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PERSONS WITH DISABILITIES ADVISORY COMMITTEE

Transforming British Columbia:Making BC Canada's Most Accessible Province - at Minimal Cost

A Submission to the White Paper Consultation

Submitted by the City of Vancouver

Persons with Disabilities Advisory Committee

March 2014

Transforming BC into Most Accessible Province at Minimal Cost: Submission from City of Vancouver Persons with Disabilities Advisory Committee ,Page 1/50

PERSONS WITH DISABILITIES ADVISORY COMMITTEE

Transforming British Columbia:Making BC Canada's Most Accessible Province - at Minimal Cost

This paper focuses on transforming British Columbia into the most accessible province

in Canada sustainably and cost-effectively. Specifically, we focus on two areas that are

central to full independent community living: housing and home support.

There are many barriers to the full participation of persons with disabilities in British

Columbia and in Canada, and there are many possible ways to remove these barriers to

become a fully accessible province.

We have chosen to focus on only two areas - housing and home support - because:

These are pivotal areas whose impact is amplified because they cause

improvements in many other areas including employment, education, poverty, and

community inclusion.

These are essential for full integrated community living, a right guaranteed in the

United Nations Convention on the Rights of Persons with Disabilities.

These are areas where significant change can transform the province at little or no

cost.

There are best practices already successfully in place in other countries/cities.

There is substantial research documenting the minimal cost and significant benefits

of these measures.


Introduction and SummaryThe current system of providing services and supports to persons with disabilities in British Columbia is fragmented, expensive, and does not provide the support required by the United Nations Convention on the Rights of Persons with Disabilities for the full and equal participation of people with disabilities in our society.

The way that supports for people with disabilities are currently organized is itself a significant barrier to people with disabilities functioning as equal, full, and productive members of our province. Services are disconnected; do not have adequate levels of assistance; do not support full productive participation; remove decision-making, autonomy, choices and freedom; and leave people with disabilities isolated, dependent and not able to help themselves or function fully in our province.

The way the province budgets services for persons with disabilities is also a significant barrier and results in services that increase overall costs and are fiscally inefficient. This is because the province budgets these services in a narrow “silo”- like way, so that only the costs and benefits of one service/program are considered, without looking at overall costs and benefits. This results in services and supports that actually cost the government more money, and at the same time, prevent people with disabilities from being full participants in our culture. 1

In addition, services and programs for persons with disabilities almost always take away people with disabilities’ autonomy, choices and control, and are almost always designed and administrated by persons who do not have a disability. This lack of an independent living model results in the fragmented inefficient and costly services we have now, which are themselves a significant cause of the isolation, poverty and exclusion of people with disabilities in British Columbia.

We need to move away from a system that basically disables people by removing their rights, autonomy, choice and freedom, to a system that recognizes the rights and potential of all people with disabilities, and is organized in a way to support people’s independence, productivity, and ability to help themselves.

We therefore recommend that the province: Commit to ensuring the provisions of the United Nations Convention on the Rights of Persons with

Disabilities are followed in British Columbia Ensure that all programs and supports for persons with disabilities in British Columbia are organized

to enable people with disabilities to have autonomy and choice over their services and their lives Commit to using the social model of disability as defined by the UN Convention on the Rights of

Persons with Disabilities in all of its programs and services for people with disabilities Use budgeting processes that consider overall benefits and costs, not just those for a single

program, so that considerations of the cost-saving benefits of people with disabilities being productive members of society can be included

Ensure that programs and supports for persons with disabilities are designed by or with people with disabilities and are administrated on an independent living model

Use an evidence and best practices model for budgeting and planning services and supports


In addition, we specifically recommend that the provincial government take a few simple measures to ensure that people with disabilities are included in society, can access appropriate housing, can function independently as full and equal citizens of British Columbia, and can work, raise families, and participate equally in our society as guaranteed by the United Nations Convention on the Rights of Persons with Disabilities.

These specific measures are:

1. Visitability: ensure all newly built housing is minimally accessible at no government cost

We recommend that the Province require visitability standards in all newly constructed housing in British Columbia.

Visitability improves housing for everyone by including a few basic inexpensive universal design features in all new homes. The three basic features are 1) one zero-step entrance on an accessible path 2) wider doors/halls 3) bathroom on main floor that can be used by a person in a wheelchair.. Universal visitability is a simple cost-effective measure that ensures that everyone, regardless of their age or ability, can access housing in BC. Visitability has substantial benefits for seniors, families, people with disabilities and government; does not cost the government any funds and actually saves significant government funds currently spent on preventable falls, hospitalizations, health care, and home care; inexpensively adds to the accessible housing stock; has negligible construction costs; and has a proven track record where it is already successfully in place in England, Ireland, Wales, Denmark, Scotland, Sweden, Norway, Austin, Tucson, Bolingbrook.

2. Targeted subsidy to preserve the rapidly diminishing wheelchair accessible housing stock

There is currently a critical shortage of wheelchair accessible suites in British Columbia, with one in five persons with spinal cord injury reporting waits of over five years to obtain housing.

This serious situation is rapidly becoming worse because many fully accessible suites do not have or are losing subsidy, so a significant amount of invaluable and urgently needed accessible housing stock is no longer available to persons with disabilities who cannot usually afford market rent.

This situation will continue to get worse quickly, because all co-ops are losing their subsidies in the next few years.

We recommend a targeted subsidy of wheelchair accessible suites that will stop the increasing loss of affordable fully accessible units in British Columbia, and ensure that persons who need accessible suites can be properly housed and able to function productively in society. We have recommended a limited targeted subsidy to contain costs and to focus resources on those most in need.

This is a cost-effective measure which preserves already-existing fully accessible housing, which is significantly less expensive than building new accessible housing stock to replace existing stock that cannot be used due to lack of subsidy, and which will enable properly housed people to contribute and participate to our society.


3. Transform the home support system so it supports full independent living, is fair and cost-effective, and enables people with disabilities to be productive members of society

The current home support system in British Columbia is a significant barrier to the participation of people with disabilities in BC. These home support barriers have been emphasized in many reviews, including one conducted by the provincial Premiers Advisory Council for Persons with Disabilities in 1991 and by a survey of persons with spinal cord injury in 2007.

The current home support system is also fiscally unsound because it causes significantly overall higher health care costs than a more appropriate support system.

We recommend a transformed home support system that provides the assistance mandated by Article 19 of the United Nations Convention on the Rights of Persons with Disabilities, follows the social model of disability and provides the support needed for all the activities of life, is fair and includes an independent appeal mechanism, and is designed on the best practice of consumer control and choice, which has been shown by significant research to promote health, employment, quality of life etc.

4. Extend the existing “no institution” policy for persons with developmental disabilities and persons with mental health issues to persons with physical disabilities. Provide appropriate support and housing so that persons with physical disabilities can actually live full and equal lives in the community.

The government of British Columbia has had a “no institutions” policy for persons with developmental disabilities and for persons with mental health disabilities for many years. This policy is consistent with Article 19 of the United Nations Convention on the Rights of Persons with Disabilities, with human rights decisions, with scientific research on the damaging impact of institutionalization, and with global best practice.

We ask that this excellent “no institution” policy be extended to persons with physical disabilities, many of whom are still living in institutions instead of the community.

To ensure that community living actually occurs as mandated by the UN Convention on the Rights of Persons with Disabilities, significant improvements in housing and home support are needed, as recommended above.

All of these measures are cost-effective, consistent with the UN Convention on the Rights of Persons with Disabilities, remove barriers, and enable persons with disabilities to lead full productive lives.

Perhaps most importantly, all of these measures are far reaching, and enable significant improvements in health, employment, independence, integration, and productivity.

These are fundamental areas where the province can ensure significant improvements in accessibility for persons with disabilities in a cost-effective and sustainable way, and in some instances (visitability) actually save significant amount of funds.


Table of ContentsTransforming British Columbia into the Most Accessible Province

Sustainably and Cost-Effectively

Introduction and Summary of Recommendations Page 3

Section One: Housing Page 7A. Universal visitability; housing for all ages and abilities Page 7

Introduction Page 7 Why is visitability important Page 8 Who needs visitability? Page 9 What is visitability? Cost effectiveness of visitability Page 10 How does visitability work? Where is it in place? Page 11

Mandatory versus voluntary visitability What are the documented benefits of visitability? Page 12

B. Protecting and building wheelchair accessible housing stock Page 22i. The crisis in wheelchair accessible housing Page 22ii. Why is wheelchair accessible housing needed? Page 23

Why are we losing crucial existing stock? Why is there such a serious shortage of wheelchair accessible suites? Page 24 What is an effective solution? Page 25 Impact of this proposal Page 26

Cost effectiveness & economic viability Page 26 Alternative solutions Page 27 Will visitability solve some of these problems? Page 27

Section Two: Home Support Page 28

A. Transforming home support for full independent community living Page 29i. UN Convention on the Rights of Persons with Disabilities:

The right to live independently in the community with appropriate support Page 29Does our system meet the UN Convention requirements?Previous analysis of our home support system

ii. Why is the current home support system a barrier to full participation? Page 30iii. What are the features of a transformed home support system? Page 36iv. The economics of transformed home support Page 38v. Table comparing current home support system to transformed system Separate file

B. No institutions in BC for people with disabilities Page 40i. Following the UN Convention

Expanding the policy of no institutions for persons with developmental or mental health disabilities to persons with physical disabilities

iii. How do we make community living work in BC? Page 40iv. What does the scientific research say about independent living? Page 41v. How do the costs of community living compare to institutions? Page 41

Section Three: References Page 42


Section 1: Housing

Part A: VisitabilityMaking housing accessible to everyone in British Columbia

The most important single step the province can take to make BC the most accessible province in Canada is to mandate universal visitability in all newly built housing.

Visitability ensures accessibility and improves homes for everyone by including a few basic inexpensive universal design features in all new homes: a no step entrance; wider doors/halls; and a bathroom on the main floor. Concrete Change 2012; Maisel et al 2008; Smith 2010; Truesdale et al 2002 It is called visitability because it enables everyone in the neighbourhood to be able to go into homes – to live, to visit, and to be part of the community.

Universal visitability ensures that everyone, regardless of their age or ability, can access housing in BC. It’s a simple cost-effective measure that ensures everyone can access housing; has substantial benefits for seniors, families, people with disabilities; does not cost government any funds, and, in fact, saves government significant funds currently spent on preventable falls, hospitalizations, health care, and home care; inexpensively adds to the accessible housing stock; has negligible construction costs; and has a proven track record where it is already successfully in place in England, Ireland, Wales, Denmark, Scotland, Sweden, Norway, Austin, Tucson, Bolingbrook.


Barrier-free design and visitability are not novel concepts. Rather, they are vital applications that should be implemented as required elements in our future communities. The cost of not putting this in place will be a constant and increasing demand on infrastructure budgets to create new housing for those who can no longer live in their current, inaccessible homes. Canadian Paraplegic Association,2012,p3

Why is visitability important?Currently, most of the homes in BC and in much of the world have stairs and narrow doorways. These architectural features of how we usually design homes present an insurmountable barrier to people with disabilities getting into and using almost all housing.

In other words, this way of designing homes (stairs & narrow doors) unnecessarily excludes people with disabilities from housing and from the rest of society.

But this exclusion of people with disabilities from most housing isn’t necessary. It is possible to design homes so that everyone, regardless of age or ability, can easily access homes. It’s easy and inexpensive to do and it works!

And visitability helps everyone: people with disabilities, seniors, families with young children, people with temporary injuries or illnesses, friends and families of seniors and people with disabilities, pregnant women, emergency responders, care givers. City of Edmonton 2009; Concrete Change 2012; Department of Planning and Community Development 2009; Herd

et al 2003; Hill et al 1999; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal Housing Design 2012; Ontaio Human Rights Commission 2001; Smith 2012; Steinfeld et al 2001, Truesdale et al 2002


Visitability is housing that is designed to be inclusive, rather than housing that excludes people by design

Visitability� Ensures basic accessibility in housing throughout BC� Costs the provincial government no money� Saves the government significant amounts of money from falls prevention, fewer

hospitalizations, less institutional care� Enables people with disabilities to be fully integrated in the community � Enables aging in place for seniors � Involves negligible construction costs� Has significant benefits to families, seniors, people with disabilities, and

government� Works!! Visitability has been successfully in place in England for 15 years, since

1999. Visitability is also successfully in place in other countries and cities including Ireland, Wales, Denmark, Scotland, Sweden, Norway, Austin, Tucson, Bolingbrook, Pima County.

Visitable homes are better for everyone: seniors, people with disabilities, families with young

children, families with grandparents, people with temporary injuries or illnesses, movers,

emergency responders.

Visitable homes are healthier: they improve safety and reduce falls; remove barriers and decrease

isolation, segregation and depression; improve the productivity of people with disabilities; enable

seniors to age in place; and build healthy resilient communities where people can help each other

and themselves.


Everyone needs visitability

Most houses will have someone living in the house at some time who needs basic accessibility features

- 60% of houses will have a resident with a disability in the lifetime of the house - 91% of houses will have a resident or be visited by a person with a disability Smith et al 2008

What is visitability? Visitability improves housing for everyone by including a few basic inexpensive universal design

features in all new homes. Maisel et al 2008; Smith 2010; Truesdale et al 2002 The three basic features are 1) one zero step entrance on an accessible path 2) wider doors/halls 3) bathroom on main floor that can be used by a person in a wheelchair. Most visitability legislation also includes a few basic no-cost accessibility/adaptability features such as reachable controls (lower light switches/higher electrical outlets) and reinforcement in bathroom walls for future grab bars. It is called visitability because it enables everyone in the neighbourhood to go into other homes to visit, to live, and to be part of the community.

