Canada-Alberta Home and Community Care and Mental Health and Addiction Services Funding Agreement
HER MAJESTY THE QUEEN 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 -
HER MAJESTY THE QUEEN IN RIGHT OF ALBERTA (hereinafter referred to as "Alberta" or "Government of Alberta") as represented by the Minister of Health (herein referred to as "the Alberta Minister")
REFERRED to collectively as the "Parties".
WHEREAS, on March 10, 2017 Canada and Alberta agreed to targeted federal funding over 10 years, beginning in 2017-18, for investments in home and community care and mental health and addictions, in addition to the existing legislated commitments through the Canada Health Transfer;
WHEREAS, Canada and Alberta agreed to a Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the "Common Statement"), attached hereto as Annex 1, on August 21, 2017, which articulated their shared vision to improve access to home and community care and mental health and addictions services in Canada;
WHEREAS, Canada authorizes the federal Minister to enter into agreements with the provinces and territories, for the purpose of identifying activities provinces and territories will undertake in home and community care and mental health and addictions services, based on a menu of common areas of action and in keeping with the performance measurement and reporting commitments, consistent with the Common Statement;
WHEREAS, Canada and Alberta agree that data collection and public reporting of outcomes is key to reporting results to Canadians on these health system priorities;
WHEREAS, the Government Organization Act authorizes the Alberta Minister to enter into agreements with Canada under which Canada undertakes to provide funding toward costs incurred by Alberta for the provision of home and community care and mental health and addictions initiatives;
WHEREAS, Alberta is responsible for the design and delivery of health care in Alberta. Alberta is also responsible for the planning, determining the objectives of, defining the contents of, setting the priorities for, and evaluating its programs and services in home and community care and mental health and addictions. In this respect, Alberta makes ongoing investments in home and community care and mental health and addictions services, consistent with its broader responsibilities for delivering health care services to its residents;
AND WHEREAS the Government of Canada makes ongoing investments in home and community care and mental health and addictions services for Indigenous communities and other federal populations.
NOW THEREFORE, Canada and Alberta agree as follows:
1.1 Building on Alberta's existing investments and initiatives, Canada and Alberta commit to work together to improve access to home and community care and strengthen access to mental health and addictions services, as further described in the Common Statement.
2.0 Action Plan
2.1 Alberta will invest federal funding provided through this Agreement in alignment with the selected action(s) from each menu of actions listed under home and community care and mental health and addictions in the Common Statement.
2.2 Alberta's approach to achieving home and community care and mental health and addictions services objectives is set out in its five-year Action Plan (2017-18 to 2021-22), as set out in Annex 2.
3.0 Term of Agreement
3.1 The Agreement, once signed by both Parties, shall be in effect from April 1, 2018 and will remain in effect until March 31, 2022, unless terminated earlier in accordance with section 10 of this Agreement (the "Term").
3.2 Renewal of Agreement
3.2.1 Alberta's share of the federal funding for 2022-23 to 2026-27, based on the federal commitment in Budget 2017 of $11 billion over ten years, will be provided upon the renewal of this Agreement, subject to appropriation by Parliament, and Alberta and Canada's agreement on, a new five-year action plan which is to be informed by the actions set out in Annex 2 and the Common Statement.
3.2.2 If both Parties ultimately agree to renew, Alberta and Canada may choose to review and, if required, agree to realign the action plan in a future agreement based on the priorities in the Common Statement.
4.0 Financial Provisions
4.1 The contributions made under this Agreement are in addition to and not in lieu of those that Canada currently provides to Alberta under the Canada Health Transfer to support delivering health care services within their jurisdiction.
4.2 Allocation to Alberta
4.2.1 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.
4.2.2 Canada has designated the following maximum amounts to be transferred in total to all provinces and territories under this initiative on a per capita basis for the Term starting on April 1, 2018 and ending on March 31, 2022.
Home and Community Care
- $600 million for the Fiscal Year beginning on April 1, 2018
- $650 million for the Fiscal Year beginning on April 1, 2019
- $650 million for the Fiscal Year beginning on April 1, 2020
- $900 million for the Fiscal Year beginning on April 1, 2021
Mental Health and Addictions Services
- $250 million for the Fiscal Year beginning on April 1, 2018
- $450 million for the Fiscal Year beginning on April 1, 2019
- $600 million for the Fiscal Year beginning on April 1, 2020
- $600 million for the Fiscal Year beginning on April 1, 2021
4.2.3 Annual funding will be allocated to provinces and territories on a per capita basis, for each Fiscal Year that an agreement is in place. The per capita funding amounts for home and community care and for mental health and addictions services, for each Fiscal Year, are calculated using the following formula: F x K/L, where:
F is the annual total funding amount available under this program (funding amount will change depending on Fiscal Year);
K is the total population of the particular province or territory, as determined using annual population estimates from Statistics Canada; and
L is the total population of Canada, as determined using annual population estimates from Statistics Canada.
4.2.4 For the purposes of the formula in section 4.2.3, the population of Alberta for each Fiscal Year and the total population of all provinces and territories for that Fiscal Year are the respective populations as determined on the basis of the quarterly preliminary estimates of the respective populations on July 1 of that Fiscal Year. These estimates are released by Statistics Canada in September of each Fiscal Year.
4.2.5 Subject to annual adjustment pursuant to updated data and based on the formula described in section 4.2.3, Alberta's funding under this Agreement is anticipated to be (in millions of dollars):
|Fiscal Year||Home and community care
Estimated amount to be paid to AlbertaTable note* (subject to annual adjustment)
|Mental health and addictions services
Estimated amount to be paid to AlbertaTable note* (subject to annual adjustment)
4.3.1 Canada's contribution will be paid in two approximately equal installments as follows:
- The first installment will be paid on or about April 15 of each Fiscal Year. The second installment will be paid on or about November 15 of each Fiscal Year.
