Canada-Ontario Aging with Dignity funding agreement (2023-24 to 2027-28)

Table 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:

- and -

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

PREAMBLE

WHEREAS, on February 23, 2023, Canada and Ontario 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 Ontario acknowledged the importance of helping Canadians age closer to home;

WHEREAS, in the area of home and community care, Working Together to Improve Health Care for Canadians also includes a commitment by Canada and Ontario 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 ten 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, Ontario has the primary responsibility for delivering health care services to its residents and makes ongoing and significant investments in health consistent with its broader responsibilities for delivering health care services to its residents and in supporting 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, and 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);

WHEREAS, the Ministry of Health and Long-Term Care Act authorized the provincial Ministers to enter into agreements with the Government of Canada under which Canada undertakes to provide funding toward costs incurred by the Government of Ontario associated with the federal investment for long-term care, and home and community care consistent with the Common Statement; and

NOW THEREFORE, this Agreement sets out the terms between Canada and Ontario 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 Ontario 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 Ontario 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 Ontario 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 Ontario acknowledge a mutual intent to engage in a two-phased formal review process:

1. 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
2. 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 Ontario agree that, with financial support from Canada, Ontario will continue to build and enhance its health care system towards achieving some or all of the objectives of:

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

3.0 Action plan

3.1 Ontario 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 Ontario 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 Ontario 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 In developing initiatives under this Agreement, Ontario 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+.

3.5 Ontario's approach to achieving home and community care and long-term care objectives is set out in their five-year 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, 2028, unless terminated in accordance with section 12 of this Agreement. Funding provided under this Agreement will be for five years and will cover the period April 1, 2023 to March 31, 2028 ("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 Ontario

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

1. $600 million for the Fiscal Year beginning on April 1, 2023
2. $600 million for the Fiscal Year beginning on April 1, 2024
3. $600 million for the Fiscal Year beginning on April 1, 2025
4. $600 million for the Fiscal Year beginning on April 1, 2026

Budget 2021 Long-Term Care

1. $600 million for the Fiscal Year beginning on April 1, 2023
2. $600 million for the Fiscal Year beginning on April 1, 2024
3. $600 million for the Fiscal Year beginning on April 1, 2025
4. $600 million for the Fiscal Year beginning on April 1, 2026
5. $600 million for the Fiscal Year beginning on April 1, 2027

5.2.3 Allocation Method

1. 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 × K/L, where:
   • F is the annual total funding amount available under this program;
   • K is the total population of Ontario, 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.
2. 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 × 1,200,000)) × (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 Ontario, 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, Ontario estimated share of the amounts will be:

Ontario estimated share of the amounts

Fiscal Year	Budget 2017 Home and Community Care Estimated amount to be paid to Ontario Table 1 Footnote a (subject to annual adjustment)	Budget 2021 Long-Term Care Estimated amount to be paid to Ontario Table 1 Footnote a (subject to annual adjustment)
2023-2024	$232,870,000	$228,020,000
2024-2025	$232,870,000	$228,020,000
2025-2026	$232,870,000	$228,020,000
2026-2027	$232,870,000	$228,020,000
2027-2028	n/a	$228,020,000

5.3 Payment

5.3.1 Funding provided by Canada will be paid in semi-annual installments as follows:

1. 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.g.
2. Starting in 2024-25, 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.
3. 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.
4. 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.
5. Canada will notify Ontario 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 Ontario of the amount of the second installment as determined under sections 5.2.3 and 5.2.4.
6. Canada shall withhold payments if Ontario has failed to provide reporting in accordance with 8.1.
7. Canada shall withhold the second payment in 2023-24 if Ontario has failed to satisfy all reporting requirements associated with the preceding Canada – Ontario 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 the province's Chief Financial Officer, of funding received the preceding Fiscal Year from Canada for home and community care under the Canada – Ontario 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.
8. The sum of both installments constitutes a final payment and is not subject to any further payment once the second installment has been paid.
9. Payment of Canada's funding for this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.

5.3.2 Where Ontario will use cost-recovery agreements as an accountability measure and Ontario has failed to put in place a cost-recovery agreement at the time it delivers funding to facilities, Canada shall deduct from the payment referred to in subsection 5.3.1(b) an amount equivalent to the amount of funding tied to the specific identified initiative noted in Annex 4 to be provided by Ontario to those long-term care homes 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 2026-27, upon request, Ontario may retain and carry forward to the next Fiscal Year up to 10 percent 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 percent 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 2027-28, Ontario is not entitled to retain any amounts beyond March 31, 2028. 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 Ontario 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 Ontario 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, Ontario 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 Ontario 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 Ontario 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 funding may be provided to:

• publicly-owned long-term care settings;
• privately-owned not-for-profit long-term care settings; and
• subject to section 6.0, privately-owned for-profit long-term care settings.