Visitability doesn’t mean the same degree of accessibility as fully adapted or accessible housing. But adopting visitability in all housing develops a universally designed community. Visitability allows basic access, easy modification in future, and makes neighbourhoods accessible. The cost is very low and the benefits substantial. Campbell et al 2007; Maisel et al 2008; Steinfeld et al 2001; Truesdale et al 2002


Visitability is cost-effective Cost effectively increases the supply of accessible housing, meets the

needs of the increasing population of seniors, and enables aging in place. Cost-effectively builds cohesive neighbourhoods. Reduces health care costs by preventing accidents and falls; reduces

expensive nursing home/institutional care by enabling people to live in the community; reduces expensive home support by enabling people to function independently in their homes Confino-Rehder 2008; Department of Planning and Community Development 2009; City of City of

Edmonton 2009; Maisel et al 2008; Heywood et al 2007; Ratzda 2004

Saves money by reducing the need for expensive renovations and reducing unnecessary moves to a new home due to sudden health issues or injury. Campbell et al 2007; Heywod et al 2007; Maisel et al 2008; Smith 2010; Truesdale et al 2002

Visitability is a cost-effective way to build housing stock that meets most people’s needs at all stages of life

How does visitability work? Where is it in place? Visitability has been required for all newly built dwellings in England since 1999 (Part M of the

National Building Code).Office of the Deputy Prime Minister 2004 It is also required in Ireland, Wales, Norway, Denmark and Sweden, and in some US counties and cities such as Austin, Tucson, Pima County and Bolingbrook.

Hundreds of thousands of homes have been built to visitable standards. There is widespread consumer satisfaction with visitable homes: virtually no complaints and no

moisture damage from level entrances in cities requiring visitability. Khawam 2010; Maisel et al 20080

Visitable homes look the same as conventional homes, sometimes more attractive. Concrete Change 2012; Khawam 2010;

Smith 2010; Truesdale et al 2002

Building visitable homes does not have to increase the square footage of the house. Concrete Change 2012; Department of

Planning and Community Development 2009;; Hill et al 1999; Maisel et al 2008; Sangster et al 1997; Truesdale et al 2002

Impact on businesses is negligible. Department of Planning and Community Development 2009; Khawam 2010

Visitable homes can be built on slab or over basement, on flat or steep terrain, in different climates, even with heavy snow. Smith 2010; Truesdale et al 2002 The site does not have to be flat; Concrete Change 2012; Steinfeld et al 2001; Truesdale et al 2002 The entire site of a visitable house does not need to have a gentle slope – only one entrance is required to be flat or have a gentle slope. Concrete Change 2012

All countries and states that require visitability include provision for exceptions (see Approved Document M). Office of the Deputy Prime Minister 2004 Some sites are not suitable for visitable design: 1-5% of sites can’t be done with zero step entrance. Concrete Change 2012

Pima County has required visitability in all new dwellings since 2002; 21,000 homes built to visitable standards from 2002-2010. Khawam 2010 Visitable homes are more marketable; can’t tell they are accessible from outside. No complaints; many compliments. Khawam 2010

40,000 visitable homes have been built in the US; Smith 2010 hundreds of thousands of visitable homes have been successfully built in England, Ireland, Wales, Sweden, Denmark & Norway.


Mandatory visitability works betterthan voluntary visitability

US cities where visitability is mandatory have built 28,600 visitable homes. Cities with voluntary visitability programs have built 1,000 homes, even though the overall population served is much larger. Maisel et al 2008

Research confirms that voluntary programs are less effective. A recent evaluation of two mandatory and three voluntary options concluded that mandatory regulation for all newly built dwellings homes is the best option based on cost and effectiveness. Voluntary adoption with an education campaign was the least effective option: five times less effective than mandatory regulation.

Department of Planning and Community Development 2009; A different review of the literature confirms that voluntary programs are less effective. Saville-Smith et al 2007

In England, visitability was made mandatory because not enough visitable homes were being built on a voluntary basis. Communities & Local Government 2007 In the US, there’s been minimal building of visitable homes with voluntary models. Concrete Change 2012; Maisel et al 2008

What are the documented benefits of visitability?

Everyone benefits - Families with children Concrete Change 2012; Department of Planning and Community Development 2009;; City of Edmonton 2009; Herd et al 2003; Hill et al 1999; Livable Housing Australia 2012;

National Dialogue on Universal Housing Design 2012; Truesdale et al 2002

- People with disabilities Concrete Change 2012; City of Edmonton 2009; Herd et al 2003; Livable Housing Australia 2012; National Dialogue on Universal Housing Design 2012; Nova Scotia League

for Equal Opportunity 2006; Steinfeld et al 2001

- People with chronic illnesses or conditions Department of Planning and Community Development 2009

- Seniors City of Edmonton 2009; Conference of Mayors 2005; Department of Planning and Community Development 2009; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal Housing

Design 2012; Ontario Human Rights Commission 2001; Smith 2010; Truesdale et al 2002

- People with temporary illness or injury City of Edmonton 2009; Concrete Change 2012; Department of Planning and Community Development 2009Department of Planning and

Community Development 2009; Herd et al 2003; Livable Housing Australia 2012; National Dialogue on Universal Housing Design 2012; Steinfeld et al 2001; Truesdale et al2002

- Friends & relatives of seniors & people with disabilities Concrete Change 2012; Department of Planning and Community Development 2009; Livable

Housing Australia 2012; National Dialogue on Universal Housing Design 2012

- Pregnant women Livable Housing Australia 2012

- Care givers Concrete Change 2012; Department of Planning and Community Development 2009; National Dialogue on Universal Housing Design 2012

- Movers of furniture/packages City of Edmonton 2009; Concrete Change 2012; Department of Planning and Community Development 2009;; Herd et al 2003; Hill et al 1999; Livable Housing

Australia 2012; National Dialogue on Universal Housing Design 2012

- Escaping in emergencies/faster access by emergency workers Concrete Change 2012; Department of Planning and Community Development

2009;

Inclusion of people with disabilities in the community - Enables people with disabilities to be part of community Department of Planning and Community Development 2009; Maisel

et al 2008; Human Resources and Skills Development Canada 2010; Smith 2010

- Removes isolation and segregation of people with disabilities Campbell et al 2007; Maisel et al 2008; Smith 2010

- Increases housing stock usable by people with disabilities and seniors without added government cost Campbell et al 2007; Maisel et al 2008; Smith 2010

Improves the lives of people with disabilities- Improves health Campbell et al 2007; City of Edmonton 2009; Heywood et al 2007; Heywood 2004; Smith 2010

- Increases economic participation Campbell et al 2007; Department of Planning and Community Development 2009

- Decreases in chronic health problems, depression, isolation Campbell et al 2007; City of Edmonton2008; Smith 2010

- Improves quality of life Communities and Local Government 2007; Department of Communities and Local Government 2012; Heywood et al 2007; Heywood 2004

Meets changing needs at every stage of life City of Edmonton 2009; Concrete Change 2012; Department of Planning and Community Development

2009; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal Housing Design 2012; Smith 2010; Truesdale et al 2002

- Accommodates wide range of ages/family size initially City of Edmonton 2009; National Dialogue on Universal Housing Design 2012;; Truesdale et al 2002

- Easy to adapt later City of Edmonton 2009; Concrete Change 2012; Livable Housing Australia 2012; National Dialogue on Universal Housing Design 2012; Truesdale et al 2002


Aging in place City of Edmonton 2009; Conference of Mayors 2005; Department of Planning and Community Development 2009; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal

Housing Design 2012; Ontario Human Rights Commission 2001; Smith 2010; Truesdale et al 2002

Aging in place results in:- Increased independence City of Edmonton 2009; Ontario Human Rights Commission 2001

- Increased community participation & connection to community City of Edmonton 2009; Maisel et al 2008

- Improved health, satisfaction, self-esteem City of Edmonton 2009

- Improved quality of life Ontario Human Rights Commission 2001

- Reduction in health care costs City of Edmonton 2009; Heywood et al 2007; Smith 2010

Builds & maintains community City of Edmonton 2009; Conference of Mayors 2005; Department of Planning and Community Development 2009; Smith 2010; Truesdale et al

2002

- Makes neighbourhood accessible for everyone Steinfeld et al 2001

- Builds viable sustainable communities Department of Planning and Community Development 2009; Maisel et al 2008; Smith 2010

- Full access to social participation in community/interactions with neighbours for everyone Department of

Planning and Community Development 2009; City of Edmonton 2009; Maisel et al 2008; Truesdale et al 2002

- Builds stable communities because people can remain in their neighbourhood & community as their needs change Department of Planning and Community Development 2009; City of Edmonton 2009; Maisel et al 2008; Truesdale et al 2002

Safety improvements: falls and accidents are reduced by housing without barriers City of Edmonton 2009; Communities and Local Government 2007; Confino-Rehder 2008; Department of Planning and Community Development 2009; Heywood et al 2007; Hill et al 1999; Livable Housing Australia

2012; Maisel et al 2008; National Dialogue on Universal Housing Design 2012; Ratzda 1994; Smith 2010; Steinfeld et al 2001

Improved safety for older adults, young children, blind people, people with balance/depth perception issues, people with disabilities City of Edmonton 2009; Communities and Local Government 2007; Confino-Rehder 2008; Department of Planning and

Community Development 2009; Heywood et al 2007; Hill et al 1999; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal Housing Design 2012; Ratzda 1994; Smith 2010; Steinfeld et al 2001

Falls and accidents are reduced by housing without barriers City of Edmonton 2009; Communities and Local Government 2007; Confino-

Rehder 2008; Department of Planning and Community Development 2009; Heywood et al 2007; Hill et al 1999; Livable Housing Australia 2012; Maisel et al 2008; National Dialogue on Universal Housing Design 2012;

Ratzda 1994; Smith 2010; Steinfeld et al 2001

Falls are a significant cause of injury and death- 85% of injury hospital admissions are due to falls City of Edmonton 2009

- Accidents cause more deaths than any single illness except cancer & heart disease World Health

Organization/Confino-Rehder 2008

Seniors have a very high risk of falls- 1 in 3 seniors falls each year City of Edmonton 2009; Office of the Provincial Health Officer 2004; Public Health Agency 2010: WHO

- Falls are the leading cause of injury, emergency department visits, and hospitalization for people over age 65; Smith 2010 almost all injury‐related hospitalizations for seniors in Canada are due to falls (85%) Public Health Agency 2010

- Falls among the elderly account for the largest proportion of all injury related deaths and hospitalizations in British Columbia. Office of Provincial Health Officer 2004


I mpact of fall related injuries among older Canadians is staggering Public Health Agency 2010

- 1.4 million Canadian seniors had a serious fell leading to hospitalization in 2005; 3.3 million hospitalized falls/year projected by 2036. Public Health Agency 2010

- Canada spends $2.8 billion/year for fall-related injuries for seniors (Office of the Provincial Health Officer 2004); costs will double by 2036 Public Health Agency 2010. Alberta spends $96 million/year on seniors’ falls; projected to reach $228 million/year by 2031. City of Edmonton 2009 Each hospital admission for falls costs $15,500 in Alberta. City of Edmonton 2009

- The cost of hip fractures from falls is much higher: Falls are the leading cause of hip fractures, which lead to hospitalization and often to

disability; each hip fracture costs $24,400 to $28,000 in BC Office of the Provincial Health Officer 2004 and $45,291 in England. Heywood et al 2007 England spends $1.15 billion/year on hip fractures. Heywood et al

2007

Hip fractures have significant consequences: almost half of people who sustain a hip fracture never recover fully; 50% need to use a cane, walker or other mobility aid permanently after a hip fracture; Office of the Provincial Health Officer 2004 more than half need help to shower, bathe, do housework, personal care. Heywood et al 2007 77% of seniors hospitalized for fall-related injuries in BC have a fracture; half of these are hip fractures. Public Health Agency 2010

20% of seniors die within a year of a hip fracture. City of Edmonton 2009; Office of the Provincial Health Officer 2004;

Public Health Agency 2010

- Hospitalization time to treat fall-related injuries is much longer than other injuries. Two recent Canadian reports note that the length of hospitalization for falls is double the length of hospitalization stays for all other causes of hospitalizations. Office of the Provincial Health Officer 2004; Public Health Agency 2010

- Costs for falls are three times greater than the costs of motor vehicles injuries in BC. Office of the

Provincial Health Officer 2004

- Falls have a significant impact on productivity in Canada.Provincial Health Officer BC 2004 More productivity is lost from falls in the US than leading causes of death. Heywood et al 2007

The impact of falls will increase dramatically as the population ages:- Population of seniors is increasing and the number of fall-related hospitalizations will more

than double by 2036. Public Health Agency 2010 Canada would need to build thirteen additional 200-bed hospitals, “where all of the beds would be filled with older adults with fall-related injuries every day of the year” if the expected doubling of falls is not prevented. Public Health Agency 2010 p20

Young children, blind or visually impaired people, and older women also have higher risk for falls :

- Young children have the highest rate of falls after seniors. Department of Planning and Community Development 2009; Livable Housing

Australia 2012; National Dialogue on Universal Housing Design 2012

- Blind or visually impaired people also have higher risk of falls; people with poor depth perception have six times higher risk of hip fracture. Heywood et al 2007

- Older women are more likely to fall than older men (Public Health Agency 2010). Most deaths (57%) due to injuries for elderly women are caused by falls. Office of the Provincial Health Officer 2004

- Older women with depression have a 30% increased risk of hip fracture. Heywood et al 2007


Construction design is the largest cause of preventable injuries/falls leading to hospitalization/death . Department of Planning and Community Development 2009