- The amount of the first installment will be equal to 50% of the notional amount set out in Article 4.2.5 as adjusted by Article 4.2.3.
- The amount of the second installment will be equal to the balance of Canada's contribution to Alberta for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
- Canada will notify Alberta at the beginning of the 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. Canada will notify Alberta of the actual amount of the second installment in each Fiscal Year as determined under the formula set out in sections 4.2.5 and 4.2.3.
- Canada shall withhold payment of the second installment for the Fiscal Year until Alberta provides its annual financial statement for the previous Fiscal Year and provides data and information related to home and community care and mental health and addictions to the Canadian Institute for Health Information (CIHI) for the previous Fiscal Year in accordance with section 5.1.2.
- The sum of both semi-annual installments constitutes a final payment and is not subject to any further adjustment once the second installment of that Fiscal Year has been paid.
- Payment of Canada's funding for each Fiscal Year of this Agreement is subject to an annual appropriation by Parliament of Canada for this purpose.
4.4 Carry Over
4.4.1 At the request of Alberta, Alberta may retain and carry forward to the next Fiscal Year, the amount of up to 10 percent of the contribution paid to Alberta for a Fiscal Year under subsection 4.2.5 that is in excess of the amount of the eligible expenditures actually incurred by Alberta in that Fiscal Year, and use the amount carried forward for expenditures on eligible expenditures incurred in that Fiscal Year. Any request by Alberta to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters.
4.4.2 For greater certainty, any amount carried forward from one Fiscal Year to the next under this section is supplementary to the maximum amount payable to Alberta under this Agreement in the following Fiscal Year.
4.4.3 In the event this Agreement is renewed in accordance with the terms of section 3.2.1, and at the request of Alberta, Alberta may retain and carry forward up to 10 percent of funding provided in the last Fiscal Year of this Agreement for eligible expenditures in the renewed 5-year agreement (2022-23 to 2026-27), subject to the terms and conditions of that renewed agreement. The new Action Plan (2022-23 to 2026-27) will provide details on how any retained funds carried forward will be expended. Any request by Alberta to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters.
4.5 Repayment of overpayment
4.5.1 In the event payments made to Alberta exceed the amount to which Alberta 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, Alberta shall repay the amount within sixty (60) calendar days of written notice from Canada.
4.6 Use of Funds
4.6.1 Canada and Alberta agree that funds provided under this Agreement will only be used by Alberta in accordance with the areas of action outlined in Annex 2.
4.7 Eligible Expenditures
4.7.1 Eligible expenditures for funds provided under this Agreement are the following:
- capital and operating funding;
- salaries and benefits;
- training, professional development;
- information and communications material related to programs;
- data development and collection to support reporting; and,
- information technology and infrastructure.
5.0 Performance Measurement and Reporting to Canadians
5.1 Funding conditions and reporting
5.1.1 As a condition of receiving annual federal funding, Alberta agrees to participate in a Federal-Provincial-Territorial process through CIHI, to develop common indicators and to share relevant data to permit CIHI to produce annual public reports on pan-Canadian progress on home and community care and mental health and addictions services.
- Alberta will designate an official or official(s), for the duration of this agreement, to work with CIHI and represent the interests of Alberta related to performance measurement and reporting for home and community care, as well as mental health and addictions services.
- Sharing of data with CIHI is subject to an appropriate agreement between Alberta and CIHI to enable the sharing of information as required by this Agreement, and subject to applicable law.
5.1.2 As a condition of receiving annual federal funding, by no later than October 1 of each Fiscal Year during the Term of this Agreement, Alberta agrees to:
- Provide data and information (based on agreed-to indicators through the FPT process) related to home and community care and mental health and addictions services in the province to CIHI annually. This will support CIHI to measure progress on the shared commitments outlined in the Common Statement and report to the public.
- Provide to Canada an annual financial statement, with attestation from Alberta's accounting officer for the Ministry of Health, of funding received from Canada under this Agreement during the Fiscal Year compared against the action plan, and noting any variances between actual expenditures and Alberta's action plan:
- The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year;
- The total amount of eligible expenditures actually incurred by Alberta for home and community care and mental health and addictions programs and services;
- If applicable, the amount of any amount carried forward by Alberta under section 4.4; and
- If applicable, the amount of any surplus funds that are to be repaid to Canada under section 4.5.
5.2.1 Alberta will ensure that expenditure information presented in the annual financial statement is, in accordance with Alberta's standard accounting practices, complete and accurate.
5.3.1 Responsibility for evaluation of programs rests with Alberta in accordance with Alberta's own evaluation policies and practices.
6.1 Canada and Alberta agree on the importance of communicating with citizens about the objectives of this Agreement in an open and transparent manner through appropriate public information activities.
6.2 Each Party will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.
6.3 In the spirit of transparency and open government, Canada will make this Agreement, including any amendments, publicly available on a Government of Canada website.
6.4 Canada, with prior notice to Alberta, may incorporate all or any part or parts of the data and information in 5.1.2, or any parts of evaluation and audit reports made public by Alberta 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.
6.5 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 Alberta 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.
6.6 Alberta reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Alberta 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.
7.0 Dispute Resolution
7.1 Canada and Alberta 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.
7.2 If at any time either Canada or Alberta 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, Canada or Alberta, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Alberta will endeavour to resolve the issue in dispute bilaterally through their designated officials, at the Assistant Deputy Minister level (hereafter "Designated Officials").
7.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Canada and Alberta responsible for Health, and if it cannot be resolved by them, then the respective Ministers of Canada and Alberta most responsible for Health shall endeavour to resolve the dispute.
