Canada-Newfoundland and Labrador Aging with Dignity funding agreement (2023-24 to 2028-29)

Tables of contents

Funding agreement
Annex 1 – Common statement of principles on shared health priorities
Annex 2 – Shared pan-Canadian interoperability roadmap
Annex 3 – Indicators: Access to home and community care
Annex 4 – Action plan

Funding agreement

(the "Agreement")

Between:

His Majesty the King in right of Canada (hereinafter referred to as "Canada" or "Government of Canada") as represented by the Minister of Health (herein referred to as "the federal Minister")

- and -

His Majesty in right of Newfoundland and Labrador (hereinafter referred to as "Newfoundland and Labrador" or "Government of Newfoundland and Labrador") as represented by the Minister of Health and Community Services and the Minister for Intergovernmental Affairs (herein referred to as "the provincial Ministers")

Referred to collectively as the "Parties", and individually as a "Party"

Preamble

Whereas, on February 23, 2023, Canada and Newfoundland and Labrador announced an overarching agreement in principle on Working Together to Improve Health Care for Canadians, supported by almost $200 billion over ten years in federal funding, including $46.2 billion in new funding to provinces and territories, Canada and Newfoundland and Labrador acknowledged the importance of helping Canadians age closer to home;

Whereas, Canada has also announced a five per cent Canada Health Transfer (CHT) guarantee for the next five years, starting in 2023-24, which will be provided through annual top-up payments as required. This is projected to provide approximately an additional $17 billion over 10 years in new support. The last top-up payment will be rolled into the CHT base at the end of the five years to ensure a permanent funding increase, providing certainty and sustainability to provinces and territories;

Whereas, in the area of home and community care, Working Together to Improve Health Care for Canadians also includes a commitment by Canada and Newfoundland and Labrador to continue to work to support collaboration on the Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the "Common Statement", attached hereto as Annex 1), supported by the federal Budget 2017 investment of $6 billion over 10 years;

Whereas, this Agreement also provides financial support for long-term care as it relates to the Government of Canada's Budget 2021 investment of $3 billion over 5 years to support provinces and territories in keeping long-term care residents safe and improve their quality of life;

Whereas, the Working Together to Improve Health Care for Canadians plan also includes a commitment of $1.709 billion over 5 years to support provinces and territories to increase the wages of personal support workers and related professions (hereinafter collectively referred to as “PSW”), and support other recruitment and retention measures;

Whereas, Newfoundland and Labrador has the primary responsibility for delivering health care services to its residents and supports diversity, equity, and the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+;

Whereas, Canada authorized the federal Minister to enter into agreements with the provinces and territories, for the purpose of identifying activities that provinces and territories will undertake in respect of long-term care, for funding in this Agreement associated with the federal investment for home and community care consistent with the Common Statement (and menu of actions outlined in Annex 1), and PSWs;

Whereas, the Executive Council Act and the Intergovernmental Affairs Act authorizes the Government of Newfoundland and Labrador to enter into agreements with the Government of Canada;

Whereas, Canada undertakes to provide funding to Newfoundland and Labrador that will further help provide Newfoundlanders and Labradorians with improvements in health care associated with long-term care, home and community care consistent with services consistent with the Common Statement, and PSWs; and

Now therefore, this Agreement sets out the terms between Canada and Newfoundland and Labrador as follows:

1.0 Key principles and collaboration

The key principles and commitment to collaboration agreed to in Working Together to Improve Health Care for Canadians are outlined below.

1.1 Canada and Newfoundland and Labrador acknowledge that this Agreement will mutually respect each government's jurisdiction, and be underpinned by key principles, including:

A shared responsibility to uphold the Canada Health Act that strengthens our public health care system;
Principles agreed to in the Common Statement (outlined in Annex 1);
Reconciliation with Indigenous Peoples, recognizing their right to fair and equal access to quality and culturally safe health services free from racism and discrimination anywhere in Canada, including through seamless service delivery across jurisdictions and meaningful engagement and work with Indigenous organizations and governments; and
Equity of access for under-served groups and individuals, including those in official language minority communities.

1.2 Canada and Newfoundland and Labrador acknowledge the importance of supporting health data infrastructure, data collection and public reporting, and will work together to improve the collection, sharing and use of de-identified health information, respecting federal/provincial/territorial privacy legislation, to improve transparency on results and to help manage public health emergencies, and to ensure Canadians can access their own health information and benefit from it being shared between health workers across health settings. This includes:

collecting and securely sharing high-quality, comparable information needed to improve services to Canadians, including disaggregated data on key common health indicators with the Canadian Institute for Health Information (CIHI);
adopting common interoperability standards (both technical exchange and content of data), including the Shared pan-Canadian Interoperability Roadmap (outlined in Annex 2), to improve Canadians' access to their health information in a usable digital format and support the exchange and analysis of health data within and across Canada's health systems in a way that protects Canadians' privacy and ensures the ethical use of data to improve the health and lives of people;
work to align provincial and territorial policies and legislative frameworks where necessary and appropriate to support secure patient access to health information, and stewardship of health information to support the public good, including improving care quality, patient safety, privacy protection, system governance and oversight, planning and research;
promoting health information as a public good by working with federal-provincial-territorial Ministers of Health to review and confirm overarching principles, which would affirm Canadians' ability to access their health information and have it follow them across all points of care. The existing Health Data Charter, as outlined in the Pan-Canadian Health Data Strategy would serve as the starting point for the discussion of these principles; and
collecting and sharing available public health data (e.g., vaccination data, testing data) with the Public Health Agency of Canada to support Canada's preparedness and response to public health events, building on commitments made as part of the Safe Restart Agreements.

1.3 Canada and Newfoundland and Labrador acknowledge they will work with other provinces and territories to streamline foreign credential recognition for internationally-educated health professionals, and to advance labour mobility, starting with multi-jurisdictional recognition of health professional licences.

1.4 Canada and Newfoundland and Labrador acknowledge a mutual intent to engage in a two-phased formal review process:

Phase 1: This review will be done in 2026 by a joint committee of Federal, Provincial, and Territorial health and finance officials to assess results and determine next steps for bilateral agreements related to improvements to home and community care, mental health, substance use, and addiction services associated with the Common Statement and long-term care; and
Phase 2: A formal five-year review of the healthcare plan outlined on February 7, 2023, recognizing the importance of long-term sustainability for provincial/territorial health systems. This review would consist of an assessment of both the bilateral agreements (herein) and the CHT investments (not included as part of this bilateral agreement). The review will be done by a joint committee of Federal, Provincial, and Territorial health and finance officials, commencing by March 31, 2027, and concluded by December 31, 2027, to consider results achieved thus far in the four shared health priority areas and will include:
1. an assessment of progress-to-date on public reporting to Canadians using the common indicators;
2. sharing of de-identified health information, and other health data commitments; and
3. current and forward-looking Federal, Provincial, and Territorial investments to support this plan.

2.0 Objectives

2.1 Canada and Newfoundland and Labrador agree that, with financial support from Canada, Newfoundland and Labrador will continue to build and enhance health care systems towards achieving some or all of the objectives:

Improving access to home and community care services (listed in the Common Statement, attached as Annex 1);
Supporting workforce improvements for long-term care and standards, to keep long-term care residents safe and to improve their quality of life; and
Increasing the wages of PSWs, and supporting other recruitment and retention measures.

3.0 Action plan

3.1 Newfoundland and Labrador will set out in their Action Plan (attached as Annex 4) how the federal investment under this Agreement will be used, as well as details on targets and timeframes for each of the initiatives supported under the Agreement.