- Most falls occur at home. Livable Housing Australia 2012; National Dialogue on Universal Housing Design 2012; Office of the Provincial Health Officer 2004 Falls at home are 5 times more frequent than falls on the street. Office of the Provincial Health Officer 2004

- Steps and stairs are among the most frequent sites of falls and are the leading cause of death from falls in British Columbia. Office of the Provincial Health Officer 2004

- Home stairs account for 87% of all hospital-treated stair-related injuries. Office of the Provincial Health Officer 2004

- One stair-related death occurs for every million hours of use, making stairs more dangerous than cars. Office of the Provincial Health Officer 2004

- Stairs: people with poor balance struggling to open entry doors while negotiating a step; people in wheelchairs being carried up steps. Smith 2010

Falls are preventable and can be reduced by housing with built-in accessibility or by removal of home barriers/hazards Heywood et al 2007; Livable Housing Australia 2012; National Dialogue on Universal Housing Design 2012; Office of the Provincial

Health Officer 2004; Smith 2010; Steinfeld et al 2001

- Visitable features reduce falls 50% in 70-84 yr olds. Department of Planning and Community Development 2009

- Eliminating stairs decreases falls. Steinfeld et al 2001

- Making a house more accessible also reduces falls. Heywood et al 2007; Office of the Provincial Health Officer 2004 Improving accessibility decreases falls for blind/low vision/poor depth perception people who have increased risk. Heywood et al 2007

- A recent special report from BC’s Provincial Health Officer notes that “It is clear that preventing falls and the resulting injuries among the elderly must become a public health priority.” “This means not only targeting prevention strategies through health care workers, but also involving those who design, build and maintain buildings, private homes and public settings....” Office of the Provincial Health Officer 2004, p74, 75 The same report notes that “Building codes for private dwellings in Canada are inadequate...The home construction industry needs to support initiatives...that promote simple building code design changes...that allow aging in place and also reduce the risk of falls or injuries.” Office of the Provincial Health Officer, BC 2004. p56, p75

Health care costs are reduced City of Edmonton 2009; Cobbold 1997; Communities and Local Government 2007; Confino-Rehder 2008;

Department of Planning and Community Development 2009; Heywood et al 2007; Hill et al 1999; Maisel et al 2008; National Dialogue on Universal Housing Design 2012;

Smith 2010

Prevention of falls saves significant health care funds- Canada spends $2.8 billion/year for fall-related injuries for seniors; Office of the Provincial Health Officer 2004 costs will

double by 2036. Public Health Agency 2010 Alberta spends $96 million/year on seniors’ falls; projected to reach $228 million/year by 2031. City of Edmonton 2009 England spends $1.2 billion/year on cost of hip fractures from falls. Heywood et al 2007 Australia spends $1.8 billion/year on costs of falls in homes. Livable

Housing Australia 2012; also in National Dialogue on Universal Housing Design 2012

- Each hospital admission for falls costs $15,500 in Alberta; City of Edmonton 2009 each fractured hip costs $24,400 to $28,000 in BC Office of the Provincial Health Officer 2004 & $45,291 in England. Heywood et al 2007


Savings from reduced hospital costs : - Prevention of hospital admissions by preventing accidents/falls/illness. Heywood et al 2007; National Dialogue on Universal

Housing Design 2012; Smith 2010

- Reduction of length of hospital stays by speeding discharge Length of time in the hospital is reduced by being able to return to a home that meets the

person’s changed needs. Cobbold 1997; Communities and Local Government 2007; Department for Communities and Local

Government 2012; Department of Planning and Community Development 2009; Heywood et al 2007; National Dialogue on Universal Housing Design

2012 People return home sooner after illness/injury if housing is accessible. Cobbold 1997; City of

Edmonton 2009; Heywood et al 2007

Shorter stays in acute & sub-acute care. Communities and Local Government 2997; Department of Planning and Community Development 2009 For example, one study reports that more than 10% of people in acute care beds were ready to go home, but couldn’t due to inappropriate housing. Cobbold 1997

A one week average decrease in hospital stay saves $3,934/person in England, with annual savings of up to £40 million. Heywood et al 2007

See previous section on preventing falls for more details.

Savings in health care costs due to improved physical and mental health - Inappropriate housing leads to long term health problems for people with disabilities; improving

accessibility/equipment prevents health problems. Heywood et al 2007; Smith 2010

- Significant health costs for people living in inaccessible housing; significant health care cost savings when accessibility is improved. Heywood et al 2007

- Connection to community/people important determinant of mental & physical health. Statistics Canada 2006

Older seniors with strong sense of belonging to community have significantly better health than those who do not. Statistics Canada 2006

- Improvements in mental health and decreases in depression Department for Communities and Local Government 2012; Department of

Planning and Community Development 2009; City of Edmonton 2009; Heywood et al 2007; Smith 2010

Poor accessibility in homes leads to reduced mental health. Heywood et al 2007; Smith 2010 Consistent international research that improving accessibility improves mental health and decreases depression, which have a significant impact on physical health and health care costs. Heywood et al 2007; Heywood 2004; Smith 2010

Older people who are unable to take a bath or shower or get in or out of their home experience reduced autonomy leading to depression; after accessibility is improved, seniors experience improved mental health & quality of life. Communities and Local Government 2007; Heywood et al 2007

Reduces expensive institutional care

Visitable housing reduces the need for expensive institutional care. City of Edmonton 2009; Concrete Change 2012; Confino-

Rehder 2008; Department of Planning and Community Development 2009; Heywood et al 2007; Hill et al 1999; National Dialogue on Universal Housing Design 2012; Ratzda 1994; Smith 2010 - Need for institutional care reduced or often not needed when housing is appropriate City of Edmonton

2009, Concrete Change 2012, Communities and Local Government 2007, Cobbold 1997, Confino-Rehder 2008, Department for Communities and Local Government

2012, Department of Planning and Community Development 2009, Heywood et al 2007, Hill et al 1999, Maisel et al 2008, National Dialogue on Universal Housing

Design 2012, Ratzda 1994, Smith 2010

- In Canada, costs of institutional care are significantly higher than living in the community. Chappell et al

2004; Hollander 2007; Hollander 2003 In the US, costs of institutional care can be three times higher than living in the community for persons with severe disabilities using ventilators. Bach et al 1992


Delayed admission to residential care has huge benefits:- Delayed admission to residential care saved $2.18 billion/year in England. Cobbold 1997 An

Australian study reports savings of $666 million for delayed admission to elder hostels, group homes & institutions with appropriate housing. Hill et al 1999

- A recent UK study found that a delay of one year due to improved accessibility saves $53,720/person. Even 1-2 cases of delayed admission in each housing authority saves $16 million savings/year: savings grow cumulatively each year. Heywood et al 2007

Many people are admitted to residential care after hospitalization from a fall- In Canada, 68% of seniors discharged to Continuing Care after fall-related hospitalization were

not living in residential care before the fall. Public Health Agency 2010. - In BC, the Provincial Health Officer reports that almost half of admissions to nursing

homes/long-term care facilities in BC are due to falls (40%). Office of the Provincial Health Officer 2004 70% of nursing care admissions are from hospital. Smith 2010.

- Prevention of falls as noted in previous sections has a significant impact on the costs & impact of institutionalization/residential care.

Improving conditions for carers with accessible housing decreases expensive residential care & health care cost for carers - Carers have a 90% risk of musculoskeletal damage; a higher risk of falls leading to

hospitalization; and higher stress due to inadequate space for parent carers. Heywood et al 2007

Temporary living in institutions and residential care is reduced . Concrete Change 2012; Communities and Local Government 2007;

Department for Communities and Local Government 2012

- Cost savings of $427 million/year from reduced admissions to temporary residential care when people are able to return to their homes promptly because their homes do not have barriers. Cobbold

1997

Reduces future costs of building long term care facilities: - Alberta will have to build 15,000 more long term care facilities if housing does not meet

people’s accessibility needs. City of Edmonton 2009 - Canada would need to build thirteen additional 200-bed hospitals, “where all of the beds

would be filled with older adults with fall-related injuries every day of the year.” if the expected doubling of falls is not prevented. Public Health Agency 2010 p20

Home care costs are substantially reduced Cobbold 1997; Department for Communities and Local Government 2012; Department of Planning

and Community Development 2009; Heywood et al 2007; Hill et al 1999; National Dialogue on Universal Housing Design 2012; Ratzda 1994

- Potential to save millions. Even with later adaptations to improve accessibility, these pay for themselves in a few months to 3 years, followed by cumulative savings. Heywood et al 2007 In the UK, annual home care savings range from $1,900 to $45,820/year/person, and these savings would be greater with initial accessibility. Heywood et al 2007 UK currency:£1,200 to £29,000/year/person

- An older English study reports home care cost savings of $1.64 billion/ £1.04 from building to Lifetime Homes Standards (Cobbold 1997); an older Australian study calculates home care savings of $ 291 million from building to adaptable standards (Hill et al 1999).


Reduces or eliminates expensive adaptations City of Edmonton 2009; Concrete Change 2012; CMHC 2010; Cobbold 1997; Confino-Rehder

2008; Department of Planning and Community Development 2009; Hill et al 1999; Khawam 2010; Maisel et

al 2008; National Dialogue on Universal Housing Design 2012; Smith 2010

- Houses that have built-in accessibility do not require later significant adaptation costs: adaptations are less expensive/easy to do or not necessary if house is built to visitable or adaptable standards. City of Edmonton 2009; Concrete Change 2012; CMHC 2010; Confino 2008; Department of Planning and Community Development 2009; Hill et al 1999;

Maisel et al 2008; National Dialogue on Universal Housing Design 2012; Smith 2010

- Adaptations on non-visitable homes are expensive & often not feasible. Concrete Change 2012; Communities and Local

Government 2007; Department of Planning and Community Development 2009; City of Edmonton 2009;

National Dialogue on Universal Housing Design 2012; Smith 2010

A recent comprehensive study reports that adaptations for a conventionally built home are 22 times more expensive than including accessibility features at the building stage. Department of Planning and Community Development 2009; National Dialogue on Universal Housing Design 2012 In this study, costs of incorporating visitable features at the building stage were less than 0.3%; incorporating the same features after a house was built was more than 6%, 22 times higher. Department of Planning and Community

Development 2009; Livable Housing Australia 2012 Another study reports that later adaptation costs are 12 to 17 times higher than built-in basic accessibility for single family homes, and 24 to 38 times higher for townhouses. Hill et al 1999 Other studies confirm very high adaptation costs compared to the minimal costs of incorporating accessibility features at the building stage. Cobbold 1997; Concrete Change 2012; Confino-Rehder 2008; Maisel et al 2008; Ratzda 1994; Smith 2010; Truesdale et al 2002

- Savings are substantial if homes have built-in visitability or adaptability: Building homes to UK Lifetime Home Standards saves $3.7 billion on major adaptation

costs and $.81 billion for minor adaptations (£2.34/£.51 billion Cobbold 1997). Annual savings $187-$273 million/year in adaptation costs building to “Livable Home”

standard in Australia (estimate) (National Dialogue on Universal Housing Design 2012); an earlier Australian study estimated overall savings of $483 million in adaptation costs (Hill et al 1999).

Reduces or eliminates the costs of the health consequences of waiting for a needed home adaptation and the health consequences if a home adaptation is not possible

- If a home does not have “built-in” accessibility, expensive adaptations may be needed later on.

- Waiting time for adaptations due to insufficient funds causes significant health/home care costs. Heywood et al 2007

Adaptations are often delayed up to two years in England due to inadequate funding; delays increase health care, home care & other costs. Heywood et al 2007 In Canada, the previous RAP adaptation program had a two year wait. CMHC 2012

Examples of unnecessary costs incurred while waiting for home adaptations in England include a person who received £1,400 in home care waiting for a £300 door-widening adaptation which was delayed 7 months due to lack funding; a local authority spent £89,000 adaptations in one year for applicants who died before they received benefit from adaptations due to long delays. Heywood et al 2007

NOTE: Houses that have accessibility features built-in from the beginning – such as visitable homes, adaptable homes etc - will not have the wasted financial expenses noted above, either because there is no need for adaptations or because adaptations are much more minor and easy to implement.

-


- Many adaptations cannot be done at all, due to insufficient funds, and this causes health issues and costs which can be avoided if the home is built with minimal accessibility.

Public funding for adaptations is very limited, so many needed adaptations are not completed. In England, Audit Commission figures indicate adaptation funds meet less than 4% of the need. Because there are not enough funds, not all needed adaptations are made, resulting in more falls/health issues and their related costs. Audit Commission 1998 ; Heywood et al

2007 These costs are eliminated or significantly reduced if the house was built to visitable or adaptable standards.

Narrow eligibility requirements for publically funded adaptations are another reason why needed adaptations often can’t be made to a house that doesn’t have built-in visitability or adaptability. Again, in England, one study reports that 64% of people who withdrew adaptation applications were not able to afford completing the adaptation themselves, and their needs remained unmet, with consequent health and social care costs. Heywood et al

2007 Again, these costs are not incurred in homes with built-in accessibility such as visitable or adaptable homes.

In British Columbia, funds for adaptations are only available to families whose combined income is less than $38,000 – this criteria eliminates assistance for many who need adaptations.

