“Basic health care is a foundation in our society and differences are never justifiable. Seniors’ needs are real and they surely deserve easy access to basic health care in the same manner afforded to other groups in Ontario.”
The submissions received by the Commission consistently mentioned the barriers faced by older persons in the areas of health care, institutions and services. The Commission heard about concerns with the current health care system, including: insufficient funding and the resulting inadequacy of community-based care, the shortage of care professionals; and a number of concerns regarding long-term care facilities. Submissions mentioned physical barriers such as building accessibility and social barriers such as restrictive attitudes within the health care system as major obstacles facing older persons. Similarly, the Commission heard that physical and social barriers exist in the area of general services, and a number of consultees noted barriers specific to transportation. The message offered by participants throughout the consultation process was clear: barriers to health care, institutions and services serve to adversely affect the dignity, self-worth, independence and full-participation of older persons in the province of Ontario.
Community-based care: limited funding and services
Insufficient funding of community-based care was identified as a critical barrier for older persons seeking access to the health care system. The Ministry of Health and Long-term Care (MOHLTC) told the Commission that “significant investments have been directed to the expansion of long-term care community services designed to help people remain in their own homes for as long as possible.” The Commission was pleased to learn that MOHLTC committed to an investment of $1.6 billion in long-term care community services for the fiscal year 2000-01, of which, $1.1 billion is for Community Care Access Centres (CCACs). Another $448 million of that investment is for other long-term care community services such as adult day programs and attendant care services.
“The Ministry recognizes the long-term care service system as an essential component of an integrated health service system and is committed to ensuring a quality system of community and facility long-term care services.”
(Ministry of Health and Long-Term Care)
Despite such investments, the Commission heard about concerns regarding the insufficient funding of community-based services resulting in diminished capacity to appropriately address the health care needs of older persons. The Chatham-Kent CCAC indicated that over 50% of the population that they serve are older persons. However, the chronic under-funding of CCACs serves to severely limit their capacity to address the unique care needs of older persons. They noted that due to an emphasis on cost containment, they have been forced to reduce their caseload from 3,000 to 2,600 persons daily, translating into approximately 200 fewer older persons receiving care daily. Without appropriate funding, CCACs told the Commission that it is difficult to respond to the current demand for services.
“Many seniors cannot access physicians because there is such a shortage of physicians and because seniors with health problems require an above average amount of time and attention... available physicians do not welcome seniors as patients.”
Health care for older persons is unique and requires an approach that takes into account evolving needs throughout the process of aging. A number of groups told the Commission that the care needs of older persons often demand more time of care professionals. However, the health care system in Ontario is not funded to allow care providers to spend the appropriate amount of time tending to their unique health care needs. The Advocacy Centre for the Elderly emphasized this very point in stating, “ there are maximum limits with respect to services...strict limitations on the amount of hours [of care] you can get...in no way [do they] meet the needs of many seniors in the community... that’s what we are finding with many of the services...It is the system itself, the structure that has the negative impact on the older person because the hours aren’t there, the time isn’t there to deal with the senior.”
Addressing this very issue, the Chatham-Kent CCAC noted that due to inadequate funding, they have been forced to reduce the hours of home support from 12 to 16 hours per week down to currently less than eight hours per week. The Ottawa-Carleton CCAC added that the Long-Term Care Act, 1994, sets limits on the quantity of services that CCACs can provide to older person within the community. They noted that as a result, the level of community care can, at times, be insufficient to address the health care needs of older persons. In the context of early discharge and a shortage of convalescent care beds, they stated that older persons are often discharged into the community without a comprehensive care plan. For those older persons in need of longer periods of convalescent care, this can translate into lives at risk.
“If we want to keep people in the community and out of hospitals, you need to find the money to do so. When we have a shortage of beds and therefore discharge people after a very short period of time, they go home very frail and are still very much in need of help at home...they suffer like everybody else from a lack of medical care services, but more so because they are so vulnerable.”
(Ontario Association of Social Workers)
A number of submissions also emphasized that the inadequate funding of community-based services negates that capacity for older persons to “age in place”. As the Ottawa- Carleton CCAC noted, in order for older persons to be able to remain within their own communities, there is a need for an expansion of the care currently provided by CCACs and government-sponsored residential care facilities. In the context of inadequate funding, several groups noted that this is difficult to achieve.
