiles and Trends. Retrieved from https://www.labour.gov.on.ca/english/es/pubs/mwap/section_02.php.

44 Hennessy, T., Tiessen, K., & Yalnizyan, A. (2013). Making every job a good job. Retrieved from https://www.policyalternatives.ca/publications/reports/making-every-job-good-job.

45 The nominal minimum wage reflects the wage for that year in that year's dollars. The real minimum wage has been adjusted for inflation using the Canadian Consumer Price Index (CPI) in constant 2017 dollars.

46 Hennessy, T., Tiessen, K., & Yalnizyan, A. (2013). Making every job a good job, pp19-20. Retrieved from https://www.policyalternatives.ca/publications/reports/making-every-job-good-job.

47 For similar findings, see: Yew, M. (2014, July 16). Minimum wage in 2013 just a penny more than 1975, after inflation: Statistics Canada. Toronto Star. Retrieved from https://www.thestar.com/business/2014/07/16/ minimum_wage_in_2013_same_as_1975_in_constant_dollars_statistics_canada.html.

48 Tiessen, K. (2015). Making ends meet: Toronto's 2015 living wage, pp5-8. Retrieved from https://www.policyalternatives.ca/publications/reports/making-ends-meet.

49 Peterborough Social Planning Council. (2016). 2016 living wage report. Retrieved from http://www.pspc.on.ca/sites/default/files/attach/Living%20Wage%202016%20report.pdf.

50 Niagara Poverty Region Network. (2017). Calculating the living wage for Niagara Region 2017. Retrieved from http://www.livingwagecanada.ca/files/1815/0425/3193/8ea78d_b7d6f19e6ac74729ae3ff74996724353.pdf.

51 Community Development Council of Durham. (2016). Living wage in Durham Region. Retrieved from http://www.cdcd.org/wp-content/uploads/2016/02/LivingWage_Report_CDCD.pdf.

52 Social Research and Planning Council Perth and Huron. (2015). .A living wage: What it takes to make ends meet in Perth and Huron Counties. Retrieved from http://www.livingwagecanada.ca/files/7014/3921/0759/SRPC- LivingWageReport-WEB.pdf.

53 Social Planning Council of Sudbury. (2015). The living wage for a family of four in the city of greater Sudbury. Retrieved from http://spcsudbury.ca/wp-content/uploads/2014/08/Living-Wage.pdf.

54 All of the communities in Figure 3 used the Canadian Centre for Policy Alternatives' living wage calculator. These expenses include rent, food, child care, transportation, clothing, internet, and laundry costs. The income calculations are based on a 37.5 hour work week and includes relevant government transfers such as child benefits and the Working Income Tax Benefit. Source: Tiessen, K. (2015). Making ends meet: Toronto's 2015 living wage, pp5-8. Retrieved from https://www.policyalternatives.ca/publications/reports/making-ends-meet.

55 Toronto Public Health. (2016). May 2016- nutritious food basket scenarios. Retrieved from http://www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-96418.pdf.

56 Tarasuk, V., Mitchell, A. & Dachner, N. (2016). Household food insecurity in Canada, 2014. Retrieved from http://proof.utoronto.ca/wp-content/uploads/2016/04/Household-Food-Insecurity-in-Canada-2014.pdf.

57 Tarasuk, V., Mitchell, A. & Dachner, N. (2016). Household food insecurity in Canada, 2014. Retrieved from http://proof.utoronto.ca/wp-content/uploads/2016/04/Household-Food-Insecurity-in-Canada-2014.pdf..

58 Tarasuk, V., Mitchell, A. & Dachner, N. (2016). Household food insecurity in Canada, 2014. Retrieved from http://proof.utoronto.ca/wp-content/uploads/2016/04/Household-Food-Insecurity-in-Canada-2014.pdf.

59 Tarasuk, V., Mitchell, A. & Dachner, N. (2016). Household food insecurity in Canada, 2014. Retrieved from http://proof.utoronto.ca/wp-content/uploads/2016/04/Household-Food-Insecurity-in-Canada-2014.pdf.

60 Tarasuk, V., Mitchell, A. & Dachner, N. (2016). Household food insecurity in Canada, 2014. Retrieved from http://proof.utoronto.ca/wp-content/uploads/2016/04/Household-Food-Insecurity-in-Canada-2014.pdf.

