HLTB01H3F: Health, Aging and the Life Cycle
Department of Health Studies
University of Toronto at Scarborough
Instructor: Anna Walsh.
Term: Winter 2010 Mondays 3 p.m.-5 p.m.
Lecture Room: Room AA 112.
Aldwin, Carolyn M. & Diane F. Gilmer. 2004. Health, Illness, and Optimal Aging:
Biological and Psychosocial Perspectives. Thousand Oaks, California: Sage Publications,
Ontario’s Health Care Program
Working Towards Better Health Care for US ALL
Neonatal doctor, after a bicycle accident was in 3 month hospitalization
“ was recovering from a hospital visit.
In ICU one must attend to patients and watch what they say
He looked at
1) looking at how the government can save money and provide access to medical
care for poor ppl/ those who don’t have doctors.
2) 30-50 Family Health care teams.
Table of Contents
Ontario’s Health Care System: General Overview/Introduction
Ontario Health Insurance Plan
Health Care Providers
Commitment to Care: Plan for Long-term Care in Ontario- Seniors
Telehealth Ontario – e-technology
Budgets- Current Challenges
Government’s Priorities- Future Challenges
Provinces are individually responsible for organization and distribution of health
Know process in textbook
Provinces have ability to design healthcare system.
1) Important case: shaole case
Very important on development of private or for profit care.
Man in quebec who was put on waiting list for his hip. He sued the government.
1 “ If I want to wait for a publically fund system. If I want to pay properly I should be able
to jump the cue” As a result he won, therefore privatization was initiated
People of ages 19-65
Since 2006 the government has delisted certain services. (we have to pay for this)
Dental has always been private.
1. Ontario’s Healthcare System- General Overview/ Introduction
Ontario has a model health care system
Doctors who have joined these health teams have increased from 180 thousand dollars
from 2004 and 250 thousand from last year
Efficiency is measured in cost efficiency and quality. Healthcare is a business as well.
Population aging: as the baby boomers adv in age, there will be an increase in ppl. inage
of 65 which forces us to look at care of elderly
History=familys were structured differently, elderly were revered. Aging process was
different. Now women are working outside of the home and fertility rates decline
therefore we can’t after the elderly
Model=Aging in place
Where they look for a program to take care of eldery in ones home.
Kind of plan elderly prepare, most don’t want long-term facilities.
History=elderly were, wise acquired experiences.
Society reveres the youth now. Today we are focused on staying young.
Unrealistic assumptions that we have on elderly people
Liposuction is the top adjustment in Canada.
Must understand healthcare program
Patient safety is important in health care program
Hospital mortality rates=2007 established protocol to publicaly report in hospital death
WHY=accountability. Cannot have programs to protect patients without knowing whats
going on. Alexander Pope” to err is human”
Must know how hospitals are doing.
humber rivier regional hospitals has highest rate of patient death. (2006-2007)
death rate of 136 people died that year
Scarborough 2007 =122
National avg= 100.
2009=worst death rate is Markham stove-ville due to adverse events.
2 Risks in any procedure.
Government is trying to make hospitals more accountable to reduce incidents of adverse
Looking at research studies and determining if they are ethically sound.
Determine if patients over age of 65 are mentally competent.
Physicians obligation to act in the patients best interest
Use disclosure and have openness trustworthy ness etc.
Released mortality rates for disclosure and give people the chance to trust the hospitals.
Dec 2009= new regulation came into form BILL 179
Proclaimed and called “ regulated health professions statue law ammendmant act 2009. “
Look up legistation= details of legistlation not on exam
Highlights of legistlation
1) according to this law it provides the ability of diff professionals to have expanded
health care available to provide to patients
Example : Nurse are able to do some assessment that they were unable to do
can prescribe medication
physical therapist can provide xrays
dental hygenist can pesscribe drugs
midwives, pharmacists and dentists , restrictions were removed and expanded scope of
Needed refill of pharmacist, you were able to get a repeat without going to doctor.
Section 241 of criminal code= everyone who councils a patient to commit suicide,
whether suicide is ensues or not, is guilt, indictable offense and liable to imprisonment.
If physician was to help a person commit suicide, the doctor would be guilty regardless of
the outcome. (ie if they die or not)
On dec 1992, 17 Sue Rodriguez launched a challenge to the criminal code
Suffering from ALS Lukarigs disease.