3.2 Newfoundland and Labrador will invest federal funding as part of the 2017 commitment for home and community care provided through this Agreement in alignment with the menu of actions listed in the Common Statement.

3.3 Newfoundland and Labrador will invest federal funding for long-term care provided through this Agreement to bolster efforts to support workforce improvements and standards by:

Supporting activities/initiatives to achieve stability in the long-term care workforce, including through hiring and wage top-ups and/or improvements to workplace conditions (e.g., staff to patient ratios, hours of work); and
Applying long-term care standards, with an emphasis on strengthened enforcement (e.g., enhanced inspection and enforcement capacity, quality and safety improvements to meet standards).

3.4 Newfoundland and Labrador will invest the federal PSW funding provided under this Agreement to support incremental activities to raise wages for PSWs.

3.5 With a plan (outlined in Annex 4) to make a meaningful difference to raise the wages of the lowest-paid PSWs by 20% or to reach $25/hour over the 5 years of funding, Newfoundland and Labrador may use the remaining federal funds to support additional non-wage related recruitment and retention measures.

3.6 In developing initiatives under this Agreement, Newfoundland and Labrador agrees to implement measures that also respond to the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+.

3.7 Newfoundland and Labrador's approach to achieving home and community care, long-term care, and PSW objectives is set out in their Action Plan, as set out in Annex 4.

4.0 Term of agreement

4.1 This Agreement comes into effect upon the date of the last signature of the Parties and will remain in effect until March 31, 2029, unless terminated in accordance with section 12 of this Agreement. Funding provided under this Agreement will be for six years and will cover the period April 1, 2023 to March 31, 2029 ("the Term").

5.0 Financial provisions

5.1 The funding provided under this Agreement is in addition to and not in lieu of those that Canada currently provides under the CHT to support delivering health care services within the province.

5.2 Allocation to Newfoundland and Labrador

5.2.1 In this Agreement, "Fiscal Year" means the period commencing on April 1 of any calendar year and terminating on March 31 of the immediately following calendar year.

5.2.2 Canada has designated the following maximum amounts to be transferred in total to all provinces and territories under this initiative based on the allocation method outlined in subsection 5.2.3 for the Term of this Agreement.

Budget 2017 Home and Community Care

$600 million for the Fiscal Year beginning on April 1, 2023
$600 million for the Fiscal Year beginning on April 1, 2024
$600 million for the Fiscal Year beginning on April 1, 2025
$600 million for the Fiscal Year beginning on April 1, 2026

Budget 2021 Long-Term Care

$600 million for the Fiscal Year beginning on April 1, 2023
$600 million for the Fiscal Year beginning on April 1, 2024
$600 million for the Fiscal Year beginning on April 1, 2025
$600 million for the Fiscal Year beginning on April 1, 2026
$600 million for the Fiscal Year beginning on April 1, 2027

Budget 2023 PSW

$325 million for the Fiscal Year beginning on April 1, 2024
$333 million for the Fiscal Year beginning on April 1, 2025
$342 million for the Fiscal Year beginning on April 1, 2026
$350 million for the Fiscal Year beginning on April 1, 2027
$359 million for the Fiscal Year beginning on April 1, 2028

5.2.3 Allocation Method

For funds associated with Budget 2017 Home and Community Care committed by the federal government in 2017, annual funding will be allocated to provinces and territories on a per capita basis. The per capita funding for each Fiscal Year is calculated using the following formula: F x K/L, where:
F is the annual total funding amount available under this program;

K is the total population of Newfoundland and Labrador, as determined using the annual population estimates on July 1^st from Statistics Canada; and

L is the total population of Canada, as determined using the annual population estimates on July 1^st from Statistics Canada.
For funds associated with Budget 2021 Long-Term Care committed by the federal government in 2021, annual funding will be allocated to provinces and territories with a base amount of $1,200,000 and the remainder of the funding allocated on a per capita basis. The total amount to be paid will be calculated using the following formula: $1,200,000+(F-(N x 1,200,000)) x (K/L), where:
F is the annual total funding amount available under this program;

N is the number of jurisdictions (13) that will be provided the base funding of $1,200,000;

K is the total population of Newfoundland and Labrador, as determined using the annual population estimates on July 1^st from Statistics Canada; and

L is the total population of Canada, as determined using the annual population estimates on July 1^st from Statistics Canada.
For funds associated with Budget 2023 committed by the federal government in 2023 on PSWs, annual funding will be allocated to provinces and territories with a base amount of $680,000, and the remainder of the funding allocated on a per capita basis. The total amount to be paid will be calculated using the following formula: $680,000+(F- (N x 680,000)) x (K/L), where:

F is the annual total funding amount available under this program;

N is the number of jurisdictions (all 13) that will be provided the base funding of $680,000;

K is the total population of Newfoundland and Labrador, as determined using the annual population estimates on July 1st from Statistics Canada; and,

L is the total population of Canada, as determined using the annual population estimates on July 1st from Statistics Canada.

5.2.4 Subject to annual adjustment based on the formulas described in section 5.2.3, Newfoundland and Labrador estimated share of the amounts will be:

5.2.4 Subject to annual adjustment based on the formulas described in section 5.2.3, Newfoundland and Labrador estimated share of the amounts will be:
Fiscal Year	Budget 2017 Home and Community Care Estimated amount to be paid to Newfoundland and Labrador^{Footnote *} (subject to annual adjustment)	Budget 2021 Long-Term Care Estimated amount to be paid to Newfoundland and Labrador^{Footnote *} (subject to annual adjustment)	Budget 2023 PSW Estimated amount to be paid to Newfoundland and Labrador^{Footnote **} (subject to annual adjustment)
2023-2024	$8,110,000	$9,100,000	n/a
2024-2025	$8,110,000	$9,100,000	$4,930,000
2025-2026	$8,110,000	$9,100,000	$5,030,000
2026-2027	$8,110,000	$9,100,000	$5,160,000
2027-2028	n/a	$9,100,000	$5,260,000
2028-2029	n/a	n/a	$5,380,000
* Amount represent annual estimates based on Statistics Canada's July 1st, 2022, population estimates. Return to footnote * referrer Amount represent annual estimates based on Statistics Canada's July 1st, 2023, population estimates. Return to footnote referrer

5.3 Payment

5.3.1 Funding provided by Canada will be paid in semi-annual installments as follows (except as outlined in 5.3.1.b):

In 2023-24, the first installment will be paid within approximately 30 business days of execution of this Agreement by the Parties. The second installment will also be paid within approximately 30 business days of execution of this Agreement by the Parties, subject to 5.3.1.h.
In 2024-25, the Budget 2023 PSW funding will be paid as a single installment within approximately 30 business days of execution of this Agreement by the Parties. This installment is not subject to 5.3.1.h.
Starting in 2024-25, and 2025-26 for Budget 2023 PSW funding, the first installment will be paid on or about April 15 of each Fiscal Year and the second installment will be paid on or about November 15 of each Fiscal Year.
The first installment will be equal to 50% of the notional amount set out in section 5.2.4 as adjusted by section 5.2.3.
The second installment will be equal to the balance of funding provided by Canada for the Fiscal Year as determined under sections 5.2.3 and 5.2.4.
Canada will notify Newfoundland and Labrador prior to the first payment of each Fiscal Year, of their notional amount. The notional amount will be based on the Statistics Canada quarterly preliminary population estimates on July 1 of the preceding Fiscal Year. Prior to the second payment, Canada will notify Newfoundland and Labrador of the amount of the second installment as determined under sections 5.2.3 and 5.2.4.
Canada shall withhold payments if Newfoundland and Labrador has failed to provide reporting in accordance with 8.1.
Canada shall withhold the second payment in 2023-24 if Newfoundland and Labrador has failed to satisfy all reporting requirements associated with the preceding Canada – Newfoundland and Labrador Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23, specifically to:
1. continue to participate in a Federal-Provincial-Territorial process to improve reporting on and provide data to CIHI for the 6 common indicators (listed in Annex 3) to measure pan-Canadian progress on improving access to home and community care; and
2. submit an annual financial statement, with attestation from Newfoundland and Labrador's Chief Financial Officer, of funding received the preceding Fiscal Year from Canada for home and community care under the Canada – Newfoundland and Labrador Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23 compared against the Expenditure Plan, and noting any variances, between actual expenditures and the Expenditure Plan.
The sum of both installments constitutes a final payment and is not subject to any further payment once the second installment has been paid.
Payment of Canada's funding for this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.