61 Syal, R. (2017, June 30). Public health experts blame Ontario government for gap in food insecurity data. Globe and Mail. Retrieved from https://beta.theglobeandmail.com/life/health-and-fitness/health/food-insecurity- ontario/article35510687/?ref=http://www.theglobeandmail.com&.

62 Matthews, D. (2016). Realizing our potential: Ontario's Poverty Reduction Strategy (2014-2019). Retrieved from https://www.ontario.ca/page/realizing-our-potential-ontarios-poverty-reduction-strategy-2014-2019-all.

63 Ontario Ministry of Community and Social Services. (2017). Ontario Basic Income Pilot. Retrieved from https://www.ontario.ca/page/ontario-basic-income-pilot.

64 Ontario Ministry of Labour. (2017). Changing Workplaces Review final report. Retrieved from https://www.labour.gov.on.ca/english/about/workplace/.

65 Ontario Ministry of Community and Social Services. (2016). Ontario establishing Income Security Reform Working Group. Retrieved from https://news.ontario.ca/mcss/en/2016/06/ontario-establishing-income-security- reform-working-group.html.

66 Government of Canada. (2016). Current and forthcoming minimum hourly wage rates for young workers and specific occupations. Retrieved from http://srv116.services.gc.ca/dimt-wid/sm-mw/rpt3.aspx.

67 Government of Canada. (2016). Current and forthcoming minimum hourly wage rates for young workers and specific occupations. Retrieved from http://srv116.services.gc.ca/dimt-wid/sm-mw/rpt3.aspx.

68 One per cent of planned expenditures for 2017-2018 would be roughly $1.4 billion. Source: Ontario Ministry of Finance. (2017). 2017 Ontario budget: A stronger, healthier Ontario. Retrieved from https://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/ch6b.html#t6-17.

69 Older Women's Network and Association of Design Professionals for Accessibility. (2016). Universal design in new residential construction. Retrieved from http://www.toronto.ca/legdocs/mmis/2016/ah/bgrd/backgroundfile- 94585.pdf.

70 MHALAC. (2016). Moving forward: Better mental health means better health. Annual report of Ontario’s Mental Health and Addictions Leadership Advisory Council. Retrieved from http://www.health.gov.on.ca/en/common/ ministry/publications/reports/bmhmbh_2016/moving_forward_2016.pdf.

Do you agree that Ontario must meet or exceed its greenhouse gas emission targets?

Will you push for a provincial carbon pricing system that is sufficient for the province to reach its greenhouse gas emission targets, while protecting vulnerable populations?

RNAO believes dedicated and sustainable revenue sources are needed to pay for the operation and expansion of transit and active transportation across Ontario. Do you agree with us?

Climate change The evidence is clear: climate change is real, and is caused by human activity that increases the volume of greenhouse gases (GHGs) in the air.

Carbon dioxide (CO2) concentrations in our air have risen steadily from about 280 parts-per- 1 2 million (ppm) at the start of the industrial era to 410 ppm as of April 2017. The annual CO2 increases in 2015 and 20163 were the largest ever recorded since air measurements began in 1958. Today, the levels of carbon in the air far exceed those at any time in the last 800,000 4 years. And when other GHGs besides CO2 are factored in, one estimate shows there were 70 per cent more GHGs in the air in 2012 than in the preindustrial era.5

These dramatic changes to the composition of the Earth's atmosphere have resulted in dangerous changes to the planet's temperature. Measurements from February 2017 showed the average global temperature was 1.5 C higher than in preindustrial times6 – the same threshold signatories of the Paris climate agreement said could not be exceeded.7 Without strong intervention, average temperatures are predicted to increase another 2.0-4.9 C by the end of the century.8 This could produce disastrous outcomes for the entire planet.

Registered nurses (RN), nurse practitioners (NP) and nursing students are concerned about climate change because of its serious environmental and health implications. We are already seeing weather disturbances causing severe population dislocation (e.g., drought in the Horn of Africa, hurricanes in the Caribbean Sea). Climate change also affects Ontarians' health by contributing to extreme weather events, poor air quality, and the spread of diseases. By fighting climate change, we are not merely protecting the environment; we are protecting people's health. We are also fighting for environmental justice, because populations the most vulnerable are the ones who have contributed the least to climate change.

Ontario’s GHG emissions Table 1 shows Ontario’s GHG emissions profile. It highlights a shift in the source of GHG emissions away from industry and electricity towards transportation, buildings and waste.

