Canada-Newfoundland and Labrador Home and Community Care and Mental Health and Addictions Services Funding Agreement
Table of Contents
- Funding Agreement
- Annex I - Common Statement of Principles on Shared Health Priorities
- Annex II - Action Plans
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 THE PROVINCE OF NEWFOUNDLAND AND LABRADOR (hereinafter referred to as "Newfoundland and Labrador" or "Government of Newfoundland and Labrador") as represented by the Minister of Health and Community Services and the Minister of Intergovernmental and Indigenous Affairs herein referred to as "the provincial Ministers")
REFERRED to collectively as the "Parties"
WHEREAS, on December 23, 2016 Canada and Newfoundland and Labrador 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 Newfoundland and Labrador 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 as well as 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 Newfoundland and Labrador agree that data collection and public reporting of outcomes is key to reporting results to Canadians on these health system priorities, and that the performance measurement approach taken will recognize and seek to address differences in access to data and health information infrastructure;
WHEREAS, the Executive Council Act and the Intergovernmental Affairs Act authorize 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 Newfoundland and Labrador for the provision of health services which includes home and community care and mental health and addictions initiatives;
WHEREAS, Newfoundland and Labrador 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;
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.
WHEREAS, since March 2020, Canada has been in the midst of the COVID-19 global pandemic, which has disproportionately affected Canadians living in supportive care settings in the community, namely long-term care facilities, assisted living facilities, and seniors' residences where they receive continuing care services (hereinafter referred to as long-term care settings), and which is requiring provinces and territories to put in place stronger measures to reduce the risk of harm to residents of these facilities;
WHEREAS, the Government of Canada announced an investment of $19 billion to help provinces and territories to safely restart their economies and make Canada more resilient to possible future surges in cases of COVID-19, of which $740M is to support provinces and territories through 2020-21 with one-time investments for infection prevention and control, including in long-term care settings;
WHEREAS, on November 30, 2020, the Government of Canada committed to a further investment of $1 billion to support provinces and territories to protect residents in long-term care settings, given the continued serious risk to health of these vulnerable Canadians;
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 to protect residents in long-term care settings through increased infection prevention and control measures and in keeping with performance measurements and reporting commitments;
AND WHEREAS, the Executive Council Act and the Intergovernmental Affairs Act authorize the provincial Ministers to enter into agreements with the Government of Canada under which Canada undertakes to provide Safe Long-term Care Funding toward expenditures incurred by Newfoundland and Labrador for activities to protect residents in long-term care settings through increased infection prevention and control measures.
NOW THEREFORE, Canada and Newfoundland and Labrador agree as follows:
1.1 Building on Newfoundland and Labrador’s existing investments and initiatives, Canada and Newfoundland and Labrador commit to work together to improve access to home and community care and strengthen access to mental health and addictions services (listed in the Common Statement, attached as Annex 1).
1.2 Further, Canada and Newfoundland and Labrador commit to work together to improve access to safe care through increased infection prevention and control in long-term care settings.
2.0 Action Plan
2.1 Newfoundland and Labrador will invest federal funding for Home and Community Care and Mental Health and Addictions Services 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 Newfoundland and Labrador’s approach to achieving home and community care and mental health and addictions services objectives is set out in their five-year Action Plan (2017-18 to 2021-22), as set out in Annex 2.
2.3 Newfoundland and Labrador will invest the federal Safe Long-term Care Funding provided under this Agreement on infection prevention and control activities in long-term care settings in each of the following three areas:
- retention measures for existing staff, including wage top-ups, and/or hiring of additional human resources (e.g. personal support workers, licensed practical nurses, cleaners);
- new infrastructure and renovations to existing infrastructure, such as ventilation of self-isolation rooms and single rooms; and,
- readiness assessments conducted in long-term care settings to prevent COVID infections and spread.
2.4 In addition, Newfoundland and Labrador may also invest the federal Safe Long-term Care Funding through this Agreement on infection prevention and control activities in long-term care settings in one or more of the following areas;
- strengthened infection prevention and control measures and training for existing staff;
- adequate supply of personal protective equipment for staff and visitors;
- rapid training programs to increase the number of supportive care workers, including training for students and workers from other sectors;
- enhanced screening and regular testing of staff and visitors to quickly detect, prevent or limit spread; and,
- additional inspectors and infection prevention and control specialists to support in-person inspections of all facilities, as well as accreditation costs associated with meeting long-term care standards.
2.5 Newfoundland and Labrador’s approach to achieving the objective of the Safe Long-term Care Funding, as set out in section 1.2, in the areas identified above, is set out in Annex 2, as amended.
3.0 Term of Agreement
3.1 The term of this agreement is four years, from April 1, 2018 to March 31, 2022 (the Term).
3.2 Subject to sections 4.4 and 4.5, the Safe Long-term Care Funding provided under this Agreement may be used by Newfoundland and Labrador for expenditures that are incurred from December 1, 2020, to March 31, 2022.
3.3 Renewal of Bilateral Agreement
3.3.1 Newfoundland and Labrador’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 bilateral agreements, subject to appropriation by Parliament, and Newfoundland and Labrador and Canada’s agreement on a new five-year action plan.
3.3.2 The renewal will provide Newfoundland and Labrador and Canada the opportunity to review and course correct, if required, and realign new priorities in future bilateral agreements based on progress made to date.
4.0 Financial Provisions
4.1 The contributions made under this Agreement are in addition and not in lieu of those that Canada currently provides to Newfoundland and Labrador under the Canada Health Transfer to support delivering health care services within their jurisdiction.
4.2 Allocation to Newfoundland and Labrador
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
Safe Long-term Care
a. $1 billion for the Fiscal Year beginning on April 1, 2021
4.2.3 For Home and Community Care and Mental Health and Addictions Services, 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 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.
For Safe Long-term Care, annual funding will be allocated to provinces and territories with a base amount of $2,000,000 for each province and territory, and the remainder of the fund allocated on a per capita basis, for each Fiscal Year that an agreement is in place. The total amount to be paid to Newfoundland and Labrador will be calculated using the following formula: $2,000,000+(F- (N x 2,000,000)) x (K/L), where:
- F is the total one-time funding amount available under this initiative;
- N is the number of jurisdictions (all 13) that will be provided the base funding of $2,000,000;
- K is the total population of a particular province or territory, as determined using the 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 formulas in section 4.2.3, the population of Newfoundland and Labrador 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 based on the formulas described in section 4.2.3, Newfoundland and Labrador' estimated share of the amounts will be:
|Fiscal Year||Home and community care
Estimated amount to be paid to Newfoundland and LabradorFootnote * (subject to annual adjustment)
|Mental health and addictions services
Estimated amount to be paid to Newfoundland and LabradorFootnote * (subject to annual adjustment)
4.2.6 Subject to annual adjustment based on the formulas described in subsection 4.2.3, Newfoundland and Labrador's estimated share of the amounts will be:
|Fiscal Year||Safe Long-term Care
Estimated amount to be paid to Newfoundland and LabradorFootnote * (subject to annual adjustment)
4.3.1 Canada's contribution for Home and Community Care and Mental Health and Addictions Services will be paid in approximately equal semi-annual 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 Newfoundland and Labrador for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
- Canada will notify Newfoundland and Labrador 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 Newfoundland and Labrador 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 if Newfoundland and Labrador has failed to provide its annual financial statement for the previous Fiscal Year or to provide data and information related to home and community care and mental health and addictions to 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.
4.3.2 Canada's contribution for Safe Long-term Care will be paid in approximately equal semi-annual installments as follows:
- The first installment will be paid within 30 days of Canada's acceptance of Newfoundland and Labrador's proposed approach and initiatives for the use of the Safe Long-term Care Funding, as set out in Annex 2.
- The second installment will be paid on or about December 15, 2021, following Newfoundland and Labrador's fulfillment of the obligations identified in subsection 5.1.2, and amendment of Annex 2 in accordance with subsection 5.1.3.
4.3.3 Where Newfoundland and Labrador fails to put in place a cost-recovery agreement as required pursuant to section 4.8, Canada shall deduct from the payment referred to in subsection 4.3.2(b) an amount equivalent to the amount of funding provided by Newfoundland and Labrador to those facilities with whom they do not have the required cost-recovery agreements in place.
4.4 Carry Over
4.4.1. At the request of Newfoundland and Labrador, Newfoundland and Labrador may retain and carry forward to the next Fiscal Year the amount of up to 10 per cent of the contribution paid to Newfoundland and Labrador for a Fiscal Year under subsection 4.2.5 and 4.2.6. that is in excess of the amount of the eligible costs actually incurred by Newfoundland and Labrador in that Fiscal Year, and use the amount carried forward for expenditures on eligible areas of investment incurred in that Fiscal Year. Any request by Newfoundland and Labrador to retain and carry forward an amount exceeding 10 per cent 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 subsection is supplementary to the maximum amount payable to Newfoundland and Labrador under subsection 4.2.5. and 4.2.6 of this Agreement in the next Fiscal Year.
4.4.3. In the event this bilateral agreement is renewed in accordance with the terms of section 3.2.1, and at the request of Newfoundland and Labrador, Newfoundland and Labrador may retain and carry forward up to 10 percent of funding provided in the last Fiscal Year of this Agreement for eligible areas of investment 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 Newfoundland and Labrador to retain and carry forward an amount exceeding 10 per cent 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 Newfoundland and Labrador exceed the amount to which Newfoundland and Labrador is entitled under this Agreement, the amount of the excess is a debt due to Canada and, unless otherwise agreed to in writing by the Parties, Newfoundland and Labrador shall repay the amount within sixty (60) calendar days of written notice from Canada.
4.6 Use of Funds
4.6.1. Canada and Newfoundland and Labrador agree that funds provided under this Agreement will only be used by Newfoundland and Labrador 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.
4.7.2. Canada and Newfoundland and Labrador agree that amounts paid to Newfoundland and Labrador under the Safe Long-term Care Fund may be provided by Newfoundland and Labrador to:
- publicly-owned long-term care settings;
- privately-owned not-for-profit long-term care settings; and,
- subject to section 4.8, privately-owned for-profit long-term care settings.