6.0 Accountability Mechanisms for Long-Term Care

6.1 Where federal funding is provided to municipal, non-profit, and for-profit long-term care homes in accordance with this Agreement, Ontario agrees to apply the accountability mechanisms described in Annex 4.

6.2 Where Ontario has cost-recovery agreements in place pursuant to subsection 6.1, Ontario 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 Ontario 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:

1. 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;
2. Work to develop new common indicators for long-term care that are mutually agreed upon; and
3. 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, Ontario agrees to:

1. 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 that are mutually agreed upon.
2. Beginning in Fiscal Year 2024-25, report annually and publicly in an integrated manner to residents of Ontario on progress made on targets outlined in Annex 4 (Action Plan).
3. Beginning in Fiscal Year 2024-25, provide to Canada an annual financial statement, with attestation from the province'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 and long-term care;
   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 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 Ontario 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 Ontario will ensure that expenditure information presented in the annual financial statement is, in accordance with Ontario's standard accounting practices, complete and accurate.

8.3 Evaluation

8.3.1 Responsibility for evaluation of programs rests with Ontario 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 Ontario will make publicly available, clearly identified on a Government of Ontario webpage, this Agreement, including any amendments to the Agreement.

9.5 Canada, with prior notice to Ontario, 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 Ontario 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 Ontario 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 Ontario reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Ontario 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 Ontario agree to participate in a joint announcement upon signing of this Agreement.

9.9 Canada and Ontario 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 Ontario responsible for health, and if it cannot be resolved by them, then the federal Minister(s) and the provincial Minister(s) responsible for health 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 Ontario, 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 Officials for Ontario shall be:

Assistant Deputy Minister: Strategic Policy, Planning & French Language Services
Ministry of Health
438 University Avenue, 10th Floor
Toronto, Ontario
M7A 1N3

Email: greg.hein@ontario.ca

Assistant Deputy Minister: Long-Term Care Policy Division
Ministry of Long-Term Care
400 University Avenue, 6th Floor
Toronto, Ontario
M5G 1S5

Email: Sean.Court@ontario.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 Ontario.

14.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Ontario 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 Ontario by the Minister of Health

The Honourable Sylvia Jones, Deputy Premier and Minister of Health

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Ontario by the Minister of Long-Term Care

The Honourable Stan Cho, Minister of Long-Term Care

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

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

Introduction

Ontario's health care system serves over 14.5 million people through a wide range of services, including long-term care and home and community care. The province is taking action to strengthen all aspects of health care, including care for seniors and those needing long-term care, through the government's plan to fix long-term care and Your Health: A Plan for Connected and Convenient Care. Introduced in February 2023, this patient-centred plan focuses on three pillars:

1. The right care in the right place
2. Faster access to care
3. Hiring more health care workers

Under each of these pillars is a broad set of initiatives that delivers connected and convenient care in several settings, including long-term care homes and a wide range of residential settings and community settings. These initiatives build on the significant progress made to date by the province, including a $6.4 billion investment to build more than 30,000 new long-term care home beds by 2028 and 28,000 upgraded long-term care beds across the province which will result in shorter wait times for seniors to obtain the 24/7 care they require. This also includes $4.9 billion to retain and hire thousands more long-term care staff over four years to increase the province-wide average of direct hours of care provided to residents by nurses and personal support workers to four hours per day by March 31, 2025.

Furthermore, in its 2022 Budget, the Ontario government announced a plan to invest $1 billion over three years to get more people connected to care in the comfort of their own home and community. The Ontario government is now accelerating investments in home and community care services as part of the 2023 Budget to bring funding up to $569 million, including nearly $300 million to support contract rate increases to stabilize the home and community care workforce. This funding will also expand home care services and improve the quality of care, making it easier and faster for people to connect to care that meets their needs.

When more care is offered in the community in ways that are convenient for Ontarians, unnecessary hospital and long-term care home admissions are avoided, hospital stays are shortened, and overall pressures on other parts of the health care system are reduced.

Home and Community Care

Home and Community Care in Ontario

In Ontario, home and community care is provided to children, seniors and people of all ages who require nursing, personal support, or other services in their homes, school, or community.