Table 1. Ontario’s GHGs by sector (Mt CO2e)9 1990 2013 % of total 1990 % of total 2013 Transportation 45.9 60.2 25% 35% Industry 64.2 47.7 35% 28% Buildings 27.9 32.6 15% 19% Electricity 25.8 10.9 14% 6% Agriculture 11 10 6% 6% Waste 7.5 9 4% 5% Total 182 171 100% 100%

Carbon reduction programs Ontario has taken significant steps to reduce its carbon emissions, producing multiple benefits. For example, closing the province's coal-fired power plants not only reduced carbon emissions, it also improved air quality. The number of smog days in Ontario went from 53 in 2005 to zero in 2014 and 2015.10 Another example is the movement towards more walkable and bikeable communities, which reduces emissions from motor vehicles and promotes physical exercise.

As part of these efforts, Ontario has also set ambitious but necessary GHG reduction targets (as demonstrated in Figure 1).11 12

Figure 1: Ontario GHG Reduction Targets

2014 2020 2030 2050

Carbon pricing Economists generally agree pricing carbon emissions can help meet GHG reduction targets. A strong price signal will promote necessary behaviour changes to support the environment.

The government is currently implementing a cap-and-trade system to price carbon. This involves creating a capped number of permits to emit carbon, in line with the province's emission targets, and auctioning them off.

The 2017 cap-and-trade program covered the bulk of emissions (including electricity, transportation fuel, industry, large commercial and institutions). This is an excellent start, but the 2017 cap was not aggressive enough, as it allowed for significant growth in emissions between 2015 and 2017.

More troubling is that the program gave most large emitters 100 per cent of their permits for free for the first four years (2017-2020) in an effort to compete with other jurisdictions that don't have carbon pricing.13 This is unnecessary because most Ontario producers are not emissions intensive and/or do not tend to compete with companies outside Ontario. To the extent that competition from outside Ontario is an issue, the province should pursue all opportunities to level the playing field by working with the federal government to implement border adjustments whereby imports are taxed according to their carbon content.14

In 2016, Ontario took a step back on carbon pricing by announcing it would take the harmonized sales tax (HST) off residential and small business electricity bills.15 While financial support must be offered to low income families, it is important to retain the price signal for other users to encourage them to conserve energy.

The government then cancelled $3.8 billion in renewable energy projects in September 2016.16 This misguided effort to reduce costs will result in continued reliance on nuclear power. Environmental advocates like the David Suzuki Foundation point out that with nuclear costs rising, it would be cheaper to rely more heavily on renewable energy.

At least one other option is on the table: the leader of the Ontario Progressive Conservatives is quoted as saying he would scrap cap-and-trade, and proceed with a revenue-negative carbon tax.17. While RNAO prefers a straight carbon tax to cap-and-trade, the ideal approach would be a revenue-positive tax that helps fund GHG reduction efforts and protect vulnerable populations.

Transit and active transportation Automobiles are a major source of pollution, particularly in urban environments. They also cause congestion on our roadways, which costs Ontarians billions of dollars in time, vehicle operating costs, accidents, emissions, and lost economic opportunities.18 Yet many people in urban areas

have no choice but to drive, with public transit options inadequate and opportunities for active transportation like biking and walking undeveloped or unsafe.

The Big Move is the regional transportation plan developed in 2008 by Metrolinx, 19 which focused on transforming transit in the GTHA. The plan was reviewed in 2013 by the Anne Golden panel, 20 which urged the province to develop substantial new dedicated revenue streams to pay for the next wave of transit infrastructure, and to align the Big Move with the Growth Plan for the Greater Golden Horseshoe. The panel also recommended $300 million funding for a kick- start program to deliver immediate visible improvements in transit service.21

The Big Move was also supported by the medical officers of health for the GTHA in their 2014 report on designing healthier transportation systems and healthier cities.22 The report concluded that better community design and implementing The Big Move could prevent 338 premature deaths every year by increasing physical activity, reducing harmful vehicle emissions and reducing the staggering cost of congestion.23 It recommended Ontario provide long-term transit funding, work with Metrolinx and the municipalities to implement and optimize access to transportation options, and change government policies to better support active transportation and public transit.