5.41 Where Newfoundland and Labrador will use cost-recovery agreements with one or more privately-owned for-profit facilities as an accountability measure and Newfoundland and Labrador has failed to put in place a cost-recovery agreement by April 1, 2024, Canada shall deduct from the payment referred to in subsection 5.3.1(c) an amount equivalent to the amount of funding noted in Annex 4 to be provided by Newfoundland and Labrador to those facilities with whom they do not have the required cost-recovery agreements in place.

5.4 Retaining funds

5.4.1 For Fiscal Years 2023-24 through 2028-29, upon request, Newfoundland and Labrador may retain and carry forward to the next Fiscal Year up to 10 per cent of funding that is in excess of the amount of the eligible costs actually incurred in a Fiscal Year and use the amount carried forward for expenditures on eligible areas of investment. Any request to retain and carry forward an amount exceeding 10 per cent will be subject to discussion and mutual agreement in writing by their designated officials, at the Assistant Deputy Minister level (herein referred to as "Designated Officials"), and is subject to monitoring and reporting to Canada on the management and spending of the funds carried forward on a quarterly basis.

5.4.2 For Fiscal Year 2028-29, Newfoundland and Labrador is not entitled to retain any amounts beyond March 31, 2029. Any amounts that remain unexpended at the end of that Fiscal Year are considered debts due to Canada and shall be repaid in accordance with section 5.5.2.

5.4.3 Any amount carried forward from one Fiscal Year to the next under this subsection is supplementary to the maximum amount payable to Newfoundland and Labrador under subsection 5.2.4 of this Agreement in the next Fiscal Year.

5.5 Repayment of overpayment

5.5.1 In the event payments made exceed the amount to which Newfoundland and Labrador is entitled under this Agreement, the amount of the excess is a debt due to Canada and, unless otherwise agreed to in writing by the Parties, Newfoundland and Labrador shall repay the amount within sixty (60) calendar days of written notice from Canada.

5.5.2 Funds not spent within the Term of the Agreement will be considered a debt due to Canada and Newfoundland and Labrador shall repay the amount within sixty (60) calendar days of written notice from Canada.

5.6 Use of funds

5.6.1 The Parties agree that funds provided under this Agreement will only be used by Newfoundland and Labrador in accordance with the initiatives outlined in Annex 4.

5.7 Eligible expenditures

5.7.1 Eligible expenditures under this Agreement are the following:

data development and collection to support reporting;
information technology and health information infrastructure;
capital and operating funding;
salaries and benefits;
training, professional development; and
information and communications material related to programs.

5.7.2 The Parties agree that the long-term care and PSW funding may be provided to:

publicly-owned settings;
privately-owned not-for-profit settings;
home care settings (to be provided only through Budget 2023 PSW funding); and
subject to section 6.0, privately-owned for-profit settings.

6.0 Accountability mechanisms for long-term care

6.1 Where federal funding is provided to privately-owned, for-profit facilities in accordance with this Agreement, Newfoundland and Labrador agrees to put in place the accountability mechanisms outlined in Annex 4.

6.2 Where Newfoundland and Labrador has cost-recovery agreements in place with one or more privately-owned for-profit facilities pursuant to subsection 6.1, Newfoundland and Labrador agrees to report on these in accordance with the requirements set out in subsection 8.1.1 and invest all funds recovered through those agreements in accordance with the terms of this Agreement and the initiatives outlined in Annex 4.

7.0 Performance measurement

7.1 Newfoundland and Labrador agrees to designate an official or official(s), for the duration of this Agreement to participate in a CIHI led Federal-Provincial-Territorial indicator process to:

Improve reporting on common indicators to measure pan-Canadian progress on improving access to home and community care, associated with the commitment in the Common Statement;
Develop new common indicators for long-term care and PSWs; and
Share available disaggregated data with CIHI and work with CIHI to improve availability of disaggregated data for existing and new common indicators to enable reporting on progress for underserved and/or disadvantaged populations including, but not limited to, Indigenous peoples, First Nations, Inuit, Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+.

8.0 Reporting to Canadians

8.1 Funding conditions and reporting

8.1.1 By no later than October 1, in each fiscal year, with respect of the previous Fiscal Year, Newfoundland and Labrador agrees to:

Provide data and information annually to CIHI related to the home and community care common indicators (listed in Annex 3) identified as part of the commitment made in the Common Statement, and, new common indicators on long-term care and PSWs.
Beginning in Fiscal Year 2024-25, report annually and publicly in an integrated manner to residents of Newfoundland and Labrador on progress made on targets outlined in Annex 4 (Action Plan).
Beginning in Fiscal Year 2024-25, provide to Canada an annual financial statement, with attestation from Newfoundland and Labrador's Chief Financial Officer, of funding received the preceding Fiscal Year from Canada under this Agreement or the Previous Agreement compared against the Action Plan, and noting any variances, between actual expenditures and the Action Plan:
1. The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year;
2. The total amount of funding used for home and community care, long-term care and PSWs;
3. If applicable, the amount of any funding carried forward under section 5.4;
4. If applicable, the amount of overpayment that is to be repaid to Canada under section 5.5; and
5. With respect to the long-term care funding under this Agreement, where cost-recovery is used, the annual financial statement will also set out:
  1. The amount of the federal funding flowing to private, for-profit facilities; and
  2. The estimated amount of funds to be recovered under cost-recovery agreements, where applicable, and the priority areas where those funds will be reinvested.

8.1.2 Newfoundland and Labrador will provide quarterly reporting to Canada on the management and spending of the funds retained to the next Fiscal Year.

8.2 Audit

8.2.1 Newfoundland and Labrador will ensure that expenditure information presented in the annual financial statement is, in accordance with Newfoundland and Labrador's standard accounting practices, complete and accurate.

8.3 Evaluation

8.3.1 Responsibility for evaluation of programs rests with Newfoundland and Labrador in accordance with its own evaluation policies and practices.

9.0 Communications

9.1 The Parties agree on the importance of communicating with citizens about the objectives of this Agreement in an open, transparent, effective and proactive manner through appropriate public information activities.

9.2 Each Party will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.

9.3 In the spirit of transparency and open government, Canada will make this Agreement, including any amendments, publicly available on a Government of Canada website.

9.4 Newfoundland and Labrador will make publicly available, clearly identified on a Government of Newfoundland and Labrador website, this Agreement, including any amendments.

9.5 Canada, with prior notice to Newfoundland and Labrador, may incorporate all or any part of the data and information in 8.1, or any part of evaluation and audit reports made public by Newfoundland and Labrador into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

9.6 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Canada agrees to give Newfoundland and Labrador 10 days advance notice and advance copies of public communications related to the Common Statement, this Agreement, and results of the investments of this Agreement.