Supreme court of CANADA said NO she can’t commit suicide.
If this is not allowed, people are suffering needlessly.
Ontario has a model health care system. We can get access to certain services.
Back in the day no charge was given to doctors notes.
We have a two tear system (private and public)
Ontarians receive most health care services at no cost to the individual but Ontario health
premium based on incomes that provides no premium for taxable incomes under
$20,000 and $900 incomes greater than $200,000. The Ontario Health Insurance Plan
(OHIP) covers the full cost of all necessary:
3 diagnostic and treatment medical services for all citizens and most permanent
residents in Ontario - coverage includes doctor examinations, most medical testing,
emergency care, hospital care and emergency dental care.
DEB mathews =minister of health care
There are currently 96 hospitals across the province ranging from community emergency
facilities to specially and research hospitals.
There are 211 hospitals sites across the province, ranging from community emergency
facilities to specialty and research hospitals.
The Ontario Ministry of Health and Long-Term Care is responsible for regulating and
administering healthcare to all Ontarians.
In 2000, Ontario introduced TeleHealth Ontario, aimed at improving patient access and
the reduction of overall costs ~ 24-hour telephone access to registered nurses for
consultation is provided to OHIP patients.
Ontario Health System Overview
4 The Ministry of Health and Long-Term Care
The ministry is responsible for administering the health care system and providing
services to the Ontario public through such programs as health insurance, drug
benefits, assistive devices, care for the mentally ill, long-term care, home care,
community and public health, and health promotion and disease prevention.
Also regulates hospitals and nursing homes - operates psychiatric hospitals and medical
laboratories – and co-ordinates emergency health services.
Created by Public Health Act of 1882 - first permanent health care administrative body in
the province- Ministry of Health originally known as the Provincial Board of Health of
Ontario - became Department of Health in 1925.
1930 - Department of Hospitals established under direction of first Minister of Health -
became a division of the Department of Health in 1934.
Insured hospital services and insured physicians' services - introduced in 1959 and 1966
respectively - were combined under the Ontario Health Insurance Plan (OHIP) in
The Department of Health became the Ministry of Health in 1971- then the Ministry of
Health and Long-Term Care in June in 1999.
The Honourable George Smitherman, Minister
Running for mayor and he resigned.
Dr.Sheela Bansur Chief medical officer of health and assistant deputy
Health planning branch
Health Care system framework
long term facility care
home and community based care
Ontario Drug Benefit program
ODB cost coverate
Emergency Health Services = know they are emergency health servies
Land and Air Ambulance
Until beginning of 1998 - operations of all land ambulance services in Ontario fully
funded and directed by the Ministry of Health and Long-Term Care.
In January 1, 1998 - province commenced process of transferring responsibility for land
ambulance operations to upper tier municipalities and designated delivery agents.
In most areas of the province - ministry is still funding and directing the provision of
service - bills municipalities for ½ the cost of land ambulance services.
5 By January 1, 2001- upper-tier municipalities and delivery agents assumed responsibility
for contracting or directly delivering land ambulance services.
The ministry will continue to fund ½ of the approved cost of land ambulance service
provided by a municipality or delivery agent.
Emergency Management Unit (EMU)
Dec. 2003 - Emergency Management Unit (EMU) created to ensure state of readiness
for any emergency faced by ministry and/or the health care system.
Infection control and surveillance standards - protect against infections - provide early-
warning system for an infectious disease outbreak- minimize likelihood of an
Emergency management plan- stockpiling critical equipment like N95 masks and
respirators and conducting event simulations - prepares ministry for eventuality of an
emergency that has health implications (e.g. power outage, biological accident, or
contaminated water supply).
Emergency preparedness - allows quick recovery to regular activities within the health
care system that may be suspended during a crisis.
Beyond acute care plan also accounts for business continuity for health care services like
long-term care compliance advisors and public health laboratory activities.
3. Ontario Health Insurance Plan (OHIP)
A resident of Ontario must have a health card to show that he or she is entitled to health
care services paid for by OHIP.
The Ministry of Health and Long-Term Care - pays for a wide range of services -
however it does not pay for services that are not medically necessary such as cosmetic
Most Ontario health benefits are covered across Canada - the province or territory being
visited usually bills the Ontario Ministry of Health and Long-Term Care directly for
hospital and physician services.