The provincial ($31 billion), municipal ($1.9 billion) and federal ($6.5 billion) governments have since stepped up with transit capital funding.24 25 This is a significant step forward, but another $28.8 billion26 is required to complete the construction of the rapid transit expansion for the GTHA under The Big Move. There has also been a recent scaling back of Metrolinx rapid transit plans,27 and a recent report put the annual net funding gap for rapid transit construction and operation at over $2 billion.28

The government has devoted part of the proceeds from the sale of Hydro One to transit, but this is not a sustainable strategy. As Ontario's financial accountability officer pointed out, it secures some money up-front, but foregoes more in the future, leaving a net loss.29 RNAO cautions against privatizing Hydro One because of this revenue loss, and because of the dangers of turning Hydro One over to private interests.30

 Whichever carbon pricing system is used, it must do the heavy lifting in reducing GHG emissions, and must be accompanied by a credible commitment to meeting Ontario's GHG targets.

 In the case of cap-and-trade, RNAO is asking the province to:31 32 o Set the carbon cap at a level that would deliver GHG reductions on the targeted schedule or earlier o Only link to other cap-and-trade markets when it promotes Ontario emission standards, rather than allowing the purchase of underpriced permits from other jurisdictions o Make free or subsidized emission permits highly targeted and temporary - the current program of free permits is neither

 In the case of a carbon tax, if one were to be implemented, RNAO asks that: o The tax be set at a level that will provide incentives for carbon users to meet Ontario's GHG emission targets o The tax be revenue-positive, to generate targeted revenue

 In either case, RNAO asks the government to: o Direct carbon pricing revenues to GHG reduction and to mitigate the impact on vulnerable populations affected by higher carbon prices o Manage revenues transparently with strong public oversight o Develop a complementary suite of programs targeting all emitting sectors

 On the issue of transportation, RNAO urges the province to take all necessary steps to: o Work with federal and municipal partners to ensure dedicated and sustainable revenue sources to pay for ongoing operation and substantial expansion of transit and active transportation in Ontario o Support cost-effective and expeditious delivery of those expansions, implemented by transparent governance and informed expert opinion o Avoid resorting to public asset sales like the privatization of Hydro One to fund transit expansions

References:

1 US Environmental Protection Agency. (2014). Atmospheric concentrations of greenhouse gases, p2. Retrieved from https://www.epa.gov/climate-indicators/climate-change-indicators-atmospheric-concentrations-greenhouse- gases.

2 Kahn, B. (2017). We just breached the 410 PPM threshold for CO2. Climate Central. Retrieved from https://www.climatecentral.org/news/we-just-breached-the-410-parts-per-million-threshold-21372.

3 Kahn, B. (2017). Carbon dioxide is rising at record rates. Climate Central. Retrieved from http://www.climatecentral.org/news/carbon-dioxide-record-rates-21242.

4 US Environmental Protection Agency. (2014). Atmospheric concentrations of greenhouse gases, p3. Retrieved from https://www.epa.gov/climate-indicators/climate-change-indicators-atmospheric-concentrations-greenhouse- gases.

5 The EEA estimates that the atmospheric concentration of CO2 equivalents from long-lived GHGs, excluding water vapour, ozone and aerosols, rose from 278 to 472 parts per million between the start of the industrial era and 2012 – a 69.8 per cent increase. Source: European Environment Agency. (2015). Atmospheric greenhouse gas concentrations. Retrieved from http://www.eea.europa.eu/data-and-maps/indicators/atmospheric-greenhouse-gas- concentrations-4/assessment.

6 Kahn, B. (2017). Flirting with the 1.5oC threshold. Climate Central. Retrieved from http://www.climatecentral.org/ news/world-flirts-with-1.5C-threshold-20260.

7 Kahn, B. (2017). Flirting with the 1.5oC threshold. Climate Central. Retrieved from http://www.climatecentral.org/ news/world-flirts-with-1.5C-threshold-20260.

8 Raftery, AE., Zimmer, A., Frierson, DMW., Startz, R. & Liu, P. (2017). Less than 2℃ warming by 2100 unlikely. Nature Climate Change, 7, 637-641.

9 Government of Ontario. (2017). Greenhouse gas emissions by sector. Retrieved from https://www.ontario.ca/data/ greenhouse-gas-emissions-sector.

10 Miller, G. (2017, January 20). On coal closures and straw men: Why shutting down Ontario's coal plants wasn't a waste of money. TVO. Retrieved from http://tvo.org/article/current-affairs/climate-watch/on-coal-closures-and- straw-men-why-shutting-down-ontarios-coal-plants-wasnt-a-waste-of-money.

11 Ontario Ministry of Environment and Climate Change. (2015). Ontario's climate change discussion paper 2015, p6. Retrieved from http://www.downloads.ene.gov.on.ca/envision/env_reg/er/documents/2015/012-3452.pdf.