9.7 Newfoundland and Labrador reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Newfoundland and Labrador agrees to give Canada 10 days advance notice and advance copies of public communications related to the Common Statement, this Agreement, and results of the investments of this Agreement.

9.8 Canada and Newfoundland and Labrador agree to participate in a joint announcement upon signing of this Agreement.

9.9 Canada and Newfoundland and Labrador agree to work together to identify mutually agreeable opportunities for joint announcements relating to programs funded under this Agreement.

10.0 Dispute resolution

10.1 The Parties are committed to working together and avoiding disputes through government-to-government information exchange, advance notice, early consultation, and discussion, clarification, and resolution of issues, as they arise.

10.2 If at any time a Party is of the opinion that the other Party has failed to comply with any of its obligations or undertakings under this Agreement or is in breach of any term or condition of the Agreement, that Party may notify the other Party in writing of the failure or breach. Upon such notice, the Parties will endeavour to resolve the issue in dispute bilaterally through their Designated Officials.

10.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Canada and Newfoundland and Labrador responsible for health, and if it cannot be resolved by them, then the federal Minister(s) and Minister of Health and Community Services shall endeavour to resolve the dispute.

11.0 Amendments to the agreement

11.1 The main text of this Agreement may be amended at any time by mutual consent of the Parties. Any amendments shall be in writing and signed, in the case of Canada, by the federal Minister(s), and in the case of Newfoundland and Labrador, by the provincial Minister(s).

11.2 Annex 4 may be amended at any time by mutual consent of the Parties. Any amendments to Annex 4 shall be in writing and signed by each Party's Designated Official.

12.0 Termination

12.1 Either Party may terminate this Agreement at any time if the terms are not respected by giving at least 6 months written notice of intention to terminate.

12.2 As of the effective date of termination of this Agreement, Canada shall have no obligation to make any further payments.

12.3 Sections 1.0 and 9.0 of this Agreement survive for the period of the 10-year Working Together to Improve Health Care for Canadians plan.

12.4 Sections 5.4 and 8.0 of this Agreement survive the termination or expiration of this Agreement until reporting obligations are completed.

13.0 Notice

13.1 Any notice, information, or document provided for under this Agreement will be effectively given if delivered or sent by letter, email, postage or other charges prepaid. Any communication that is delivered will be deemed to have been received in delivery; and, except in periods of postal disruption, any communication mailed by post will be deemed to have been received eight calendar days after being mailed.

The address of the Designated Official for Canada shall be:

Assistant Deputy Minister, Strategic Policy Branch

Health Canada
70 Colombine Driveway
Brooke Claxton Building
Ottawa, Ontario
K1A 0K9

Email: jocelyne.voisin@hc-sc.gc.ca

The address of the Designated Official for Newfoundland and Labrador shall be:

Assistant Deputy Minister of Corporate Services
Department of Health and Community Services
Government of Newfoundland and Labrador
P.O. Box 8700
1^st Floor, West Block Confederation Building
100 Prince Philip Drive
St John's, NL
A1B 4J6

Email: patrickmorrissey@gov.nl.ca

14.0 General

14.1 This Agreement, including Annexes, comprises the entire Agreement entered into by the Parties.

14.2 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Newfoundland and Labrador.

14.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Newfoundland and Labrador shall be admitted to any share or part of this Agreement, or to any benefit arising therefrom.

14.4 If for any reason a provision of this Agreement, that is not a fundamental term, is found by a court of competent jurisdiction to be or to have become invalid or unenforceable, in whole or in part, it will be severed and deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.

14.5 This Agreement may be executed in counterparts, in which case (i) the Parties have caused this Agreement to be duly signed by the undersigned authorized representatives in separate signature pages in accordance with the following signature process, which together shall constitute one agreement, and (ii) the Parties agree that facsimile signature(s) and signature(s) transmitted by PDF shall be treated as original signature(s). Electronic signature(s) may be accepted as originals so long as the source of the transmission can be reasonably connected to the signatory.

In witness whereof the Parties have executed this Agreement through duly authorized representatives.

Signed on behalf of Canada by the Minister of Health

The Honourable Mark Holland, Minister of Health

In witness whereof the Parties have executed this Agreement through duly authorized representatives.

Signed on behalf of Newfoundland and Labrador by the Minister of Health and Community Services

The Honourable John, K.C., Minister of Health and Community Services

In witness whereof the Parties have executed this Agreement through duly authorized representatives.

Signed on behalf of Newfoundland and Labrador by the Minister for Intergovernmental Affairs

The Honourable Dr. Andrew Furey, Minister for Intergovernmental Affairs

Annex 1 – Common Statement of Principles on Shared Health Priorities

Common Statement of Principles on Shared Health Priorities

Annex 2 – Shared pan-Canadian interoperability roadmap

Figure 1. Text version below. — **Figure 1: 5-Year Shared Pan-Canadian Interoperability Roadmap**

Annex 3 – Indicators: Access to home and community care

Indicator

Death at home or in community (Percentage)
Home care services helped the recipient stay at home (Percentage)
Wait times for home care services (Median, in days)
Caregiver distress (Percentage)
New long-term care residents who potentially could have been cared for at home (Percentage)
Hospital stay extended until home care services or supports ready (Median, in days)

Annex 4 – Action plan

Overview and introduction

On February 23, 2023, the Government of Canada and the Government of Newfoundland and Labrador publicly agreed to a shared plan that will invest $2.282 billion in federal funding over 10 years to help improve health care for Newfoundlanders and Labradorians. Part of this funding will be invested in the Aging with Dignity bilateral agreement based on principles that support people to age with dignity close to home, with access to home care or care in a safe long term care home. The Aging with Dignity Action Plan outlines how federal funding will support the ongoing initiatives of the 2017 Statement of principles on Shared Health Priorities over the next four years (fiscal years 2023-24 to 2026-2027) and long-term care over the next five years (fiscal years 2023-24 to 2027-28). Newfoundland and Labrador is experiencing a significant demographic change with approximately 23 per cent of the population aged 65 years and over. As well, other demographic factors are exerting significant impact on the province including low birth rate and outmigration of younger people from rural Newfoundland and Labrador.

While the population has changed significantly in the last 50 years, the health system has not adapted to meet the changing needs of the population. The focus is often on the societal and health system impacts of caring for older adults, rather than enabling quality care and quality of life and health system performance. There are often gaps in knowledge and understanding of the needs of older adults that leave older adults and their essential care partners feeling ignored and de-valued. The impact of demographic changes, coupled with high rates of chronic disease and gaps in service demand a re-design in health service delivery. While work to advance realignment of the health system is underway, more is required to fully realize a shift from acute, episodic care to sustainable, integrated models to enable and support older adults to live in their homes and communities.

In 2020, Health Accord NL was created to use evidence, strategies, and public engagement to create a 10-year health transformation plan that will improve health in Newfoundland and Labrador, in a fiscally sustainable manner. Recognizing the impacts of changing demographics and the gaps in supports and services for older adults, Health Accord NL identified "Aging Population" as one of the unique six strategic areas of focus. Health Accord NL made 59 calls to action, many that are focused on care of older adults. To support a provincial approach to the health transformation plan, in April 2023, consolidation of the four regional health authorities and the Newfoundland and Labrador Centre for Health Information formed a single provincial health authority known as Newfoundland and Labrador Health Services (NLHS).