8.0 Amendments to the Agreement
8.1 This Agreement (not including Annex 1) may be amended at any time by mutual consent of the Parties. To be valid, any amendments shall be in writing and signed, in the case of Canada, by Canada's Minister of Health, and in the case of Alberta, by Alberta's Minister of Health.
9.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Alberta by giving at least 12 months written notice of its intention to terminate. Alberta may terminate this Agreement at any time if the terms of this Agreement are not respected by Canada by giving at least 12 months written notice of its intention to terminate.
9.2 As of the effective date of termination of this Agreement under section 10.1, Canada shall have no obligation to make any further payments to Alberta after the date of effective termination, and Alberta may reduce or cancel its commitments commensurately.
10.1 Any notice, information, or document provided for under this Agreement will be effectively given if delivered or sent by letter or email, postage or other charges prepaid. Except in periods of postal disruption, any notice mailed will be deemed to have been received eight calendar days after being mailed.
The address for notice or communication to Canada shall be:
70 Colombine Driveway
Brooke Claxton Building
Attention: Associate ADM, Strategic Policy
The address for notice or communication to Alberta shall be:
Intergovernmental Relations, Alberta Health
19th Floor, ATB Place
10025 Jasper Avenue NW
Attention: Executive Director, Intergovernmental Relations
11.1 This Agreement, including Annexes 1 and 2, comprise the entire agreement entered into by the Parties with respect to the subject matter hereof.
11.2 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Alberta.
11.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Alberta shall be admitted to any share or part of this Agreement.
11.4 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 deemed to be severable and will be deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.
11.5 Notwithstanding the dates of the signatures below, this Agreement to be effective as of April 1, 2018.
SIGNED on behalf of Canada by the Minister of Health at Ottawa this 28th day of September, 2018.
The Honourable Ginette Petitpas Taylor, Minister of Health
SIGNED on behalf of Alberta by the Minister of Health at Edmonton this 1st day of May, 2018.
The Honourable Sarah Hoffman, Minister of Health
Pursuant to the Government Organization Act
Intergovernmental Relations, Executive Council
Date: May 7, 2018
Annex 1 to the Agreement
Annex 2 to the Agreement
Alberta Action Plan: Federal Funding Contributions for Home and Community Care and Mental Health and Addiction Services
The Government of Alberta is committed to a stable, accountable, high quality, person-centered and sustainable health system that emphasizes staying healthy and well, while also supporting equitable access to required care when needed. We are also committed to reducing the gap in health outcomes between Indigenous and non-Indigenous peoples through collaborative program design and delivery. As the population increases and demographics change, the demands for health services in Alberta continue to grow. There is an increased need for home and community care, as well as a coordinated and integrated mental health system. To help Albertans remain independent and active in their communities as they age or as their needs change, Alberta is shifting focus towards community-based care.
The Canada-Alberta Home and Community Care and Mental Health and Addiction Services Agreement will support Alberta towards achieving its vision for community-based health care. The vision for health in Alberta is where Albertans' health and wellbeing are improved through an integrated healthcare system that structures and plans around the diversity of individuals and their communities, and connects people to needed care and services regardless of who they are (ethnicity, language, gender, sex) or where they reside in the province. Achieving this vision requires a shift from a focus on higher-cost facility based care to more integrated community-based care and supports that are accessible to all Albertans closer to home.
Areas of Action
This vision will be implemented through a multi-pronged approach involving a number of health system programs and areas such as home and community care, primary care, mental health and addiction services. The initiatives described in this action plan align with the areas of action outlined in the Common Statement of Principles for Shared Health Priorities.
Home and Community Care
Overview of Current Home and Community Care Services in Alberta
Alberta's Home Care Program offers an array of health and support services to Albertans of all ages in their own homes and communities. In 2016/17, almost 119,000 Albertans received services from the home care program. Home care services are provided in a wide range of settings including: private homes or apartments, community settings (e.g. schools, public health clinics, adult day programs) and congregate living facilities (e.g. seniors' lodges, supportive living facilities). Of these 119,000 clients, approximately 70% were seniors, and 30% were children and adults under the age of 65.Footnote1
Challenges in the provision of home and community care in Alberta are not dissimilar to challenges faced by other provinces and territories. For example, home care clients living in rural and remote areas, including Indigenous communities, do not have access to the variety or amount of home and community care services available to clients in urban and metropolitan areas. Home and community care can also place additional burden on friend and family caregivers, who are more often womenFootnote2, as they provide upwards of eighty to ninety percent of care in the home. Furthermore, demand for home and community care services is steadily increasing, with total client volume in Alberta rising nearly 20% from 2010/11 to 2016/17. This growing demand across the province is being driven by an aging population that is living longer, changing rates of chronic disease, and an expressed desire among Albertans to remain in their own homes and communities as they age or as their care needs changeFootnote3. The number of seniors in Alberta is expected to nearly double in the next twenty years from 550,000 in 2017 to more than 1 million by 2035Footnote4. Overall, home care clients in Alberta are very satisfied with the quality of home and community care services they receiveFootnote5, but additional resources and strategic investments will be needed to maintain this quality over time as supporting clients with more complex care needs to remain in their own homes and communities will place further demands on caregivers and the system as a whole.
Plans and Priorities for the Next Five Years
To support Alberta's shift towards more community-based care, Alberta's Budget 2017 increased provincial funding for home and community care by $150 million, which included the $23.4 million in federal investments for home and community care in 2017-2018. The budget for home and community care in Alberta in 2017-18 was $2.02 billion. Additional provincial investment is planned to augment the federal investment over the next four years. The ultimate goal for this targeted investment is to help Albertans maintain their independence and avoid, or delay, the need for higher levels of care.