The Older Women’s Network and the Ontario Association of Social Workers emphasized that the Commission should not forget those older persons who are most marginalized within the context of the current system of community-based care. Older women who have disabilities, are poor, are from diverse racial and/or ethno-cultural backgrounds, or are lesbian or transgendered suffer “double jeopardy” in the context of community-based care. Age discrimination, in addition to exclusion based on other personal characteristics, means that vital community-based services are even more difficult to access.
In response to these concerns, a number of the consultees recommended that funding must be made available so that CCACs and others providing care to older persons have the capability, both in terms of resources and time, to provide the highest level of care. Multidisciplinary services, including community-based care, rehabilitation, chronic and complex continuing care and supports such as nursing care, home support services, therapies and case management services, should receive the appropriate focus in funding. The Ontario Association of Social Workers recommended that Commission policy initiatives related to age, “must encourage and promote equal access to a comprehensive range of community-based services and supports regardless of age or other attributes”.
“We know that elderly people and their families want assurance that care in a long-term care facility will be available when care in the home and community is no longer possible. The expansion and redevelopment facilities (nursing homes and charitable homes for the aged) are specific goals of this Ministry.”
Long-Term Care Facilities: Barriers and Concerns
MOHLTC told the Commission that it recognizes the importance of long-term care as a key element of Ontario’s health system, and has committed to investment in long-term community-based and facility services. It told the Commission that, “in 1998, to meet the needs of a growing elderly population, Government announced support for the construction of 20,000 new long-term care facility beds and the redevelopment of approximately 16,000 existing beds. This investment in long-term care beds is $602.4 million”. Recognizing that residents of long-term facilities have increasingly complex needs, MOHLTC also introduced new design standards and guidelines for long-term care facility design in 1998. These standards and guidelines will apply to the 20,000 new beds and 16,000 renovated beds expected to be completed in 2004.
Furthermore, MMAH told the Commission that through the protections provided under the TPA, it maintains its role in the regulation of care homes. MMAH said that protections include the ability of care home tenants to terminate their tenancies with 30 days notice; the requirement that care providers give tenants written tenancy agreements outlining care and meal services to be provided; and the requirement that care providers provide tenants with information packages regarding the cost and availability of meal and care services and emergency services.
Nevertheless, a number of the submissions identified concerns with long-term care facilities in Ontario. The Canadian Mental Health Association highlighted the shortage of long-term care beds. They told the Commission that, at times, this has resulted in the inappropriate placement of older adults who experience mental health issues, a particularly vulnerable group of older persons.
Senior Link and a number of other groups highlighted the concern regarding the lack of regulation of rest and retirement homes. The Commission was told that the lack of regulation in such facilities allows for substandard care to exist and the abuse of older persons to occur (Ontario Coalition of Senior Citizens’ Organization and Canadian Pensioners Concerned). ARCH (A Legal Resource Centre for Persons with Disabilities) expressed concern about “the indiscriminate use of physical restraints in institutions on elderly patients and the psychologically disabled”. Another group noted, “low income seniors are at a disadvantage because they have to take what they can afford in a retirement home which may be sub-standard (Alliance of Seniors to Protection Canada’s Social Programs)”. A number of groups told the Commission of the need for monitoring, standards and legislation that will ensure appropriate care and safety for older persons living in retirement residences. The need for a Residents’ Bill of Rights was highlighted. CARP specifically recommended that the provincial government take responsibility for developing the necessary legislation and standards.
Alternatively, the Chatham-Kent CCAC suggested that MOHLTC should enhance the capacity of the Ontario Residential Care Association (ORCA) to enable it to self-regulate the industry. The MOHLTC submission provided insight into government action on this issue. It noted that “with funding assistance from the government, the Ontario Residential Care Association (ORCA) is expanding its self-regulatory program for retirement homes [to include] a consumer complaint investigation system and the development of a checklist for consumers on what to look for in a resident’s contract with a retirement home.” Details as to the progress of this expansion were not provided.
Several groups expressed concern regarding the cultural, linguistic and religious needs of older persons living in long-term care facilities. One group noted that not all ethnic groups have their needs addressed equally within such facilities. Dieticians of Canada noted that the cultural, linguistic and religious needs of older persons must be given equal consideration. They suggested that the provincial government support the development of educational packages to be used in long-term care facilities that would assist staff in providing appropriate and respectful care (for example in the provision of food, religious observation and culturally specific social activities).