The COVID-19 pandemic put an intense focus on the gaps in quality of care in long term care and the value placed on older adults. This prompted a call to action by the public to improve staffing, hours of care, quality of care and resident experience. Newfoundland and Labrador is currently undertaking a comprehensive review of the Long Term Care and Personal Care Home Programs to identify opportunities to improve quality of care and quality of life of residents, enhance staff engagement and improve quality of staff work-life. Newfoundland and Labrador is committed to ensuring the recommendations from the review are aligned with the recently released Canadian Standards Association and Health Services Standard Organization's complimentary Long-term Care Services Standards.

The Government of Newfoundland and Labrador is driving meaningful change across the health care system and continues to develop and implement initiatives to build a comprehensive, coordinated, person-centered system of care rooted in respect and choice to meet the diverse needs of older persons across the care continuum. These changes will lead to better health outcomes, more appropriate utilization of health resources, and reduced presentation and admissions to acute care and delayed placement in long term care homes.

The federal investment around the Shared Health Priorities including the Aging with Dignity agreement closely align with provincial health priorities and will complement work led by the province to date. The Aging with Dignity Action Plan highlights the ongoing and planned initiatives necessary to support health system changes to improve the quality of life and quality of care for older adults.

Newfoundland and Labrador will continue to participate in a Federal-Provincial-Territorial process, including working with stakeholders and experts, through the Canadian Institute for Health Information (CIHI), to develop common indicators and to share relevant data to permit CIHI to produce annual public reports that will measure pan-Canadian progress on home and community care services.

Home and community care

Newfoundland and Labrador's focus is on service delivery in the most appropriate space and provided by the most suitable and trained individual, and to continue to work collaboratively with service providers on new service offerings that can support a more effective and efficient health care system.

Since 2017, the Department of Health and Community Services has worked closely with Newfoundland and Labrador Health Services to develop and implement a Home First Initiative. Home First is a health care management philosophy that aims to shift from acute and institutional care to the enhancement of home and community based integrated care. Implementation of a Home First approach continues across the health care system using an interdisciplinary team focusing on a flexible and responsive approach to care coordination and service delivery. Significant investment has been made to support implementation including new human resources, hospice care, staff education and direct client care costs. Priority areas include supporting individuals with complex care needs, dementia care, and palliative, and end of life care.

Health Accord NL is guiding the continued transformation of health services and supports a strong community based supportive care system as key in health care system sustainability. Family Care Teams were recently introduced to improve access to primary health care. In addition, enabling access to community based continuing care options, such as home care and personal care homes is essential to support appropriate utilization of health care resources and health system flow, and allows individuals to remain in their home communities. These initiatives support the Home First approach and will prevent inappropriate hospital admission, support discharge to home, and increase access to end-of-life services, using existing and enhanced home and community based services.

Improving access to community based services and ensuring integration with new and existing care models across the continuum continues to be a priority.

Initiatives to be supported by federal funding over the next four years

1. Continue implementation of 2017 bilateral agreement action plan

On December 23, 2016, the Government of Canada and the Government of Newfoundland and Labrador publicly agreed to new federal funding for investments in home and community care. Accordingly, the province has been developing and implementing Home First initiatives to remove the barriers to access home and community care by providing older adults with choices to ensure that they receive care which is appropriate and dignified.

Home First initiatives:
- Enhance home care and coordination of supports for clients with complex needs in the community and clients discharging from acute care;
- Develop new community based supportive care options including an adult day program, rehabilitative and restorative care, and specialized dementia care to provide choice for individuals and appropriate use of health care resources;
- Integrate a palliative approach across the health care system with enhancements to supports, services, and coordination of care and implement a consistent policy on advance health care planning;
- Enhance services for persons with dementia with a specific focus on individuals to remain in their own homes through the use of technology;
- Provide educational opportunities and access to training to home support workers to strengthen and develop a competent workforce;
- Support recruitment and retention initiatives for self managed care home support workers, including an hourly rate increase to ensure strong and accessible services are available in the community;
- Provide better access to services for those living in rural, remote, and northern areas, including supporting indigenous people to age in place and for those who must leave their communities access to Aboriginal Patient Navigators: and,
- Provide education to policy makers, community agencies, physicians, and NLHS staff on inclusion to ensure accessibility and inclusion requirements for all services.

To support activities within the Home and Community Care initiative, federal funding continues to be allocated to the following areas as part of the Home First Initiative:

Home First Integrated Network (~$19.3 million between 2023-24 and 2026-27)

Clinical services in the NLHS health zones provide wrap around services to clients where they are located. The hiring of additional clinical staff including case managers, nurse practitioners, community health nurses, licenced practical nurses, physiotherapists, and occupational therapists has supported the development of a Home First Integrated Network of professionals to provide services to clients with complex and palliative support needs living in the community. Federal funding will be used to support these positions.

Services are now available in the community beyond traditional work hours. While the zones have been able to recruit for several clinical positions in more densely populated areas, the use of technology for potential new models of service delivery continue to be developed to further expand services to improve access especially for individuals in more remote areas, including Indigenous communities. This will include the use of federal funds to support the expansion of virtual clinical assessments, remote client monitoring, home monitoring technologies.

To reduce barriers such as financial ineligibility and timely access to home supports, several initiatives have been implemented to ensure clients receive supports and services at point of clinically assessed need including home supports, medications, and medical equipment and supplies. Through Home First, the financial contribution is waived for individuals with complex care needs to enable immediate access to home support services, equipment and supplies without a financial contribution. Federal funding supports this increased expenditure.

Palliative Care/End-of-Life Improvement (~$7.8 million between 2023-24 and 2026-27)

For those involved in the provision of palliative and end-of-life care, federal funds will continue to support access to educational opportunities is ongoing, in particular, Learning Essential Approaches to Palliative Care (LEAP) training. LEAP training offers several different platforms specific to the learning needs of various care providers including clinicians, service providers, personal care attendants, home support workers, self managed care providers, caregivers, and Indigenous groups. Specifically, NLHS entered into a three-year agreement with Pallium Canada to provide access to two online training modules for home/ personal support workers as well as personal care attendants in long term care.

The Government of Newfoundland and Labrador also partnered with Pallium Canada to develop an Indigenous Cultural Safety Course to support staff in working with Indigenous people in providing palliative and end-of-life care.

The Province is currently assisting to develop and fund a community hospice. Approximately $1 million in funding through this agreement will be used to support ongoing operational costs for a 10-bed hospice in Grand Falls-Windsor.

Support for Individuals living with Dementia (~$5.3 million between 2023-24 and 2026-27)

In addition to initiatives already underway, in March 2023, the Government of Newfoundland and Labrador released a Dementia Care Action Plan. The Dementia Care Action Plan aims to increase awareness, improve supports and services for people living with dementia and their care partners, and improve the capacity of the workforce to better support individuals living with dementia. The Dementia Care Action Plan will provide a coordinated, collaborative approach to making meaningful changes within the system to ensure individuals living with dementia can continue to achieve life goals and continue to obtain meaning and enjoyment in their lives. New actions identified in the plan will raise awareness of dementia in support of risk reduction; promote social inclusion; reduce stigma; increase awareness of rights of individuals with dementia; increase knowledge of signs and symptoms; support early diagnosis; and improve access to care, treatment and supports.

The Provincial Home Dementia Care Program provides access to a primary care provider (nurse practitioner or physician) to clients living with moderate to advanced dementia at home. The Province is working with NLHS to expand access to this service across the province. Remote patient monitoring technology where a health care team will provide geriatric and allied health e-consults, comprehensive geriatric assessments and coordinate care planning is improving access to rural and remote areas of the province. This project also supports essential care partners of individuals living with dementia with a key focus on supporting caregiver distress which supports improved mental health. Federal funding directly supports this program.