In recent years, the Ministry of Health has provided its provincial health authority, Alberta Health Services (AHS), with over $95 million in grant funding to develop, implement and evaluate home and community care initiatives aimed at supporting more Albertans with complex care needs to receive care in their homes and communities rather than in more costly facility-based settings such as hospitals or long-term care facilities. For example, a number of projects focused on the provision of interdisciplinary team-based care to home care clients with complex care needs related to chronic disease, aging or frailty. These initiatives were found to cause significant reductions in the use of emergency departments (25-40% reduction 6 months after intervention) and hospital admissions (33-52% reduction 6 months after intervention) among clients who received this specialized community careFootnote6. The provision of additional adult day program spaces as well as enhanced community rehabilitation services were found to significantly increase client satisfaction with home and community care services and, in some cases, reduce the strain experienced by family caregiversFootnote3. Evidence from these and other community-based Alberta initiatives have guided the selection of priorities for this federal investment. The selected initiatives also support the objectives of the recently released Alberta Dementia Strategy and Action Plan as well as AHS' Enhancing Care in the Community initiatives.
The funding provided through this Agreement will support and improve access to existing home and community care programs and services and help to scale and spread innovative initiatives over the next four years. Federal funding will augment the funding from Alberta for the programs and services listed in this action plan. These initiatives include:
1 Spreading and scaling evidence-based models of home and community care
a) Standardized basket of services
Description: Implementing a standard basket of home care services accessible by all Albertans regardless of where they reside in the province, including more intensive services and restorative care. This will include increasing basic home and community care services, particularly in rural and remote areas, as well as the provision of more intensive/restorative services and team-based care for clients with complex care needs. This may also include offering more client-directed funding options with more flexible funding limits. Keeping up with increasing demand growth will ensure home and community care services are available to all Albertans who require them.
The target population for this initiative is Albertans requiring home and community care services, particularly those in rural and remote areas of the province (including Indigenous communities) who have been chronically under-served. More intensive and/or restorative services will target clients at risk for hospitalization, or support clients to return safely to community more quickly after hospitalization.
These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:
- Spreading and scaling evidence based models of home and community care that are more integrated and connected with primary health care.
Federal contribution: Alberta anticipates spending in excess of $522.7 million over the five years included in this action plan to offer a more equitable and extensive basket of services to an ever increasing population of home and community care clients. Federal funding will contribute approximately 44 per cent of this planned expenditure.
Expected outcomes: A larger proportion of individuals will receive care and support within their homes and communities rather than in higher cost hospitals or facility-based continuing care. Fewer people will be assessed for facility-based continuing care while in hospital, and more people will be supported to return home and given a chance to rehabilitate prior to being assessed for facility-based continuing care.
b) Access to specialized, interdisciplinary programs, services and teams
Description: In response to existing programs that have been effective and well-received by Albertans, this initiative will increase access to specialized interdisciplinary programs, services and teams. This initiative will:
- Expand the Assess, Treat, Refer (ATR) community-based Emergency Medical System (EMS) program and EMS Urgent Response Teams. These innovative team-based care approaches involve EMS responding with the goal of treating clients with complex care needs in place and avoiding unnecessary transfers to emergency department (ED) or hospital. EMS teams also coordinate and collaborate with primary care providers and home care case managers.
- Expand Virtual Hospital and Integrated Care Teams for clients with complex chronic conditions (e.g. frail elderly, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF]). Specialized interdisciplinary care teams can provide care to clients with complex needs in community and are better positioned to coordinate with primary and acute care providers.
- Expand interdisciplinary community support teams that maximize health care workers' scopes of practice and coordinate with a client's primary care provider as necessary.
Specialized interdisciplinary team-based care such as the initiatives described above will support clients with complex care needs to avoid hospitalization or to return home more quickly after hospitalization. Better integration in health care service delivery can improve quality of care and reduce unnecessary use of more costly services.
The target population for this initiative is Albertans with complex and high needs (e.g. frailty, COPD, CHF, addiction or mental health issues, dementia, end of life).
These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:
- Spreading and scaling evidence based models of home and community care that are more integrated and connected with primary health care; and
- Enhancing access to palliative and end-of-life care at home or in hospices.
Federal contribution: Alberta anticipates spending ~$89 million over the next five years on the initiatives/programs described above. Federal funding will contribute to approximately 80 per cent of the planned expenditures.
Expected outcomes: With increased access to specialized interdisciplinary programs and services, we anticipate a reduction in hospital admissions/readmissions, as well as emergency department use, among program clients.
2 Enhancing access to palliative and end-of-life services
Description: This initiative will focus on the scale and spread of palliative and end-of-life services in home and hospice. Expansion of palliative home care and hospice services for clients throughout their health care journey allows clients to die in the place of their choice, in alignment with their goals of care. Currently some Albertans die in hospital while waiting for a hospice space. Making hospice spaces available to all Albertans who would prefer to receive care in a hospice setting would improve the quality of life for people in the final stages of their life.
The target population for this initiative will be all Albertans who require palliative and end-of-life care.
These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:
- Enhancing access to palliative and end-of-life care at home or in hospices.
Federal contribution: Alberta anticipates spending $35.6 million over and above current expenditures to enhance palliative home care programming and services to rural and remote parts of the province and to expand the number of hospice spaces. Federal funding for home and community care will fully fund this expansion.
Expected outcomes: With this initiative, we anticipate an increase in the number of Albertans receiving end-of-life care in community (in home and/or hospice), and a reduction in transfers to hospital by clients with an end-of-life prognosis.
3 Increasing support for caregivers through in-home respite and Adult Day Programs
Description: Increase the provision of in-home respite services as well as basic and comprehensive adult day program (ADP) spaces. Adult day programs provide important socialization, physical activity, and monitoring for home and community care clients while simultaneously providing family caregivers with respite.