Home care plays an important role in the lives of approximately 700,000 families in Ontario annually. Home care services include nursing and other regulated health professional services, and personal support services for higher-needs patients. They are complemented by community care services, which include personal support services, homemaking services, and community support services such as meals, transportation, caregiver support and respite services, adult day programs, friendly visiting, security checks, and other services.

Ongoing provincial funding of approximately $5 billion annually provides greater access to home and community care services, including caregiver respite and palliative and other end-of-life care. With these supports, individuals can often stay in their own homes or be cared for in the community longer.

At the same time, all areas of the health system are experiencing increased demand for health care services due to Ontario's aging and growing population. Between 2021 and 2022, Ontario's population grew by more than 300,000. Based on the most currently available projections, Ontario will add nearly 3 million people in the next 10 years. The population of seniors aged 75 or older and 85 or older are expected to increase by approximately 50% to 1.8M and 525,000 respectively. Between 2022 and 2032:

• The overall population is expected to grow by 20%
• The 65+ population is expected to grow by 34%
• The 75+ population is expected to grow by 48%

Home care demand in particular is expected to increase due to the aging population, with more people needing higher levels of care. Public awareness has grown of the important role of home and community care in keeping vulnerable people out of long-term care homes and hospitals, and stakeholders are calling for increased funding and a 'home care first' commitment from government.

Since 2021, access to home and community care has been facilitated by Home and Community Care Support Services organizations across the province. As the province of Ontario takes steps to modernize the home care system and expand access to home care services, home care responsibilities will be transitioned to Ontario Health Teams. These interprofessional care teams bring together health care providers across various sectors to better coordinate care and share resources.

To advance these changes, on October 4, 2023, the Ontario government introduced the proposed Convenient Care at Home Act, 2023, which would amend the Connecting Care Act, 2019 to consolidate the 14 Home and Community Care Support Services organizations into a new service organization, Ontario Health atHome. The Convenient Care at Home Act, 2023 was passed by the legislature and received Royal Assent on December 4, 2023. The Act is expected to be proclaimed into effect in summer 2024, at which time Ontario Health atHome would be established.

Initially, Ontario Health atHome would provide the same services that Home and Community Care Support Services currently provide. Responsibility for providing home care will be transitioned to Ontario Health Teams as they mature and are designated by the Minister of Health. Ontario Health atHome's role would shift to providing them back-office and care coordination supports for home care.

The province's vision for home care modernization includes:

• Connecting Ontarians to high-quality home and community care, with better and more convenient transitions from hospital to home and strong linkages with primary care
• Ensuring better and faster access to home care services that are more responsive to changing client needs
• Introducing new innovative models of care and expanding models that demonstrate improved patient care
• Improving the care experience of clients and caregivers

Some of the steps that the province has taken to actualize this vision include funding new models of integrated care delivery, taking steps to update contracts for service providers, and providing funding to employers to increase the compensation of the workforce.

Further in alignment with the vision for home care, funding under the first five years of the Canada-Ontario Home and Community Care and Mental Health and Addictions Services Funding Agreement was used to expand services to improve access and support targeted digital initiatives that improved the capacity for home and community care providers to deliver virtual care. As detailed in the next section, over the next four years, federal funding will support the continuity of these initiatives.

Achievements during the first five years under the Canada-Ontario Home and Community Care and Mental Health and Addictions Services Funding Agreement include:

Expanded access to home care:

• Increased base investments that enabled approximately 2,451,000 more hours of personal support, 464,000 more nursing visits, and 95,000 more therapy visits, including for palliative and end-of-life care. These were estimated based on the funding invested for service expansion under the 2018 Action Plan – the first years of the Canada-Ontario Home and Community Care and Mental Health and Addictions Services Funding Agreement.
• Allocated base funding to improve access to home care services in Indigenous communities across Ontario by providing direct funding to First Nations communities and organizations serving Indigenous populations outside of those geographies.

Caregiver supports:

• Increased base investments in home and community services to provide additional caregiver in-home respite.

Information Technology (IT):

• Deployed digital tools to improve client and caregiver participation in care, including providing improved access to information such as assessments and care plans.
• Improved capacity of operational tools, including expanding capacity of the Client Health Record and Information System (CHRIS), the existing home care data system, and enhancing communication within home care and across care sectors.

Base funding for all of the above (except time-limited initiatives for IT, which are examined on an annual basis) will continue and will be supported by the federal investment.