The Canadian Association of the Deaf and the Canadian Hearing Society expressed great concern regarding the treatment of Deaf older persons in long-term care facilities and senior residences. The lack of TTY systems, visual alarms in bedrooms, hallways and bathrooms, and shake awake alarms means that Deaf persons are placed at risk and excluded within their own living spaces. There is a critical need for more residences specifically designed for Deaf seniors given that there currently exists only one (The Bob Rumball Centre for the Deaf) in the entire province. Several groups noted that this issue is further compounded for those living in rural areas where programs for Deaf persons may not be available at all. It was recommended that all levels of government, in partnership with the Deaf community, must work to ensure that nursing homes and retirement homes are accessible to Deaf older persons (Canadian Association of the Deaf).
“Current practices tend to generalize and treat all people over the age of 65 as identical...this can unfairly limit access to required services for people with Alzheimer Disease, ultimately threatening the independence and dignity of this growing segment of the population.”
(The Alzheimer Society of Ontario)
The Alzheimer Society of Ontario raised specific concerns regarding the treatment of persons living with Alzheimer Disease while residing in long-term care facilities. MOHLTC told the Commission that, “half of the residents in facilities have Alzheimer Disease or related dementia.” The Alzheimer Society of Ontario emphasized that this group has unique needs, however, “current practices tend to generalize and treat all people over the age of 65 as identical...this can unfairly limit access to required services for people with Alzheimer Disease, ultimately threatening the independence and dignity of this growing segment of the population.” As well, the way in which funding levels for long-term care facilities are determined, does not take into account the cognitive and behavioural care needs of persons with Alzheimer Disease. This impacts on the ability of care facilities to appropriately address the needs of this growing group of older persons.
Others expressed concern regarding the independence of certain groups of older persons in care facilities. The Canadian Mental Health Association noted that sometimes, a conflict of rights occurs, wherein the right of an older person to live at risk comes into conflict with the rights of caregivers to intervene. The Ottawa-Carleton CCAC stated that staff in institutions must be knowledgeable of the older person’s right to refuse treatment or care, a right that must be respected, even if it leaves the older person at risk. The Ontario Association of Social Workers emphasized that health decision-makers within long-term care facilities must take seriously and support the wishes and decisions of the older person in care. With respect to end of life decisions, the Alzheimer Society of Ontario added that, “it is the right of all individuals to be able to make choices regarding end of life and to have those choices respected. In Ontario, legislation exists to protect this right, however, the legislation is not always followed, for example, when family members are vigorously opposed to an Advance Directive or the decision of the Substitute Decision Maker.”
Finally, a number of organizations commented on the barriers faced by older couples once they reside in a care facility. Dieticians of Canada noted that older couples face difficulty in obtaining accommodation in the same room, the result of which can be “forced separation” of the couple. Anxiety and loneliness can occur as a result. This, in turn, can have a negative impact on the older couple’s health and well-being. Separation may also occur due to differing levels of care required by the couple. They suggested that multi-level care facilities that can address varying levels of care would assist in ensuring older couples are not forced to live separately. As noted earlier, ACT and CLGRO added that gay and lesbian couples face considerable barriers in care facilities, given that at the outset, their relationships are often not even recognized or validated.
The focus on acute care
“Health care for seniors takes second place to other aspects of the health care system. Comparative spending on community health care and long-term care, whose target population is primarily seniors, is a fraction of the health care spending for acute care.”
A number of the submissions noted an emphasis on acute care, which diverts attention from the long-term care needs of older persons. Senior Link told the Commission that, “in the process of hospital restructuring, what we have found is that community-based care has become acute care...long-term care has been put on the shelf...” The Alzheimer Society of Ontario emphasized that the focus on acute care means that, “elderly people, particularly those with chronic diseases like Alzheimer Disease or related dementia are not able to get adequate services, or in some cases any services at all.”
A shortage of knowledgeable health care professionals
Consultees also noted that access to health care professionals who are knowledgeable about the aging process is a key concern, particularly in the context of the growing population of older persons in Ontario. The Alzheimer Society told the Commission that its own research has revealed that minimal amounts of teaching time are currently allocated to the issues of aging and dementia in Ontario medical schools. As they and others noted, “[the] lack of training in these areas will lead to barriers for older adults who need to utilize the health care system and will compromise the quality of care and/or access to appropriate care” (Alzheimer Society of Ontario).