The work of unpaid family and friend caregivers in Canada has been valued at more than $25 billion per yearFootnote7, and the health system cannot afford to replace this care. In-home respite services can reduce the strain experienced by family and friend caregivers as a result of caregiving responsibilities, and can help families support home and community care clients to remain living at home as long as possible. ADPs are also a key form of respite services to support family and friend caregivers who provide the majority of care to Albertans with long-term health care needs. Comprehensive ADPs also offer programming for the monitoring and maintenance of the health and well-being of individuals with dementia or other complex health conditions to allow them to remain living in the community as long as possible. Clients and family caregivers report significantly improved quality of life from participation in comprehensive ADPs.Footnote8
Target populations for this initiative include Albertans receiving care from family or friend caregivers, as well as caregivers at risk of burden from the stress of caregiving.
- Increasing support for caregivers.
Federal contribution: Alberta anticipates spending $15.4 million over and above current expenditures to enhance respite services and supports for informal caregivers. Federal funding for home and community care will fully fund this expansion.
Expected outcomes: This initiative will result in increased basic and comprehensive ADP spaces. It is expected to reduce hospital and emergency department usage among adult day program clients and also result in fewer caregivers reporting stress or burden.
Measurement and Reporting
There will be several positive outcomes from the initiatives that have been listed as priorities for this federal investment. It is anticipated that home care clients with basic, and even the most complex, needs would be able access and receive the intensity of supports they and their caregivers require to remain safely at home for longer. As well, more Albertans who require palliative and end-of-life care will receive community-based supports so they can die in their place of choice. Previous evaluations of similar initiatives indicate that unnecessary use of higher cost health care services by home care clients can be avoided as a result of the more comprehensive and intensive supports available to them and their caregivers. Finally, it is anticipated that these initiatives will reduce caregiver burden and improve client and family experience and satisfaction with home and community care services.
Alberta Health will be engaged in collaborative work with AHS, the O'Brien Institute and the Health Quality Council of Alberta to measure and monitor the impact of Alberta's investment in home and community care. The following measures are among those being considered for evaluating the impact of the provincial and federal investment in home and community care:
- Home care client counts;
- Alternate Level of Care days for persons waiting in hospital for continuing care facility space;
- Percent of clients transitioned to facility-based continuing care, from the community rather than from acute care;
- 30 day unplanned readmission to hospital for home care clients;
- ED visits for home care clients;
- EMS transfers for home care clients;
- Number of adult day program spaces;
- Percent of clients whose caregivers are expressing continued distress;
- Overall client experience with home care.
Alberta is participating in the federal/provincial/territorial working group with the Canadian Institute for Health Information (CIHI), which is seeking to reach consensus on a focused set of common indicators for monitoring progress on health system priorities. Alberta will also continue to submit home and community assessment data to CIHI's Home Care Reporting System (HCRS) through the Alberta Continuing Care Information System (ACCIS).
Mental Health and Addiction
Overview of Current Mental Health and Addiction Services in Alberta
Addiction and mental health conditions involve a complex interplay of genetics, personality, childhood experiences or trauma, and social determinants of health, resulting in a diverse range of needs. This complexity demands a high-functioning system to deliver and support a continuum of services. Services that are comprehensive, well-coordinated and integrated within Alberta Health Services (AHS) and with partner organizations and ministries are required to meet the needs of Albertans. Addiction and mental health services offered by AHS align with a tiered model of care. Clients and families receive care according to their needs along this continuum, stepping-up to higher levels of intensity as their needs for services increase and stepping-down to lower levels of intensity as their needs decrease.
Alberta spent over $850 million in 2016-17 to support addiction and mental health initiatives across the province. Alberta's Budget 2017-18 committed a $15 million increase for addiction and mental health and support, including funding to support the implementation of the recommendations of the Valuing Mental Health Report. Funding for mental health and addiction services in the province is provided to Alberta Health Services and community based services that provide addiction and mental health prevention and promotion, community based treatment, and specialized services. Two examples of priorities include expansion of the Opioid Dependence Program (ODP) and the Mental Health Capacity Building Program (MHCB). ODP services are currently located in all Zones throughout the province. For children and youth, the MHCB is made up of 37 programs in Alberta serving children and youth under age 19 years, and their families, located in 85 communities, 182 schools and 74 additional outreach schools.
As the single health authority in the province, AHS employs more than 9,000 Addiction and Mental Health (AMH) staff and contracted employees. Addiction and mental health services are provided in approximately 104 acute care hospitals and psychiatric facilities, 107 emergency departments and urgent care centers, 236 AMH community clinics, and 39 addiction residential and detoxification facilities. Further, AHS and its contracted services provide approximately 3,304 beds located in addiction, community mental health, psychiatric and acute care settings. Primary care physicians, private providers, non-governmental organizations and self-help groups also provide addiction and mental health care and supports throughout the province.
In 2015/16, over 130,000 clients were treated in AHS community/outpatient addiction and mental health services. In 2016/17, there were over 28,000 mental health and substance use discharges from acute care hospitals and psychiatric facilities, as well as over 102,000 visits to emergency departments and urgent care centres for mental health or substance use problems. Over 930,000 individuals in Alberta consulted a physician for addiction and mental health services during the 2016/17 fiscal year. Tele-mental health served 11,179 clients in 2016/17, and during the same period, there were 18,573 mental health related calls to the Mental Health Helpline and Health Link and 13,511 calls to the Addiction Helpline. Service volumes have been increasing across these sectors of the care continuum.