4.8 Cost Recovery
4.8.1. Where Newfoundland and Labrador provides Safe Long-term Care Funding to privately-owned, for-profit facilities in accordance with this Agreement, Newfoundland and Labrador agrees to put in place cost-recovery agreements with these facilities and report on these agreements through amendments to Annex 2 by no later than December 1, 2021 in accordance with the requirements set out in subsection 5.1.3
4.8.2. Where Newfoundland and Labrador has cost-recovery agreements in place with one or more privately-owned for-profit facilities pursuant to subsection 4.8.1, Newfoundland and Labrador agrees to invest all funds recovered through those agreements in accordance with the terms of this Agreement and the initiatives outlined in Annex 2.
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, Newfoundland and Labrador agrees to participate in a Federal-Provincial-Territorial process, including working with stakeholders and experts, through the Canadian Institute for Health Information (CIHI), to develop common indicators and to share relevant data in order to permit CIHI to produce annual public reports that will measure pan-Canadian progress on home and community care and mental health and addictions services.
- Newfoundland and Labrador will designate an official or official(s), for the duration of this agreement, to work with CIHI and represent the interests of Newfoundland and Labrador related to performance measurement and reporting for home and community care, as well as mental health and addictions services.
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, Newfoundland and Labrador agrees to:
- Provide data and information (based on existing and new indicators) related to home and community care and mental health and addictions services to the CIHI annually. This will support the 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
the province's Chief Financial Officer, 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
Newfoundland and Labrador's Action Plan (Annex 2):
- The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year;
- The total amount of funding used for home and community care and mental health and addictions programs and services;
- If applicable, the amount of any amount carried forward by Newfoundland and Labrador under section 4.4; and
- If applicable, the amount of any surplus funds that is to be repaid to Canada under section 4.5.
- For the Safe Long-term Care Funding, the annual financial statement will
also set out, for the previous fiscal year:
- The amount of the federal funding flowing to each facility, and the type of facility (as set out in 4.7.2); and,
- The estimated amount of funds to be recovered under cost-recovery agreements, where applicable, and the priority areas where those funds will be reinvested.
5.1.3 As a condition of receiving the second payment installment of the Safe Long-term Care Funding, Newfoundland and Labrador agrees to, by no later than December 1, 2021, amend Annex 2 to:
- Provide up-to-date information on performance measures, targets and intended outcomes for the three areas identified in section 2.3, and for any other areas in which Newfoundland and Labrador has used Safe Long-term Care Funding to support infection prevention and control, and interim results for each initiative.
- Provide a breakdown of the facilities receiving funding under this Agreement, and specifically, identifying those privately-owned, for-profit facilities receiving funding pursuant to this Agreement and whether or not cost-recovery agreements are in place with them with respect to this funding;
- Indicate the amount paid to each recipient operating a privately-owned, for-profit facility and describe the incremental impact that will be achieved through these investments;
- Provide information on the estimated amount of funding to be recovered pursuant to the cost-recovery agreements; and,
- Indicate how Newfoundland and Labrador will use recovered funding to increase infection prevention and control pursuant to the terms of this Agreement.
5.1.4 Newfoundland and Labrador also agrees to amend Annex 2, by March 31, 2022, to report, in accordance with the performance measures set out in Annex 2, on the outcomes and results achieved using the Safe Long-Term Care Funding.
5.2.1 Newfoundland and Labrador will ensure that expenditure information presented in the annual financial statement is, in accordance with Newfoundland and Labrador's standard accounting practices, complete and accurate.
5.3.1 Responsibility for evaluation of programs rests with Newfoundland and Labrador in accordance with its own evaluation policies and practices.
6.1 Canada and Newfoundland and Labrador 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.
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 spirt of transparency and open government, Canada will make this Agreement, including any amendments, publicly available on a Government of Canada website and Newfoundland and Labrador shall make the results under this Agreement related to the Safe Long-term Care Funding, as set out in Annex 2, publicly available on its Government of Newfoundland and Labrador website.
6.4 Canada, with prior notice to Newfoundland and Labrador, may incorporate all or any part or parts of the data and information in 5.1.2 and 5.1.3, or any parts of evaluation and audit reports made public by Newfoundland and Labrador into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.
6.5 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement, Safe Long-term Care Funding and bilateral agreements. Canada agrees to give Newfoundland and Labrador 10 days advance notice and advance copies of public communications related to the Common Statement, Safe Long-term Care Funding, bilateral agreements, and results of the investments of this Agreement.
6.6 Newfoundland and Labrador reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement, Safe Long-term Care Funding and bilateral agreements. Newfoundland and Labrador agrees to give Canada 10 days advance notice and advance copies of public communications related to the Common Statement, Safe Long-term Care Funding, bilateral agreements, and results of the investments of this Agreement.
7.0 Dispute Resolution
7.1 Canada and Newfoundland and Labrador 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 Newfoundland and Labrador 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 Newfoundland and Labrador, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Newfoundland and Labrador will endeavour to resolve the issue in dispute bilaterally through their designated officials, at the Assistant Deputy Minister level (hereinafter the "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 Newfoundland and Labrador responsible for health, and if it cannot be resolved by them, then the respective Ministers of Canada and Newfoundland and Labrador most responsible for Health shall endeavour to resolve the dispute.
8.0 Amendments to The Agreement
8.1 The main text of this Agreement (not including attached annexes) 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 Newfoundland and Labrador, by Newfoundland and Labrador's Minister of Health and Community Services and Minister of Intergovernmental and Indigenous Affairs.
8.2 Annex 2 may be amended at any time by mutual consent of the Parties. To be valid, any amendments to Annex 2 shall be in writing and, signed, in the case of Canada, by their Designated Official, and in the case of Newfoundland and Labrador, by their Designated Official.
9.0 Equality of Treatment
9.1 During the term of this Agreement, if another province or territory, except the province of Quebec, negotiates and enters into a Home and Community Care and Mental Health and Addictions Services Agreement with Canada, or negotiates and enters into an amendment to such an agreement and if, in the reasonable opinion of Newfoundland and Labrador, any provision of that agreement or amended agreement is more favourable to that province or territory than the terms set forth in this Agreement, Canada agrees to amend this Agreement in order to afford similar treatment to Newfoundland and Labrador, if requested by Newfoundland and Labrador. This includes any provision of the bilateral agreement except for the Financial Provisions set out under section 4.0. This amendment shall be retroactive to the date on which the Home and Community Care and Mental Health and Addictions Services Agreement or the amendment to such an agreement with the other province or territory, as the case may be, comes into force.
10.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Newfoundland and Labrador by giving at least 12 months written notice of its intention to terminate. Newfoundland and Labrador 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.
10.2 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 Newfoundland and Labrador after the date of effective termination.
11.1 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. Any notice that is delivered will have been received in delivery; and, except in periods of postal disruption, any notice mailed by post 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
The address for notice or communication to Newfoundland and Labrador shall be:
Department of Health and Community Services
Government of Newfoundland and Labrador
P.O. Box 8700
1st Floor, West Block Confederation Building
100 Prince Philip Drive
St John's, NL
12.1 This Agreement, including Annexes 1 and 2, comprise the entire agreement entered into by the Parties with respect to the subject matter hereof.
12.2 This Agreement is based on the Common Statement of Principles on Shared Health Priorities, Annex 1, finalized on August 21, 2017.
12.3 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Newfoundland and Labrador.
12.4 No member of the House of Commons or of the Senate of Canada or of the Legislature of Newfoundland and Labrador shall be admitted to any share or part of this Agreement, or to any benefit arising therefrom.
12.5 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.
SIGNED on behalf of Canada by the Minister of Health at St. John's, Newfoundland this 24th day of January, 2018.
The Honourable Ginette Petitpas Taylor, Minister of Health
SIGNED on behalf of Newfoundland and Labrador by the Minister of Health and Community Services at St. John's, Newfoundland this 24th day of January, 2018.
The Honourable John Haggie, Minister of Health and Community Services
SIGNED on behalf of Newfoundland and Labrador by the Minister of Intergovernmental and Indigenous Affairs at St. John's, Newfoundland this 24th day of January, 2018.
The Honourable Dwight Ball, Minister of Intergovernmental and Indigenous Affairs
Annex 1 to the Agreement
Annex 2 to the Agreement
Newfoundland and Labrador Action Plan on Home and Community Care and Mental Health and Addictions Services
On December 23, 2016, the Government of Canada and the Government of Newfoundland and Labrador publically agreed to new federal funding for investments in home and community care, including palliative care, and mental health and addictions. Over the 10-year period (2017-18 to 2026-27), the Government of Canada will support home and community care and mental health and addictions initiatives in Newfoundland and Labrador through combined funding of an estimated $160.7 million ($87.7 million for home care and $73 million for mental health initiatives). This Action Plan outlines how federal funding will be invested for the first five years of this ten-year period.
Ensuring the long-term sustainability of the health care system is a continuous challenge in Newfoundland and Labrador. The province is challenged to meet the needs of rural and remote communities, a rapidly aging population, the increasing prevalence of chronic diseases, and the growing rates of mental health and addictions. The targeted federal investments will allow the province to move forward in supporting the delivery of more and better home care services and making high quality mental health services more available to people who need them.
The Action Plan outlines the Province's approach to achieving home and community care and mental health and addictions services objectives. In home and community care, Newfoundland and Labrador has been developing and implementing a Home First Initiative, which will make transformational changes in how services are delivered to individuals with complex care needs who want to receive their care at home. Newfoundland and Labrador will advance this initiative and use federal funding to support three pillars of activity which will: create a Home First Integrated Network of care for clients with complex needs in the community and for clients discharging from acute care; integrate a palliative approach across the health care system with enhancements to supports, services, and coordination of care and implementation of a consistent policy on advance health care planning; and enhance services for persons with dementia with a specific focus on supporting caregivers, including psychological interventions, training and support.