The Commission also heard that it is very difficult for older persons without a physician to obtain one (KFL&A CCAC). The CCAC of Timiskaming told the panel that accessibility to health care is limited by the shortage of physicians throughout Ontario. To address this issue, they suggested “incentives for physicians to specialize in geriatrics”. It was emphasized that because many physicians no longer make home visits, accessibility is limited for some older persons. The Commission heard that this issue is compounded in rural communities where the access to doctors, and in particular specialists, is “virtually non-existent”. As the number of older persons increases, these problems will intensify. The Canadian Mental Health Association – Windsor-Essex, branch added that as a result of shortages in physicians, nursing staff and personal support staff, inadequate and inappropriate care can result.
To address the shortage of physicians within the province, MOHLTC told the Commission that it has implemented the “Underserviced Area Program” to attract and retain health care providers within the northern, rural and remote areas of the province. The program includes “financial incentives for physicians willing to relocate to under serviced areas, recruitment initiatives, practice supports and enhancements to access to medical services for affected communities”.
Barriers to health care information
The Commission heard that a number of groups of older persons are not receiving information about health care services, thereby limiting access. They emphasized that while CCACs have services to offer, many older persons are either unaware of the existence of CCACs and the availability of their services or are reluctant to ask about them. Additionally, the Commission was told that internet-based communication is not very effective in reaching older persons. Consultees noted the need for outreach so that older persons throughout Ontario are aware of the services that are available. CCACs indicated that with additional funding, they would acquire greater capacity to do so.
The Commission learned about barriers to health information that extend beyond the issue of public education. Issues such as language and citizenship status pose particular barriers for certain groups of older persons:
“We have often found that a family will be reunited in Canada and [the older person] will not have citizenship status and that leaves them very vulnerable because they cannot access the health care system.”
The Ontario Association of Social Workers noted health care and other service providers must ensure that linguistically appropriate services are available: “services in the language of the elderly person is of course crucial...[service providers should] make it a policy to employ people who speak the language of the people [they] are serving”. In addition, they noted that CCACs should ensure that their materials are published in various languages.
“Health care, long-term care, elder care, mental health service providers, employed by the public and private sectors must be provided with in-service training to give them a better understanding of ...the use of various communication strategies for Deaf, deafened and hard of hearing people.”
(The Canadian Hearing Society)
The Canadian Hearing Society noted that Deaf, deafened and hard of hearing older persons experience communication barriers in the context of health care services. It told the Commission that staff within the health care system are unable to communicate with older persons who experience hearing loss. The Supreme Court of Canada’s decision in Eldridge v. British Columbia (Attorney General), has confirmed that sign language interpretation, where necessary to ensure equal access to health care, must be provided. Nevertheless, consultees indicated that while the decision was a significant milestone, its implementation has been slow.
It is the Commission’s view that health care providers in Ontario should abide by the Eldridge decision by providing sign language interpretation to respond to the needs of Deaf persons. As consultees noted, it would appear that health care and other service providers should be trained in appropriate communication techniques that respond to the needs of Deaf, deafened and hard of hearing people.
Cost as a barrier to access
The consultation revealed that a critical barrier for older persons is the limited access to health care benefits often experienced in later life. Many employer drug benefit programs cease on retirement or termination. Those who are too young to be eligible for the Ontario Drug Benefit plan, or those who find themselves “in-between” private coverage are often required to pay for health related products and services. Some older persons may not be able to afford to do so.
Canadian Pensioners Concerned emphasized the reality of cost as a barrier to health care services for older persons. They told the Commission that the costs of prescriptions can sometimes place older persons in a position of choosing between buying medicine or other necessities of life. This can, in turn, lead to a life at risk. The Alzheimer Society of Ontario added that drugs to treat Alzheimer Disease cost approximately $5 per day, creating a significant barrier for older persons who are not covered by a health plan or the Ontario Drug Benefit (ODB). As they noted, “without coverage, many adults do not have access to timely interventions that can maximize quality of life and minimize their stress, anxiety and caregiver burden.” Dieticians of Canada added that, “coverage of nutrition supplements [under the ODB] is not adequate. Many of Ontario’s elderly, whether living at home, in retirement homes or in long-term care facilities are experiencing complications of malnutrition.” The Commission was told that to address this issue, MOHLTC should work to expand the types of prescription drugs and alternative therapies that will be covered for older persons by the Ontario Health Insurance Plan (OHIP).