Ontario also supported expanded services beyond the federal investment during this time, including investments in general home care service expansion, the provision of funding to address cost increases and targeted investments for palliative care capacity-building and residential hospices. In addition, Ontario made more investments for caregivers, including education and training, as well as the creation and funding for the new Ontario Caregiver Organization.

Home and Community Care Initiatives to be Supported by Federal Funding over the Next Four Years

As noted above, Ontario fully allocated federal funding as base investments in home and community care in the first five years of the agreement to expand services for clients and caregivers and to invest in IT and digital initiatives. Expanded services for clients included palliative services and services for First Nations, Metis and Inuit clients. These are ongoing services and, in the case of IT, ongoing needs. During that time, Ontario invested additional funding for these purposes.

For the next four years, Ontario will invest the $930 million in federal funding to maintain initiatives that are currently being funded under the 2017 Agreement as detailed below:

• $207.87M annually (from 2023-2027) for continuation of investments for in-home services such as nursing, personal support, therapies, and palliative/end-of-life care.
  • These services are provided around the province to home care clients of all ages, including those being discharged from hospital and people who are being supported to live independently at home, deferring or avoiding admission to long-term care.
  • Specifically, these investments will maintain increased annual capacity of approximately 2,048,000 hours of personal support, 463,000 nursing visits, and 77,000 therapy visits, including for palliative and end-of-life care.
  • Services are provided primarily by organizations contracted by Home and Community Care Support Services; some are provided by staff employed by Home and Community Care Support Services. In addition, some funding is provided to individuals under the Family-Managed Home Care program administered by Home and Community Care Support Services to purchase their own services or employ their own providers. A small portion of funding is provided to non-profit health service provider organizations, who also hold contracts for care delivery. During the term of this agreement, health service provider members of Ontario Heath Teams will begin to assume responsibility for more home care delivery as part of system modernization.

Ontario tracks the impact of investments through a number of provincial and federal indicators, noted below. In addition, Ontario monitors volumes of delivery and a number of capacity indicators. The federal investment plus additional investment from Ontario has led to expanded capacity: 11% increase in volumes in 2022-23 vs. 2017-18, the first year of federal funding, with continued expansion in 2023-24. However, indicators show that demand continues to exceed capacity:

• Median wait time from hospital discharge to first home care service was 2 days in Q1 2023-24, not meeting the 1-day target
• Wait lists in 2023 declined from year before levels above 20,000+ but remain above 13,000

Concurrently, for the next four years, Ontario will maintain its direct investments begun in 2017-18 to improve access to home care services in 127 First Nations communities and four Indigenous organizations serving Indigenous populations outside those communities. The Ministry of Health is providing $28.2M in 2023-24, increasing to $32.9M in 2024-25, in direct investments to improve access to home care services for Indigenous persons across Ontario. This direct funding is intended to complement, not replace, federal funding targeted to Indigenous communities, and provincial funding for home and community care services provided by health service providers funded by Ontario Health and/or by Home and Community Care Support Services.

In addition, Ontario will continue its investment in expanding access to palliative services including residential hospice. In 2023-24, the Ministry of Health announced that it is expanding access to palliative care services across the province through a $147.4M investment over three years to ensure providers have access to standardized models of palliative care and clinical expertise, an increase in funding for clinical services delivered in residential hospices, improved access to grief and bereavement community programs, advanced care planning initiatives, and expansion of perinatal palliative care.

• $20M annually (from 2023-2027) for respite for caregivers
  • To maintain the increased capacity enabled by ongoing base investments of approximately 600,000 more hours and visits of respite for caregivers.
  • These services are generally provided by organizations contracted by Home and Community Care Support Services and will be transitioned to Ontario Health Teams over time.

This reflects the continuity of the priorities reflected in the caregiver supports under the 2018 Action Plan to provide:

• Additional caregiver supports, including education, training and resources, provided through a range of third-party health system organizations
• Enhanced support to navigate existing resources, through the Ontario-funded Ontario Caregiver Organization (ontariocaregiver.ca)
• Additional caregiver in-home respite, provided by Home and Community Care Support Services

Concurrently, Ontario will continue to fund the Ontario Caregiver Organization, to provide a range of supports for caregivers.

• $5M annually (from 2023-2027) for related digital-IT supports
  • Support the digital needs of the home and community care sector by investing annually in enhancing digital tools for home care delivery.
  • Ontario expects these investments to focus on modernizing the CHRIS system, which is used by Home and Community Care Support Services to manage the home care needs of Ontarians and improving the digital connectivity of the sector. The digital infrastructure will be upgraded to support the home care modernization plan, including improved communication between integrated delivery teams.
  • These investments will improve how health information related to home care is shared amongst care teams and is an important enabler of integrated care.