In mental health and addictions, policy priorities in Newfoundland and Labrador are guided by the recent All-Party Committee on Mental Health and Addictions Review, which was conducted to identify gaps in services and areas for improvement in the province. The Committee's report, Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador, outlines 54 recommendations to address service gaps and to support what is currently working well in the mental health and addictions system in the province. In June 2017, the Provincial Government released Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador. The Plan sets out short, medium, and long-term goals to ensure implementation of all the recommendations. Newfoundland and Labrador will use federal funding to implement elements of this Plan in four areas: implement integrated service delivery for youth to help them effectively manage stress and anxiety; introduce e-mental health services and initiatives to improve access to care; expand access to addictions services; and invest in community-based services to support individuals with complex needs.
Newfoundland and Labrador will participate in a Federal-Provincial-Territorial process, including working with stakeholders and experts, through the Canadian Institute for Health Information (CIHI), to develop common indicators and to share relevant data in order to permit CIHI to produce annual public reports that will measure pan-Canadian progress on home and community care and mental health and addictions services.
Home and Community CareOverview
An aging demographic, high incidence of chronic disease and a large rural population have created social and economic challenges in Newfoundland and Labrador. Individuals in need of care have stated they want to receive necessary supports at home. This, combined with growing evidence that community-based care is often the most appropriate and cost-effective approach, have been compelling arguments to enhance community-based health care services to meet the needs of individuals who are otherwise high users of acute and long term care services.
Newfoundland and Labrador has identified that a lack of integration of health care services has resulted in a fragmented system that is more responsive to organizational priorities than to the changing health needs of the population. Services and supports are built around programs, hospitals, long term care facilities, clinics or community offices which has resulted in a health system that is difficult to navigate and an over reliance on costly facility-based care.
Home and Community Care in Newfoundland and Labrador Today
Home and Community Care
Newfoundland and Labrador is committed to improving home and community care as indicated in the Department of Health and Community Services Strategic Plan (2017-2020) and consistent with the commitment to the implementation of recommendations from a 2016 review of the Province's Home Support Program. The 2016 review recommended significant changes and improvements in the quality of services delivered with an enhanced focus on integration of care and improved clinical outcomes.
In Newfoundland and Labrador, individuals with complex care needs are the highest users of facility-based care, often for care that could be provided in the community. In response, Newfoundland and Labrador will invest federal health accord funding in a community-based approach to service delivery for clients with complex needs, including palliative/end-of-life care needs. This initiative will complement the work the province is already undertaking to improve the quality of and access to community-based services.
Priority Areas for Cost-Shared Investment
Newfoundland and Labrador has been developing and implementing a Home First Initiative, which will see transformational change in how services are delivered to individuals with complex care needs, including palliative and end-of-life care, who want to receive their care at home. The Home First Initiative is the umbrella term used to capture all the improvements identified within the Action Plan.
The Home First Initiative will integrate with regular programming. The federal funding will add to Regional Health Authority (RHA) funding for clinical positions and programs and services. The federal funding alone cannot sustain the scope and reach of the Home First Initiative. The approach is built on maximizing existing regional resources while using the federal funding to increase the regional capacity to support people with complex and palliative care needs.
Through this initiative, Newfoundland and Labrador will:
- Enhance home care and coordination of supports for clients with complex needs in the community and clients discharging from acute care;
- Integrate a palliative approach across the health care system with enhancements to supports, services, and coordination of care and implement a consistent policy on advance health care planning;
- Enhance services for persons with dementia with a specific focus on supporting individuals to remain in their own homes through the use of technology and by supporting caregivers.
To support these objectives, federal funding will be allocated to the following areas as part of the Home First Initiative:
- Home First Integrated Network: Enhance clinical services in the Regional Health Authorities (RHAs) with additional clinical positions necessary to provide complex care in the community. Clinicians funded will include nurse practitioners, community health nurses, licensed practical nurses, social workers, occupational and physiotherapists.
- Palliative Care/End-of-Life Improvement: Enhance clinical positions for palliative and end-of-life care; implement a professional development plan focused on enhancing awareness and skill development for clinicians, service providers and caregivers involved in the provision of palliative/end-of-life and dementia care; fund a broad public awareness campaign and the development of supporting tools to promote palliative care and advance health care planning; and support the creation and operation of hospice beds in two RHAs.
- Support for Individuals with Dementia: Provide better respite services for caregivers; implement professional development for providers and caregivers; and expand remote monitoring technology through a Provincial Dementia Care Program.
1. Home First Integrated Network
In Newfoundland and Labrador, regular programming is most often provided through a structure that is organization-centered, with policies, rules and budgetary allocations that can serve to prevent individuals from accessing the care they need, forcing individuals to shop around for the right package of supports. Clients with complex needs, including palliative/end-of-life needs, are most vulnerable to falling through gaps in programming and often need assistance to help in navigating through systems.
To address the barriers and limitations of regular programming, Newfoundland and Labrador will develop and implement a Home First approach across the health care system to ensure access to timely supports and services for individuals with complex and palliative/end-of-life care. To support the intended design, the following service principles were developed:
- Services will wrap around clients where they are located;
- Implementation will not be constrained by policies that present barriers to a seamless service or the heath sector boundaries of existing professional staff;
- Existing regional health system resources will be maximized; and
- Services will be available in the community beyond traditional work hours.
Action: Additional Clinical Positions to Create the Network
Federal funding for additional clinical positions will support the development of a Home First Integrated Network of professionals who will provide services to clients with complex and palliative support needs in their geographical zones, and also support the implementation of Home First throughout the region. Funding will support salaries and operational costs to implement the network.
How it will work
- Learnings from Home First approaches in this province and in other jurisdictions point to key service areas that have proven to be most significant in supporting individuals with complex care needs in their homes, including:
- Case Management;
- Home Support Services (including personal care, homemaking and respite);
- Rehabilitation Services;
- Nursing Services;
- Pharmacy Services;
- Counselling and or spiritual supports; and
- Medical Equipment.
- In the Home First approach, once a client has been identified as having complex/palliative/end-of-life needs and is at high risk for unfavorable outcomes, he/she will be assigned a singular point of contact for case planning and care coordination. The clinicians assigned will have a responsibility to help identify and access the supports required, coordinate the care, as well as to include family, build relationships and to individualize the support plan.
- The client will work with a clinician in the development of a person centered care plan. The clinician will ensure an integrated approach through intensive care coordination with all identified service providers, in particular, primary health care, and provide active support throughout the transition to longer term services if required. The design allows for up to 8 weeks of enhanced supports to facilitate smooth transitions for clients with complex needs and, as long as clinically-required for palliative/end-of-life clients.
- Clinicians responsible for care coordination will draw on supports and services available where the client lives, and, where no required service exists, will draw on the Network to problem solve. For example, Networks will have clinicians with expertise in palliative care that clinicians in other areas of the region who may not have the same level of expertise will draw on to mentor and coach them in providing the type of care required.
- Clients with complex needs may have significant non-clinical needs that are contributing to their health outcomes. Partnerships at the community level through collaboration with other community and social services are therefore critical to meeting needs. Case managers will help facilitate access to medical care as well as community services and supports. Regular monitoring, frequent communication and open exchange of information are key activities in coordination of care.
- Case managers will support clients to transition from regular programing or facility-based care to the community through the Home First Initiative, and from Home First to regular programming if required. This could include Community Support Services, Personal Care Homes, Long Term Care or other supports external to services and programs offered through the RHAs. Successful transitions use case management strategies that include a broad range of health and other supportive services, face to face communications and full participation of the client, family and support network. Case management strategies will span across and integrate with emergency and acute care, primary health care (in particular family physicians), community and facility-based care.
- Managing transitions will entail warm handoffs to the next service or program. This approach ensures the smooth transfer of professional responsibility and accountability to another clinician or service provider for longer term services and wherever possible will include a structured meeting between services.
- The RHAs will reorganize service delivery processes to ensure clinicians are available to support this initiative beyond traditional community-based office hours.
- Individuals with palliative conditions, complex chronic disease or dementia, and the frail elderly, are some of the populations who will benefit from this flexible, person-centered approach.
- The addition of funding for clinical positions, combined with maximizing existing regional resources, and the development of technology solutions will allow individuals in areas less densely-populated to access better care at home.
- The RHAs have been able to recruit for clinical positions for Home First in more densely populated areas and have been able to access privately-contracted services in some more remote areas where RHA professional services are not available. The use of technology in the provision of professional services is also being explored to enhance the capacity of the regions to implement Home First in more remote locations, such as the use of technology to conduct remote occupational therapy assessments. Newfoundland and Labrador is undertaking a review of occupational and physiotherapy services in the province with a view to enhancements, efficiency and potential new models of service delivery.
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.
2. Palliative Care/End-of-life Improvement
Currently in Newfoundland and Labrador clients who are palliative but not eligible for regular programming must wait until the predicted last 28 days of life before they can access the supports and services required to manage their condition at home. The limitations in regular programming have resulted in clients seeking supports from facility-based care, including emergency departments and admissions to acute care beds throughout their illness and at end-of-life.
Some of the barriers include: financial ineligibility and a lack of timely access to home support services such as personal care and housekeeping; lack of timely access to equipment and supplies from regular programming such as hospital beds, medications and nursing supplies; and lack of timely access to professional nursing services. The current capacity of nurse practitioners, community health nurses, licensed practical nurses, social workers and other allied health professionals to deliver high quality, timely care in all areas of the province is limited.
In Newfoundland and Labrador, the emphasis on advance health care planning is limited across the health care system with critical decisions often happening in acute care. There are regional policies to support community-based conversations with clients on advance care planning but it is not standardized, monitored or supported consistently. Newfoundland and Labrador has recognized the need to promote and support advance health care planning much earlier in an individual's health care journey.
Additionally, Newfoundland and Labrador does not have hospice facilities. Options for individuals who prefer residential care at end-of-life are therefore limited to dedicated acute care beds within hospitals and regular acute care beds where capacity in dedicated beds has been maximized.