12 Graph retrieved from https://files.ontario.ca/moecc-ccs-figure2.png. Source: Ontario Ministry of the Environment and Climate Change. (2017). Climate change strategy. https://www.ontario.ca/page/climate-change-strategy.

13 Government of Ontario. (2017). Cap and trade: Program overview. Retrieved from https://www.ontario.ca/page/ cap-and-trade-program-overview.

14 Registered Nurses’ Association of Ontario (RNAO). (2016). Bill 172: Climate Change Mitigation and Low- Carbon Economy Act: RNAO submission to the Standing Committee on General Government. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_response_Bill_172_final_1.pdf.

15 Government of Ontario. (2016). Speech from the throne: A balanced plan to build Ontario up for everyone. Retrieved from https://news.ontario.ca/opo/en/2016/09/speech-from-the-throne.html.

16 Ferguson, R. (2016, September 27). Ontario government scraps plan for $3.8 billion in renewable energy projects. Toronto Star. Retrieved from https://www.thestar.com/news/queenspark/2016/09/27/ontario-liberals-scrap-plans- for-38-billion-in-renewable-energy-projects.html.

17 Zochodne, G. (2017, March 21). Brown now supporting 'revenue-negative' carbon tax. QP Briefing. Retrieved from http://www.qpbriefing.com/2017/03/21/pc-leader-patrick-brown-now-supporting-revenue-negative-carbon- tax/.

18 Metrolinx. (2008). Costs of road congestion in the Greater Toronto and Hamilton Area: Impact and cost-benefit analysis of the Metrolinx Draft Regional Transportation Plan. Retrieved from http://www.metrolinx.com/en/ regionalplanning/costsofcongestion/ISP_08-015_Cost_of_Congestion_report_1128081.pdf.

19 Metrolinx. (2008). The Big Move: Transforming Transportation in the Greater Toronto and Hamilton Area. Retrieved from http://www.metrolinx.com/thebigmove/Docs/big_move/TheBigMove_020109.pdf.

20 “In September 2013, the Transit Investment Strategy Advisory Panel was appointed with the mandate to review the Metrolinx Investment Strategy, engage with the public, and recommend how transit in the Greater Toronto and Hamilton Area (GTHA) should be funded.” Source: Transit Investment Strategy Advisory Panel. (2013). Making the move: Choices and consequences, p4. Retrieved from http://www.toronto.ca/legdocs/mmis/2014/ex/bgrd/ backgroundfile-67455.pdf.

21 Transit Investment Strategy Advisory Panel. (2013). Making the move: Choices and consequences. Retrieved from http://www.toronto.ca/legdocs/mmis/2014/ex/bgrd/backgroundfile-67455.pdf.

22 Mowat, D., Gardner, C., Mckeown, D. & Tran, N. (2014). Improving health by design in the Greater Toronto- Hamilton Area. Retrieved from https://www.peelregion.ca/health/resources/healthbydesign/pdf/moh-report.pdf.

23 Increases in physical activity would prevent 184 premature deaths and reductions in traffic-related air pollution would prevent 154 premature deaths. Source: Mowat, D., Gardner, C., Mckeown, D. & Tran, N. (2014). Improving health by design in the Greater Toronto-Hamilton Area, p42. Retrieved from https://www.peelregion.ca/health/ resources/healthbydesign/pdf/moh-report.pdf.

24 Move the GTHA. (2016). Backgrounder to report: Are we there yet? The state of transit investment in the Greater Toronto & Hamilton Area. Retrieved from http://movethegtha.com/wp-content/uploads/2016/08/AreWeThereYet_ Backgrounder.pdf.

25 Move the GTHA. (2016). Are we there yet? The state of transit investment in the Greater Toronto & Hamilton Area. Retrieved from http://movethegtha.com/wp-content/uploads/2016/08/AreWeThereYet.pdf.

26 Move the GTHA. (2016). Backgrounder to report: Are we there yet? The state of transit investment in the Greater Toronto & Hamilton Area. Retrieved from http://movethegtha.com/wp-content/uploads/2016/08/ AreWeThereYet_Backgrounder.pdf

27 Munro, S. (2017). Metrolinx previews the next big move. Retrieved from https://stevemunro.ca/2017/08/21/ metrolinx-previews-the-next-big-move/.