Ontario residents are eligible for provincially funded health coverage (OHIP). To be
eligible for Ontario health coverage you must:
be a Canadian citizen or have immigration status as set out in Ontario's Health Insurance
make Ontario a permanent and principal home
be physically present in Ontario 153 days in any 12-month period.
OHIP coverage normally becomes effective 3 months after the established date of
residency in Ontario.
De-listing of OHIP Services
To save costs, some services will no longer be covered by OHIP:
Routine optometry exams, except for seniors and those under the age of 20
6 Physiotherapy services, except for seniors through home-care or long-term care facilities.
4. Health Care Providers
Regulated Health Professions
Ontario regulates the practice of most health professionals through independent Colleges
(e.g., College of Physicians and Surgeons)
Professional Colleges - determine what is professional conduct i.e. minimum training
standards, issuance of licenses to practice as a physician, psychologist, chiropractor,
optometrist, pharmacist, nurse, audiologist, etc.
Ontario's 23 self-regulated health professions have governing bodies called colleges that
set the standards for skills, knowledge and behavior for their members.
Ontario laws - administered by Ministry of Health and Long-Term Care- sets legal
framework for regulated health professions- colleges independent of the ministry.
The colleges provide assistance with finding health care professionals – complaints can
be issued about treatment received or behavior of members of colleges - colleges must
look into all complaints.
Colleges - negotiate with government and among one another to determine who can
perform what practices (e.g. diagnosis of psychiatric illness, referral requirements
Trade Associations (e.g., OMA) represent the collective interests of its members,
negotiate fee schedules, employment conditions, etc.
Not all licensed professionals choose to belong to a trade association.
Scope of practice has been expanded Bill 168
Integrated policy and planning updates
regulation of MRI technologists
regulation dragted and being circulated to CMRTO
Regulation of not-for-profit Facilities
Not-for-profit hospitals and community health centers (CHCs) - governed by a Board of
Trustees - board members community members appointed by government to represent
Practices and services - specified by legislation and regulation (e.g., Hospital Services
Hospitals and community health centres receive funding - based on complex formulas
that consider factors such as the type of services offered and the volume of services
provided, “performance”, etc..
Regulation of for-profit Facilities
Governed by Board of Directors on behalf of shareholders
7 Community interest - not primary concern
May not use health professionals paid through provincial insurance plans
Public Public-Private Partnerships
Hospitals may subcontract out services to a private company e.g. cafeteria services,
Private sector may finance and build a new hospital or
health facility and lease it back to the public sector
Minister of Health
and Long-Term Care
Health Professions Health Professions Appeal
Regulatory Advisory and Review Board
23 Regulatory Health Professional Colleges
Regulated Health Professions- examples:
Audiology/Speech Language Pathology
Diagnostic Medical Sonographers
8 Magnetic Resonance Imaging (MRI ) Technology
Medical Laboratory Technology
Medical Radiation Technology
Responsibilities of the Colleges
To serve and protect the public’s interest
To regulate the practice of one or more health professions
To set entry to practice standards
To set standards of practice for quality care
To promote the continuing competence of members
To develop codes of ethics for the profession
To ensure their members comply with the Acts and regulations that apply to their
Any profession code of ethics is there to set standard and guide professionals.
Specific Scopes of Practice –what can be done and what cant be done.
We have right to know.
Scope of practice statement
Standards of practice regulations
Professional practice guidelines (eg, delegation)
Scope of practice statement
Authorized acts of the profession (if any)
Title(s) restricted to members
Composition of college council
Scope of Practice Model of RHPA:
Controlled Acts Nurse can apply a splint look at scope of practice
1. Communicating a diagnosis
2. Performing a procedure below the dermis
9 3. Setting/casting fracture/dislocation
4. Moving joints of spine
5. Administering a substance by injection/inhalation
6. Putting instrument/hand/finger in body opening
7. Applying/ordering a form of energy
8. Prescribing/dispensing/selling/compounding a drug
9. Prescribing/dispensing eye glasses
10. Prescribing a hearing aid
11. Fitting/dispensing dental prosthetic
12. Managing labour/delivery
13. Allergy challenge testing
14. Performance restricted to members of profession(s) authorized to use these acts
15. Other health services left in the public domain
16. Harm clause intended to capture unforeseeable risky conduct
“No person, other than a member treating or advising within the scope of practice of
his or her profession, shall treat or advise a person with respect to his or her health in
circumstances where it is reasonably foreseeable that serious physical harm may
result from the treatment or advice…”
5. Public Health
Public health - concerned with health and well-being of whole community rather than the
treatment of illness and disability.