Action: Enhanced Access to Palliative Home Care
- As part of the Home First Initiative, federal funding will support enhanced access to supports and services to clients with palliative conditions earlier in the trajectory of the illness (above current eligible coverage and funding levels). When a client is assessed as nearing the end stage of their illness, an individualized plan will be developed and implemented. Clients will receive supports and services at point of clinically-assessed need, eliminating the delays inherent in regular programming. This includes home supports, medications, and medical equipment and supplies.
- Federal funding will also support additional clinicians, including nurse practitioners, community health nurses, licensed practical nurses, occupational therapists and social workers in each of the regional health authorities to enhance the regional capacity to provide the clinical services necessary to support palliative clients in managing their condition at home. Working with community partners, Newfoundland and Labrador will assist to develop and fund hospice bed capacity in two RHAs.
- Federal funding will be used to cost-share the cost of 20 new hospice beds (60% federal; 40% provincial).
Action: Improved Quality of Service
- Clinicians will be educated throughout the healthcare system to direct palliative/end-of-life clients/patients/residents - who need supports and services but are not eligible under regular programming - to the Regional Home First Integrated Network.
- Clinicians across the health system will be better prepared through the implementation of professional development initiatives to provide palliative/end-of-life care across the RHAs. Specifically, all clinicians in the RHAs who are currently and/or are likely to provide services to clients with palliative conditions, at any point in the trajectory of the illness, will receive consistent education on palliative care, in particular, Learning Essential Approaches to Palliative Care (LEAP). Staff are very keen to receive this training and funding will be allocated to support the staff relief to allow staff to attend. Initially this training is targeted to regional health staff. Initiatives under development from the review of the Provincial Home Support Program will target development of qualifications for home support workers.
Action: Better knowledge and preparation
- A public campaign will be launched to raise awareness of palliative care and to increase uptake of advance health care planning. The purpose of the initiative is to develop standardized health policies and tools specific to Newfoundland and Labrador that individuals, or the clinicians that are supporting them, can use to help facilitate the process. A public awareness campaign will promote the process and tools both to the public and within the RHAs to remove barriers to planning and increase the incidence of individuals seeking health care services with an advance health care plan that is accessible at all points of intersection in the health care system.
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;
- Enhancing access to palliative and end-of-life care at home or in hospices; and
- Enhancing home care infrastructure, such as digital connectivity, remote monitoring technology and facilities for community-based service delivery.
3. Support for Individuals with Dementia - Improvement Initiative
In Newfoundland and Labrador, supports for individuals with dementia to live at home longer is limited by barriers within regular programming often resulting in premature admission to facility-based care. Barriers include financial eligibility, limits on allocations of home support hours, lack of coverage for wearable technology and clinician capacity to provide the intensive levels of support required to support individuals with advancing dementia at home. For example, currently the Home Support Program allows for a maximum of 6.4 hours of care per day for clients with the highest level of care needs. A client with dementia will often require up to 9 hours a day of respite to allow a caregiver to work during the day and in some cases up to 24 hours of care in the short term until a longer term plan can be developed. Often in these situations of higher need, caregivers experience burnout and bring their loved ones to emergency departments in the absence of adequate supports from the community.
Additionally, not all clinicians, service providers and caregivers have the knowledge and level of awareness necessary to support an individual with dementia. If those providing care lack training and understanding of how best to work with a client with dementia, then the supports are often ineffective and clients again will resort to facility-based care. Enhancing core competencies in community care is a key element in ensuring clients with dementia can live at home longer. Home support workers (known as personal support workers (PSW) in some areas), in particular, will spend the greatest length of time with client. Currently in this province, specialty area expertise is not required when assigning a worker to a client. Newfoundland and Labrador is working on this more broadly as a recommendation from the Provincial Home Support review, but this initiative will focus specifically on dementia care within the context of Home First.
Action: Respite for Caregivers
- Federal funding will be allocated to support enhanced access to home care services through the Home First Initiative for clients with complex needs, palliative care needs and dementia through a range of activities that will be of direct benefit to caregivers of dementia patients, including better access to respite services, training and psychological intervention.
Action: Expand Remote Monitoring through the Provincial Dementia Care Program
- Newfoundland and Labrador will implement a Provincial Dementia Care Program that will provide support to persons with moderate to severe dementia and their caregivers, as well as to primary care physicians. Using technology, a health care team will provide geriatric and allied health e-consult, comprehensive geriatric assessment and coordinated care planning.
- Federal funding will be used to support two nurse practitioners and related service delivery costs. The program will begin in 2018 in Newfoundland and Labrador's largest RHA and expand across the province in the second year. The program will target 400-500 clients in the first year, 800-1000 in the second. This technology will integrate with existing services including the remote technology projects currently in place in the regional health authorities.
Action: Professional Development for Caregivers
- Clinicians, service providers and caregivers will be better prepared to provide care for individuals with dementia through the implementation of a professional development initiative, beginning with training in the Gentle Persuasion Approach. Initial targets are 50 community dwelling clients with an estimated three caregivers, including home support workers, per client equating to approximately 150 receiving training in this approach.
- Home support workers will be compensated for training time. This cost is included in the Enhanced Access to Care line in the funding table below as part of the Home First Integrated Network.
These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:
- Enhancing home care infrastructure, such as digital connectivity, remote monitoring technology and facilities for community-based service delivery; and
- Increasing support for caregivers.
Expected outcomes and results from implementing these initiatives
These initiatives will prevent unnecessary hospital admission, support earlier discharge to home, and increase access to end-of-life services, using additional and existing home and community-based services. This approach will empower clients to be more actively involved in their plan of care, assist in achieving better outcomes, improve quality of life and create a more effective and efficient health service delivery system.
Specifically at the individual level
- Increased access to home care supports including nursing, personal support, homemaking services, respite for caregivers, occupational and physiotherapy for individuals with complex care needs, including palliative and end-of-life care.
- Individuals will be supported at home while waiting for long term care versus waiting in acute care.
- Individuals who choose to manage the palliative/end-of-life stage at home will be supported to do so.
- Individuals will experience person centered and integrated care; supporting safe transitions to other longer term services.
- Reduced waitlist for long term care facilities;
- Reduced alternate level of care stays;
- Reduced length of stay for required acute care services; and
- Increase in number of individuals moving to long term care from the community.
Currently, Newfoundland and Labrador uses Resident Assessment Instrument - Home Care (RAI-HC) in community and Personal Care Homes and RAI-Minimum Data Set (MDS) in long term care facilities. This requires reporting to the Home Care Reporting System (HCRS), which reports data to CIHI. Newfoundland and Labrador uses these indicators in measuring program performance.
Additionally, there are other sources of data but they are somewhat inconsistent and fragmented. The review of the provincial home support program recommended the development of a performance management framework which, when implemented, will also provide data relevant to these initiatives.
Individual level data is collected on the Home First Initiative, which can be used to inform common indicators across the provinces and territories. Additionally, the province is implementing the RAI-Contact assessment, which will report into CIHI in the same manner as RAI-HC and RAI-MDS.
Newfoundland and Labrador will work with CIHI and through our participation in the Canadian Partnership Against Cancer (CPAC) to identify indicators to be used for regional and jurisdictional comparisons (for example, patient deaths in acute care hospitals, patient admissions to hospitals and visits to emergency departments in the last month of life). Also, data collection will be standardized across regions to ensure the province is capturing program utilization data.
The performance management framework for Home First Initiative in still under development but below are some key performance indicators under consideration.
Performance Domain: Access
- Indicator: Time from completion of RAI- Contact Assessment (CA) to service provision
- Indicator: Number of individuals at end-of-life who die at home
Performance Domain: Quality and Safety
- Indicator: Number of clients receiving enhanced services with a brief support plan within three days
- Indicator: Client inclusion in development of support plan
- Indicator: Client satisfaction on care continuity, integrated service delivery and responsiveness of case manager
Performance Domain: Effectiveness
- Indicator: Waitlist for long term care placement
- Indicator: Number of Alternate Level of Care (ALC) stays
- Indicator: Number of early supported discharges for social admissions
Performance Domain: Sustainability
- Indicator: Change in service provision over 8-week period for enhanced services
- Indicator: Cost per client
Allocation of Health Accord Funding - Home First Initiative
|Home First Integrated Network|
|Additional Clinicians for Palliative/Complex Care||$2.82||$3.10||$3.23||$3.29||$3.77||$16.21|
|Enhanced Access to Palliative/Complex/Dementia CareFootnote *||-||$3.94||$4.53||$3.97||$7.10||$19.54|
|Palliative Care/End-Of-Life Improvement|
|Public Awareness Campaign for Advanced Health Care Planning||-||$.10||-||-||-||$.10|
|Additional Hospice Bed Capacity||-||$1.10||$1.10||$1.10||$1.10||$4.4|
|Support for Individuals with Dementia - Improvement Initiative|
|Provincial Dementia Program||-||$.20||$.30||$.80||$.80||$2.1|
|Professional Development - Palliative/Dementia Care||$.10||$.20||$.20||$.20||$.20||$0.9|
Mental Health and Addictions
Mental Health and Addictions in Newfoundland and Labrador Today
Mental illness or addiction touches almost everybody in Newfoundland and Labrador either directly or through family, friends or co-workers. In any given year, one in five people will experience a mental illness or addiction. The chance of developing a mental disorder at some point in life is close to 50 per cent.
The province's four RHAs provide direct services for individuals who experience mental health and addiction challenges. RHAs are supplemented by other health care providers, including fee-for-service physicians, psychologists, social workers, pharmacists and community agencies. There are over 900 dedicated and highly skilled mental health and addictions staff in the province. In communities where there is no psychiatrist, access to a psychiatrist is available through telehealth.
Nearly 40 per cent of the total provincial budget is allocated to health care. RHAs spend 5.7 per cent ($135.9 million) of their total expenditures on mental health and addictions. This does not include other public expenditures, such as Medical Care Plan and prescription drugs.
The province's psychiatric hospital, the Waterford Hospital, is located in St. John's. There are currently 127 beds, which consist of acute care, short stay, forensic, geriatric assessment and residential and psychiatric rehabilitation. There are additional acute care psychiatric units located in general hospitals within three of the four RHAs (Eastern Health, Central Health, and Western Health). Labrador Grenfell Health is the Newfoundland and Labrador RHA that does not have a dedicated psychiatric unit; however, most acute care facilities in the province, including those in the Labrador Grenfell Health region, admit patients for mental health and addictions care.