The funding provided under this agreement will advance care continuity, providing necessary ongoing services (e.g., through a modernized CHRIS system and projects exploring digital supports for home care delivery), and new digital investments that is augmented by additional provincial investment and initiatives to modernize home care delivery.

Targeted areas of new Ontario investments that are underway include additional home care expansion to address the aging population and the increasing complexity of home care clients, funding to address rising costs and funding to address workforce compensation, including but not limited to personal support workers.

Modernization initiatives are part of Ontario's plan for better connected and more convenient care and include new care models of care delivery to improve client and caregiver experiences and outcomes, updated contracts with service providers and care delivery that is led by integrated partnerships within local Ontario Health Teams.

Ontario's investments align with the following actions in the Common Statement of Principles on Shared Health Priorities:

• Spreading and scaling evidence-based models of home and community care that are more integrated and connected with primary health care
• Enhancing access to palliative and end of life care at home or in hospices
• Increasing support for caregivers
• Enhancing home care infrastructure, such as digital connectivity, remote monitoring technology and facilities for community-based service delivery

Funding allocation – home and community care

Measuring and Reporting on Results

The Ontario Ministry of Health (MOH) currently holds membership on the Canadian Institute for Health Information's (CIHI) Shared Health Priorities Advisory Council. This national Council meets quarterly to support the ongoing collaboration and work that CIHI leads related to the six pan-Canadian indicators for home and community care developed under the Shared Health Priorities. MOH will continue to engage and participate on the Advisory Council, working alongside jurisdictional partners and under CIHI's leadership to further this work.

Additionally, MOH will be reporting on readmissions for home care patients in 30 days after leaving hospital and caregiver distress. This reflects Ontario's focus on improving outcomes for patients in community and supporting effective use of acute resources.

Indicators – home and community care

Ontario looks forward to measuring the progress that will be made in expanding access to home and community care through this investment of new federal funding and demonstrating this progress to Canadians through annual, public reporting on the above indicators, which are reported via Health Quality Ontario at hqontario.ca.

Long-Term Care

Long-Term Care in Ontario

In Ontario, long-term care homes provide on-site 24-hour nursing care and assistance with activities of daily living for those who can no longer live in their own home safely. All long-term care homes across the province are licensed, inspected and funded by the Ontario Ministry of Long-Term Care (MLTC).

Approximately 75,000 people live in long-term care homes. These residents are supported by around 100,000 long-term care staff, including nurses, personal support workers, and other staff (e.g. food preparation, housekeeping, etc.). There are 620 long-term care homes in Ontario of which 344 are for-profit homes, 175 are non-profit homes, and 101 are municipal homes. Each long-term care home has a distinct resident population and offers a wide array of services, with some homes, such as Francophone and Indigenous-led homes, offering tailored services to meet the needs of residents of a particular religion, ethnic origin, or linguistic origin. Long-term care homes also vary in size and bed availability, with 225 small homes (0-96 beds), 246 medium homes (97-160 beds) and 149 large homes (more than 160 beds) located across the province. ^{Footnote 1}

All long-term care home licensees in Ontario are obligated to meet the standards of care, services, and accountability set out in the Fixing Long-term Care Act, 2021 (FLTCA) and its associated Regulation 246/22. This includes delivering care and services in a way that takes account of residents' physical, psychological, social, spiritual, and cultural needs, and respecting their rights set out in the Residents' Bill of Rights (regardless of race, ancestry, ethnic origin, sex, sexual orientation, etc.).

The federal government committed several in kind and financial supports to assist Ontario with reducing the spread of COVID-19 in long-term care homes, including approximately $380 million under the Safe Long-Term Care Fund to help further protect those in long-term care homes through increased infection prevention and control measures.

Long-standing issues in long-term care were both highlighted and exacerbated by the COVID-19 pandemic, resulting in a consensus that fundamental change is needed, with a deliberate focus on residents' quality of care and quality of life. Additionally, as Ontario's population ages and residents' needs become more complex, there is a growing demand for responsive initiatives and investments.