Although many Albertans are served through the existing addiction and mental health service system, recent reports that have highlighted gaps in available services. The Gap Analysis of Public Mental Health and Addiction Programs (GAP-MAP), 2014 report analyzed service gaps in adult addiction and mental health services, compared to population need. This report concluded that approximately 1 in 10 adults in Alberta had an unmet addiction and mental health service need because they either did not receive any services or received an insufficient amount of service. The report also concludes that the system invests the majority of resources in inpatient, crisis and residential services and operates on a reactive, acute model of care; it also indicates that mental health services are comparatively better resourced than addiction services and a large majority of resources are dedicated to services for adults. Further, community support services are not well integrated into addiction and mental health services.
Similarly, the Office of the Auditor General concluded that mental health services in Alberta need to be improved in their 2015 follow-up audit of mental health services. More specifically, they found that care planning and delivery was disjointed with limited coordination across service settings, programs and providers. The OAG highlighted housing supports as a key area for greater investment and coordination. Most recently, the government of Alberta sponsored a review of the mental health service system in 2015. Valuing Mental Health: Report of the Alberta Mental Health Review Committee (the Report), released in early 2016, reported that addiction and mental health services were difficult to access and navigate, were fragmented, and often did not meet the needs of vulnerable populations (e.g., children and youth, Indigenous peoples, persons with complex needs).
AHS monitors the performance of its services through a series of public and internal performance measures. These measures also suggest that clients may have difficulty accessing services. The proportion of children offered an appointment with a mental health therapist within 30 days decreased from 85% in 2015/16 to 81% in 2017/18, while the number of enrolments increased from 8,913 to 9,387 (5% increase). Likewise, wait times for adult addiction outpatient services are significantly longer in rural and remote areas of the province, compared to urban areas which often offer walk-in intake services. Overall, 1 out of 10 adults waited more than 15 days for outpatient addiction services in 2016/17. In addition, a significant proportion of available bed days in acute psychiatric units (approximately 15% in 2016/17) are used by clients who could be in alternative level of care (ALC). The most common reason why clients are designated as ALC is because they are waiting for services in the community.
Taken together this suggests that Alberta's addiction and mental health service system would benefit greatly from resourcing to enhance service integration and care coordination, expand access to services to meet growing demands, and make improvements for specific sectors of the service continuum and populations (e.g. services for children and youth).
Plans and Priorities for the Next Five Years
One strategy to support the vision for community-based health care is the creation of a Primary Care Network governance structure. On June 19, 2017, the Minister established a Provincial Primary Care Network (PCN) Committee by Ministerial Order. The Provincial PCN Committee will provide governance, leadership, strategic direction and priorities for the PCNs. It will provide a forum for PCNs, through their zonal leadership, to raise opportunities and issues to the provincial level. Zone Committees will work to align planning across PCNs in their zone, create and implement a zone-wide service plan, optimize service delivery for populations across zones, and create efficiencies through shared services. These committees will be instrumental in ensuring Albertans have access to AMH services in primary care settings and will promote greater integration of primary care and specialty addiction and mental health services.
Enhancing community-based programs is supported in the Valuing Mental Health (VMH): Next Steps (June 2017) document, which outlines actions to respond to recommendations made in the Report. To achieve the transformational change that the Committee's report calls for, actions focus on improving system continuity through coordinating and integrating services across health and with community service providers, and supporting those who are most likely to experience vulnerabilities.
Stakeholders, who provided feedback into development of VMH: Next Steps, recognized that while actions must serve all Albertans, particular focus should be given to groups who are underserved including:
- Children, youth and families;
- People with multiple and complex needs;
- People seeking addiction services; and
- Indigenous Peoples and communities.
As the largest organization responsible for the delivery of health care services in the province, AHS is tasked with leading the operationalization of Alberta Health's vision of enhancing care in the community, improving the integration of health and social services, and ensuring the needs of the four priority target populations identified in VMH: Next Steps are met. To achieve this, AHS Addiction and Mental Health has four strategic directions and each play an important role in enhancing delivery of addiction and mental health services:
- Provide community treatment services to Albertans in need (e.g., promotion and prevention, specialized community services, primary care, and follow-up/transition from inpatient and hospital-based care).
- Provide addiction and mental health supports in home care and supportive living environments.
- Enhance appropriate use of crisis and emergency service (e.g., help people who would otherwise use crisis/emergency services instead access services in their home and community).
- Provide specialized interventions for complex and high-risk populations (e.g., provide services in community settings, provide transitional/follow-up support for people moving from specialized facility-based care to the community).
The funding provided through this Agreement will support and improve access to existing mental health and addiction programs and services. Federal funding will be augmented by funding from Alberta for the programs and services listed in this action plan. These initiatives include:
1 Community-based addiction and mental health services
Description: Alberta currently has well-established core community health addiction and mental health services, including community-based follow-up from specialized services or inpatient services. An example of these services includes the expansion of Inpatient Psychiatric Staffing in St. Paul to provide comprehensive care to patients with complex needs on the acute care unit ($0.7 million per annum). Alberta also provides a range of emergency, crisis and outreach services to Albertans at risk of or in crisis, often in partnership with local agencies and police forces. An example is the Assertive Outreach Teams in the North Zone to serve patients with severe and persistent mental illness who present at Emergency Departments (ED) and require further support and follow-up ($0.5 million per annum).
In accordance with Alberta's vision towards community-based health care and in alignment with the AHS addiction and mental health strategic directions, this initiative will improve and increase access to community-based addiction and mental health services. This will include:
- Implementing evidence-informed models of community care by translating research, introducing innovations and supporting the spread of effective models of care. The increase of evidence-based models of care will improve access and transition between services. An example of this type of service includes the addition of the North Zone Aboriginal Travel Teams.
- Increasing access to community treatment services, including specialized community services and follow-up from emergent or crisis situations (e.g., discharge from acute care/emergency care, disasters or community crises). Example of this type of service includes the addition of outreach services for the homeless in Central Zone.