Reduces crisis accommodation costs when no suitable rental housing is available Department of Planning and Community Development 2009

Improved environmental impact- Visitable and adaptable homes are considered an important environmental measure because

they reduce unnecessary and carbon-intensive household moves. - Adaptable and visitable homes receive points on England’s Code for Sustainable Homes and

the International LEEDs standard because they reduce these unnecessary environmental costs. Communities and Local Government 2007


What are the costs of visitability? No cost to government Khawam 2010

Minimal construction costs- Costs of visitability are very low and are less than 0.5% of the overall building cost Concrete Change

2012; Confino-Rehder 2008; Smith 2010

- English studies, where visitability has been in place for fifteen years, report that the costs are negligible. Ainsley Gommon 1999; Department for Communities and Local Government 2012; Sangster et al 1997

- Recent US research on the costs of visitability based on the actual building costs of visitable homes reports actual costs $100 to $600 depending on whether the house is on a concrete slab or basement, and depending on the experience of the builder and the design. Concrete Change 2012;

Confino-Rehder 2008; Maisel et al 2008; Nova Scotia League for Equal Opportunity 2006; Smith 2010; 2013; Steinfeld et al 2001; Truesdale et al 2002

- A recent Canadian paper verified US cost figures with a Halifax architect. Nova Scotia League for Equal Opportunity 2006

- A recent Australian study commissioned by the Victoria government estimated costs rather than reporting actual building costs: the estimated Australian costs were slightly higher than the actual building costs reported by US studies: Australian estimated costs to build a house to visitable standards was $870, as compared to US reports of actual building costs of $0-$600. This careful study used a Quantity Surveyor to estimate costs, and then verified these costs with estimates from three developers/builders. The costs from builders were very similar to the figures from the Quantity Surveyor $1,000 vs $870. Department of Planning and Community Development 2009

Minimal costs of building visitable homes are significantly less than the expensive costs of adapting a house later and significantly less than the significant costs if the housing is not adapted and has built-in hazards/barriers City of Edmonton 2009; Concrete Change 2011, 2012a,b; Confino-Rehder 2008; Department of Planning and Community Development 2009; City of Edmonton 2009; Hill et al 1999; Khawam 2010; Livable Housing Australia 2012; Maisel et al

2008; National Dialogue on Universal Housing Design 2012; Smith 2010; Steinfeld et al 2001; Truesdale et al 2002

- A recent comprehensive study reports that adaptations on a conventionally built home are 22 times more expensive than including the features at the building stage. Department of Planning and Community Development

2009; National Dialogue on Universal Housing Design 2012: in this study, costs of incorporating visitable features at the building stage were less than 0.3%; incorporating the same features after a house was built was more than 6%, 22 times higher. Department of Planning and Community Development 2009; Livable Housing Australia 2012

- Another study reports that later adaptation costs are 12 to 17 times higher than built-in basic accessibility for single family homes, and 24 to 38 times higher for townhouses. Hill et al 1999

- Other studies confirm very high adaptation costs compared to the minimal costs of incorporating accessibility features at the building stage. x Cobbold 1997; Concrete Change 2012; Confino-Rehder 2008; Maisel et al

2008, Ratzda 1994; Smith 2010; Truesdale et al 2002


Even if later adaptations are targeted to only those homes that “need” it, the costs are twice as high as incorporating accessibility features in all homes at the beginning. Department of Planning and Community Development 2009

A recent thorough study commissioned by the Victoria government in Australia calculates the cost of including visitability at construction for all homes versus the targeted cost of adapting only those new houses that have a resident needing adaptation. Retrofitting only for those who “need” it is more than twice the cost of including visitability features in all new homes. Department of Planning and Community Development 2009

The benefits of visitability far exceed the costs. Department of Planning and Community Development 2009: Heywood et al 2007; Hill et al 1999;

National Dialogue on Universal Housing Design 2012 Widespread adoption is essential to realize the benefits. Department of

Planning and Community Development 2009

Please see the section on benefits for description of other considerable savings.


Visitability is housing that is designed to be inclusive, rather than housing that excludes people by design

Visitability is the most important single step the province can take

to make BC the most accessible province in Canada.

Part B: Wheelchair Accessible Housing

Responding to the Housing CrisisProtecting and increasing the accessible housing stock

The crisis in wheelchair accessible housing There is a critical shortage of wheelchair-accessible suites in British Columbia and in Canada, even though the need for these suites is substantial. Gibson 2012; Nova Scotia League for Equal Opportunity 2006 + more refs

The situation has reached crisis proportions. In British Columbia, Spinal Cord Injury BC reports an average of one wheelchair accessible vacancy per month with over 200 people and groups looking for accommodation. One in five people with spinal cord injuries have been waiting over five years for appropriate housing in British Columbia.Spinal Cord Injury BC, 2014 Other provinces report similar severe housing shortages, and that it is almost impossible to find accessible housing. Gibson et al 2012;, Kirk 2012, Nova Scotia League for Equal Opportunity 2006

In British Columbia, the situation is urgent and rapidly becoming worse. In addition to the already critical shortage of wheelchair-accessible suites, we are actually losing already-built wheelchair accessible suites at an alarming rate. In Vancouver alone, we know of eight already-built wheelchair accessible suites which will no longer be available to persons who use wheelchairs this month.

We are losing existing wheelchair accessible suites faster than we can build new ones.

If this situation is not remedied promptly, a significant proportion of people who use wheelchairs will be unable to function in any meaningful way, no matter what other measures are taken to make British Columbia an accessible province.


Why is wheelchair accessible housing needed?Why are we losing crucial existing stock?Housing is important for all of us. Appropriate housing is the base that enables people to function – to work, to play, to be healthy & productive, to raise families. The link between adequate housing and health and productivity is well established. Audit Commission for Local Authorities and the National Health Service in England

and Wales 1998; Heywood et al 2007; Smith 2010 For people with disabilities, inappropriate housing with barriers has a profound impact on the ability to function and participate in society. Gibson et al 2012;, Heywood et al 2007; Nova Scotia League for Equal Opportunity

2006; Smith 2010 Inappropriate housing leads to significant long term health problems for people with disabilities and significant health care costs. Heywood et al 2007; Heywood 2004; Smith 2010 When living in appropriate accessible housing, there are significant improvements in health and reductions in health care costs. Heywood et al 2007; Heywood 2004; Smith 2010

People with disabilities have the same need for adequate housing as other people, but because most disabled people are poor, Human Resources and Skills Development Canada 2011 our choices are more limited.

In addition, many people with disabilities also need special design features in housing in order for them to live and function in their homes. For example, people with mobility challenges are not able to live in housing that has stairs.

This makes finding housing much more difficult because much of the affordable rental housing is in older buildings or secondary suites, and these often have stairs. That means for a person with a mobility challenge or who uses a wheelchair, there are significantly less housing options available than for other persons with disabilities or for other persons who are poor. And that means it is much more difficult to find housing.

Persons who use wheelchairs are thus uniquely disadvantaged in the current housing market. Persons who use wheelchairs need wider doors, larger circulation space, barrier-free showers, lower counters etc. Unless housing units have been purpose built or adapted, virtually none of low income housing has those features. The situation for persons who use motorized wheelchairs is even more critical, as they require even wider doors, larger bathrooms with wheel in showers, ceiling lifts and environmental controls – features not usually present in most wheelchair modified units.

As a result, there is a critical lack of wheelchair-modified suites in British Columbia, even though the need for these suites is increasing.


People with disabilities have more difficulty finding adequate housing for two reasons: Lower incomes than most of the population Need for housing that has specific design features

The situation is urgent and is rapidly getting worse.

Many well-designed wheelchair accessible suites are losing subsidy, and since most people with disabilities are poor, they cannot afford housing without a subsidy. In Vancouver, we know of eight well-designed wheelchair accessible suites that will revert to market rent this month, and these suites will therefore likely be rented by persons who do not have a disability, as they are more likely to afford the higher rent. If this happens, those suites will be lost to persons with disabilities, who cannot afford market rent.

And this is just the tip of the iceberg because most housing co-ops are losing their subsidy pool in the next few years, and co-ops have a significant portion of the already-existing wheelchair accessible housing stock.

The impact on people who cannot find appropriate housing is devastating and an insurmountable barrier to participation in the community. Persons who use wheelchairs and who have to be carried up or down stairs to their own housing, are obviously not able to go in or out often, and certainly cannot go to school, work, or participate in any meaningful way in our province.


We are losing wheelchair accessible housing stock faster than we can build it

We need to find a solution promptly, ora significant proportion of people who use wheelchairs

will be unable to function in any meaningful way, no matter what other measures are taken

to make British Columbia an accessible province

Why is there such a serious shortage of wheelchair accessible suites?

Fully wheelchair accessible suites are expensive to build, require specific expertise, have a specific market.

Many wheelchair accessible suites are in co-ops, but new co-ops haven’t been built in years, so this source of new wheelchair modified suites is no longer available.

The amount of new wheelchair accessible units is limited, but the number of people using wheelchairs who need wheelchair accessible suites is increasing.

Most people with disabilities are poor, and can only afford affordable rent. Most of the affordable housing stock is in older buildings, which often have stairs. Many already-built wheelchair accessible suites are losing subsidy, and this means

they are no longer available to people with disabilities who cannot afford market rent.

All co-ops are losing their subsidies in the next few years, and their wheelchair accessible suites will no longer be usable by persons with disabilities without subsidy.

What is an effective solution?It takes years and significant expense to build new wheelchair modified housing.

It is significantly less expensive to subsidize existing stock so that it can be used by persons with significant disabilities.

The targeted solution focuses on those persons most in need and who cannot function due to the lack of appropriate housing.


Advantages of a targeted subsidyThis proposal involves an initial outlay of funds, so we are specifically requesting that this subsidy only be applied to a very small number of rental units – those that are wheelchair accessible.

This targeted subsidy ensures: Subsidy amount is finite Subsidy goes to those most in need Wheelchair modified suites will be used by persons who need them The existing stock of wheelchair accessible suites will not be lost due to lack

of subsidy Subsidy acts an incentive for private market wheelchair accessible builds,

which will also lessen government spending in the long run

Targeted subsidyWe recommend a targeted subsidy for wheelchair modified suites sufficient to bring the rental payment down to the shelter portion of disability benefits, or to 30% of income for those persons not on disability benefits.

We also recommend that these subsidized suites be reserved for persons who use wheelchairs, and that suites that are specially adapted for the needs of severely disabled persons who use motorized wheelchairs be reserved for persons using motorized wheelchairs.

Impact of this proposal The immediate impact will be to ensure that the already critically low stock of existing

wheelchair accessible suites is not further reduced by the lack of subsidy. The stock of wheelchair accessible suites will stabilize and will be used exclusively by those

who need it. The stock of wheelchair accessible suites in the private sector will then begin to increase as

new suites are built and existing suites are preserved. Persons who use wheelchairs will begin to find appropriate housing, and thus be able to go to

school, to work – in short, to be active members of society. Employment rates for persons who are properly housed will begin to rise. Need for subsidy will decrease as the employment of people with disabilities improves.


Economic viability of this proposalThe initial outlay of subsidy funds will be offset by: Increased taxes from persons with disabilities who are now able to work. Decreased disability payments due to increased productivity of persons now

properly housed. Decreased hospitalization costs for persons unable to leave hospital due to

inaccessible housing

Decreased health care costs for persons with health issues due to inadequate housing.

Decreased expensive institutionalization costs for persons now able to live in the community.

Reduction of subsidy funds in the long term as the employment of persons with disabilities improves.

Cost effectivenessThe initial outlay of subsidy funds is: Less expensive than the cost of building new accessible suites to

replace those being lost Less expensive than the costs of adapting existing inaccessible suites,

since later adaptations are 15-20 times more expensive that building suites that are fully accessible

Less expensive than the disability benefits and health care costs incurred when a segment of the population is unable to function due to inaccessible housing.

Alternative solutionsAn alternative suggestion would be to increase the shelter allowance for all recipients of disability benefits to a level consistent with “actual” rents – ie up to $800-1,500 for residents of large cities such as Vancouver or Victoria. Some persons with disabilities require a second bedroom for an attendant

While this measure may be more fair, it is also more expensive. We believe a targeted subsidy for wheelchair accessible suites is more fiscally sustainable, and will make a significance difference to those most in need. A targeted subsidy also has the advantage that the cost will decline as the productivity and employment of people with disabilities improves.

Another option might be a special additional housing allowance of up to $1,200/month for persons who use wheelchairs. While this would have a similar impact on people’s ability to function productively as the proposed targeted subsidy for wheelchair accessible sites, it would also be more expensive because some people who use manual wheelchairs do not need a wheelchair accessible suite, and this option would likely be more complex and administratively expensive to operate. Another disadvantage of this option is that it would not help preserve the existing accessible housing stock, nor would it be an incentive for private developers to build more accessible stock.

Will visitability solve some of these problems?Yes, visitability will improve housing and community inclusion for people with disabilities. Many people with disabilities, including most people who use canes or walkers and some people who use manual wheelchairs, will be able to live in visitable housing, and all people with disabilities will be able to visit people in visitable housing.

However, mandatory visitability only applies to newly constructed homes, so this is a longer term solution which will increase in impact each year.

Moreover, people who use motorized wheelchairs and some people who use manual wheelchairs will be not be able to live in visitable homes and will need fully accessible homes. The cost of necessary adaptations for this group of people would be prohibitive..

For those people - some people who use manual wheelchairs and all people who use motorized wheelchairs -, fully wheelchair accessible housing is essential.


Section Two: Transforming Home

Support Part A: Transforming Home Support

UN Convention on the Rights of Persons with DisabilitiesSupporting full inclusion & independent community living

Creating a more sustainable & cost-effective system

“Parties to the present Convention recognize the equal right of all persons with disabilities to live in the community, with choices equal to others, and shall take effective and appropriate measures to facilitate full enjoyment by persons with disabilities of this right and their full inclusion and participation in the community, including by ensuring that:

a. Persons with disabilities have the opportunity to choose their place of residence and where and with whom they live on an equal basis with others and are not obliged to live in a particular living arrangement;

b. Persons with disabilities have access to a range of in-home, residential and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation or segregation from the community”...