28 Transport Action Ontario. (2017). Update on funding gaps for GTHA rapid and conventional transit: Backgrounder report. Retrieved from http://ontario.transportaction.ca/wp-content/uploads/2017/09/TAO- GapUpdate2017-09-Backgrounder.pdf.

29 Morrow, A. (2015, October 29). Budget watchdog warns Hydro One sale will deepen Ontario's debt. Globe and Mail. Retrieved from http://www.theglobeandmail.com/news/national/hydro-one-sale-to-hurt-not-help-ontarios- bottom-line-report/article27026080/.

30 Grinspun, D. (2016). Re: Privatization of Hydro One. Retrieved from http://rnao.ca/sites/rnao-ca/files/RNAO_ to_Premier_of_Ontario_on_Hydro_privatization_-_29_April_2016.pdf.

31 For fuller recommendations, see: RNAO. (2016). Bill 172: Climate Change Mitigation and Low-Carbon Economy Act: RNAO submission to the Standing Committee on General Government. Retrieved from http://rnao.ca/sites/rnao- ca/files/RNAO_response_Bill_172_final_1.pdf.

32 Full submission and recommendations: RNAO. (2015). Cap and trade program design options: Submission to the Ministry of Environment and Climate Change: EBR Registry Number 012-5666. Retrieved from http://rnao.ca/sites/ rnao-ca/files/Cap_and_Trade_Program.pdf.

Ontario is not adequately investing in infrastructure and services. To restore these investments while balancing the provincial budget, RNAO advocates for expanding government revenue through a combination of fairer taxes and other revenue sources. Do you agree with RNAO?

Insufficient revenue means cutting or foregoing services Taxes and other government revenues pay for the public services required in a civilized and healthy society – including health care, education, social services, environmental protection and public security. They also pay the wages of workers who deliver those services, including nurses and other health professionals.

The province has chosen to limit the revenue it receives through taxation. This has resulted in government austerity measures that have reduced critical public services. We must ask: do we really benefit as a society with fewer public services? For example, pharmacare and publicly funded dental care programs would greatly improve access to necessary health services for those with moderate and low incomes. The benefits of these programs for Ontarians would well exceed their costs. However, lack of adequate revenue prevents their implementation.

Ontario’s deficit has always been manageable The focus on deficit reduction hijacks other concerns. Budget deficits are a fact of life and are not a problem at reasonable levels. They rise during recessions and fall during recoveries. For example, Ontario went from a small surplus of 0.1 per cent of GDP in 2007-08 to a deficit of 3.2 per cent in 2009-10, as the province increased expenditures to fight the effects of the global financial crisis. As the economy recovered, the deficit shrank to 0.5 per cent in 2015-16. It is projected to decrease to 0.2 per cent in 2016-17 and disappear entirely in 2017-18.1

From 2009-10 to 2015-16, deficit reduction was accomplished through austerity measures: program spending as a share of GDP fell 2.1 per cent, while revenue increased just 0.7 per cent.2

There are other economic objectives that must be considered in addition to deficit reduction, such as employment. While Ontario’s unemployment rate has come down, its employment rate (the percentage of the population 15 years of age and older who are employed) remains stubbornly low – less than 61 per cent compared to more than 63 per cent between August 2002 and October 2008. There should be capacity for at least two per cent more to join the workforce.3

Ontario's Monthly Employment Rate 1976-2017 68% 67% 66% 65% 64% 63% 62% 61% 60% 59%

58%

77 80 83 86 89 92 95 98 01 04 07 10 13 16

76 79 82 85 88 91 94 97 00 03 06 09 12 15

------

Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb

Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug Aug

The province would be better served by shifting the focus from keeping taxes low and balancing the budget to restoring infrastructure and decent jobs. Ongoing austerity has resulted in a huge social and physical infrastructure deficit, and has likely delayed economic recovery by restraining consumer spending. A society that invests too little in social, educational and physical infrastructure limits its development prospects. Given that borrowing costs are at historically low levels, there is no compelling reason not to make these necessary investments now.

Tax cuts are not the way to go Low taxes are rationalized on the grounds that they stimulate the economy. However, any private spending stimulus is more than offset by corresponding government spending cuts, resulting in net job losses. As the Task Force on Competitiveness indicated, substantial federal and Ontario tax cuts were accompanied by falling investment rates per worker.4 That isn't the kind of "stimulus" package that benefits the province.

Ontario is an outlier compared to other provinces Although Ontario has a higher per capita GDP than six of the nine other provinces, its per capita program expenditures are the second lowest in Canada, after Quebec. And when one takes into account the availability of resources (GDP), Ontario's austerity measures are more severe than any other province.