Health viewed as a resource for everyday living - influenced by everyday environment
that we are part of.
Public health focuses on three areas:
i. Preventing conditions that may put health at risk (health protection)
ii. Early detection of health problems (screening)
iii. Changing peoples and societies attitudes and practices regarding lifestyle choices
Health protection - works particularly in areas of food and water safety environmental
risks e.g. toxic waste handling, air pollution, second-hand smoke, public sanitation,
spread of rabies, vaccinations against major communicable diseases, and mandatory
tuberculosis screening of immigrants to Canada.
Screening programs - aimed at specific groups – e.g. the Healthy Babies, Healthy
Children program, Preschool speech and language program, school-age dental exams,
and breast and cervical screening for cancer- the early detection of an illness or
problem can lead to significant improvements in health.
Programs targeted at either the public eg physical activity dangers of second hand smoke
or sub h
Health promotion programs - include providing education on tobacco use, nutrition,
physical activity, injury prevention , birth control and reproductive health, prevention
of sexually transmitted diseases including HIV/AIDS, and breastfeeding.
Public health - delivers its programs and services on a population health approach
Programs targeted at either the public e.g. physical activity, dangers of second-hand
smoke - or sub-groups of the population i.e. expectant mothers (pre-natal health), high
school students (drinking and driving), or women aged 50-70 (breast cancer
Funded - either directly from a Provincial Ministry of Health (Ontario) - or from a
Regional Health Authority
Hospitals, CHCs etc.,- use money to pay salaries (nurses, pharmacists, technicians,
therapists, etc.)- purchase supplies and equipment
Large capital investments - equipment (e.g., an MRI) or buildings receive special funding
grants - often require matching money from donations
Money to operate equipment - comes from operating budgets
Non-insurable services - paid for through donations
SARS - Lessons Learned
(Krever Commission, Red Cross, Walkerton Inquiry)
What worked well in our response:
PTAS -a centralized, inter-facility, patient-transfer system
24/7 call centre support service for health care workers
Screening efforts at health facilities and telephone screening
Human resources under-supply (global challenge)
Mask inventory issues (both nationally and internationally)
Better utilization of existing information technology
Need to build on our collaborative health system approaches
Need to strengthen contingency planning (individually and as a system)
Behaviour change for everyone
Everyone’s responsibility to safe-guard public health
Heightened vigilance by health system
Monitoring for respiratory symptoms and fever, especially for pneumonia in all hospitals
Planning for the Future
•Identifying what caused the outbreak, how it spread, and what should be done to
protect Ontarians in the future.
•Identify key lessons from Ontario’s SARS experience
•Advise on measures to strengthen infectious-disease
11 •Assess measures needed to strengthen infectious-disease control, public health and
•Develop recommendations to strengthen Ontario’s capacity to prevent and contain
future infectious-disease outbreaks
• Emergency preparedness and response for
• International comparisons on surveillance, legal and
ethical issues, information technology, control of nosocomial infections
The Universal Influenza Vaccination Program
Ontario makes the influenza vaccine available free to all residents.
This program is part of an ongoing commitment to health promotion and disease
prevention. With this program, the flu vaccine is free and will enable individuals to
protect themselves and those around them against the illness and, at the same time,
reduce the impact on the healthcare system during influenza season.
West Nile Virus
In 2003 there were a total of 89 human cases of West Nile virus in Ontario. Surveillance
statistics for the 2004 season on human, bird, mosquito and horse cases of West Nile
virus will be available through this site when tracking activities begin this summer.
Public health also directed in rabies and Hepatitis C initiatives
Only a Plane Ride Away....
“Globalization, world travel, intensive agricultural techniques, dense urban populations,
substandard public-health conditions in many parts of the world, and the uncanny
ability of microbial pathogens to evolve rapidly, all conspire to guarantee that SARS is
just the latest in a string of diseases that include cholera, plague, influenza, polio,
HIV/AIDS, mad-cow disease and West Nile virus.” Canadian Institutes of Health
We will have a pandemic. Question of when.