“More and more seniors are having to resort to the use of food banks because they can’t afford to buy food and the very expensive drugs which are often prescribed but not included on the list covered by the provincial health plan (The Ontario Drug Benefit)...the alternative is to go without drugs.”
(Canadian Pensioners Concerned)
Older persons who have or may develop a disability also experience barriers because of the cost and availability of assistive devices. The cost related to assistive devices presents a significant barrier, particularly since those who may need them most may be the least likely to be able to afford them.
Even where government funded assistive devices programs exist, they may only offset some of the costs or pay for basic technology instead of better devices that would improve an individual’s quality of life. In addition, age limits in the provision of such programs pose another barrier and have been challenged as a form of age discrimination. For example, in Ontario (Human Rights Commission) v. Ontario (Ministry of Health) the Court of Appeal found that the Ontario Ministry of Health’s Assistive Devices Program could not restrict the provision of closed circuit television magnifiers only to persons under the age of 25. A 71-year-old man had been refused this visual aid. Additionally, the Commission has recently initiated a complaint against the MOHLTC and its contractor, the West Park Healthcare Centre, for using age-based criteria in the provision of assistive devices. Under the program, access to incontinence devices is restricted to persons born after July 1, 1963, thereby excluding older persons.
Consultees also mentioned the cost associated with dental benefits as a significant barrier for older persons. The CCAC of Halton noted that “Ontario does not have a universal dental program for seniors [and]...the majority of older adults are without dental insurance”. It told the Commission that without a dental plan and with limited income, older persons do not access regular dental care. This can result in poor oral health leading to “physical, psychological and social problems”. Dieticians of Canada and the CCAC of Halton noted the importance of good oral care to the ability of an older persons to maintain weight and avoid “systemic health problems”. The need for affordable and accessible dental coverage for older persons was emphasized as a critical aspect of any efforts to address the health-related needs of older persons in Ontario (Halton Health Department).
Social barriers to access
Throughout the consultation, the Commission heard about the social barriers to accessing health care and institutions experienced by older persons. The Ontario Association of Social Workers told the Commission that, “older adults are frequently characterized as non-contributing members of our communities and their need for services [are] portrayed as being a drain on scarce public resources”. The Ontario Coalition of Senior Citizens’ Organizations and others told the Commission that older persons are often labelled as “bed-blockers”. The Ontario Association of Social Workers added that this labelling of older persons, “infers that patients who are legitimately in need of long-term care beds are partially responsible for the shortage of emergency room beds...[and] shifts attention away from the vitally needed public debate about government priorities and funding for our health care system”.
“The health care system tends to place priority on those who are younger and those who are working...If you are older, the younger person gets to the top...that is age discrimination.”
(Canadian Pensioners Concerned)
A number of organizations told the Commission about the impact of ageist assumptions upon the care of older persons. Canadian Pensioners Concerned told the Commission that older persons in Ontario are the last to be considered when it comes to health care services. The Canadian Mental Health Association provided the Commission with an example of how this is experienced by older persons. It told the Commission that older persons, particularly those facing mental health issues, are often faced with the comment “what do you expect for your age” when they meet with health care professionals. A number of groups added that some physicians “normalize” concerns of older persons, often relating them to the aging process and, in turn, providing inadequate assessment and follow-up.
The Ontario Coalition of Senior Citizens’ Organizations emphasized that older persons are often identified as a lower priority for surgical procedures and are often over-prescribed medication. Additionally, a couple of organizations expressed concern that powers under the Canada Health Act could allow for health care providers to limit access to health care procedures on the basis of age. A number of the consultees, including the Chatham-Kent CCAC noted that they had heard anecdotal evidence of doctors limiting the access of older persons to procedures and to their practice. As ESAC told the Commission, the health care system in Ontario must provide older persons with the same level of care and consideration as would be provided to a younger person.