There are two new youth residential treatment centres for male and female (ages 12-18). The Tuckamore Centre located in Paradise provides treatment for youth with complex mental health issues and the Hope Valley Centre located in Grand Falls-Windsor provides treatment for youth with addictions issues.
There are two adult addictions treatment centres: the Grace Centre located in Harbour Grace and the Humberwood Centre located in Corner Brook. Both centres are part of a continuum of care for adults impacted by addictions. Other adult addictions services include outpatient counselling available through each RHA as well as the Opioid Treatment Centre (Methadone Maintenance Treatment Program) and the Recovery Centre (withdrawal management service) located in St. John's.
Mental health and addictions services can be difficult to navigate and individuals are not always matched with the most effective or efficient service/level of intensity to meet their needs. The system consists of a continuum of services and supports for individuals and families ranging from primary care, to specialized community-based mental health and addictions services, to inpatient and residential programs, to highly specialized tertiary care and programs. The system also has services and supports provided in other locations such as schools, housing programs and correctional settings. Cutting across the entire continuum, involvement of people with lived experience, family and significant others, peer support and self-help supports are recognized as being central to a "recovery-oriented" system.
Mental health and addictions referrals are steadily increasing in the province. On average, there are 20,000 referrals annually; approximately 12,000 calls placed to the 24/7 provincial Mental Health Crisis Line; and, about 3,000 admissions to in-patient mental health and addictions services, 15 per cent of which are for treatment of concurrent mental health and addiction disorders. While some services have no wait times and wait times for other services have been reduced, services that have long wait times are keeping people from getting the treatment they need in a timely manner. The number of people waiting for mental health and addictions counselling services increased by about 56 per cent between September 2014 and September 2016. At the end of September 2016, there were approximately 3,000 people throughout the province waiting for mental health and addictions counselling, not including psychiatry services.
Rural, remote and northern areas, as well as urban areas, each present unique challenges for health systems planning, particularly for mental health. Urban areas may face challenges with inadequate resources for population density and difficult-to- navigate access points, whereas rural, remote and northern areas disproportionately face challenges with recruiting and retaining mental health professionals, resulting in inadequate access to services.
Canada is currently facing an opioid crisis. The Government of Newfoundland and Labrador has responded by implementing an Opioid Action Plan. Components of the plan include:
- Implementing a Provincial Prescription Monitoring Program focused on prescription drugs with high potential for abuse;
- Implementing a provincial Take Home Naloxone Kit program to increase capacity for Opioid Overdose response; and,
- Access to Suboxone as a first line treatment for opioid addiction.
While prescription drug abuse is a real concern, alcohol dependence remains the most common form of addiction. In 2014, Newfoundland and Labrador exceeded the national rate of heavy drinking, with the third highest heavy drinking rates in the country (exceeded only by Yukon and Northwest Territories). The 2014-15 Canadian Student Tobacco, Alcohol and Drugs Survey reported that in the previous 12 months, 44.6 per cent of students, Grades 7 to 12, in Newfoundland and Labrador drank and 30.1 per cent reported binge drinking.
For young people aged 16 to 25 years old, seeking help for the first time for a mental health or addictions issue is particularly challenging. There are very few services dedicated to the emerging adult population and their needs are often not met by either the child or adult systems. Young people who received services in the child system are often not well supported as they move into the adult system.
In the Provincial Government's plan entitled Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador, short, medium, and long-term goals are established to ensure implementation of all 54 recommendations contained in the All-Party Committee Report. The following four pillars, and related focus areas, set the policy direction for the mental health and addictions system over the next five years.
- Promotion, prevention and early intervention:
- Promote positive mental health and well-being;
- Prevent mental health problems, mental illness, substance use and addiction problems;
- Prevent suicide; and
- Adopt a school health and wellness framework.
- Focusing on the person:
- Place the person at the center of the system;
- Reduce harms associated with substance use and mental health problems; and
- Work together toward a recovery-focused system.
- Improving service access, collaboration and continuity of care:
- Reduce wait times to access services;
- Replace services at the Waterford Hospital with services closer to home;
- Introduce stepped care, including e-health options;
- Implement provincial opioid dependence treatment system; and
- Create provincial policies and programs applied consistently and equitably across all regional health authorities.
- Including all people everywhere
- Educate policy makers, community agencies, physicians and regional health authority staff on inclusion;
- Address mental health needs of people incarcerated;
- Address mental health needs of students;
- Eliminate stigma and discrimination;
- Support Indigenous people with their mental wellness goals; and
- Incorporate accessibility and inclusion requirements into all services.
Priority Areas for Cost-Shared Investment
In addition to sustained provincial investments, federal funding will be used to advance and expand initiatives under the Towards Recovery Mental Health and Addictions Action Plan. Federal funding will be directed towards significant planning initiatives such as: provincial integrated service delivery model for children and youth/emerging adults; new e-mental health initiatives; improved access to addiction services; and improved community-based services.
1. Integrated Service Delivery for Children, Youth, and Emerging Adults
- The Provincial Government will complete a plan for a comprehensive integrated service delivery program to meet the needs of children, families, youth and emerging adults ages 0 to 29 as outlined in the Towards Recovery Action Plan. This new service delivery model will address existing barriers or gaps in current services and forge a responsive and seamless continuum of services from prevention and early intervention to more intensive mental health and addictions treatment services.
- The new integrated service delivery model will be collaborative in nature and include key service providers from the community. The model will also address a broad spectrum of issues that impact the mental wellbeing of this population including family breakdown, housing, employment, education and daily living challenges. Once implemented, the new model will have a substantial impact on access to mental health and addictions services by providing a continuum of care that includes prevention and early intervention. The integrated service delivery model will also assist with reducing wait times for services because fewer children and youth will be on waitlists.
- Federal funding will be used to hire two Child, Youth, and Emerging Adult Mental Health and Addictions specialist positions. These positions will lead the planning and implementation of provincial mental and addictions programs and policies aimed at improving the mental health and well-being of children, youth and emerging adults. These positions will develop the integrated service delivery model for multiple sites throughout the province with a focus on transforming mental health and addiction services into a person-centered, accessible and efficient system that is responsive to the mental health and substance use/addiction needs of children, youth and their families/guardians.
- These positions will engage and partner with children, youth and their families with lived experience, multiple government departments, school boards, RHAs, community agencies, and others to ensure that an inclusive continuum of services is provided at the right time, right intensity, right place and by the right people. They will also help inform the work related to children, youth and emerging adults for all project teams under the Towards Recovery Action Plan.
- 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; and,
- Expanding availability of integrated community-based mental health and addiction services for people with complex needs.
2. New E-mental Health Initiatives
- The Department of Health and Community Services has a number of e-mental health solutions in operation including, but not limited to, Bridge the gApp, the Breathing Room™ program, Strongest Families Institute (SFI), telehealth, and a number of helplines including the Provincial HealthLine, Gambling line and Crisis line.
- E-mental health uses the Internet and related technologies, like phone-apps, to let patients receive care when and where they need it most, regardless of how close they live to their care provider. When integrated properly, e-mental health is proving to be just as effective as face-to-face services and the technology is improving every day. Not only can this result in more people accessing help, it can also improve the quality of care delivered, reduce costs, and overcome challenges and barriers that are present in our current traditional health care system.
- Newfoundland and Labrador will expand existing services as well as introduce new e-mental health initiatives that support a continuum of e-health for all ages and ensure evidence-based models of community mental health care and culturally- appropriate interventions are integrated with primary health care. E-mental health services will support the province's new integrated stepped care service delivery model, as well as improve access to mental health and addiction services for rural and remote areas of the province. As part of a larger continuum of care, e-mental health is also used by the Towards Recovery Wait Time Reduction Team to help reduce wait times for mental health and addiction services.
- Federal funding will be used to expand SFI. The award-winning evidence-based program, endorsed by the Mental Health Commission of Canada, provides customized telehealth and coaching to children and youth ages 3-17 and their families for mild to moderate mental health and behavioural problems. The program has strong uptake in Newfoundland and Labrador with local families having an 87 per cent success score in resolving the presenting issue. Newfoundland and Labrador aims to increase access to SFI to prevent an increase in wait times in this province and ensure families receive early interventions in a timely manner. SFI is part of the province's circle of care whereby a family or child in need of additional services is referred to local RHAs for appropriate services.
- Federal funding will also be used to hire four new e-Mental Health Positions (one in each RHA). These positions are health care providers with an expertise in the delivery of mental health and addiction services through technology. These positions will provide leadership to further advance and integrate current e-mental health services as well as support the uptake and launch of new services across the continuum of care and in accordance with a new stepped care model.
- The provincial government will also use federal funding to implement Therapy Assisted Online (TAO) throughout the province. TAO is a platform that pairs online education materials with brief clinician contact by phone, chat or video conferencing to improve treatment outcomes for individuals with mental health problems. TAO consists of engaging modules on a variety of topics including anxiety and depression, which individuals complete online via computers, tablets or smartphones.
- 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; and
- Spreading evidence-based models of community mental health care and culturally appropriate interventions that are integrated with primary health services.
3. Improved Access to Addictions Services
- The provincial government will complete a plan for redesigned addictions treatment services, including a plan for provincial opioid dependence treatment. A working group has been formed to focus on Opioid Dependence Treatment. This group is comprised of regional health authority management and staff, representatives from professional associations and regulatory bodies, community representatives, and persons with lived experiences. The main objective of the working group is to support the development, implementation and evaluation of a provincial opioid treatment system. Currently, there is significant regional disparity for people wanting to access opioid dependence treatment. In many parts of Newfoundland and Labrador, people must travel over two hours daily to receive methadone maintenance treatment or Suboxone.