6. Commitment to Care: Long-term Care in Ontario -Seniors
Long-term Care in Ontario - Seniors
Over 70,000 residents live in long-term care (LTC) homes in Ontario. –not all seniors
live in long term care.
Change in demographics
Declined fertility rates.
News= issue with respect to budget, budget fears are hitting Ontario hospital
This spring we will hear difficulties hospitals will experience in Ontario.
Reduction in beds, nurses laid off.
12 Elderly will get less care.
More waiting time.
Many women working outside of the home.
A long-term care facility is a “home” to resident seniors- here is therefore a need to
provide and protect a quality of life and a level of respect in government-funded
Changing demographics - placing a greater burden on long-term care facilities - both the
% of the population aged ≥ 65 yrs. and aged ≥ 85 almost doubled between 1961-2001
Seniors now enter long term care homes at a more advanced age and with greater health
In denial that we will be old.
The number of seniors requiring tube feeding, dialysis and catheters, once rare in these
homes, is rising.
The average age - resident - long term care - 83 years old.
Changes in the family and labour force participation have also affected how families can
care for seniors. Example: number of women aged ≥ 15 in the labour force doubled
Seniors have voiced a preference for “aging in place” with the appropriate community
Ontario’s Home and Continuing Care Sector
Ontario’s home and continuing care sector has a unique
opportunity to make a major contribution to the national debate on the future of home
and continuing care.
Ontario has the highest health care budget in the country and represents Canada’s largest
provincial population group in need of home and community care.
The three home and community care provider Associations in Ontario can speak with a
A number of change initiatives are currently underway in Ontario’s Home and
Community Care Sector to improve the provincial system.
Home Care- Community Care Access Centers- Mandate and Service Priorities
In Ontario, 42 Community Care Access Centers (CCACs) are responsible for assessing
eligibility and arranging for the provision of what are generically termed “home care’
Health Canada defines home care as:
“an array of services which enables clients, incapacitated in whole or in part, to live
at home, often with the effect of preventing, delaying or substituting for long-term care
or acute care alternatives.”
Also a budget for elderly health care system.
Community care access centres, elders are given 1
She called CCCAC.
There are three commonly identified objectives of home care programs:
1. Substitution for services provided traditionally in long-term care facilities and
2. Maintenance of clients’ independence in their own home environment
to delay or prevent the need for moving to more costly institutional care; and
3. Prevention by investing in services and monitoring to prevent deterioration and
support family caregivers.
Personal support workers are sent to homes.
CCACs also manage placement in long-term care facilities - provide health services to
children at schools - provide information about other community services - divert
clients to services when appropriate to clients’ needs.
In July 1999 - a joint work group of the Ministry of Health and the Ontario Association
of Community Care Access Centers (OACCAC) developed and circulated a statement
summarizing the mandate of CCACs:
“ Community Care Access Centers are key to the planning, management, delivery and
evaluation of community-based services and, in their unique position as the major
broker for Long-Term Care services, exercise a leading role in the health
care system. CCACs coordinate the efficient provision of high quality, client-centered
services for people of all ages.”
Informal care is when, families help elders themselves=no pay
Formal is when privately hired or through public systems.
Advilo columbo, women live on their own and were getting 3 hours of home care service.
Informal care or private care was involved to compensate.
Limited policy direction - available to CCACs - ensures consistent and equitable access
to services across the province.
Long-Term Care Act, 1994 (LTCA) - sets out broad purposes of community long-term
care services - lists core services to be provided.
CCACs considered “approved agencies” under the Long-Term Care Act, 1994 (LTCA)-
regulation making power exists to address service eligibility, service limits,
prioritization, waiting lists management and discharge from services - comprehensive
regulations and policy directions have not yet been put in place.
Existing Home Care Policies and Procedures Manual - created 1984 - therefore predates
creation of CCACs and significant changes in the health care system - although work
is underway to update the Policies and Procedures Manual, and service directions to
guide regulation development have been drafted and consulted on - they have not been
14 The existing regulation under the LTCA outlines eligibility only for homemaking
services, and sets service limits for homemaking, personal support services, and
Eligibility for professional services is not addressed in the LTCA, but is outlined in
section 13 of Re