UN Convention on the Rights of Persons with Disabilities, 2006, Article 19, pg 13-14.

The United Nations Convention on the Rights of Persons with Disabilities establishes the right of persons with disabilities to live in the community with the same range of choices as other people, and that governments must take measures to ensure these rights are realized including sufficient community support services to support full living and inclusion in the community.

Unfortunately, the home support system in British Columbia is not currently organized to meet the rights guaranteed in the UN Convention, and the system needs significant transformation to enable people with disabilities to fully participate as equal citizens in British Columbia.

In fact, the way the home support system is organized in British Columbia has been recognized as a significant barrier to the full participation of people with disabilities in our province for many years.


British Columbia recognized significant limitations in BC’s home support system over twenty years ago. In 1991, the British Columbia Premier's Advisory Council for Persons with Disabilities established a Community Services Task Team to investigate the effectiveness of community supports, identify barriers, and recommend solutions.

The Premier’s Advisory Council on Persons with Disabilities Community Services Task reviewed existing research and held extensive hearings across British Columbia. As a result of these consultations, home support was identified as the most important issue, and the current way that home support was provided was identified as a major barrier to the full participation of people with disabilities. The Community Services Task Team prepared a report and recommendations, including a chapter on home support. These recommendations are included in our submission below.

The finding of the Premiers Advisory Council on Persons with Disabilities Community Services Task Team, that home support was thought to be the most important issue, and that the way home support is currently organized in British Columbia is a significant barrier, was recently confirmed by a survey of persons with spinal cord injury conducted by the BC Paraplegic Association. Backman 2007

This survey, conducted sixteen years after the Premier’s Advisory Council on Persons with Disabilities Community Services Task Team report, reported that improving home support was the top ranked issue for persons with spinal cord injury in BC, and that the way home support is organized has a significant impact on people’s ability to participate in society and on people’s health.

“Over the past decade, home support services have been cut, creating a gap between what people need and what they receive. The focus is on practical issues such as eating and bathing, or medical needs, and not on issues such as social inclusion or facilitating employment. Yet social issues, including income and employment, are primary health determinants, and home support is integrally linked to social participation in the community.” (Backman 2007, p5).

The findings from the Premier’s Advisory Council on Persons with Disabilities Community Services Task Team and the BC Paraplegic Association are confirmed by international research that adequate home support is a crucial determinant of people’s ability to participate in society, to work, to go to school, to be productive, to be a healthy member of society. Batavia 1998; DeJong 1981; DeJong et al 1992; Heywood et al 2007; Heywood 2004; Litvak et al

1987

In addition to the current home support system being a barrier to the full participation of persons with disabilities, it is also unnecessarily expensive because it increases overall health care costs. Hollander


Transforming BC’s home support system to enable people with disabilities to fully participate in our province

makes human and fiscal sense.

This transformation is essential for BC to become the most accessible province in Canada.

Why is the current home support system a barrier to the full participation of people with disabilities in BC?The current home support system is a barrier to the full participation of persons with disabilities. It is also unnecessarily expensive because it increases overall health care costs.

Insufficient amount of assistance for people with disabilities to be active members of societyThe current amount of home support assistance is enough to keep people alive, but not sufficient for persons with disabilities to be healthy or to function normally in society. The lack of adequate amounts of assistance was identified as a major barrier in the 1991 Premiers Advisory Council on Persons with Disabilities Community Services Task Team as well as sixteen years later in the survey of persons with spinal cord injuries in BC in 2007. Backman 2007; Premiers Advisory Council on Persons with Disabilities 1991

Adequate amounts of support are crucial determinants of people with disabilities’ health and ability to live in the community, Batavia 1998; Gibson et al 2012; Nosek et al 1993; Stout et al 2008 and are essential for people with disabilities to live normally in society. Dejong 1981, Dejong 1992; Litvak 1987 The lack of adequate home support has a significant impact on people’s health and is a significant barrier to people with disabilities functioning in society. Batavia; DeJong 1981,

DeJong 1992; Litvak 1987; Nosek et al 1993; Stout et al 2008

The current amount of assistance in BC’s home support system is insufficient to meet the requirement of adequate and appropriate support services specified in the United Nations Convention on the rights of Persons with Disabilities. In fact, the usual maximum amount of assistance in BC’s home support system is less than half of the average amount provided in Sweden. Westberg 2010 The isolation and lack of productivity experienced by people with disabilities in British Columbia is a significant result of the inadequate amount of assistance currently provided.

Lack of appropriate community support forces people into institutions, which is a violation of Article 19 of the UN Convention on the Rights of Persons with Disabilities, deprives people of their liberty and human rights, and is documented to result in reduced quality of life, reduced skills, reduced productivity, and reduced ability to actively participate in society. Bulic 2012, Freyhoff et al

2004, Kim et al 2001, National Council on Disability 2012, Larson et al 2012, Lemay 2009, Mansell et al 2007, Mansell et al 2010, National Council on Disability 2012, Ratzda 2003; Stancliffe et al 2004


Narrow limits on the type of assistance – “personal care only” – ensures that people with disabilities are kept alive, but don’t have the support needed to function & be productive

- Not able to go to work or school- Insufficient assistance to live full integrated lives- Persons who need assistance to function are literally not able to work, go to school, or be

productive if full assistance is not provided. Batavia; DeJong 1981; DeJong et al 1992; Gibson et al 2012; Litvak et al 1987; Nosek 1991

A broad range of services is essential for persons with disabilities to function in society. DeJong et al 1992; Litvak et al,

1987; National Council on Disability, 1988

“both the medical and nonmedical domains of personal assistance services are essential to the maintenance of independent lifestyles as well as the health and productivity of disabled persons and that both domains should be included within the scope of covered services” DeJong et al 1992 p4

In British Columbia, we recognize the importance of a full range of services for persons with developmental disabilities, but we do not do so for persons with physical disabilities. In fact, the limited of assistance provided to persons with physical disabilities is very different than that provided to persons with developmental disabilities. Assistance to persons with developmental disabilities in BC is provided under a different ministry through an independent crown corporation, and support is based on the support needed to live a full life, in contrast to the narrow restrictions on support to persons with physical disabilities.

The home support assessment was designed for seniors, who have very different needs than younger people with disabilities. Most seniors have already completed their education, their employment, and have raised a family. Designing a support system based on people who have already completed work, education & raising families, literally means that services to support those crucial activities for young adults with physical disabilities are not included.

“Perhaps the main reason that the [independent living] IL model is largely overlooked by policy makers… is that long-term-care policy has focused primarily on the frail elderly population, often assumed to be dependent… policy makers largely have overlooked the needs of the younger disabled population.” DeJong et a l1992, p2-3

Medical modelThe current home support system in British Columbia is based on the medical model, a model that experts believe is itself a barrier to the full participation of people with disabilities. Bulic 2012; Brisenden 1986; European

Coalition for Community Living 2008; Martínez-Leal et al 2011; National Council on Disability 2013; Ratzda 2003; Tromel 2010

The medical model defines disability as a personal physical/mental condition or “deficit” that is permanent and not likely to change. As a result, services are limited to medical needs, and because disability is defined as a permanent condition residing in the individual, systems based on medical models do not usually consider what assistance would enable the person to be productive.

In contrast, the social model defines disability as an interaction between the person’s condition and the way society is organized. Since disability resides in the interaction of the way society is organized and the person’s condition, it can be changed, and with proper assistance and removal of barriers, people with disabilities can have the same possibilities as other people.


A Comparison of the Medical & Social ModelMedical model Social modelDisability is a personal physical/mental condition Disability results from the interaction between the

person and the way society is organized

Disability is a permanent deficit in the individual Disability is based on the way society is organized, which isn’t permanent & can be changed

Needs are primarily medical Needs are support for full participation & removal of barriers

Clients are passive recipients of care Clients are active productive members of society

Limitations and lack of participation are due to the person’s medical condition

Limitations and lack of participation are due to the way society is organized

Since people’s situation is due to a permanent medical condition, it can’t be changed

Since people’s situation is due to the way society is organized, it can be changed

Static, limited view: custodial care Dynamic positive view: equal possibilities

Illustrative examplesMedical model Social modelUnable to get into buildings because cannot climb steps

Unable to get into buildings because there are no ramps or lifts

Unable to open heavy doors because cannot use hands

Unable to open doors because they are too heavy and lack power-assisted doors

Difficulties in getting around in the city due to poor vision

Unable to get around in the city because there are no voice-assisted signs in busy junctions and on public transport

Unable to understand complex written text because of learning difficulties

Texts are too complicated when they could use plain language and easy-to-read format

The table with illustrative examples is taken from “Creating successful campaigns for community living” European Coalition for Community Living, 2008 p63

The United Nations Convention on the Rights of Persons with Disabilities uses the social model of disability instead of the outmoded medical model which leaves people with disabilities as passive recipients of care rather than active productive members of society

“disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others” United Nations 2006, Preamble, p2


Assessments of support are not transparent, not based on a client’s needs to be a productive member of society, often erratic and unfair, and there is no independent appeal process. The assessment process is not transparent, which is unfair and limits client’s autonomy and rights. When an assessment is conducted, clients are not given a copy of the assessment with the reasons for the assessment, and the assessment report is not provided afterwards if the client requests it.

This means that a person has no information on which to base an appeal (clients can only obtain copies of their assessments by making a freedom of information request, but this takes about 3 months, and most people are not aware of the freedom of information process). A person with a disability who does not have access to information about their assessment has significant difficulty challenging an assessment that may not meet their needs.

Lack of independent appealThere is currently no independent appeal mechanism in the BC Home Support system. This means that if a person is assessed at less than adequate support or if their support is reduced unfairly, they have no real recourse and cannot remedy the inadequate assessment. This literally means that the person may be unable to function and may not be able to change that situation.

It’s important to note that the lack of an independent appeal in the home support system is very different from the mechanism for resolving issues for other services/assistance for persons with disabilities in BC. For example, there is an established independent appeal mechanism to ensure fairness in decisions about income support and equipment.

This lack of independent appeal in home support was identified as a significant issue in the Premier’s Advisory Council for Persons with Disabilities Community Services Task Team report in 1991.

Lack of portability and insecurity of supportEach Health Authority uses different criteria to assign service hours, so when a person with a disability moves to a different area, their service is re-assessed, and they may then receive significantly reduced service simply because they now reside in another area. People thus risk losing their support and ability to function whenever they move.

This lack of portability and insecurity of service is a significant barrier and makes it difficult for people with disabilities to function.

There is also no security of support even for people who don’t move. It is common for Health Authorities to re-assess and reduce client’s services significantly, even if the person has received the same service for many years and their condition has not changed.


No autonomy, choice or control on how service is provided

In British Columbia, the vast majority of clients have no choice of whether to hire their own workers, no choice about whether they want their service provided by an agency, no choice of agency or worker, and no choice of when and how the service will be delivered, except the few enrolled in CISL. (CISL is a small program that provides direct funding to individuals, who are then allowed to hire, train and supervise their own workers.

However, eligibility for CISL is limited, and only a small percentage of persons with disabilities are allowed to participate.)

This lack of control over one’s service has a significant impact on people with disabilities ability to function. There is significant scientific documentation that clients who do not have choice and control over their service (ie service provided by an agency) have lower quality of life, Chase et al 2000;

Prince et al 1995 poorer health and more hospitalizations, Beatty et al 1998; Carlson et al 2005; Chase et al 2000; Kim et al 2006; Nosek 1993; Mattson-Prince et al

1995; Mattson-Prince 1997; Richmond et al 1997 and lower productivity and employment. Beatty et al 1998; Benjamin 2001; Richmond et al 1997 Clients using agency provided service (no control over their service) also report less satisfaction with their service, Beatty et al 1998; Benjamin et al 2000; Benjamin 2001; Carlson et al 2005; Clark et al 2008; Doty et al 1996; Foster et al 2003; Gray et al 2009; Hagglund et al 2004; Heller 2005; Kim et al 2006;

Prince et al 1995 poorer quality of service and safety concerns, Benjamin et al 2000; Carlson et al 2005; Clark et al 2008 and higher unmet needs. Benjamin et al 2000; Carlson et al 2005; Clark et al 2008; Foster et al 2003

Consumer choice and control is an essential part of personal autonomy and rights. The UN Convention on the Rights of Persons with Disabilities specifically notes that people with disabilities have the right to choice and decision-making about policies and programs affecting them, United Nations 2006 and there is significant scientific research that persons who control their own service have better quality of life, Chase et al 2000; Mattson-Prince et al 1995 better health, Carlson et al 2005; Chase et al 2000; Kim et al 2006; Nosek 1993;

Mattson-Prince et al 1995; Mattson-Prince 1997; Richmond et al 1997 less hospitalizations, Beatty et al 1998; Carlson et al 2005; Chase et al 2000; Kim et al 2006; Mattson-Prince et al 1995 better quality of care and safety, Benjamin et al 2000; Carlson et al 2005; Clark et al 2008 less unmet needs, Benjamin et al 2000; Carlson et al 2005; Clark et

al 2008; Foster et al 2003 and higher employment and productivity. Beatty et al 1998; Benjamin 2001; Richmond et al 1997


The province does enable people to have complete choice for other services. For example, the government pays for medical practitioners, but clients have their choice of practitioner.

In the area of home care, there is no reason to take this choice away because a person has a disability and needs assistance.