- The plan proposes a provincial system that includes: increasing access to Suboxone; enhancing harm reduction initiatives, including needle exchange, naloxone, and safe consumption sites; improving capacity for addictions with treatment providers, including physicians, psychiatrists, nurses, pharmacists and counsellors; and supporting a peer group of persons with lived and living experience. The plan will include a number of peer support programs and harm reduction initiatives.
- In partnership with community-based groups, federal funding will be used to hire two peer support workers in community organizations and expand peer support programs for those in recovery from addictions. Peer support is the process by which like-minded individuals with similar experience encourage and assist each other to continue growing. Peer support programs have demonstrated positive outcomes in Newfoundland and Labrador.
- In partnership with community-based groups, federal funding will also be used to expand the needle exchange program from select sites to throughout the province. Needle exchange programs focus on harm reduction and provide people with accurate information, compassion and support that enable them to make informed choices about their own health care.
- Federal funding will be used for the distribution of additional Naloxone Take Home Kits. The initiative increases access to naloxone, a safe and effective compound that reverses the effects of opioid overdose. The kits, and the education on how to use them, provide drug users and their families with valuable information on overdose prevention.
- Expanding availability of integrated community-based mental health and addiction services for people with complex needs.
4. Improved Community-based Services
- Psychiatric hospitals, such as the Waterford Hospital, provide care to 2-3 per cent of the provincial population who require access to mental health services. Access to beds and community services is needed closer to home. Good outcomes are yielded when psychiatric hospital beds are replaced with community services and small residential facilities in communities, when well-planned and adequately resourced.
- Adequate funding and a continuum of alternatives are needed to replace hospital care, including: access to peer support; partial hospitalization; psychological therapies; evidence-based intensive case management teams, such as flexible assertive community treatment (FACT); community crisis beds; housing and appropriate home support; transportation; self-help; employment programs; family/caregiver supports; supports for schools, correctional settings and workplaces; and a range of promotion/prevention initiatives.
- Adequate multi-year funding of community groups would provide stability to enable them to focus on delivery of their respective mandates, as well as planning and evaluation. Appropriately supported, evidence-based services delivered in the community are responsive, efficient, and lead to reduced hospitalizations, lengths of stay and ER visits, and an improved quality of life.
- The Provincial Government will provide a provincial mental health and addictions community-based model of programs and services across the four RHAs to replace the Waterford Hospital. Federal funding will be used to implement new community-based services aimed and reducing/lessening hospitalizations. These services include single session walk-in clinics, day treatment hospitals, and community crisis beds located in the community throughout the province.
- Single-session clinics provide individual access to a health care professional on a first-come, first-serve basis, for those who feel they need to speak to someone right away. These clinics greatly improve access to services and reduce waitlists. Funding will be used for additional clinical and clerical staff.
- Day hospitals provide acute treatment of mental illness by day and serve as a step down/alternative to admission to an acute care facility. These services lead to reduced hospitalizations, lengths of stay and ER visits, and an improved quality of life.
- Community crisis beds provide a safe place for people experiencing a mental health crisis. Several models will be explored for these beds, based on emerging needs of each RHA.
- Federal funding will also be used to increase individual and group access to psychological therapies, including dialectical behavior therapy (DBT), throughout the province. DBT is a form of cognitive behavioural therapy used for depression, anxiety and addictions.
- Federal funding will also be used to scale up Flexible Assertive Community Treatment (FACT) teams in all regions of the province. FACT is a multidisciplinary team-based approach to support individuals living in the community who are dealing with significant mental health issues. FACT teams have demonstrated positive results in reducing hospitalization and allow people with moderate to severe mental illness to be treated within the community and closer to home. A review of existing case management is currently underway with a reorganization into FACT teams expected to take place in 2020/21.
- Responding to mental health and addictions issues is a shared responsibility and requires the support of community-based partners and advocates. Government departments, RHAs, community groups and individuals with lived experience must work together to address challenges. In partnership with the community, federal funding will be used to expand peer support services at single session walk-in clinics and expand the Warm Line. The Warm Line is a peer-led, pre-crisis support service available 12 hours a day, seven days a week. Peer support programs have demonstrated positive outcomes in Newfoundland and Labrador.
- Federal funding will also be used to hire two Knowledge Exchange positions and two Evaluation Specialist positions to support all aspects and project teams under the Towards Recovery Action Plan. These positions will ensure an evidence-based approach to the transformative redesign of hospital to community services. These positions will also provide analytical support and provide recommendations for improvement or change to existing programs and services as well as support the development of a stepped care approach to accessing mental health and addictions services.
- 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; and,
- Spreading evidence-based models of community mental health care and culturally-appropriate interventions that are integrated with primary health services.
The Provincial Government will collaborate with the other PTs and CIHI to develop a focused set of common indicators in mental health and addictions. The Province is also working with the Newfoundland and Labrador Centre for Health Information (NLCHI) to develop indicators as part of an evaluation framework that will measure improvements in community-based mental health and addictions services and a person-focused health care system. The evaluation framework is currently under development, but the following key performance indicators, which are tracked over time and included in NLCHI's Mental Health and Addictions Programs Performance Indicator report, are currently under consideration.
Performance Domain: Quality
- Indicator: Readmission
- Indicator: Repeat hospitalizations
- Indicator: Client inclusion in treatment plan
Performance Domain: Safety
- Indicator: Adverse inpatient events
- Indicator: Inpatient self-harm events
- Indicator: Inpatient suicide events
Performance Domain: Access
- Indicator: Mental health and addictions hospitalizations
- Indicator: Average Alternative Level of Care (ALC) days
- Indicator: Psychiatric/mental health providers
Performance Domain: Utilization
- Indicator: Hospitalization rate
- Indicator: Patient days
Performance Domain: Efficiency
- Indicator: Alternate Level of Care (ALC) days
Performance Domain: Health Outcomes
- Indicator: Perceived mental health status
- Indicator: Prevalence of mood disorders
- Indicator: Suicide
- Indicator: Intentional self-injury hospitalizations
Allocation of Health Accord Funding - Mental Health and Addictions
|Integrated Service Delivery for Children, Youth and Emerging Adults|
|Child/Youth/ Emerging Adult Specialists||$0.05||$0.23||$0.23||$0.23||$0.23||$0.97|
|E-Mental Health Initiatives|
|E-mental health positions (4)||$0.12||$0.52||$0.52||$0.52||$0.52||$2.2|
|Therapy Assisted Online||$0.10||$0.10||$0.10||$0.10||$0.10||$0.50|
|Strongest Families Initiative||$0.35||$0.50||$0.50||$0.50||$0.50||$2.35|
|Improved Access to Addiction Services|
|Peer Support Program||-||$0.12||$0.12||$0.12||$0.12||$0.48|
|Needle Exchange Program||-||$0.20||$0.20||$0.20||$0.20||$0.8|
|Naloxone Take Home Kits||$0.05||$0.20||$0.23||$0.25||$0.25||$0.98|
|Improved Community-Based Services|
|Knowledge Exchange Specialists||$0.11||$0.22||$0.22||$0.22||$0.22||$0.99|
|Peer Support Walk- in Clinics||$0.05||$0.18||$0.18||$0.18||$0.18||$0.77|
|Single Session Walk-in Clinics||$0.25||$0.65||$0.90||$1.00||$1.00||$3.8|
|Additional 4 Peer Support Positions||$0.18||$0.18||$0.18||$0.18||$0.18||$0.9|
|Psychological Therapies (DBT program)||-||-||$0.40||$0.40||$0.40||$1.2|
|6 New Community Crisis Houses||$0.04||-||$2.00||$2.50||$2.50||$7.04|
|New Fact Teams||$0.04||-||-||$1.54||$1.54||$3.13|
Newfoundland and Labrador Action Plan for Increased Infection Prevention and Control
In Newfoundland and Labrador (NL), continuing residential care is provided by long term care homes, personal care homes and community care homes. Long term care (LTC) homes provide care and accommodation to seniors and adults with complex care needs requiring daily access to nursing care. Provincially, there are just over 3,000 LTC beds in 41 LTC sites (stand alone facilities or adjacent to acute care health centres). All LTC homes in NL are publicly operated by the regional health authorities (RHAs) with the exception of one home, where some beds are publicly subsidized. Oversight and monitoring for the publicly subsidized beds in the one private home is the responsibility of Eastern Health and is governed by a service contract. The RHAs are mandated to deliver services in LTC homes in accordance with the Provincial Long Term Care Home Operational Standards. The Department of Health and Community Services (HCS) works closely with the four health authorities to support effective implementation of policies and programs and to collaboratively identify and implement quality improvement opportunities. Homes are inspected for compliance with food safety, environmental, fire and life safety standards by the Department of Digital Government and Service NL (DGSNL). In addition, all LTC homes in the province are accredited through Accreditation Canada.
Personal care homes (PCHs) are licensed, private, for-profit residential care settings that provide care and accommodations to seniors and other adults with low care needs requiring assistance with activities of daily living. Provincially there are about 4,800 beds in 89 PCHs. PCHs are governed by the Personal Care Home Regulations, and the Provincial Personal Care Home Operational Standards. The RHAs are mandated to license and monitor PCHs for compliance with the Personal Care Home Regulations and the Provincial Personal Care Home Program Operational Standards. DGSNL inspects PCHs for compliance with standards concerning fire and life safety, environmental health, food safety and physical building design.
Community care homes (CCHs) are private, for-profit residential settings that provide care and accommodations to adults with severe and persistent mental illness. There are 163 beds in 12 CCH homes, all of which are located in the Eastern Health region and are overseen by the Eastern Health Mental Health and Addictions Housing Services Program. CCHs also follow the Provincial Personal Care Home Operational Standards and are subject to DGSNL inspections.
Challenges and issues faced in the delivery of long-term care services prior to the COVID-19 pandemic:
Many LTC homes have aging infrastructure and require ventilation, furniture and surface upgrades to meet best practices in infection prevention and control. Some older LTC homes have shared rooms and bathrooms with some homes having three or four residents in a room. A number of LTC sites, particularly in smaller, rural communities, are co-located in acute care health centres; in addition to shared rooms and bathrooms, these sites are often challenged with low access to suitable indoor and outdoor recreation spaces.