- Enhancing the appropriate use of crisis and emergency services, to support Albertans at risk of or in process of emergent or crisis situations. Initiatives will be based on population need, in order to provide addiction and mental health patients and their families focused care in the most appropriate service setting.
Increasing availability of community-based services will help meet growing demands and reduce wait times for services. This initiative will support Albertans who are at risk for or have addiction and mental health concerns, those who require treatments, or those who are met with crisis or emergency situations. An example of this program is the North Zone Indigenous Travel Team, which has been funded to recruit two addiction and mental health outreach teams to provide access to culturally appropriate services in high needs communities ($0.7 million per annum).
- Spreading evidence-based models of community mental health care and culturally-appropriate interventions that are integrated with primary health services.
Federal contribution: It is anticipated that $33.9 million of the federal funding will be used to build upon these community services and enhance innovative approaches to improve service access. This funding will provide additional support towards enhanced follow-up in the community, and enhanced crisis support and outreach services, in order to reduce avoidable admissions to acute care or emergency care for vulnerable Albertans or for those in - or at risk of - crisis.
Expected outcomes: The demand for mental health and addiction services is growing in the province, which results in Albertans having long wait times for services, not receiving services, or receiving an insufficient amount of service. We anticipate that providing increased access to services in the community will result in more individuals served for an addiction or mental health need over the fiscal year. This will result in fewer people requiring acute care admissions for an addiction or mental illness.
2 Mental health and addiction services for children and youth
Description: Alberta currently provides a spectrum of community addiction and mental health services to children and youth. Services include prevention / promotion, outreach, and scheduled and non-scheduled services (e.g., walk in), within the continuum of addiction and mental health services. The Mental Health Capacity Building (MHCB) Program works in schools and communities to promote positive mental health in children, youth and families and supports community members who work with children and youth ($10.4 million per annum). There are currently 37 programs in 85 communities and 182 schools with an outreach to 74 additional schools, throughout Alberta. Of the 37 Programs, 28 are located in rural and remote geographic areas in Alberta with a formalized connection for 14 of those rural programs to Indigenous communities. The focus of the program is mental health promotion, prevention, early and brief intervention for children, youth and families by: raising awareness, reducing stigma, building personal and interpersonal skills, supporting positive community norms, and intervening early to help children, youth and families who are at risk for addiction and mental health issues. A primary role for MHCB is to assist in connecting children, youth and families to treatment services when they need them.
There are currently a range of crisis and emergency services in conjunction with acute care sites, emergency departments, local schools and other child-serving community agencies across Alberta. The province also currently provides highly specialized services in community and residential care settings for children and youth with acute mental illness or addiction issues. For example, the Protection of Children Abusing Drugs (PCHAD) program, under a protection order, allows a child to be confined up to 10 days for detoxification, stabilization and assessment at 4 protective safe houses in Alberta with a total of 25 beds ($1.1 million enhancement per annum).
Federal funding will provide additional services in key targeted areas to improve wait times for children and youth at high risk or experiencing complex addiction and mental health issues. Studies show that half of those who develop mental health disorders show symptoms by age 14Footnote9, which may be linked to a number of root causes and social determinants of health. This initiative will improve community care on the addiction and mental health continuum for children, youth and families. Areas of focus will include:
- Community-based mental health services for children and youth, such as promotion and prevention, specialized community services, and follow-up from emergent or crisis situations (e.g., discharge from acute care/emergency care, disasters or community crises). Examples of this type of service include the addition of the AHS operated Rutherford Clinic in the Edmonton Zone.
- Crisis and emergency services to support children, youth and families at risk of, or in the process of, emergent or crisis situations. Based on population need, initiatives will provide AMH patients and their families focused care in the most appropriate service setting.
- Intensive and specialized interventions for high-risk children and youth. This will involve partnering with stakeholders (e.g., schools, social services) to support children and youth with significant mental health and addiction concerns. Examples of this type of service include the addition of a youth mental health day program in the North Zone.
This initiative will focus on both prevention and treatment, as it supports children and youth either at risk of, or currently experiencing, mental illness or addiction. Enhancing community mental health and addiction services for children and youth will support individuals before they reach a crisis point. Focusing intensive and specialized interventions for high-risk youth, as well as increasing access to crisis and emergency services, will provide help when it is needed. This will benefit their families, the community and the province. It will also reduce or prevent acute care admissions for mental health or addiction. Target populations will include children or youth at risk for experiencing mental health concerns, those at risk of or in crisis situations and those with acute and/or severe mental illness and addiction.
- Expanding access to community-based mental health and addiction services for children and youth (age 10-25), recognizing the effectiveness of early interventions to treat mild to moderate mental health disorders.
Federal contribution: It is anticipated that $76.2 million of the federal funding will be used to support: community day programs and residential services for children and youth at risk for serious mental health or addiction issues (such as the Rutherford Clinic in the Edmonton Zone, which provides assessments and treatments for children and youth with mental health issues, and works with primary care providers); a youth mental health day program in the North Zone, which partners with three surrounding school districts to support children and youth with significant mental health concerns ($0.8 million per annum); and the expansion of PChAD Beds in the Calgary Zone ($1.1 million per annum).
Expected outcomes and results: These initiatives will reduce the wait times for children and youth seeking mental health services. We anticipate an increase in the number of clients served for mental health or addiction services during the fiscal year. In the long-term, increasing access to these services will result in healthier and happier children, and will reduce later-stage expenses, such as hospital stays and social services.