Professional development is ongoing for home/personal support workers through support to the Alzheimer Society of Newfoundland and Labrador's Dementia Passport^TM, an eLearning platform on a large number of topics related to dementia. This funding also supports the Alzheimer Society of Newfoundland and Labrador's First Link^TM Program to support individuals and caregivers through education, support groups, and Memory Cafes. In addition, funding to the Alzheimer Society will fund training for first responders and businesses to support development of dementia friendly communities, which are places where people living with dementia are understood, respected, and supported. In total Federal funding of approximately $400,000 annually support these projects.

The implementation of new community based supportive care options supports a Home First philosophy and is in alignment with Dementia Care Action Plan and Health Accord NL. The programs will support individuals living with dementia and their essential care partners to live well at home and to remain in community settings. Community-based supportive care options include enhanced dementia care in personal care homes and adult day programs. Federal funding will support these initiatives.

In addition to continuing the successes noted above, Newfoundland and Labrador identified the following priority areas for home and community care for the next four years:

increased focus on assessment and care planning including early identification and management of frailty using a geriatrics informed approach to care;
implementation of client navigator for individuals living with dementia;
increased education and training for home/personal support workers;
expansion of the Provincial Home Dementia Care Program;
support age- and dementia-friendly communities;
improve advance care planning;
implement community-based rehabilitation and restorative care; and,
develop community hospice care.

Over the next four years, approximately $6 million in Federal funding will be used to support clinical positions (nurse practitioner, registered nurses, licensed practical nurses, social worker, rehabilitation staff, social assistance workers, behaviour management specialists) to improve community-based care and service delivery.

Provincial Indigenous Government and Organizations have identified accessing care closer to home as a priority, including home care support services to assist the elderly Indigenous population. Any new revised operational standards include requirement to include cultural, ethnic, gender, sexual, religion diversity, and inclusion. In addition, there is a requirement to provide care and services that are trauma-informed.

Funding allocation – Home and community care
Home and Community Care	2023-24	2024-25	2025-26	2026-27	Total
Home First Integrated Network	4,830,000	4,830,000	4,830,000	4,830,000	19,320,000
Palliative Care/End-of-life Improvement	1,950,000	1,950,000	1,950,000	1,950,000	7,800,000
Support for Individuals with Dementia Improvement Initiatives	1,330,000	1,330,000	1,330,000	1,330,000	5,320,000
Total ($)	8,110,000	8,110,000	8,110,000	8,110,000	32,440,000

Home and community care indicators, targets, and timeframes

Newfoundland and Labrador has worked collaboratively with CIHI and other provinces and territories on the development of the Shared Health Priority Indicators. Although significant efforts have been made to extract data to inform the indicator "Wait time for home care services", Newfoundland and Labrador has not been able to provide sufficient data to meet CIHI's reporting requirements. Newfoundland and Labrador is investing in a new health information system that will improve future ability to report on wait times. Newfoundland and Labrador will continue to work with CIHI on any future development of indicators to support the Aging with Dignity Action Plan. The table below highlights specific indicators to be measured and includes CIHI data and provincial data collection.

Indicators – Home and community care
Headline Indicator	Baseline	Target	Timeframe
Home and Community Care
New long term care residents who potentially could have been cared for at home	CIHI report for 2021-22 indicate NL is performing above average at 7.4% compared to Canadian benchmark at 9.6%	Remain below the Canadian benchmark with a target of 7%	Annually through 2026-27
Home care services helped the recipient stay at home	CIHI report for 2021-22 indicate NL is performing above average at 85.8% compared to Canadian benchmark at 83.2%	Remain above the Canadian benchmark of 83.2%	Annually through 2026-27
Hospital stay extended until home care services or supports ready (median, in days)	CIHI report for 2021-22 indicate NL is performing average at 8 compared to Canadian benchmark at 8	Decrease the number of days patients are waiting for home care services to 7 days	By 2026-27
Death at home or in Community	CIHI report for 2021-22 indicate NL is 57.1% (partial data due to incomplete reporting) compared to Canadian benchmark 54.5%	Meet Canadian benchmark of 54.5%	By 2026-27
Decrease caregiver distress	CIHI reports for 2021-22 NL is above average performance at 29.1 % compared to the Canadian benchmark at 37.4%	Remain below the Canadian benchmark, and increase performance to below 29 %	Annually through 2026-27
Wait time for home care services	Data currently unavailable (work underway to obtain this data in 2025-26)	TBD once baseline data is available	By 2026-27
Provincial Indicator
Percentage patient days designated as alternate level of care days	23% of all patient days designated as alternate level of care days (2022-23)	17% as per the national average (2022-23)	By 2026-27
Percentage of long term care residents admitted from acute care and not from community	65% of all individuals admitted to LTC are admitted directly from acute care (2022-23)	50% of all individuals admitted to LTC are admitted directly from acute care	By 2026-27

Long term care

Long term care (LTC) homes provide care and accommodation to older adults with complex care needs requiring daily access to nursing care. Provincially, there are 3,291 LTC beds in 43 LTC sites (stand-alone facilities or adjacent to acute care health centres). All LTC homes in the province are publicly operated with the exception of one home, where some beds are publicly subsidized. NLHS is responsible for service delivery where organizational policies are aligned with the Provincial Long Term Care Operational Standards established by government.

Personal care homes (PCHs) are licensed, private, (for-profit and not-for-profit) settings that provide care and accommodation to seniors and other adults who require assistance with the activities of daily living. Provincially, there are 5,289 beds in 89 PCHs. PCHs are governed by the Personal Care Home Regulations, and the Provincial Personal Care Home Operational Standards. NLHS is responsible for licensing and monitoring of PCHs.

During the COVID-19 pandemic, the federal government provided funding through the Safe Long Term Care Fund and Safe Restart funding to protect residents living in continuing care. In Newfoundland and Labrador, the allocation of funding was used for infection prevention and control measures including new infrastructure upgrades, personal protective equipment, staff retention measures, readiness assessment to prevent COVID-19 infection and spread, and other infection and prevention control efforts, i.e., staff training, enhanced screening, and testing).

In January 2023, two new complementary national standards were released by the Health Standards Organization (HSO) and the Canadian Standards Association (CSA) to ensure Canada's Long Term Care settings are delivering safe, reliable, and high-quality care. Newfoundland and Labrador is committed to ensuring LTC home standards are aligned with the CSA and HSO's National Long-Term Care Services Standard.

Due to an ageing workforce, work-life balance priorities, and other factors, Newfoundland and Labrador is experiencing significant challenges with recruitment and retention. Several initiatives have been implemented to ensure a sustainable and stabilized workforce, particularly in rural sites. There has been an increased awareness and emphasis on employee mental health and initiatives have been implemented to ensure timely access to psychological support and services.

Health Accord NL recommended the formation of inter-professional geriatric teams that would support care across the continuum including primary care, community, long term care and acute care. These teams will support a Home First philosophy and adopt a proactive and responsive approach to frailty identification and management. This is anticipated to support individuals to remain at home and in community and reduce inappropriate use of acute care and improve quality of care and quality of life in PCHs and LTC homes.

Initiatives to be supported by incremental federal funding over the next five years

1. Workforce stability

Expansion of the Care of the Elderly Training Program and Establishing a Geriatric Medicine Fellowship at Memorial University (~$2.5 million between 2023-24 and 2027-28)

There is an urgent need to train specialists in older adult care in Newfoundland and Labrador to support the care of the rapidly aging, comorbid population.

The expansion of the Care of the Elderly (COE) Training Program will benefit primary care, long-term care, assisted living, and rural geriatric medicine services.