The Canadian Mental Health Association, Windsor-Essex branch, told the Commission that for older persons experiencing mental health issues, ageist assumptions continue to compound their marginalization within the health care system. Such attitudes lead to insufficient levels of attention paid to the mental health needs of older persons. They told the Commission that this frequently results in the use of chemical or physical restraints that have been documented in research as leading to further deterioration. The Ontario Coalition of Senior Citizens’ Organizations noted that older persons also experience infantalization at the hands of health care providers and that when an older person requires admittance to a hospital, they are often faced with resistance, particularly if the person is also experiencing mental health issues. Karen Henderson emphasized that in response to such treatment, “there is a critical need for training to be instituted for health care providers so that they may be equipped to address the health care needs of older persons in a manner that is effective and respectful of human dignity”.
“There is a critical need for training to be instituted for health care providers so that they may be equipped to address the health care needs of older persons in a manner that is effective and respectful of human dignity.”
“The Canadian Hearing Society would recommend that you, the Human Rights Commission, urge the Secretary of Cabinet and the Deputy Minister of Management Board Secretariat to ensure that all Ontario Ministries are aware that the Ontario Human Rights Code requires their services, including contracted services, be accessible to all older people with disabilities.”
(The Canadian Hearing Society)
A number of consultees said that ageism and age discrimination extend beyond health care services into other areas of service delivery. The Canadian Centre for Activity and Aging told the Commission that older persons are “politely discriminated against” by virtue of the fact that many public buildings and facilities are not accessible. As the Golden Years Club of Lakefield pointed out, access to buildings for older persons, particularly those who experience a disability, remains an issue of access to services. They told the Commission that municipalities should ensure that municipally owned buildings are accessible. Canadian Pensioners Concerned and others noted that there is a strong need for a disability act and a [revised] building code in Ontario that would require service providers to ensure that their buildings and services are fully accessible. The Advocacy Centre for the Elderly noted that, “ the impact of this type of legislation, if made mandatory compliance and if applied to all sectors (not just government), could result in a great improvement in services and systems for seniors”.
Several organizations told the Commission that older persons who are Deaf, deafened and hard of hearing face additional barriers to services because of the systemic exclusion that they experience throughout their lives. The Canadian Association of the Deaf told the Commission that the major barriers tend to be systemic and economic discrimination. The Canadian Hearing Society told the Commission that the shortage of persons trained and available for interpretation presents a substantial barrier for older Deaf persons. The Canadian Association of the Deaf added that barriers are created when a hearing person refuses to pay for interpretation services or when funding is unavailable to cover the costs related to interpretation and other forms of accommodation. As well, they noted that older persons may face communication issues when younger interpreters do not recognize or understand the signs used by older persons. This can lead to frustration and a loss of confidence as to whether others are receiving their information correctly. The Commission heard that when appropriate supports, such as interpreters, are available and accessible for Deaf seniors’ a greater balance of power is had and self-determination encouraged because they are able to express their needs and concerns in their first language.
Others reported that older persons also face attitudinal barriers in the area of services. The Advocacy Centre for the Elderly told the Commission that they receive complaints regarding the paternalism experienced by older persons at the hands of service providers. It noted that older persons are often labelled as “hard-to-serve” clients. At other times, they are treated as if they are incapable and when important decisions are required, service providers often defer to family rather than to the older person him or herself. It explained to the Commission that, “in the end it has a discriminatory effect upon the older person because they are not involved in the service delivery themselves... it exacerbates the situation and lessens the contact they have with the service provider”. Clearly such practices negate the principles of dignity, independence and full–participation for older persons in such circumstances.
“The paternalism we see in service delivery...we receive complaints from seniors who identify that they are not the people being dealt with in terms of services...its their family...[seniors] are not treated as the decision maker or they are treated as if they are incapable.”
(Advocacy Centre for the Elderly)
Many of the submissions identified the same concerns that the Commission noted in its recent Discussion Paper on Accessible Transportation Services in Ontario. Senior Link told that Commission that, “the transit system and wheel trans are not accessible for many seniors who need assistance getting to a doctor or into a hospital...they need to be supported so that seniors can access programs...in rural Ontario, this issue is amplified because of the isolation and the lack of transit”. Canadian Pensioners Concerned echoed this concern and told the Commission that for older persons, particularly those with mobility impairments, transportation is extremely limited and this can lead to isolation from family, community and from the general activities of daily living. One group told the Commission that, “ travel to the doctor, dentist, or store for rural seniors is very difficult...if they cannot drive or there is no public transportation, they must rely on family or home support” (Council on Aging for Renfrew County). Given what the Commission heard about limitations in community-based supports and the availability of physicians, transit inaccessibility compounds the barriers to health care and other services for older adults.