Some older PCHs and CCHs require furniture, flooring and surface upgrades. Many PCHs and CCHs have shared rooms and bathrooms. PCHs and CCHs do not have access to dedicated infection control practitioners (ICPs), as such, managing influenza and gastrointestinal outbreaks has been challenging in some homes. While RHA staff supported homes to deal with outbreaks, additional resources are needed to build infection prevention and control capacity in these settings.
Challenges and issues faced in the delivery of long-term care over the course of the pandemic.
One of the most significant challenges with respect to managing COVID-19 in LTC is the large number of shared rooms and washrooms. Homes were challenged to identify suitable spaces for isolation of residents. While recognized as a best practice, conversion of shared rooms to private rooms will likely result in a decrease in LTC beds. There is a wait list for LTC beds and demand is expected to increase as NL's population continues to age. Further enhancements in community based care will be required to address potential increased demand for LTC.
Significant challenges arose with implementation of the Chief Medical Officer of Health's Special Measure Order (SMO) to limit care home staff to working in one home and no other setting. As noted above some LTC sites are located adjacent to acute care sites, and some staff are shared. To support implementation of the SMO, in some cases, resident transfers to other rooms or homes was required.
During the pandemic, residential care homes experienced staffing challenges. This was due, in part, to COVID relief funding, self-isolation requirements, fear of contracting COVID-19 and the SMO that limited staff to work in one care home and no other setting.
All LTC homes have access to ICPs and resources. While the RHAs provided significant support to PCHs and CCHs, these homes do not have dedicated ICPs. This remains a challenge and additional resources are required to support continued management of the COVID-19 pandemic.
All homes were required to develop a site specific pandemic preparedness plan. The RHAs provided significant support to PCHs and CCHs in development of their plans.
One of the most significant impacts on residents and families was restrictions on visitation. Through provision of technology, homes were supported to implement virtual visitation, however not all residents could avail of virtual visitation, particularly in parts of the province with low or no internet access. While outdoor visitation was supported, this was not feasible for many residents owing to lack of sheltered outdoor spaces in some homes.
Initial steps taken to mitigate the impact of COVID-19 in the long term care sector:
Over the course of the pandemic, NL implemented a number of public health measures to mitigate risk of COVID-19 infection in residential care, including:
- Physical Distancing: Residential care homes were advised to practice physical distancing to the greatest extent possible, large group activities were not permitted and changes were made to communal dining.
- Routine Admissions: There was a hold on routine admissions, including short stay for respite and internal transfers. Clients with urgent and emergent care needs continued to be placed in residential care, often with prior consultation with public health or regional medical officer of health (MOH).
- Visitation: Restrictions are placed on visitation in residential care homes, with exceptions for residents at end-of life.
- Day Passes: No day passes were issued for residents in LTC. Residents of PCHs and CCHs were strongly discouraged from going out in the community with the exception of attending urgent or essential medical appointments. Where residents were required to attend medical appointments outside the home, residents were educated on public health measures and were provided a mask.
- Daily Symptom Monitoring: Residents are monitored for signs and symptoms of COVID-19, including daily temperature checks of residents in LTC.
- Masking: All visitors and staff are required to wear masks.
- Staff Self-Screening: All staff are required to self-screen for risk of COVID-19 exposure prior to beginning work.
- Resident Admission Process: all residents are screened for risk of COVID-19 exposure prior to placement. Residents must be tested for COVID-19 and undergo 14 day isolation period prior to or upon admission or re-admission to residential care, including following acute care stay (24 hours or longer).
- Limit Staff Movement: Staff were limited to work in one home and no other setting (including home care or retail).
- Virtual Visitation: homes were supported to utilize virtual visitation, in place of in person visitation, and this continues to be encouraged.
- Virtual Care: was used to minimize number of people entering residential care homes.
- Pandemic Preparedness Plans: All residential care homes developed a site-specific pandemic preparedness plan that outlined processes in the event of a suspect or confirmed case of COVID-19 in the home, including plans for isolation or transfer of residents.
- Infection Prevention and Control: All LTC homes have access to ICP resources. While PCHs and CCHs do not have dedicated ICP resources, the RHAs provided significant support in these settings. Homes implemented enhanced environmental cleaning protocols.
- Personal Protective Equipment (PPE): All residential care homes were provided with adequate supplies of PPE and masks. Hand sanitizer and sanitizing wipes were also provided to PCHs and CCHs when possible.
The above measures were implemented at various stages of the pandemic, in accordance with changing prevalence of COVID-19.
Infection prevention and control measures in long term care advanced by federal funding available from the Safe Restart Agreement, and other federal supports:
Allocations for the Safe Restart agreement for NL were as follows:
- Personal Protective Equipment $41 million
- Testing, Contact Tracing, and Data Management $41 million
- Health Care Capacity $16.4 million
- Vulnerable Populations $10.1 million
Safe Restart Fund- Actions related to residential care
1. Infection control practitioners for residential care homes ($445,000).
- ICP resources (four full time equivalents) are dedicated to PCHs and CCHs to support implementation of infection prevention and control (IPAC) measures. These positions are responsible for policy development, staff training (including best practices in IPAC outbreak management and environmental health), development of educational materials, and monitoring homes for compliance with operational standards related to IPAC.
2. Support for PCHs and CCHs to implement COVID-19 protocols ($5,400,000).
- Funding was provided to PCHs and CCHs that experienced increased expenditures and reduced revenue due to COVID-19. Homes were eligible for funding to a maximum of $33,600, based on verifiable expenses to offset general operating costs for expenses incurred to meet COVID-19 protocols for the eight month period of April 1, 2020 to November 30, 2020. PCHs and CCHs were required to demonstrate that costs incurred were due to COVID-19 and were above normal operating expenses. Eligible expenses included:
- overtime costs due to staffing shortages;
- increased staffing levels required to meet operational demands to support physical distancing including changes in meal service;
- increased staffing for visitor screening and screening residents for signs and symptoms of COVID-19;
- increased staffing for environmental cleaning;
- equipment to support virtual visitation; and,
- additional cleaning supplies and equipment.
- Owing to a hold on routine admissions, some PCHs and CCHs experienced reduced occupancy. Compensation was provided to homes that had verifiable decreased occupancy from April to July 2020, compared to the previous year's average occupancy.
3. Infrastructure upgrades to address infection prevention and control in residential care homes ($4,615,000).
- Various infrastructure upgrades in LTC homes to address gaps in infection prevention and control standards, including conversion of quad and triple occupancy rooms to private rooms.
4. Personal Protective Equipment
- Funding from Safe Restart was used for PPE for the entire health system, including LTC homes, PCHs and CCHs. In addition to PPE for outbreak management, all homes were provided masks for residents, staff and visitors. While the portion allocated to residential care homes cannot be quantified, homes were consistently supplied with adequate and appropriate PPE as per all other areas of the health care system. Provincial expenditures for PPE were significant; funding from Safe Restart provided some support for this expense.
5. Testing, contact tracing and data management
- Significant investments were made to develop and expand NL's testing, contact tracing and data management capabilities. These investments enabled the RHAs to respond quickly to suspect cases of COVID-19 in residential care.
6. Other supports
- In addition to Safe Restart, NL implemented the Essential Worker Support Program with funding from the federal government to provide a wage top-up to individuals who worked during the pandemic from March 14, 2020 to July 4, 2020 and earned less than $3,500 per month. Some staff of PCHs and CCHs met the eligibility criteria. The majority of staff in LTC have income that exceeded the monthly limit.
- The Canadian Armed Forces (CAF) supported the province in a number of ways, including communications to all visiting foreign and CAF personnel regarding the SMOs, including self-isolation requirements. The CAF also supported the deployment of the Canadian Rangers in Labrador to support COVID-19 vaccinations at the request of the Nunatsiavut Government.
- In March 2020, the Government of NL entered into a contract with the Canadian Red Cross for information, support and referral services to aid NL residents impacted by self-isolation requirements arising as a result of the pandemic. Residents and travelers at ports of entry with no alternative means of support can avail of help line information and referral to agencies providing supports including food and housing options. As part of the contract, Government advanced $200,000 to CRC for these services; to date over 1,750 individuals have availed of CRC services. This is fully funded by the Government of NL.
- In LTC, RHAs provided additional resources to meet public health measures including enhanced environmental cleaning, support for residents with dementia in isolation, screening visitors, screening residents for signs and symptoms of COVID-19, limiting staff movement to one care home, and implementation of virtual visitation. The pandemic preparedness planning process highlighted the specific challenges of some homes with limited ability for safe and effective isolation owing to the large number of shared rooms and bathrooms and lack of dedicated isolation space. Funding from Safe Restart has been allocated for LTC infrastructure improvements related to infection prevention and control including conversion of quad and triple occupancy rooms to private rooms and heating and ventilation improvements.
- The RHAs provided significant support to PCHs and CCHs through regular meetings, pandemic preparedness planning, and infection prevention and control support. In addition, many private, for-profit residential care homes (PCHs and CCHs) incurred additional costs due to implementation of public health measures to mitigate risk of COVID-19 infection. Funding from Safe Restart was used to compensate operators for a portion of these costs, ensuring these homes are in a position to continue to manage the pandemic. PCH and CCH operators were required to submit receipts and demonstrate expenditures were above normal operating expenses.
- NL invested significantly in additional PPE, testing capacity, including equipment, reagents, and human resources. Funding from Safe Restart helped support these initiatives, however expenditures exceeded what was provided through Safe Restart.
Measures to support Summary of human resources:
- A significant number of initiatives were implemented to support public sector staff including staff working in LTC homes to enable this work force to continue working during the pandemic:
- Government developed a childcare assistance program for essential workers to support individuals who were required to report to work during the first wave of the pandemic. Eligible individuals could apply for spaces in regulated childcare centers that were reserved for essential workers, at no charge, or receive financial support to avail of private child care arrangements.
- Special leave with pay was introduced for employees who are asymptomatic, directed by Public Health or Occupational Health to self-isolate and are unable to work from home. Employees who become symptomatic are required to report symptoms and take sick leave or other available leaves.