Costs to the user are a barrier

The costs to the user of home support services are a barrier that should be eliminated. Four other provinces in Canada already follow best practice and do not charge for home support. Health

Association Nova Scotia

The current cost assessment also discriminates against persons with more severe disabilities because the charge is a per diem rate, which means that persons with more severe disabilities who need service every day, pay significantly more than persons with fewer needs.

These were two of the concerns mentioned in the Premier’s Advisory Council on Persons with Disabilites Community Services Task Team report in 1991, and that report recommended that either the service be provided at no charge, or that the rate be reduced by using an increased deduction and by using the resultant per diem rate as a weekly rate.

Inefficient use of government funds; not sustainable

The current home support system is not cost-effective, not sustainable, and actually increases overall government costs due to deteriorated health, increased hospitalization, increased facility care, and increased home support due to deteriorated health; DeJong et al 1992, Hollander et al 2001, Kaye 2012 The way the home support system is organized also makes employment difficult or impossible, and thus increases disability expenditures and decreases tax revenue. DeJong et al 1992


The current system keeps people alive, inactive, and dependent on disability benefits, as compared to a transformed system that provides the support to enable people with disabilities to be independent, to work, learn, raise families, participate in the community, and to help themselves.

What are the features of a transformed home support system?

Specific features of transformed home support

Commitment to provide adequate support for all activities of life and full participation in society as required by the UN Convention on the Rights of Persons with Disabilities. Services support all the activities of life: assistance with housework, education, work, recreation, family

Commitment to the social model of disability, as mandated in the UN Convention on the Rights of Persons with Disabilities.

Fair and equitable assessment based on a person’s needs for assistance.- Use assessment similar to the best practice currently in place in Sweden Westberg 2010 (or see options described in

research by Doty or Stancliffe). Individualized plan based on all activities of life & person’s needs- Transparent process- Independent appeal


Transformed home support system

Designed to enable people with disabilities to be active and full participants in the community

Meets the criteria in the United Nations Convention on the Rights of Persons with Disabilities

Based on the social model of disability, not the medical model Supports all of the activities of life. Supports employment, education, training,

recreation, family life. Provides disabled people with choice and control over home support Creates a culture of participation and independence, rather than a culture of

dependency and isolation Is cost-effective and sustainable because it decreases expensive hospitalization

and institutionalization, increases employment and productivity, and decreases dependence on disability pension

Portability and security of service

After a person has been assessed, their service can only be reduced if it can be demonstrated that there is an improvement in their condition and a subsequent decrease in their need for service.

Consumer choice and control

All clients have choice of:- Hiring & firing their own worker with direct payments- Choosing the agency of their choice and choosing the worker- Determining how and when the service is provided- Changing their choice of the options above, including agencies, whenever desired- Clients choosing to use an agency can do so with direct payments, authorized government

payment to agency, or vouchers (one system should be used; whichever is best for province)

We have modeled this on the Swedish system where all clients have individualized plans, individualized budgets, and direct payments. Clients can then choose to a) hire the worker(s) of their choice b) go through a user coop for assistance c) use agency of their choice d) use municipal services. Clients can change their choice at any time. Westberg 2010

We are suggesting a similar system with choices a) & c), either with direct payments to all, or with direct payments for those choosing to hire their own workers, and either a voucher system or a MSP like system for agencies.

It is important to note that the UN Convention on the Rights of Persons with Disabilities recognizes the right of persons with disabilities to control and direct their own service, United Nations 2006 that there is significant scientific research that this is best practice, Beatty et al 1998; Benjamin et al 2000; Benjamin 2001; Carlson et al 2005; Chase et al 2000; Clark et al 2008;

Doty et al 1996; Foster et al 2003; Gray et al 2009; Hagglund et al 2004; Heller 2005; Kim et al 2006; Mattson-Prince 1997; Mattson-Prince et al 1995 and that consumer controlled service is already in place in half of European Union countries and in most US states.Doty et al 2010; Townsley et al 2010

.

Individualized plans & individualized budgets

Individualized plans that support all the activities of life and individualized budgets are global best practice.refs In fact, almost half of European Union countries have individualized plans and budgets in place, as do most US states.refs Townsley, Doty

There are several excellent tools to generate fair individual plans & budgets,See articles by Doty or Stancliffe book and there also are some computerized systems to generate individualized budgets within spending constraints. The DOORs system in Wyoming, for example, enables the state to predict the need for support in advance, and to allocate funds for individually planned and budgeted services within budgetary restrictions. In Stancliffe Economics of Deinstitutionalization


The economics of transformed home supportTransforming home support is cost-effective and sustainable.

In fact, the current restricted home support program in British Columbia actually costs government more than a broader appropriate service. Hollander et al 2001; Kaye 2012

In British Columbia, a Health Canada study conducted in BC found that Health Units that provided more services - both housework and personal care - actually had significantly lower overall health care costs than Health Units that provided less service - only personal care. Hollander et al 2001

They found that Health Units that eliminated housework and only provided personal care actually had higher overall health care costs than Health Units who still provided housework.Hollander This increase in overall health care costs after eliminating housework was due to subsequent deterioration in client’s health, which caused increased expensive hospitalization, institutionalization, and additional home support for persons whose conditions had worsened. Hollander A recent study confirms the same result in the US: that cuts in home support services actually increase overall costs due to decreases in health and subsequent increases in other more expensive services, such as hospitalization. Kaye 2012


Providing appropriate support for persons with disabilities maintains and improves health and reduces overall health care costs.

It also enables people to work and be productive, reducing disability assistance rates and increasing tax revenue.

Basically it makes human and financial sense to enable people with disabilities to live full lives and help themselves.

UN Convention on Rights of Persons with Disabilities

Service supports Consumer choice, autonomy & control Fairness Costs to government Cost to client

Best practiceCommunity feedback

Research documentation

All activities of life

Community Inclusion Employment Education

& training

Medical or Social Model

Consumer control

Individual budget

Direct Funds

Assessment based on person with disabilities’ needs

Independent appeal

Portability & security of support

Cost effectiveSustainableImpact on government funds

Current No

Does not follow UN Convention on the Rights of Persons with Disabilities

Does not provide supports to live in the community without isolation & segregation

Does not provide assistance for disabled people to work & be productive

Minimal service results in isolation, inability to work, higher government cost

No

Only personal care

No

Barrier to community inclusion

No

Barrier to employment

No

Barrier to education & training

Medical modelMedical model is outdated & no longer used. Social model of disability is used in the UN CRPD.

No

Except CISL program which has limited eligibility

No

Except CISL which has limited eligibility

No

Except CISL, which haslimited eligibility

No

Assessment based on criteria developed for seniors.

Not based on needs of younger people with disabilities

No No

Clients who move are re-assessed by different Health Authority which may have different criteria; service can then be significantly reduced.

Service level also can be changed at any time without an independent appeal

No

Current home support system increases overall health care costs Hollanderet al 2001

Current home support system is a barrier to employment, education & training which reduces people’s productivity, reduces tax revenue, & increases reliance on government funded disability benefits.

Also, Health Canada research conducted in BC showed Health Units eliminating housework actually had significantly increased overall health care costs compared to Health Units still providing housework. The increased health care costs from eliminating housework were due to increased hospitalization, expensive residential care, and increased home support costs due to deteriorating health after housework was eliminated.Hollander et al 2001

Charge based on sliding scale per diem rate.

Cost is too high, especially for persons with severe disabilities, who need service every day.

Payment based on per diem rates discriminates against persons with severe disabilities who need help every day.

BC’s home support system was the most significant concern for disability groups and individuals in 1991, when the Premier’s Advisory Council on Persons with Disabilities Community Services Task Team held province-wide consultations on support services. The Premier’s Advisory Council on Persons with Disabilities Support Services Report made significant recommendations for reform, which are incorporated in the Transformed Home Support Program presented in this paper.

Concerns in 1991 included: inadequate amount of support, lack of support for all activities of life, lack of client control, barrier to employment & full participation, high cost to client & disproportionate cost to persons with severe disabilities, unfair & erratic assessments, no independent appeal.

In 2007, a province-wide survey or persons with spinal cord injury also found that home support was the most frequently mentioned issue. Inadequate amount of support, narrow service limits, lack of support for all activities of life, & lack of choice & control were major issues. Baclman 2007

TransformedYes

Provides full support for all activities of life necessary to live independently in the community without isolation or segregation

Yes Yes Yes Yes Social model

As per UN CRPD

Yes

Can choose to hire own worker or can choose agency and worker

Yes Yes

Clients can choose which option they want

Yes Yes Yes Yes

Sustainable & cost effective because initial increases in home care budget are offset by decreases in hospitalization, expensive institutionalization, and preventable increases in home support due to deteriorated health caused by insufficient home support.Hollander

Will also increase employment rates, increase tax revenue, & decrease disability benefits.

Free or lower cost

Service should be free as it is in some provinces.

If service is not free, the cost should be reduced so it is not a barrier.

Daily rate should be eliminated & used as a weekly rate, so persons with severe disabilities are not penalized.

Best practices: Support for all activities of life

Portability Social model, not medical model Adequate support for full community living rather than

institutionalization is best practice & is mandated by UN Convention on the Rights of Persons with Disabilities

Consumer choice & control

Community living vs institutions Community living mandated by UN Convention Institutions deemed discrimination & deprivation of liberty by

courts Hundreds of scientific research papers document better

quality of life in community & harm/deterioration in institutions Community living has same or lower cost than institutions

Consumer control mandated by UNCRPD; already used by half of European Union countries & most US states

Clients using consumer controlled services have higher quality of life; higher employment; higher productivity; better safety, continuity & security of service; higher satisfaction with service.



Part B: No Institutions in BCFollowing the UN Convention on the Rights of Persons with Disabilities

Ensuring full inclusion and independent community living in BC

Making BC an institution-free zoneIn British Columbia, we have the excellent policy of no institutions for persons with developmental disabilities and persons with mental health disabilities. This existing policy is consistent with the UN Convention on the Rights of Persons with Disabilities and with international best practice.

The UN Convention on the Rights of Persons with Disabilities delineates the right of persons with disabilities to live in the community and not in institutions.United Nations 2006 This right was confirmed by the US Supreme Court Olmstead decision that confinement to institutions constitutes discrimination and European Human Rights Court rulings that institutionalization constitutes deprivation of liberty. Bulic 2012;

National Council on Disability 2012

This legal framework is corroborated by scientific evidence: hundreds of research studies show improved quality of life and productivity in the community, compared to significant decreases in people’s skills and functioning in institutions.Bach et al 1992, Bulic 2012, Carlson et al 2012; Freyhoff et al 2004, Kim et al 2001, National Council on Disability 2012, Larson et al 2012, Lemay 2009, Mansell et al 2007, Mansell et al

2010, National Council on Disability 2012, Ratzda 2003; Stancliffe et al 2004

In British Columbia, we recognize the right to community living, and we have a policy of no institutions for persons with developmental disabilities or with mental health illness.

But British Columbia does not have a policy of no institutions for persons with physical disabilities, and hundreds of persons with physical disabilities are confined to institutions in our province.

It is essential that British Columbia ensures that this commitment to no institutions extends to persons with physical disabilities, and ensures that no person with any disability, developmental, mental or physical, is confined to an institution in British Columbia.

This is an essential step British Columbia must take to follow the UN Convention on the Rights of Persons with Disabilities, to ensure the full integration of people with disabilities, and to become the most accessible province in Canada.

How do we make community living work in BC?To ensure that full independent community living can become a reality in British Columbia, the commitment to no institutions has to be combined with a commitment to good housing and appropriate home support to support living in the community. Bulic 2012; Mansell et al 2007; National Council on Disability 2012s

Without these two measures – appropriate housing and appropriate home support – living in the community, integration, productivity, and real accessibility are not possible. Bulic 2012; Mansell et al 2007; National Council on Disability 2012s


Do I have that consumer directed less expensive?

Carefully check #2 to see if any changes highlighted

What does the scientific research say about independent community living?How do the costs of community living compare to institutions?Hundreds of scientific papers document the significant improvements in quality of life for persons living in the community. Bach et al 1992, Bulic 2012, Carlson et al 2012; Freyhoff et al 2004, Hammel 2004; Kim et al 2001, Kozma et al 2009, Lakin et al 2011, Mansell et al 2007, Mansell et al 2010, National Council on Disability 2012

In addition, there is significant evidence that providing appropriate support in the community is actually less expensive for government Kim et al 2001, Kitchener et al 2005, Lakin et al 2008, Mansell et al 2007, Mansell et al 2010, National Council on Disability 2012 , Nerney et al 1992, especially for persons with physical disabilities.Bach et al 1992; Kaye et al 2009, Kaye 2012

For example, one research paper compared the costs of community living for persons with severe disabilities using ventilators, and found that providing 24/7 assistance in the community was 70% less expensive than institutions, even though people were living by themselves in private apartments. The study’s assessment of community costs was very thorough and included income supports, housing subsidies, food stamps etc. Persons living in the community also had higher quality of life.Bach et al 1992

Another recent study that looked at costs over a ten year period found the same result: considerable savings with community living for persons with physical disabilities. This study compared overall health care costs for states that relied mainly on community-based services to states relying primarily on institutions and found that states relying on community-based services actually had lower overall health care costs for persons with physical disabilities at the end of a ten year period. This study relied on Medicare & Medicaid figures, so the figures are very accurate.Kaye et al 2009


Providing appropriate support for persons with disabilities not only maintains and improves health, it also enables people to work and be productive, reducing disability pension rates and increasing tax revenue.

Basically it makes human and financial sense to enable people with disabilities to live full lives and help themselves.

We need to create a culture of participation and independence, rather than a culture of dependency and isolation.