3 Specialized addiction and mental health services
Description: Addiction and mental health conditions involve a complex interplay of factors, including social determinants of health. This complexity demands a high-functioning system to deliver and support a continuum of services. Alberta currently provides supportive services in order to meet the complex needs of Albertans. For example, individuals covered by Persons with Developmental Disabilities (PDD), who have concurrent mental illness, are provided with enhanced housing opportunities to help them transition from Alberta Hospital in Edmonton ($0.6 million per annum).
In order to better meet the needs of those seeking specialized addiction and mental health services, this initiative will include:
- Increased housing and home-based supports to assist recovery for people with AMH needs. This initiative will improve AMH supports to Albertans who are in the housing continuum. Initiatives ensure that AMH supports are available to the most vulnerable Albertans in the community without reliance on acute or facility based care. Examples of this type of service include the addition of housing supports for chronically homeless in the North Zone and women in the sex trade in the Edmonton Zone.
- Increased availability of intensive interventions to improve short-term, acute, and intensive care options on the AMH continuum. Examples of this type of service include assertive outreach teams in the North Zone, enhanced detoxification services in the Central and South Zones, the addition of satellite homes for transition from Claresholm Care Centre in the Calgary Zone, the addition of ultra-short stay beds in the Calgary Zone, and expansion to inpatient staffing and beds in the North Zone.
- Increased specialized care options for complex and high-risk adult populations. This will cover an array of vulnerable populations which crosses a variety of conditions (e.g., severe depression, schizophrenia, dementia and aggressive behaviour) that require tailored, short or longer term services. Examples of this type of service include the addition of a rehabilitation facility in the Calgary Zone, a Person with Developmental Disabilities enhanced home in the Edmonton Zone, and a home for the not criminally responsible in the Calgary Zone.
This initiative will improve access to supportive housing options for adults challenged by homelessness and/or complex needs, and increase availability of specialized or intensive care for high-risk adult populations. The target population for this initiative is adults with complex or severe addiction and/or mental health needs, recognizing vulnerable or underserved populations.
- Expanding availability of integrated community-based mental health and addiction services for people with complex needs.
Federal contribution: Alberta currently provides community supports for those vulnerable Albertans who require transitional housing but also need addiction and mental health support to maintain community living. It is anticipated that $123.5 million of the federal funding will be used to expand these community addiction and mental health supports provided to vulnerable Albertans (e.g., homeless), needed to maintain their ability to live in the community while reducing acute care and emergency service demands. Alberta funds a range of intensive interventions across the province. Federal funding will augment this provincial investment, by adding intensive care options to the foundational intensive services across the province in a number of areas where there is clear need for improved intense service needs (e.g., rural areas, detox services). For example, enhanced detoxification services will be added to Central and South Zones with the opportunity to convert social detox beds to medical detox beds ($3.7 million for two years).
Alberta is also funding a range of community and institutional specialized services across the province, supporting the high volume of Albertans with high risk and complex mental health care needs. Federal funding will augment the provincial investments, by increasing the range and type of specialized services offered across the province in key strategic areas. This will in turn decrease the burden on the acute care and emergency services across the province. For example, a Mental Health Rehabilitation Facility for patients with severe and persistent illness is being planned for the Calgary Zone in association with a contracted service provider ($6.2 million per annum).
Expected outcomes and results: There is a growing demand for these services in Alberta. We anticipate that increasing access to these services will result in an increased number of clients served each fiscal year.
Measurement and Reporting
Alberta continues to monitor a number of measures that help inform us about the performance of our health system and support priority setting and local decision-making. The measures track our performance using a broad range of indicators that span the continuum of care. Alberta's current or potential measures in relation to mental health and addiction include:
- Percentage of mental health patients with unplanned readmissions within 30 days of leaving hospital
- Percentage of children (age 0-17 years) offered scheduled community mental health treatment within 30 days from referral
- Emergency department separations for adult and youth (in key / select targeted areas)
- Acute care admissions for adult and youth (in key / select targeted areas)
- Community addiction and mental health service volumes (scheduled and non-scheduled community services; adult and youth)
- Service volumes within intensive and specialty care programs
- Acute care length of stay in key areas of the AMH continuum
Alberta is participating in the federal/provincial/territorial working group with CIHI, which is seeking to reach consensus on a focused set of common indicators for monitoring progress on mental health and addiction services. If Alberta finds that the common CIHI indicators do not adequately align with the initiatives identified in this action plan, Alberta may identify other indicators. Measures will be analyzed in relation to the specific clinical and geographic area(s) where the initiative(s) are occurring. The identification of key performance indicators will be coordinated provincially between Alberta Health and AHS, and in consultation with provincial stakeholders.
Once indicators are agreed to, a schedule for data collection and reporting will be established. This will be coordinated provincially and consolidated into a provincial report that speaks to the overall impact of service enhancements to the continuum of addiction and mental health services in Alberta.
|Initiative name||Expenditures per Fiscal Year ($)|
|Home and Community Care|
|Standardized basket of services||13,840,606||41,860,000||47,700,000||47,700,000||76,890,000||227,990,606|
|Access to specialized, interdisciplinary programs, services and teams||6,200,000||16,300,000||16,300,000||16,300,000||16,300,000||71,400,000|
|Enhancing access to palliative and end-of-life services||3,200,000||8,100,000||8,100,000||8,100,000||8,100,000||35,600,000|
|Increasing support for caregivers through in-home respite and Adult Day Programs||200,000||3,800,000||3,800,000||3,800,000||3,800,000||15,400,000|
|Mental Health and Addiction Services|
|Community-based addiction and mental health services||2,277,921||4,190,775||9,808,614||8,808,614||8,808,614||33,894,538|
|Mental health and addiction services for children and youth||2,300,000||4,294,536||19,075,240||25,248,573||25,248,573||76,166,922|
|Specialized addiction and mental health services||7,142,382||20,704,689||23,656,146||36,002,813||36,002,813||123,508,843|
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