“The populations of many small communities have a large proportion of seniors. These communities do not now have, nor have [they] ever had, public transportation. This restricts seniors from accessing health, social and commercial services in larger centres. Recognize that any policy initiatives will have a different effect in the rural north than in, for example, Toronto, Ottawa or Sudbury.”
A number of organizations strongly emphasized the need for more accessible transportation. Ramps, elevators, escalators and low floor and lift-equipped buses are critical for ensuring equal participation of older persons with disabilities. Bright lighting, contrasting floor materials and audio announcements make it easier for persons with low vision to use public transit. TTY phones and written announcements improve accessibility for persons who are Deaf, deafened or hard of hearing. As the Canadian Hearing Society (London) noted, public transportation buildings often are not equipped with sufficient and proper TTY equipment or public address systems. Others noted that in addition to physical barriers, older persons often face “poor treatment” by public transportation employees signalling the need for sensitivity and awareness training to address such social barriers (The Ontario Coalition of Senior Citizens’ Organizations).
For those who cannot access even a well-integrated conventional system, there is a need for parallel para-transit services. The Commission heard, however, that the eligibility criteria for many para-transit services may disentitle older persons with certain types of disabilities, e.g., disabilities that arise from respiratory problems, heart conditions, and cognitive impairments resulting from stroke, dementia or brain tumours, and sensory disabilities. Consultees also noted that even those who are eligible find that para-transit services are not adequate to allow them equal access to public transit.
The Commission heard that while there have been some improvements over the last few years, transportation in Ontario remains inadequately funded. The Ontario Coalition of Senior Citizens’ Organizations noted that evidence of under-funding can be found in the area of volunteer escort services provided by MOHLTC. It told the Commission that such services are only available for medical appointments. Transportation that would allow older persons to attend social and recreational activities is either unavailable or limited. ESAC recommended the implementation of creative solutions to the transportation issues facing older persons in urban and rural areas. They suggested a subsidized taxi program while Senior Link recommended community-based volunteer networks based in local organizations that could provide older persons with transportation to their various appointments. Dieticians of Canada suggested that, “Municipalities, District Health Councils and the Ministry of Health and Long-Term Care need to support the development of funded transit systems and review eligibility so that transit is available to all who need it”. The Older Women’s Network simply suggested that to address the transportation issues facing older persons, all levels of government should provide subsidies and invest appropriate amounts of money to ensure that an adequate system of transportation is available.
Recommendations For Government & Community Action
21. THAT medical schools and training centres for health care professionals and others who work with older persons enhance education on the needs of older persons.
22. THAT health care institutions, facilities and services be made accessible to all older persons, particularly those with disabilities.
23. THAT the government should exercise caution in the use of age-based criteria in health care programs such as assistive devices, prescription drug and dental programs.
24. Consistent with the Eldridge decision, that service providers provide sign language interpretation services where necessary to ensure equal access for persons who are Deaf, deafened and hard of hearing.
25. THAT the provincial government take further steps to regulate rest and retirement homes. Issues to address might include a Resident’s Bill of Rights and standards for the use of restraints and end-of-life decisions.
5. The Commission will communicate with the Ontario College of Physicians and Surgeons, the Ontario Medical Association and the Canadian Medical Association and other appropriate organizations to advise that unequal access to medical treatment and other health care services on the basis of age or disability may constitute discrimination.
6. The Commission will contact and meet with professional faculties such as medicine, nursing, dentistry, nutritional sciences and social work to discuss the urgent need to include comprehensive education on age discrimination within their curricula and to ascertain their plans for including such education in their programs.
7. The Commission will continue to take steps to promote accessibility amongst service providers throughout Ontario.
 Long-Term Care Act, 1994, S.O. 1994, c. 24.
 Eldridge v. British Columbia (Attorney General),  3 S.C.R. 624 at para. 96.
 (1989), 10 C.H.R.R. D/6353 (Ont. Bd. Inq.), aff’d 14 C.H.R.R. D/1 (Ont. Div. Ct.), rev’d 21 C.H.R.R. D/259 (C.A.).