Prior to the TCCAC's organizational name change from the Home Care Program for Metropolitan Toronto, the largest single provider of home-care services in Canada, Camille was its Senior Vice-President. After graduating with a Master of Health Science from the University of Toronto in 1983, she joined North York General Hospital as a Manager, in two positions until her 1986 move to home care. She holds a BSc in Medical Record Administration from Viterbo College in Wisconsin, and is a Certified Health Executive, Canadian College of Health Service Executives. Camille has worked with many volunteer organizations and boards, most notably Regent Park Community Health Centre, and in 1999 was given the Leadership Achievement Award from the Society of Graduates in Health Administration at the University of Toronto.

Under Camille's leadership, the TCCAC instituted new regulations on May 1 so clients now have 24 hours to decide whether to accept a bed, with the bed held for five days, up from three under the previous policy. If clients decline or defer, they now must wait six months to reapply, a policy of concern to those working with seniors since deterioration can occur quickly. Given recommendations for national home-care services and long-term facilities are in Roy Romanow's Future of Healthcare report to be released later this year, this issue has national significance. We welcome Camille's thoughts on this and, of course, as with all our profiles, her unique personal reflections and insights.

Your career is largely in administering community health services. Why is this aspect of health intriguing?
Working in the community sector is congruent with my own values and politics. I'm one of those very fortunate people who love their work. I've always felt a need and responsibility to be active in the community and consider myself fortunate in being able to contribute. It's very gratifying to feel you can make a difference. As well, the TCCAC has cultivated staff dedicated to the community and this enhances our shared commitment and enjoyment of our work. Being active in my community is an essential part of who I am. My volunteer activities reflect my commitment, and did not always directly involve either healthcare or what's considered mainstream. I was a founding member of the Canadian Home Care Association, the Black Coalition of Aids Prevention and served on boards of Regent Park Community Health Centre, Pedahbun Lodge and Immigrant Women's Health Centre. When I first got involved in AIDS work, it was still low profile in community activism; home care responded early to providing services for the AIDS population.

Greater Toronto is served by six CCACs: Scarborough, North York, York, East York, Etobicoke and Toronto. Our community is defined by boundaries of the old City of Toronto. Ours is arguably the most diverse area of the city with clients representing a broad range of countries of origin, ethnic and cultural groups, languages, economic situations from very wealthy to those in poverty, and wide variations in health status. Providing services is interesting, challenging and, most of all, rewarding.

Since most don't actively choose to be consumers of healthcare delivery, how do you choose whether to call people clients, customers or patients?
The manner in which we communicate is a vitally important aspect of our presence. Much of our work is conducted in the homes of people whom we refer to as our clients. We're guests in their homes, and the words we use must convey our recognition of this fact. We may have knowledge, but the clients have the power in their own homes, and we respect that they've chosen us as their provider of health services.

You give information sessions and post 13 languages on your website, but it's still difficult for many to understand how the TCCAC operates. How do you connect with the silent and hard-to-reach?
Since our community is so extensive and diverse, we're well aware there are groups that may get overlooked. Attempting to reach groups by encouraging representatives to serve on boards or committees isn't really effective because you don't really get the voice of the community, but rather one voice, generally that of a well-educated, English-speaking activist. We don't want to limit ourselves to these viewpoints. This is why we put so much effort and energy into community outreach initiatives. We scan the community and, each year, target specific areas on which to concentrate outreach activities. We also invite representatives from a wide range of our population to participate in focus groups. These individuals represent specific target populations … ethnic or cultural groups, senior clients and their families, caregivers of all ages, health professionals in the community, etc. We don't want to be limited to the views of articulate activists only.

The goal of Regent Park's Community Succession Mentorship Program (www.regentparkchc.org) is to stimulate career development so children will become doctors, nurses, health professionals and administrators. How's it doing?
The Community Succession Mentorship Program for children grades 8 through 12 is part of Pathways to Education that provides educational, social and financial supports to economically disadvantaged at-risk young people in the Regent Park community. The first cohort is now completing grade 9, and results to date offer compelling reasons for optimism. Data gathered certainly shows support provided is making an important difference to these students. However, healthcare organizations could give this program a huge boost by developing initiatives by offering volunteer training and work opportunities. They could provide summer employment for these students. Hospitals are always talking about being part of the community, yet rarely can they point to a program that directly benefits the community. Well, here's their chance! We worry about recruitment … well, here we actively encourage healthcare careers among these young people. These are kids who reflect the diversity of our community and an employment pool for the future. These are excellent programs that truly make a difference and we in the healthcare sector should be giving them our full support in whatever way we can. These are the long-term initiatives that are so needed in today's healthcare system.

Another program is Parents for Better Beginnings, aimed at parents and young children. How does this lead to better health - perhaps also reduced health costs - illustrating that spending on community services is good for the system?
One really frustrating aspect of our system is its continuing emphasis on "sick care." There's little emphasis on changing the flow downstream. The Regent Park Programs make a difference upstream by focusing on the child when real health promotion can truly make a difference. Social determinants of health are now well known, yet little has been done to put this knowledge into action for change. Parents for Better Beginnings is a primary prevention program in partnership with community organizations and residents' groups to promote positive development in children. It encompasses a series of programs offering pre- and post-natal support, parent education, language and communication courses, playgroups, parent relief, outings/trips and workshops on life skills and other areas recommended by the community. These help to minimize risk factors that create serious social, emotional, behavioural, physical and cognitive problems and introduce protective interactions and activities that support development of healthy babies, healthy home environments, positive child/adult interaction and increased self-esteem in children. The end result is healthier children and a first step in refocusing from "sick care" to health promotion.