Ontario is on a pathway supported by multi-year actions and investments to help improve quality of life and quality of care for long-term care residents and expand supply to help meet current and growing demand and changing needs, with a focus on the following key areas:

• Long-Term Care Staffing/Supporting Four Hours of Care
• Long-Term Care Sustainability
• Long-Term Care Capital

Ontario will use federal funding as an opportunity to advance Ontario's plan to fix long-term care. Federal funding will be used to support initiatives that are aligned with both federal government priority areas (Workforce Stability and Long-Term Care Standards) and the following MLTC priority areas:

• Long-Term Care Staffing/Supporting Four Hours of Care
• Long-Term Care Sustainability

Initiatives for Year 1 are outlined below. Ontario will submit an updated Action Plan following the release of the 2024-25 Ontario Budget.

Long-Term Care Initiatives to be Supported by Federal Funding over the Next Five Years

Priority Area 1 – Workforce Stability

Ontario will support its priority area of Long-Term Care Staffing/Supporting Four Hours of Direct Care per resident per day by funding the following initiative:

1. Level of Care (LOC) Funding ($93.5 million annually, for the term of the agreement), which includes:
   • Sustaining the quality of direct care delivery by funding pressures arising out of inflationary growth in staff wages and equipment and supplies costs as well as increasing resident acuity; and
   • Continually supporting staff training and education costs, including attendance costs

Increasing LOC funding will provide homes with the funding needed to continue to care for residents' basic needs.

Priority Area 2 – Long-Term Care Standards

The following initiatives align with Ontario's priority area of Long-Term Care Sustainability and support coordination and integration of long-term care with other health care services and a healthy and safe workforce:

1. Right Care, Right Place (ALC) ($53.2 million annually, for the term of the agreement), which includes:
   • Funding four initiatives to accelerate the flow of Alternate Level of Care" (ALC) hospital patients to long-term care homes. An ALC patient is an individual occupying an acute care hospital bed but not acutely ill or does not require the intensity of resources or services provided in a hospital setting. The initiatives which will be funded include:
     • Behavioural Supports Ontario (BSO): Enhanced health care services for older adults, including long-term care residents with, or at risk for, responsive behaviours.
     • Baycrest Virtual Behaviour Medicine Program (VBM): A virtual inpatient neurobehavioral unit that provides services targeted to long-term care residents as well as to other clients in the community or hospital that may potentially require long-term care, without requiring travel or transfer to a clinical facility.
     • Preferred Accommodation Supplement: Covers the difference between the basic accommodation co-payment rate and the preferred accommodation rate for ALC patients who request basic accommodation but are nonetheless placed in preferred accommodation, as per Ontario Regulation 246/22.
     • Local Priorities Fund (LPF): Supports Ontario Health working in conjunction with health system partners, community service providers and hospitals to enable tailored and targeted investments in specialized staffing, equipment and services. The investments will help support the specialized needs of new and existing long-term care residents, prevent unnecessary hospitalization and enable better transitions from hospitals to long-term care homes.

These investments will expand access to specialized staff, equipment, and services to support admission and help avoid unnecessary hospitalization of residents with acute or complex needs. The investments will also enable better transitioning of people between hospital and long-term care thereby reducing the backlog of ALC patients.

2. Infection Prevention and Control (IPAC) Funding ($81.3 million annually, for the term of the agreement), which includes:
   • Supporting long-term care licensees to hire and retain qualified IPAC personnel, including the IPAC Lead;
   • Supporting continued development of IPAC capacity through IPAC related Training and Education for personnel, including dedicated funding and supports for IPAC Lead certification; and
   • Meeting related IPAC requirements under the FLTCA, including the first ever evidence based IPAC Standard for long-term care homes.

Funding allocations – Long-term care

Accountability Measures in Place for Funds Directed to Private For-Profit Long-Term Care Homes

All of Ontario's long-term care homes (i.e., municipal, for-profit or independent not-for-profit), are treated equally and subject to the same stringent accountability requirements, which include detailed rules related to the purpose for which funding can and cannot be used, as well as regular reporting intervals and associated reconciliation policies. As with all funding provided to long-term care homes, the Aging with Dignity funding will be supported by the applicable series of Long-Term Care Accountability Agreement and Direct Funding Agreement policies that work together with the reconciliation process to ensure that funds are spent as intended. MLTC requires long-term care homes to submit an audited reconciliation report annually and uses long-term care homes' submitted Long-Term Care Home Annual Reports to assess whether the long-term care homes' reported expenditures are consistent with applicable Ministry policies. Unspent funds and funds not used for the intended and approved purposes are subject to recovery in accordance with the long-term care Home Reconciliation and Recovery Policy.

Measuring and Reporting on Results

Overall Funding Allocations