Federal cutbacks Major federal cutbacks have compounded the problem. The federal government has been cutting its revenue since the early 1980s: in 1981-82, the federal revenue share of Canadian GDP was

18.3 per cent. It dropped to 14.1 per cent in 2011-12, and has only recovered to 14.4 per cent as of 2016-17. As a result, federal program spending fell from 18.5 per cent of GDP to 14.4 per cent over the same time period.5 We encourage the federal government to restore its own fiscal capacity and urge the same for the Ontario government.

Need for new revenue tools Leaders like Toronto mayor John Tory have come to the conclusion that new provincial revenue sources are urgently needed to at very least meet current commitments.6 Yet the province has rejected proposals to do so, such as the recommended Toronto road tolls.7

There are many revenue options. Green taxes, such as emission taxes or emission charges, have the advantage of discouraging harmful behaviour by making it more expensive. These taxes are more efficient, and could not only generate revenue but also help replace less efficient taxes, such as payroll taxes that discourage employment. On these grounds, the Task Force on Competitiveness has called for the implementation of an Ontario carbon tax.8 The Ecofiscal Commission has similarly called for carbon pricing, and in June 2015 released its principles for an Ontario cap-and-trade program. That program is the carbon pricing option chosen by the province.9 Ontario has started holding auctions of greenhouse gas (GHG) allowances, so the program is well under way.1011

There are a number of sin taxes already on the books, such as gasoline, diesel, wine and beer. As economist Don Drummond outlined in his report to the government, these taxes apply to volumes rather than value. Unless the taxes are continually raised to account for inflation, this is the equivalent of continual cuts in the tax rate. The Drummond Commission recommended the replacement of such taxes with taxes that apply to value, the way a sales tax is a fixed percentage of the sale price.12

Ban asset sales The government must also be wary of the temptation to sell off assets for one-shot revenue gains. At various times, Hydro One, Ontario Power Generation and the Liquor Control Board of Ontario have been mentioned as candidates for privatization.13 The Premier's Advisory Council on Government Assets recommended selling off 60 per cent of Hydro One,14 in spite of the report from Ontario's Financial Accountability Office suggesting that the sale would worsen the province's deficit position over the long run.15 Nevertheless, Ontario did sell an initial 15 per cent of Hydro One shares in the fall of 201516 and a further 15 per cent in April 201617, much to the objection of organizations like RNAO.18 In May 2017, Ontario reduced its holdings of Hydro One to 49.9 per cent through another sale of shares.19

Selling off assets is not a sustainable way of addressing revenue-expenditure imbalances, particularly when that asset is a monopoly that provides a large guaranteed stream of revenue.

And it is likely to result in receiving poor value as buyers will have to discount the price to cover uncertainty, risk and transactions costs.

 Ensure the fiscal capacity to deliver all essential health, health care, social and environmental services by building a more progressive tax system. Do not cut taxes.

 Increase revenue sources that encourage environmental and societal responsibility. Begin by phasing in environmental levies and continue implementing a cap-and-trade program for carbon emissions.

 Seize this low-interest, low-deficit opportunity to catch up on investments in human, environmental and physical capital.

 Update the gasoline tax by making it a tax on value rather than on volume.

 Reject sales of publicly owned crown corporations and assets to fund government programs (e.g. Hydro One, Ontario Power Generation, and the Liquor Control Board). Halt the further sale of Hydro One shares.

 Ensure transparency and accountability in fiscal measures to deliver services people want and deserve, and to ensure that is done in an efficient manner.

References:

1 Royal Bank of Canada. (2017). Canadian federal and provincial fiscal tables. Provincial budget balances relative to GDP. Retrieved from http://www.rbc.com/economics/economic-reports/pdf/provincial-forecasts/prov_fiscal.pdf.

2 Royal Bank of Canada. (2017). Canadian federal and provincial fiscal tables. Revenues relative to GDP & program expenses relative to GDP. Retrieved from http://www.rbc.com/economics/economic-reports/pdf/provincial- forecasts/prov_fiscal.pdf.

3 Statistics Canada. (2017). Table 282-0087: Labour force survey estimates (LFS), by sex and age group, seasonally adjusted. Retrieved from http://www5.statcan.gc.ca/cansim/a26?id=2820087.