The first requirement ofdisabled people in participating as equal citizens within the community is a home which is suited to them, together with

control over the necessary help they require to live independently.Disabling Barriers, Enabling Environments, Finklestein, et al (Eds), 1993.

ReferencesTransforming British Columbia

Making BC Canada's Most Accessible Province - at Minimal Cost

Ainsley Gommon Architects: Lifetime Homes Desktop Study: Report to the National Assembly for Wales. 16p. 1999.

Allen, S. M., & Mor, V. (1997). The prevalence and consequence of unmet need. Contrasts between older and younger adults with disability. Geriatric Nursing, 35, 1132–1148.

Audit Commission for Local Authorities and the National Health Service in England and Wales. (1998). Home alone: the role of housing in community care: National Report.104p,

Bach, J.R., Intintola, P., Alba, A.S., and Holland I.E. (1992). The ventilator-assisted individual: cost analysis of institutionalization vs rehabilitation and in-home management. Chest, 101(1), 26-30.

Backman, C., Forwell, S., Carpenter, C., & Jongbloed, L. (2007). Priority Issues for British Columbians Living with Spinal Cord Injury. International Journal of Disability, Community & Rehabilitation, 6(1), 1-19.

Batavia, A. I. (1998). Prospects for a national personal assistance services program: Enhancing choice for people with disabilities. American Rehabilitation, 24(4), 2.

Batavia, A. I., DeJong, G., & McKnew, L. B. (1991). Toward a national personal assistance program: The independent living model of long-term care for persons with disabilities. Journal of Health Politics, Policy and Law, 16(3), 523-545.

Batavia, A.I. (2002). Consumer Direction, Consumer Choice, and the Future of Long-Term Care. Journal of Disability Policy Studies, 13: 67-74.

BC Housing, personal communication, 2012. BC Ministry of Health (2011). A review of the use of antipsychotic drugs in British Columbia residential

care facilities. pp. 1-47.Beatty, P.W., Richmond, G.W., Tepper, S., & DeJong, G. (1998). Personal assistance for people with

physical disabilities: Consumer-direction and satisfaction with services. Archives of Physical Medicine and Rehabilitation, 79 (6), 674-7

Benjamin, A. E. (2001). Consumer-directed services at home: A new model for persons with disabilities. Health Affairs, 20(6), 80-95.

Benjamin, A. E., & Matthias, R. E. (2004). Work-life differences and outcomes for agency and consumer-directed home care workers. The Gerontologist, 44, 479–488.

Benjamin, A. E., Matthias, R., & Franke, T. M. (2000). Comparing consumer-direct and agency models for providing supportive services at home. Health Services Research, 35, 351–366.

Benjamin, A.E. et al (1999). Consumer Direction and In-Home Services: Recipient Perspectives on Family and Non-Family Service Provision. Journal of Rehabilitation Administration, 233-247.

Benjamin, A.E. and Matthias, R.E. (2001). Age, Consumer Direction, and Outcomes of Supportive Services at Home. Gerontologist, 1-11.

Berg, S. (2003). Personal Assistance in Sweden. Stockholm: Independent Living Institute. Retrieved from http://www.independentliving.org/docs6/berg20030520.html

Brisenden, S. (1986). Independent Living and the Medical Model of Disability. Disability, Handicap and Society, 1 (2), 173-8.


Bulic, I. (2012). Common European Guidelines on the Transition from Institutional to Community-based Care: Guidance on implementing and supporting a sustained transition from institutional care to family-based and community-based alternatives for children, persons with disabilities, persons with mental health problems and older persons in Europe. European Expert Group on the Transition from Institutional to Community-based Care, 1-168.

Bulic, I., & Parker, C. (2009). Focus on Article 19 of the UN Convention on the Rights of Persons with Disabilities. European Coalition for Community Living. pp.1-54.

Campbell NM & Memken J (2007). Accessible housing availability for the growing U.S. elderly population. Housing and Society, 34 (1), 101-115.

Carlson D, Ford, D (2012). Deinstitutionalization: what the research shows. Disability Rights Washington, pp.1-4.

Carlson, B.L., Dale, S., Foster, L., Brown, R., Phillips, B. & Schore, J. (2005). Effect of consumer direction on adults’ personal care and well-being in Arkansas, New Jersey and Florida. Mathematica Policy Research.

Chappell, N.L., Havens, B., Hollander, M.J., Miller, J.A., and McWilliam, C. (2004). Comparative costs of home care and residential care. The Gerontologist, 44, 389-400.

Chase BW, Cornille TA, English RW. Life satisfaction among persons with spinal cord injuries. J Rehabil. 2000;66:14-20.

City of Edmonton, (2009). Making our homes lifelong homes: accessible housing for seniors.

Clark MJ, Hagglund KJ, Sherman AK. A longitudinal comparison of consumer-directed and agency-directed personal assistance service programmes among persons with disabilities. Disabil Rehabil. 2008;30:689-695.

CMHC (2000). Flexhousing the Professionals’ Guide. 1-63. CMHC, personal communication, 2012. The CMHC staff who provided this information will be pleased to

confirm it, but doesn’t want her name used in a paper.Cobbold C (1997). A cost benefit analysis of Lifetime Homes. Joseph Rowntree Foundation.1- 53.Communities and Local Government (CLG) (2007). Future of the Code for Sustainable Homes: Making a

Rating Mandatory. 1-64. Communities and Local Government (CLG) (2010).Code for Sustainable Homes: A cost review. 1-138.Concrete Change (2012). Visitability costs affirmed. 1-2. Concrete Change (2012). Myths and objections about visitability. 1-6. Conference of Mayors (US). (2005). Visitability opportunities for people with disabilities: Resolution #28.

1. Confino-Rehder S (2008). Cost/benefit of visit-ability and universal design for single family homes: a USA

comparison. Paper given at the Building Comfortable and Liveable Environments for All International Meeting: Economic Issues of Accessibility, Georgia Tech University, Atlanta. 150-158.

Conroy, J. W. (1995). The Hissom outcomes study: a report on six years of movement into supported living. Brief Report Number 1 of a Series on the well being of people with developmental disabilities in Oklahoma. Center for Outcome Analysis, 1-71.

Conroy, J., & Devlin, S. (2008). Longitudinal Study of Self-Determination in Michigan. Brief Report #3: Costs of Supporting People in Allegan County, Before and During Self-Determination. Report submitted to: Allegan County Community Mental Health Services. Havertown, PA: Center for Outcome Analysis, 1-13.

Conroy, J., Efthimou, J., & Lemanowicz, J. (1982). A matched comparison of the developmental growth of institutionalized and deinstitutionalized mentally retarded clients. American Journal of Mental Deficiency, 86, 581–587.


Conroy, J.W. & Spreat, S. (1998). People who moved from Oklahoma’s public institutions to community homes in the nineties: outcomes and costs. Brief Report Number 5 Of a Series on the Well Being of People with Developmental Disabilities in Oklahoma, 1-48

Conroy, J.W. (2011). Size, Quality, and Cost of Residential Settings: Policy Analysis of Literature and Large Data Sets. Paper submitted to Michigan Association of Community Mental Health Boards and Department of Community Health, Mental Health & Substance Abuse Administration, Bureau of Community Mental Health Services, 1-102.

DeJong, G., 1981. Environmental Accessibility and Independent Living Outcomes: Directions for Disability Program and Research. East Lansing, Mich.: Michigan State University, University Center for International Rehabilitation.

DeJong, G., Batavia, A/I. and McKnew, L.B. (1992). The Independent Living Model of Personal Assistance in National Long-Term Care Policy. Generations, 16(1), 89-95.

DeJong, G.,& Batavia, A. (1990). The Americans with disabilities act and the current state of U.S. disability policy. Journal of Disability Policy Studies, 1(3), 65-75.

Deloitte, LLP. (2013). Economic impact of social care services: assessments of the outcomes for disabled adults with moderate care needs – final report. Scope, 1-55.

Department for Communities and Local Government & Building Cost Information Services (2012). Accessing the Cost of Lifetime Homes Standards, 1-390.

Department of Planning and Community Development (Victoria, Australia) (2009). Visitable and Adaptable Features in Housing: Regulatory Impact, 1-180p

Disability Council of NSW (2005). Accessible Housing in Australia, 1-29.Doty, P. (2000). The Federal Role in the Move toward Consumer Direction. Generations, 22-27.Doty, P., & Flanagan, S. (2002). Highlights: inventory of consumer-directed support programs. U.S.

Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy.

Doty, P., Benjamin, A.E., Matthias, R. E., &Franke, T. M. (1999). In-home supportive services for the elderly and disabled: A Comparison of Client-Directed and Professional Management Models of Service Delivery. U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy

Doty, P., Kasper, J., & Litvak, S. (1996). Consumer-directed models of personal care: Lessons from Medicaid. The Milbank Quarterly, 74(3), 377-409.

Doty, P., Mahoney, J. and Sciegaj, M. (2010). New State Strategies to Meet Long-Term Care Needs. Health Affairs, 29(1), 49-56.

Dowler, D.L., Tatiana I. Solovieva, Richard T. Walls. (2011). Personal assistance services in the workplace: A literature review. Disability and Health Journal, 4(4), 201-208.

Egley L. The cost of programme models providing personal assistance services (PAS) for independent Living. Oakland, CA: World Institute on Disability; 1994.

European Coalition for Community Living ECCL (2008). Creating sucessful campaigns for community living: An advocacy manual for disability organisations and service providers. 1-102.

European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities (2009). Report of the Ad Hoc Expert Group on the Transition from Institutional to Community-based Care, 24p.

Evans, H. (2013). Final Report: Research Study on Scoping a Registry of Accessible and Adaptable Homes in British Columbia. Prepared for the Real Estate Institute of BC and BC Housing, 1-54.

Forrest, G., & Gombas, G. (1995). Wheelchair-accessible housing: Its role in cost containment in spinal cord injury. Archives of Physical Medicine and Rehabilitation, 76(5), 450-452.

Foster, L., Brown, R., Phillips, B., Schore, J., & Carlson, B. L. (2003). Improving the quality of Medicaid Personal Assistance through consumer-direction. Health Affaires. Retrieved: http://www.healthaffairs.org/WebExclusives/Foster_Wed_Excl_032603.htm.


http://www.healthaffairs.org/WebExclusives/Foster_Wed_Excl_032603.htm

Freyhoff, G., Parker, C., Coué, M. & Greig, N. (Eds.) (2004). Included in society: results and recommendations of the European Research Initiative on community-based residential alternatives for disabled people. European Commission, Unit of Integration of People with Disabilities, 1-99.

Gibson, B. E., Secker, B., Rolfe, D., Wagner, F., Parke, B., & Mistry, B. (2012). Disability and dignity-enabling home environments. Social Science & Medicine, 74(2), 211-219.

Habiteg Foundation for Lifetime Homes and Neighbourhoods (2010). Costs of Lifetime Homes: for professionals. http://www.lifetimehomes.org.uk/pages/costs.html. 1-3pg..

Hagglund K, Clark M, Farmer J, Sherman A. A comparison of consumer-directed and agency-directed personal assistance services programmes. Disabil Rehabil. 2004;26:518-527.

Hagglund, K. J., Clark, M. J., Farmer, J. E., & Sherman, A. K. (2004). A comparison of consumer-directed and agency-directed personal assistance service programs. Disability and Rehabilitation, 26, 518–527.

Hagglund, K. J., Clark, M. J., Mokelke, E. K., & Stout, B. J. (2004). The current state of personal assistance services: Implications for policy and future research. Neurorehabilitation, 19, 115–120.

Hammell, K. W. (2004). Quality of life among people with high spinal cord injury living in the community. Spinal Cord, 42, 607-620.

Harris & Associates. (1986). The ICD survey of disabled Americans. New York: International Center for the Disabled.

Health Association Nova Scotia. An Interjurisdictional Comparison of Continuing Care Services in Canada. 1-9.

Heller T, Caldwell J. (2005). Impact of a consumer-directed family support program on reduced out-of-home institutional placement. Journal of Policy and Practice in Intellectual Disabilities, 2(1), 63-65.

Herd et al (2003). A national strategy for accessible housing for all. Paper presented at the National Housing Conference, Adelaide, November 2003. 1-7

Heywood F & Turner L (2007). Better outcomes, lower costs: implications for health and social care budgets of investment in housing adaptations, improvements and equipment: a review of the evidence. Office for Disability Issues, Department for Work and Pensions, UK. 1-118

Heywood, F (2004). The health outcomes of housing adaptations. Disability & Society, 19(2) Hill et al (1999). Breaking into adaptable housing: A cost benefit analysis of adaptable homes. Paper

given at the Housing for Life: 1999 ACT Adaptable and Accessible Housing Conference. 1-11. Hollander Analytical Services Ltd., 2003 (updated 2004) Unfinished Business: The case for chronic home

care services, a policy paper.Hollander, M. and Tessaro, A. (2001). Evaluation of the Maintenance and Preventive Function of Home

Care. Home Care/Pharmaceuticals Division, Policy and Communication Branch, Health Canada, 1-56.

Hollander, M.J., & Chappell, N.L. (2007). A Comparative Analysis of Costs to Government for Home Care and Long Term Residential Care Services, Standardized for Client Care Needs. Canadian Journal on Aging. 26 (SUPPL. 1), 149-162.

Human Resources and Skills Development Canada (2010). The Government of Canada’s Annual Report on Disability Issues, 1-104p.