The Government of Newfoundland and Labrador is establishing Centres of Excellence on Aging at regional hospitals and has made a commitment to fund family physicians in the COE Training and geriatric residency programs. This will provide physicians with additional knowledge and skills needed to provide high-quality care to older adults, which will improve health care outcomes, improve quality of life, and help enable seniors to maintain their independence. This initiative is a foundational action to build a stronger network of care for older adults including improving access to rural, remote and Indigenous communities.

These initiatives are aligned with recommendations from Health Accord NL to increase trained providers in older adult care in all areas of the health care system, including family care teams, acute care, emergency departments, restorative care, assisted living and long term care settings. The full funding commitment for physician training is $9.5 million annually, however, these initiatives support the full care continuum. Federal funds will be used to bolster this initiative by providing dedicated resources ($500,000) to support the training of physicians working in the LTC sector.

Long term care recruitment and retention initiative (~$4.1 million in 2023-24)

To address the staffing challenges in LTC, a retention bonus was available to registered nurses, ($2,500), licensed practical nurses, ($1,600) and personal care attendants, ($1,300) for a one-year return in service commitment. In addition, a recruitment bonus was available to attract registered nurses ($6,000), licensed practical nurses ($3,900), and personal care attendants ($3,200) (including new graduates and retired employees) to work in LTC, for a one-year return in service commitment. Total provincial investment in this initiative for 2023-24 is $ 9.7 million.

The PCH sector has not had a subsidy rate increase since 2017 despite increased costs to provide services as a result of recent changes in the marketplace and inflationary pressures. In particular, small PCHs often located in rural communities experience financial pressures due to higher staffing requirements and higher vacancy rates. To address the financial pressures, government approved a subsidy increase.

Wage Increase for Personal Care Home Workers (~$20 million between 2023-24 and 2027- 28)

The PCH sector is experiencing staffing challenges. Until recently the wage rate for these staff was established by the operator and wages may be as low as the provincial minimum wage rate. With the subsidy increase, government has, for the first time, mandated private for profit PCHs to compensate staff at a set wage rate of $17.05 for those workers who provide direct care to residents. This creates wage parity between other personal care home workers as well as home support workers which will improve retention and recruitment. Additionally, a differential rate is provided to home support agency staff and PCH staff in Labrador, in recognition the financial challenges with living in northern communities.

In keeping with priorities of both provincial and federal governments, approximately $4 million annually in federal funding will be allocated to fund wage increases for the more than 1,500 personal support workers employed in personal care homes. These staff serve an important role in supporting aging in place in community and quality of care in LTC.

The above referenced initiatives provide support to all LTC and PCH staff including internationally educated nurses and other workers.

2. Long-term care standards

Quality of care and quality of life in long term care (~$8.5 million between 2023-24 and 2027-28)

To address quality of care and quality of life for residents in LTC and PCHs, a comprehensive provincial review of both programs is underway. The aim of the review is to identify opportunities to improve resident quality of care, quality of life, and address quality of work-life for staff. An expert advisory panel in collaboration with an external consultant will submit a final report with recommendations in March 2024.

The HSO National Long Term Care standard provide LTC home teams, leaders, governing bodies and other stakeholders with criteria and guidelines to ensure the delivery of high quality resident-centered care, enabled by a healthy and competent workforce. The CSA standards addresses the infrastructure requirements for safe operations including infection and prevention control practices. The government is committed to ensuring the recommendations from the LTC and PCH review are aligned with the CSA and HSO's National Long-Term Care Services Standard.

The Provincial Long Term Care Operational Standards are currently being revised and drafted and a comparative analysis is underway to ensure alignment with the HSO and CSA National Long- Term Care Services Standard.

Resident- Centred Care Quality of Life Initiatives (~$8.5 million between 2023-24 and 2027- 28)

Actions in the Dementia Care Action Plan support both elements of the Aging with Dignity Plan (home and community care and LTC). NL will report on dementia initiatives in the appropriate funding allocation. Federal funds will be allocated to support initiatives specific to LTC including:

Improving the quality of care and quality of life for individuals living with dementia in residential care homes by implementing opportunities to make LTC homes more familiar and less institutional, with an increased focus on resident- centered care, and flexible delivery of programs and services.
Implementing opportunities to enhance social and recreational programming, across all care settings; improve access to behaviour management specialists to provide support with behavioural and psychological symptoms of dementia in community, personal care homes and long term care homes; and, ensure health care providers who regularly support individuals with dementia complete advanced dementia care education including a focus on person-centred care and empathy training.
Implementing best practices in dementia care in long term care, including improvements to physical environment (e.g., noise reduction, congregate and non-congregate dining), equipment, and personalization spaces for residents.
Implementation of a Dementia Navigator position will support individuals across the health system access the supports and services they need to live well with dementia.
Increasing access to therapeutic recreation will improve quality of life in LTC.
Support for intergenerational programming with a particular focus on individuals with dementia in LTC.

Long Term/Personal Care Home Review (~$10.4 million between 2024-25 and 2027-28)

The Department of Health and Community Services engaged an Expert Advisory Panel to complete a review of the LTC and PCH Programs. The goal of the review is to identify opportunities to improve quality of life and quality of care and improve staff work life balance. It is anticipated other quality initiatives and actions will be identified through this review, which are anticipated to require significant investment. Starting in 2024-25, approximately $2.6 million of the Aging with Dignity funding will be used annually to support implementation of the recommendations.

Newfoundland and Labrador contributes provincial data to CIHI around quality indicators in LTC with the goal of identifying and supporting areas for quality improvement. NL can appropriately compare provincial results to the rest of the country and continuously benchmark performance. Based on data to date, several quality improvement initiatives have been initiated and utilize a multifaceted approach, including additional education for staff, access to, and support from, behavioural management specialists, and enhanced social and recreational programming. Focused areas for improvement currently include:

Appropriate use of antipsychotic medications

Often, people living in LTC homes with dementia are prescribed antipsychotic medications to help manage their behaviours. Unfortunately, people taking these medications can experience significant side effects, including confusion and dizziness, which may lead to an increased risk of falls. Through a focused effort on the appropriate use of antipsychotic medications in LTC homes the quality of life and safety of those living and working in LTC is being improved.

Restraint use in LTC

Restraints, such as chairs, trunk or limb restraints, can protect residents from harming themselves or others. However, physical restraints may cause agitation and confusion and increase the risk of pressure ulcers or injury. Reporting by CIHI indicates that Newfoundland and Labrador experiences higher restraint use in its LTC homes as compared with the Canadian average. Efforts to reduce the use of physical restraints in LTC are being advanced to improve safety and quality of life for LTC residents.

Reducing pain experienced in LTC

Reporting by CIHI indicates that LTC residents in Newfoundland and Labrador experience pain more frequently as compared to the Canadian average. The consequences of pain include increased difficulty with activities of daily living, depression and lower quality of life. Through efforts to properly manage and treat pain, the health status and quality of life of those living in LTC can be improved.

Funding allocation – Long-term care
Long-term care theme	2023-24	2024-25	2025-26	2026-27	2027-28	Total
Workforce stability
Geriatric Training Programs	500,000	500,000	500,000	500,000	500,000	2,500,000
Recruitment and Retention Bonus LTC	4,100,000	0	0	0	0	4,100,000
Wage Increase for Personal Care Home Workers	4,000,000	4,000,000	4,000,000	4,000,000	4,000,000	20,000,000
Long-term care standards
Resident- Centred Care Quality of Life Initiatives	500,000	2,000,000	2,000,000	2,000,000	2,000,000	8,500,000
Long Term/Personal Care Home Review	0	2,600,000	2,600,000	2,600,000	2,600,000	10,400,000
Total ($)	9,100,000	9,100,000	9,100,000	9,100,000	9,100,000	45,500,000

Accountability Measures in Place for Funds Directed to Private For-Profit Facilities

A portion of the $20 million allocated to support wage increases for personal care home workers will flow to private for-profit PCH providers in the form of an increased subsidy rate. The Government of Newfoundland and Labrador has mandated PCH operators to use this funding only for wage increases and will ensure compliance through monitoring and audit.