4 Task Force on Competitiveness, Productivity and Economic Progress. (2013). Course correction: Charting a new road map for Ontario, p47. Retrieved from http://www.competeprosper.ca/uploads/2013_AR12_Final.pdf.

5 From 1981-82 to 2015-16, the drop was 3.6 per cent to 3.3 per cent for transfers to other levels of government vs. 10.5 per cent to 6.2 per cent for federal direct spending. Source: Canada Department of Finance. (2016). Fiscal reference tables September 2016. Retrieved from http://www.fin.gc.ca/frt-trf/2016/frt-trf-16-eng.asp.

6 Pagliaro, J. (2016, December 13). Council backs Tory’s move to impose road tolls. Toronto Star. Retrieved from https://www.thestar.com/news/city_hall/2016/12/13/council-backs-torys-move-to-impose-roll-road-tolls.html.

7 Paikin, S. (2017, January 27). Wynne rejects Toronto’s request for road tolls, and almost everyone comes out ahead. TVO. Retrieved from http://tvo.org/blog/current-affairs/wynne-rejects-torontos-request-for-road-tolls-and- almost-everyone-comes-out-ahead.

8 Task Force on Competitiveness, Productivity and Economic Progress. (2013). Course correction: Charting a new road map for Ontario, p50. Retrieved from http://www.competeprosper.ca/uploads/2013_AR12_Final.pdf.

9 Beugin, D., Cappe, M., Hodgson, G., Lanoie, P. & Ragan, C. (2015). The way forward for Ontario: Design principles for Ontario's new cap-and-trade system. Retrieved from http://ecofiscal.ca/wp-content/uploads/2015/06/ Ecofiscal-Commission-Report-Brief-The-Way-Forward-for-Ontario-Cap-and-Trade-June-2015.pdf.

10 Government of Ontario. (2017). Ontario announces results of first cap and trade program auction. Retrieved from https://news.ontario.ca/ene/en/2017/04/ontario-announces-results-of-first-cap-and-trade-program-auction.html.

11 Government of Ontario. (2017). Summary results report: Ontario cap and trade program auction of greenhouse gas allowances June 2017 Ontario auction #2. Retrieved from http://files.ontario.ca/summary_results_report_ english_2017-06-09.pdf.

12 Commission on the Reform of Ontario's Public Services. (2012). Public services for Ontarians: A path to sustainability and excellence, p426. Retrieved from http://www.fin.gov.on.ca/en/reformcommission/chapters/ report.pdf.

13 Benzie, R. (2014, April 11). TD Bank chief to 'optimize' LCBO, Hydro One and Ontario Power. Toronto Star. Retrieved from http://www.thestar.com/news/queenspark/2014/04/11/ontario_ropes_in_td_bank_chief_to_ optimize_lcbo_hydro_one_and_ontario_power.html.

14 Clark, E., Denison, D., Ecker, J., Jacob, E. & Lankin, F. (2015). Striking the right balance: Improving performance and unlocking value in the electricity sector in Ontario. Retrieved from https://dr6j45jk9xcmk. cloudfront.net/documents/4428/improving-performance-and-unlocking-value-in-the.pdf.

15 Critchley, B. (2015, October 29). Hydro One prices IPO at $20.50 a share with proceeds for infrastructure investment, debt repayment. Financial Post. Retrieved from http://business.financialpost.com/news/fp-street/hydro- one-prices-ipo-at-20-50-a-share.

16 Canadian Press. (2015, November 12). Hydro One IPO nets Ontario more than $50-billion. Globe and Mail. Retrieved from http://www.theglobeandmail.com/report-on-business/hydro-one-ipo-nets-ontario-more-than-5- billion/article27227164/.

17 Canadian Press. (2016, April 14). Ontario wraps up secondary offering of Hydro One shares. Toronto Star. Retrieved from https://www.thestar.com/business/2016/04/14/ontario-wraps-up-secondary-offering-of-hydro-one- shares.html.

18 Registered Nurses' Association of Ontario. (2015). RNAO commends government for commitments to NPs in long- term care, RN prescribing and evidence-based care, and calls for a stop to RN replacement. Retrieved from http://rnao.ca/news/media-releases/2015/04/23/rnao-commends-government-commitments-nps-long-term-care-rn- prescribin.

19 Jeffords, S. (2017, May 17). Liberals land $2.8 billion through final batch of Hydro One shares sell-off. Toronto Sun. Retrieved from http://www.torontosun.com/2017/05/17/liberals-land-28-billion-through-final-batch-of-hydro- one-shares-sell-off.