Human Resources and Skills Development Canada (2011). Disability in Canada: a 2006 profile. 1-75. Kaye, H. S. (2012). Gradual Rebalancing of Medicaid Long-Term Services And Supports Saves Money

and Serves More People, Statistical Model Shows. Health Affairs, 31(6),1195-1203.Kaye, H.S., LaPlante, M., & Harrington, C. (2009). Do noninstitutional long-term care services reduce

Medicaid spending? Health Affairs, 28, 262-272. Khawam, Y (Pima County Chief Building Official) (2010). Letter to the House Financial Services

Subcommittee on Housing and Community Opportunity.Transforming BC into Most Accessible Province at Minimal Cost: Submission from City of Vancouver Persons with Disabilities Advisory Committee ,Page 46/50

http://spph.ubc.ca/person/marcus-hollander/

http://spph.ubc.ca/person/marcus-hollander/

Kim, K. M., Fox, M. H., & White, G. W. (2006). Comparing outcomes of persons choosing consumer-directed or agency-directed personal assistance services. Journal of Rehabilitation, 72(2), 32.

Kim, S., Larson, S.A., & Larkin, K.C. (2001). Behavioral outcomes of deinstitutionalization for people with intellectual disabilities: a review of US studies conducted between 1980 and 1999. Journal of Intellectual & Developmental Disabilities, 26(1), 35-50.

Kim, S., Larson, S.A., & Larkin, K.C. (2001). Behavioral outcomes of deinstitutionalization for people with intellectual disabilities: a review of US studies conducted between 1980 and 1999. Journal of Intellectual & Devlopmental Disabilities, 26(1), 35-50.

Kirk, D. (2012). Supportive living models for younger adults with physical disabilities: A review and proposed best practice models. Edmonton: Canadian Paraplegic Association (Alberta),1-102.

Kitchener, M. et al. (2006). Institutional and Community-Based Long-Term Care: A Comparative Estimate of Public Costs. Journal of Health and Social Policy, 22(2): 31–50.

Kosciulek, J.F., (2000). Implications of Consumer Direction for Disability Policy Development and Rehabilitation Service Delivery. Journal of Disability Policy Studies,11:82-89.

Kozma, A.V., Mansell, J. & Beadle-Brown, J.D. (2009). Outcomes in Different Residential Settings for People with Intellectual Disability: a Systematic Review. American Journal on Intellectual and Developmental Disabilities, 114:3, 193-222.

Lakin, K. C., Doljanac, R., Byun, S., Stancliffe, R. J., Taub, S., & Chiri, G. (2008). Factors associated with expenditures for medicaid home and community based services (HCBS) and intermediate care facilities for persons with mental retardation (ICF/MR) services for persons with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 46(3), 200-214.

Lakin, K.C., Larson, S.A., Kim, & Kim, S. (2011). Behavioral Outcomes of Deinstitutionalization for People with Intellectual and Developmental Disabilities: A Review of Studies Conducted Between 1977 and 2010. Policy Research Brief, 2(2), 1–12.

LaPlante, M. P., Kaye, H. S., Kang, T., & Harrington, C. (2004). Unmet need for personal assistance services: Estimating the shortfall in hours of help and adverse consequences. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 59(2), S98-108.

Larson, S., Lakin, C., & Hill, S. (2012). Behavioral outcomes of moving from institutional to community living for people with intellectual and developmental disabilities: U.S. studies from 1977 to 2010. Research & Practice for Persons with Severe Disabilities, 37(4), 235-246.

Lemay, R. (2009). Deinstitutionalization of People with Developmental Disabilities: A Review of the Literature. Canadian Journal of Community Mental Health, 28 (1), pp. 181–194.

Lifetime Homes website (2008). Lifetimes Homes professional guide: Costs. 1-2 Litvak, S., Zukas, H. and Heumann, J. E., (1987). Attending to America: Personal Assistance for

Independent Living Berkeley, Calif.: World Institute on DisabilityLivable Housing Australia (2012). Livable Housing Design Guidelines. 1-68. Maisel et al. (2008). Increasing home access: designing for visitability. American Association of Retired

Persons Public Policy Institute. 117p.Malloy MP (2008). Inclusion by design: accessible housing and the mobility impaired. Hastings Law

Journal, 60(4), 1-95.Mansell J, Knapp M, Beadle-Brown J and Beecham, J (2007) Deinstitutionalisation and community living

– outcomes and costs: report of a European Study. Volume 2: Main Report. Canterbury: Tizard Centre, University of Kent. pp.1-140.

Mansell, J., & Beadle-Brown, J. (2010). Deinstitutionalisation and community living: Position statement of the Comparative Policy and Practice Special Interest Research Group of the International ASsociation for the Scientific Study of Intellectual disabilities. Journal of Intellectual Disability Research: JIDR, 54(2), 104-112.

Martin J, Martin A (2006). The Cost of the Lifetime Homes Initiative. RICS Building Cost Information Service 2006


Martínez-Leal, R., Buono, S., Germanavicius, A., van Schrojenstein Lantman‐de Valk, H., &Tossebro, J. (2011). The impact of living arrangements and deinstitutionalisation in the health status of persons with intellectual disability in Europe. Journal of Intellectual Disability Research, 55(9), 858-872.

Mattson Prince J, Manley MS, Whiteneck GG. (1995). Self-managed versus agency-provided personal assistance care for individuals with high level tetraplegia. Archives of Physical Medicine and Rehabilitation, 76(10), 919-923.

Mattson-Prince, J. (1997). A rational approach to long-term care: Comparing the independent living model with agency-based care for persons with high spinal cord injuries. Spinal Cord, 35(5), 326-331.

Metlife (2012). The 2012 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. MetLife Mature Market Institute, 1-51.

National Council on Disability (2012 ). Deinstitutionalization: Unfinished Business (Companion Paper to Policy Toolkit), National Council on Disability, pp 1-110.

National Council on Disability (2013). The Case for Medicaid Self-Direction: A White Paper on Research, Practice, and Policy Opportunities. National Council on Disability, 1- 64.

National Dialogue on Universal Housing Design (2012). Strategic Plan. FaHCSIA website.12p.Nerney, T., & Conley R. W. (1992). A policy analysis of community costs for persons with severe

disabilities. Journal of Disability Policy Studies, 3(2), 31-52.Nosek, M. A. (1991). Personal assistance services: A review of the literature and analysis of policy

implications. Journal of Disability Policy Studies, 2(2), 1-17.Nosek, M. A., Fuhrer, M. J., Rintala, D. H., & Hart, K. A. (1993). The use of personal assistance services

by persons with spinal cord injury: Policy issues surrounding reliance on family and paid providers. Journal of Disability Policy Studies, 4(1), 89-103.

Nova Scotia League for Equal Opportunity (2006).Inclusive Homes-Affordable/Accessible Housing. 1-6p.

Office of the Deputy Prime Minister (2004). Building Regulations 2000: Access to and Use of Buildings: Approved Document M, 1-87.

Office of the Provincial Health Officer (2004). Prevention of Falls and Injuries Among the Elderly: A Special Report from the Office of the Provincial Health Officer. Ministry of Health, British Columbia. 1-95p

Ontario Human Rights Commission (2001). Time for Action: Advancing Human Rights for Older Ontarians, 85p, 2001. Abbreviation: Ontario HRC 2001.

Perry J (2008).Designed for life: disabled/enabled at home. MS Thesis, University of Lethbridge, Alberta. 1-107.

Ratzda A (1994). A brief survey of studies on costs and benefits of non-handicapping environments. Presentation at the International Congress on Accessibility in Rio de Janeiro, Brazil. 1-9p.

Ratzka A. (1992). Towards an operational definition of Personal Assistance. Independent Living Institute.Ratzka AD. Independent living and attendant care in Sweden: a consumer perspective. New York, World

Rehabilitation Fund, 1986 (Monograph No. 34) (http://www.independentliving.org/files/ar1986spr.pdf, accessed 30 August 2013).

Ratzka, A. (2011). Independent living for people with disabilities of all ages. NNDR 11th Research Conference, Reyjavik, Iceland, May 27-28, pp 1-5.

Ratzka, A. (2012). Personal assistance policy features for Independent Living: The Swedish 1994 Personal Assistance Act of 1994 as illustration. Keynote Address for World Future Council Conference “Good Policies for Persons with Disabilities”, Vienna, pp. 1-4.

Ratzka, A. (1986).Independent Living and Attendant care in Sweden: A Consumer Perspective. Cornell University ILR School DigitalCommons@ILR.

Ratzka, A. (1989). Personal Assistance: The key to Independent Living. Retrieved from Transforming BC into Most Accessible Province at Minimal Cost: Submission from City of Vancouver Persons with Disabilities Advisory Committee ,Page 48/50

http://www.independ0entliving.org/files/ar1986spr.pdf

http://www.independentliving.org/docs2/enilpakeytoil.htmlRatzka, A. (1992). Towards an operational definition of Personal Assistance. Independent living institute,

1-6.Ratzka, A. (1993). The user cooperative model in personal assistance: The example of STIL, the

Stockholm Cooperative for Independent Living. Independent Living Institute, 1-10.Ratzka, A. (2003). Independent Living in Sweden. Independent Living Institute.Ratzka, A. (2003). The prerequisites for de-institutionalization. Institiutefor Independent Living, 1Ratzka, A. (2005). Independent living empowers people with disabilities. Development Outreach, World

Bank, July, pp 1-3. www1.worldbank.org/devoutreach/article.asp?id=317 Internet publication URL: www.independentliving.org/docs7/ratzka20507.html

Ratzka, A. (2012). Personal Assistance empowers persons with disabilities and benefits the national economy. Presentation at Journada FEKOOR, Bilbao, Spain, June 19, pp.1-4.

Ratzka, A. (2012). Personal Assistance: Key to Independent Living as Illustrated by the Swedish Personal Assistance Act. Invited paper presented at Colloquium “CRPD and EU Structural Funds: The way ahead for Independent Living”, United Nations Human Rights, Office of the High Commissioner, Europe Regional Office, Brussels 7 May 2012, 1-6.

Richmond, G. W., Beatty, P. W., Tepper, S., & Dejong, G. (1997). The effect of consumer-directed personal assistance services on productivity outcomes of people with physical disabilities. Journal Rehabilitation Outcomes Measure, 1(4), 48-51.

Sangster K & Richardson R (1997). Costing Lifetime Homes. Joseph Rowntree Foundation. 1-28.Saville-Smith K et al (2007). Housing and Disability: Future Proofing New Zealand's Housing Stock for an

Inclusive Society. Centre for Housing Research Aotearoa New Zealand. 1-153.Scott et al (2010). Falls & Related Injuries among Older Canadians: Fall‐related Hospitalizations &

Intervention Initiatives. Prepared for Public Health Agency of Canada, Division of Aging and Seniors. 1-186.

Smith E (2010). Testimony before the Subcommittee on Housing and Community Opportunity in support H.R. 1408 The Inclusive Home Design Act, 1-5.

Smith E (2013). Inexpensive Zero-Step Entrance Method for Houses over Basements: Inset Floor Joist System. Concrete Change. 1

Smith SK et al (2008). Ageing and Disability: Implications for the Housing Industry and Housing Policy in the United States. Journal of the American Planning Association, 74(3), 289-306.

Souza, M.T., Collinson, R.A., Martin, M., Steffen, B.J., Vancenbroucke, D.A. and Yao, Y-G. D. (2011). 2009 Worst Case Housing Needs of People With Disabilities. A supplement to the Worst Case Housing Needs 2009: Report to Congress. U.S. Department of Housing and Urban Development, Office of Policy Development and Research, 1-28.

Spinal Cord Injury BC (2014). Personal communication re survey of persons with spinal cord injuries in BC.


http://www.independe0ntliving.org/docs7/ratzka200507.html

Stainton, T., Askerova, S., & Feduck, M. (2013) A comparison of cost and service utilization across individualized and traditional funding options through Community Living British Columbia. Vancouver, BC: Centre for Inclusion and Citizenship, pp1-48.

Stancliffe, R. & Lakin, KC (Eds.) (2004). The Economics of Institutionalization. Baltimore: Brookes.Statistics Canada (2006). A portrait of seniors in Canada. 1-301. Statistics Canada (2007). : 2006 Census Bulletin #3: Population by Age. GVRD, 1-5.Statistics Canada 2002). Statistics Canada: A profile of disability in Canada 2001. Ministry of Industry. 1-

24Steinfeld E & Levine D (2001). Basics of Accessible Design. New York City Housing Authority Website.

1-74.Stout, B.J., Hagglund, K.J. and Clark, M.J. (2008). The Challenge of Financing and Delivering Personal

Assistant Services. Journal of Disability Policy Studies, 19: 44-51. Sweett C (2007). A cost review of the Code for Sustainable Homes. English Partnerships and the

Housing Corporation. 1-89.Tennstedt, S., McKinlay, S. J., & Kasten, L. (1994). Unmet need among disabled elders: A problem in

access to community long term care? Social Science and Medicine, 38, 915–924.Townsley, R., Ward, L., Abbott, D. and Williams, V. (2010). The Implementation of Policies Supporting

Independent Living for Disabled People in Europe: Synthesis Report. Academic Network of European Disability Experts (ANED), 1-52.

Tromel, S. (2010). Effective involvement of national DPOs in the UN human rights monitoring process. Newsletter of the European Coalition for Community Living, 12, 4-11.

Truesdale & Steinfeld (2002). Visit-ability: an approach to Universal Design in housing. Rehabilitation Engineering Research Centre on Universal Design, University of Buffalo, 1-50.

United Way of the Lower Mainland: Our Aging Population Faces Challenges, 1-2.Westberg, K. (2010). Personal assistance in Sweden. Independent Living Institute, 1-101.Wysocki, A., Butler, M., Kane, R. L., Kane, R. A., Shippee, T., & Sainfort, F. (2012). Long-Term Care for

Older Adults: A Review of Home and Community-Based Services Versus Institutional Care. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. 1-121.


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