With some 8,000 Torontonians waiting for a nursing-home bed and situations that can deteriorate rapidly, how crucial is coordination of home care in helping people to stay in their homes?
Most people would prefer to stay out of institutions altogether. The health continuum ranges from healthy, active and independent through to illness, frailty and, ultimately, dependence. Healthcare should reflect this complete continuum. However, there's a fundamental weakness in the system that allows only two choices: stay in your home or long-term care facility. Of course, there are retirement homes, but these are limited to the small sector of the populations able to afford them. The missing link is supportive housing. Home care tries to support clients in the home as long as possible, but there's a cap on services. Those with more bountiful resources are able to stay in their homes longer than those with only minimal reserves. There should be a policy to allow funding of additional support in the home, up to what it would cost to support the individual in a nursing home.

Is the hope that with increased coordination, the deferred option will evaporate?
The deferred option for long-term care beds was not government policy, but initiated by CCACs to help people who wanted to stay in their homes as long as possible. However, with the advent of the MDS standardized assessment, the new lists more accurately pinpoint those who truly need long-term care facilities. And that, in itself, should lead to shorter waiting lists.

If people turn down a bed, thinking it may be too soon for institutionalized care, doesn't this actually penalize them for attempting to stay or care for others at home?
The introduction of the new regulations and planned implementation of MDS-HC as the common assessment tool for the province will result in clients being deemed eligible when they are in immediate need for a long-term care bed. What's missing from the system is the ability to plan for one's future care. A couple can move into a retirement home adjacent to an affiliated facility to accommodate aging in place. They can no longer have themselves placed on the LTC facility waiting list. If they are hospitalized with a stroke and cannot return home, there is no guarantee where they will be placed while waiting for their first-choice bed. On the other hand, if individuals who can afford retirement homes get first choice and preference for affiliated LTC facilities, then others and particularly those from disadvantaged groups would not get in. One possible solution may be that every third admission to these LTC facilities be from the retirement home.

Is this policy change evolutionary? With the new system and beds (increasing from 60,000 to 74,000 by the end of 2004), what do you see in future for CCACs?
CCACs should become agencies whose key role is client assessment and the development of service plans. They would be responsible for determining client eligibility for the entire spectrum of services including in-home care, adult day programs, supportive housing and complex continuing care.

A 1999 TCCAC report predicted a disaster in community care, based on a human resource shortage and increasing demand. Was this addressed?
We're certainly experiencing a human resource shortage in healthcare, and it will get worse over the next five years as health personnel retire. The situation will be further exacerbated as new long-term beds come into the system and personal support workers are pulled from the community into institutions. The human resource crisis will continue until we effectively deal with disparity in wages and working conditions between community and institutional sectors.

One website survey on the Future of Healthcare commission solicits views on home-care funding. What's the best-case scenario you foresee for national changes?
I hope the government develops a national home-care strategy. Such a strategy would determine how we define healthcare, home care and health maintenance. Many procedures previously done in hospitals are done as day surgery procedures, with post-surgical care and recuperation at home. Health should be funded universally, wherever it's delivered. Health maintenance programs should be provided to all Canadians, with cost-sharing as an integral factor. It would involve such services as cleaning and laundry and would be based on a sliding scale so people pay according to their means.

How does your organization assist with providing urban health services?
We learned in treating the homeless and other marginal populations that it's more effective to partner with agencies and organizations in the community that have established a relationship. We then take our services to those who need them in their own environment, thus giving them a measure of control. We must recognize that equitable access to care is distinctly different from equal access to care. Services and educational materials must be designed to ensure equitable access. For some populations, you must initiate specific steps to bring them into the healthcare system. A prime example is hospitals: they offer equal access, but if they offered equitable access, they'd provide services on evenings and weekends for those unable to go weekdays between 9 a.m. and 5 p.m. Wherever and however we deliver services, equitable access requires we take that extra step. One step forward in providing equitable service is to ensure our workforce accurately reflects our community.

What's your favourite speech topic?
I most enjoy talking about how we can make a difference in the lives of children and how we can truly practise health promotion in a way that has huge payoffs for young people.

Do you have fun at work?
Yes, I do indeed! I consider myself fortunate because my work is so in keeping with my values and beliefs. My work is very gratifying because it often affords me the opportunity to make a knowledge transfer, to pass on what I've learned to the next generation and to help them define their places in the world. I am privileged to work with a great bunch of dedicated individuals who share an amazing, sometimes irreverent, sense of humour.

What would you do in a one-year sabbatical?
No question about it; I'd spend it in Africa! I'd first go to West Africa for a few months, where I'd like to work with women on development issues. This would allow me to fulfill my fierce desire to learn African dance and indulge myself in the clothing. Next I'd go to South Africa to enjoy the spectacular beauty of the land and immerse myself in the music. The final months I'd spend in East Africa on safari, going out in the day and returning to lovely lodges with all the modern amenities. There is nothing whatsoever in my genetic make-up that would tempt me to take part in any sort of "roughing it" or camping experience.

What book(s) are you reading?
John le Carre's The Constant Gardener. My reading tastes encompass black literature, spy and mystery novels and science fiction.

What do you do for fun?
I love to visit cafes and restaurants, from very expensive to tiny establishments, places little more than a hole in the wall. Toronto's wonderful multiculturalism is reflected in the availability of dishes from every corner of the world, and I love to try them all.

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