Long-term care indicators, targets, and timeframes

The table below highlights specific indicators to be measured and includes CIHI data and provincial data collection. Newfoundland and Labrador regularly reports data to CIHI through the Resident Assessment Instrument- Minimum Data Set 2.0 (RAI-MDS) and is committed to ongoing work with CIHI to develop specific indicators and share data for LTC as was done for Home Care.

Indicators – Long-term care
Indicator	Baseline	Targets	Timeframe
Workforce Stability
Expansion of the Care of the Elderly Training Program and Establishing a Geriatric Medicine Fellowship at Memorial University
Increase number of physicians/residents completing Care of Elderly training (COE)	Currently there are 10 practicing physicians with COE training	Increase to 30 trained physicians throughout province	By 2027- 2028
Recruitment and Retention
Improve staff recruitment rates in LTC	In August 2023, 6% LTC bed closed due to insufficient staff	All LTC beds are available	By 2025-2026
Long-Term Care Standards
Quality Improvement Initiatives in Long Term Care
Decrease the percentage of residents who are prescribed Inappropriate use of antipsychotics in LTC	In CIHI report for 2021-22 indicate NL is performing below average at 26.4% compared to Canadian benchmark at 23.9%	Meet the Canadian benchmark of 23.9%	By 2027-2028
Decrease the percentage of residents Experiencing Pain in LTC	In CIHI report for 2021-22 indicate NL is performing below average at 14.3% compared to Canadian benchmark at 6.1%	Meet the Canadian benchmark of 6.1%	By 2027-2028
Decrease Restraint Use in LTC	In CIHI report for 2021-22 indicate NL is performing below average at 11.0% compared to Canadian benchmark at 5.2%	Meet the Canadian benchmark of 5.2%	By 2027-2028
Improve Quality of Life in LTC	TBD, will be measured in 2024-25	TBD	By 2027-2028

Overall funding allocations
Theme	2023-24	2024-25	2025-26	2026-27	2027-28	Total
Home and Community Care	8,110,000	8,110,000	8,110,000	9,110,000	-	32,440,000
Long Term Care	9,110,000	9,110,000	9,110,000	9,110,000	9,110,000	45,550,000
Total ($)	17,220,000	17,220,000	17,220,000	17,220,000	9,110,000	77,990,000

Newfoundland and Labrador Personal Support Workers and Related Professions Addendum

Personal Support Workers and Related Professions

In Newfoundland and Labrador personal support workers (PSWs) and related professions refers to three different groups of workers, including staff who work in personal care homes, staff who work in long term care homes, acute care and in the community (personal care attendants, or PCAs) and staff who work in an individual's home (home support worker, or HSWs). In Newfoundland and Labrador, there are approximately 1,500 PSWs, 1,250 PCAs and 8,500 HSWs (6,000 agency-based HSWs and 2,500 self managed care HSWs).

Newfoundland and Labrador will allocate the Federal funding outlined in this Agreement amendment to wage increases for agency based HSWs. HSWs are integral members of the interdisciplinary team and support clients in all aspects of daily living. HSWs provide personal and behavioural supports, aid with household management, and provide respite at the minimum level to maintain client independence. Support from HSWs may allow clients to age safely at home.

The Province has a growing need for HSWs, as health care systems move to support people to remain in their homes and age in place. In addition, the level of care required is increasing as more individuals with complex needs are being supported in their homes, resulting in HSWs needing a higher level of skills to perform job requirements.

Newfoundland and Labrador has a vast geography with many communities classified as rural or remote. The HSW workforce is largely comprised of women who are employed by private home care agencies. There are 33 home care agencies in the province, with staff in 24 agencies unionized with the Newfoundland and Labrador Association of Public and Private Employees (NAPE), and nine are non-unionized. Unionized agencies provide approximately 75 per cent of all agency based home care hours. The current HSW wage is $17.05 per hour.

Newfoundland and Labrador will be implementing annual wage increases for all HSWs as follows (total rate per hour below):

April 1, 2024 - $18.00/hour,
October 1, 2024 - $18.75/hour;
April 1, 2025 - $19.45/hour;
April 1, 2026 - $20.30/hour; and
April 1, 2027 - $21.05/hour.

Category of PSW (e.g. by sector, sub-group or region)	Estimated number of lowest-paid PSWs to be supported	Current wage range for PSWs to be supported	Target wage range	Timeframe to reach increase
Home Support Worker	6,000	$17.05/hour	$21.05/hour	2027-2028

Wage increases and benefits will be administered as follows*:

Wage rate increases	April 2024 $18.00/hour	October 2024 $18.75/hour	2025-26 $19.45/hour	2026-27 $20.30/hour	2027-28 $21.05/hour
New funding required:	$4,462,500	$3,695,625	$6,918,750	$8,336,250	$7,391,250
	2024-25		2025-26	2026-27	2027-28
Annualized Funding	$8,158,125		$15,076,875	$23,413,125	$30,804,375

*Funding requirements for 2028-29 will be at least $30,801,375

The declining number of people residing in rural and remote communities in Newfoundland and Labrador and the vast geography creates challenges for the delivery of home support services. As hourly wages have been a contributing factor in retaining workers due to high competition in other sectors with higher wages. Rural and remote communities tend to have a higher population of older adults and older Indigenous individuals; supporting agencies in smaller communities to recruit and retain workers will help ensure individuals can remain within their community close to their loved ones as long as possible.

As the population ages, ensuring adequate services are available to help people stay at home and in their communities for as long as possible is essential. By investing in the home support sector, Newfoundland and Labrador is helping to ensure people have access to appropriate home supports within their home community anywhere in the province.

Home support agencies also provide employment within rural communities and by supporting this sector, the Government of Newfoundland and Labrador is helping to ensure a viable employment opportunity in areas where opportunities are declining. As a high percentage of women and new Canadians are employed within the home support sector, wage increases will ensure viable employment opportunities for these demographics of employees.

In keeping with the processes and practices followed in the province to date, where funding is provided to for-profit operators to support the wages of PSWs, and/or recruitment and retention initiatives outlined above, Newfoundland and Labrador will use practices to ensure that funding benefits PSWs through increased wages, and retention and recruitment initiatives without using the federal funding to contribute to operator profitability.

Measuring and Reporting on Results

Newfoundland and Labrador will work with the Canadian Institute for Health Information (CIHI) on a pan-Canadian indicator related to PSWs and provide relevant data. Newfoundland and Labrador will also report annually and publicly to the residents of Newfoundland and Labrador on the progress to achieve increases to PSW wages in an integrated manner with other Aging with Dignity agreement reporting.

Funding Allocation

The following table represents an estimated projection of spending across each area.

	2024-25	2025-26	2026-27	2027-28	2028-29	Total
Wage Initiative	$4,930,000	$5,030,000	$5,160,000	$5,260,000	$5,380,000	$25,760,000
Recruitment & Retention Initiative	-	-	-	-	-	-
TOTAL	$4,930,000	$5,030,000	$5,160,000	$5,260,000	$5,380,000	$25,760,000

*Allocations are rounded and notional and are subject to annual adjustment based on the formula described in the Agreement.

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Date modified:: 2024-11-15