- Staff who are re-deployed under an agreement between unions, may be eligible for compensation for "travel time" between their place of residence and a location outside the primary place of work to perform duties assigned by the employer.
- Temporary living accommodations for staff who may be suspect, positive or advised to self isolate by Occupational Health, and who fear passing virus onto family.
- Paid/annual leave approval was and is a challenge. Employees who could not use their minimum amount of leave for the fiscal year were permitted to carry over to 2021.
- In the private sector:
- Owing to significant concerns and fears related to COVID-19 infection among staff, some private residential care homes provided wage top ups or recognition pay to help retain staff. This was included as an allowable expense for COVID-19 compensation to private operators, as such private operators were reimbursed for part of these expenses.
- Homes also incurred expenses for staff overtime due to staff shortages related to staff isolation, illness or fear of contracting COVID-19. As noted above, homes required additional staff for enhanced environmental cleaning and to adhere to public health measures. This was included as an allowable expense for COVID-19 compensation to private operators, as such private operators were reimbursed for part of these expenses.
Measures to improve infrastructure:
- Many LTC homes made infrastructure upgrades including:
- Creation of isolation spaces to support residents who were required to isolate upon admission or who displayed influenza like symptoms.
- Creation of spaces to support family visitation and spaces to support point of entry visitor screening.
- Some homes increased sanitizing stations and hand hygiene sinks.
- A number of LTC homes are co-located within acute care sites and there is often sharing of some staff. This presented significant challenges in light of the public health measure requiring staff to work in one home and no other setting (including acute care). In some sites, barriers were put in place to limit traffic between LTC space and acute care.
Measures to support readiness assessments:
- All homes were required to review their operations, and develop a pandemic preparedness plan. LTC homes worked closely with ICPs to inform development of their pandemic plans.
- The Canadian Foundation for Healthcare Improvement (now Healthcare Excellence Canada) established the LTC+ Program to provide eligible homes with seed funding and coaching to identify improvement objectives for pandemic response, as well as, to provide coaching to implement their improvements. All LTC homes in Eastern Health are participating in this program which includes a self-assessment to help homes assess pandemic preparedness, inform outbreak response planning, and prepare for future waves of COVID-19.
- PCHs and CCHs were supported by the RHAs in development of their pandemic preparedness plans. These plans included staff contingency plan, communication mechanisms, equipment and supply requirements, isolation plans where one or more residents were suspect or positive for COVID-19. The ability of private homes (PCHs and CCHs) to continue to support suspect or positive residents was factored into regional health system surge plans.
- While significant work related to pandemic preparedness has occurred, additional ICP resources available through Safe Restart and Safe LTC will help support residential care homes to complete more structured and comprehensive readiness assessments, identify gaps and support implementation of initiatives to improve their ability to manage the current pandemic and future outbreaks of any communicable disease.
Additional measure to improve infection prevention and control:
- Care home staff received education on signs and symptoms of COVID-19 and residents are monitored daily. All homes were provided with adequate supplies of PPE including masks for staff and visitors. Staff are required to wear a mask for the duration of their shift. Hand sanitizer and sanitizing wipes were also provided to PCHs and CCHs homes when supply was available.
- To support enhanced screening, screening tools were developed for all staff and visitors of residential care homes. All staff were required to self-screen prior to beginning a shift. All visitors are screened upon entry to a home.
- Provincial guidance was prepared related to appropriate use of PPE, IPAC management, and pandemic preparedness planning in PCHs and CCHs. All homes were required to develop site specific pandemic preparedness plans which focused on priority actions that are necessary to prevent and control an outbreak.
- All LTC homes within Eastern Health have availed of funding from Healthcare Excellence Canada (HEC), to help homes assess pandemic preparedness, inform outbreak response planning, and prepare for future waves of COVID-19.
- In addition to ongoing monitoring for compliance to operational standards, the RHAs enhanced monitoring of PCHs and CCHs for compliance with public health measures implemented to mitigate risk of COVID-19 infection in residential care.
- Safe Long Term Care Funding Areas of Focus:
- Funding available through the Safe Long-term Care Funding will be utilized to improve access to infection prevention and control resources and equipment in residential care homes and support infrastructure upgrades as follows:
1. Human Resources:
- Infection Control Practitioners (ICPs): Lack of dedicated ICP resources in PCHs and CCHs is a significant gap in pandemic preparedness in these settings which has put a strain on limited ICP resources in the RHA. Building on investments from the Safe Restart fund, additional investments will be made through Safe LTC Fund to ensure that residential care homes have dedicated ICP resources. ICPs will provide education, training on best practice in IPAC, lead outbreak management activities, monitor homes for compliance to operational standards related to IPAC. Through Safe Restart, four FTE ICP positions were funded, an additional six FTE positions are required due to the large number of homes dispersed across the province. These resources will focus on increasing the capacity of PCHs and CCHs to implement best practices in infection prevention and control. These positions will also provide some support in LTC.
- Pandemic Coordinator: Eastern Health is the largest RHA in the province with the greatest share of residential care homes including 17 of the 41 LTC homes, 43 of the 89 PCHs and all 12 CCHs. Supporting this volume of homes has been extremely challenging. Funding from Safe LTC will support a dedicated position in Eastern Health responsible for supporting residential care homes during the pandemic. The Pandemic Coordinator will be responsible for communication of new information, education on public health measures, addressing questions and concerns from residents, homes and families, auditing of processes, and liaison with other regional programs such as IPAC and Public Health, LTC program, PCH Program and CCH Program.
- Provincial Safe LTC Fund Coordinator: this position will oversee all elements of the Safe LTC Fund to ensure successful implementation of all initiatives. The position will be responsible to identify and address challenges, support RHAs and private providers in implementation of initiatives, ensure accountability and fulfill reporting requirements to provincial and federal governments.
2. Infrastructure Upgrades
a. LTC-public sector
Many LTC homes have aging infrastructure. In many areas homes do not have adequate ventilation systems. In addition, much of the furniture within the homes is not compliant with best practices in infection control policies and standards.
The ability to safely and effectively isolate residents depends on a number of factors including size, occupancy rates, and infrastructure of the home including the availability of private rooms, private bathrooms and available auxiliary space suitable for residents.
Infrastructure initiatives under the Safe LTC Fund will include:
- outdoor recreation spaces for visitation;
- heating and ventilation upgrades;
- nursing station upgrades;
- surface upgrades, including elimination of wood and porous surfaces;
- additional hand hygiene sinks;
- upgrade or create new clean and soiled utility spaces;
- replacement of hand railings;
- privacy drapes (to increase separation); and,
- furniture upgrades.
b. Infrastructure and Equipment Grant Program - Private sector (PCHs, CCHs and LTC):
- Through this program, private, for-profit service providers (PCHs, CCHs and private LTC) must submit a proposal to the RHA for consideration of funding. The application will be reviewed and approved by the RHA in accordance with established program criteria. The private provider must enter into an agreement with the RHA after demonstrating that the request for funding meets an unmet need related to improvement of infection prevention and control practices in the home. Dedicated ICP resources will support identification of initiatives with greatest impact through the readiness assessment process. Homes that previously received funding for similar related expenses will not be eligible to apply, unless the need for additional support can be demonstrated. Homes approved for funding will complete renovations or purchase equipment and provide documentation including receipts to the RHA to demonstrate work has been completed or equipment purchased. The RHAs will be required to verify completion of work prior to reimbursement of expenses. Homes will be eligible for reimbursement of 75 per cent of expenses up to a maximum of $25,000 per home. Homes that can demonstrate significant financial hardship may be eligible for a reduced provider contribution. All work must be completed by recognized contractors and must meet all applicable building codes. Ongoing maintenance of any new equipment, installation or renovation will be the responsibility of the private provider. Eligible expenses include:
- Infrastructure upgrades: including heating and ventilation upgrades, furniture replacement that meet IPAC standards, surface upgrades, including non-porous surfaces to facilitate effective cleaning, soiled and clean utility room spaces and creation of dedicated isolation spaces.
- Outdoor Visitation Space: development of accessible, sheltered outdoor recreation spaces to support increased quality of life for residents and space for family visitation.
- Equipment: including commodes and privacy drapes to support isolation of residents, infrared thermometers to support symptom monitoring of ill residents, hand hygiene sinks, and equipment to support virtual visitation.
3. Readiness assessments conducted in long-term care settings to prevent COVID infections and spread.
- Additional ICP staff will support homes to complete comprehensive readiness assessments, identify gaps and support implementation of initiatives. Homes will be encouraged to participate in other national initiatives such as HEC's LTC+ to ensure sharing of best practices. ICP staff dedicated to PCHs and CCHs will help inform IPAC operational standards and will support monitoring for compliance to IPAC related operational standards. Additional funding is not requested for this initiative, as this will a responsibility of ICPs described under human resources, and is therefore inherent in other initiatives. Public LTC homes will be required to participate in HEC's LTC + Program.
The description that follows applies to all initiatives.
- These initiatives will build on existing supports implemented in homes during the past year. While some work related to IPAC has been implemented, these initiatives offer an opportunity for a structured, holistic approach to IPAC that will result in infrastructure improvements and build capacity of homes in IPAC which will improve health and safety of residents now and in the future.
- As noted above there are 41 LTC homes, 89 PCHs and 12 CCHs within the province that will be supported through these initiatives. All PCHs and CCHs are private, for-profit homes, and one LTC home is private for-profit. Residential care homes provide care and accommodations to older adults with significant frailty or underlying medical conditions that put them at increased risk of complications from COVID-19 infection. The average age of individuals in LTC is 81 years old and approximately 64 per cent of residents are female. Approximately 94 per cent of individuals in PCHs are aged 65 years or older. Approximately 35 per cent of individuals in CCHs are over age 65. Many PCHs and CCHs provide support to marginalized individuals, some with persistent mental illness. PCHs and CCHs are private, for-profit homes ranging in size from five to 100 beds. Homes are dispersed throughout the province, including in rural and remote communities. Many residents in smaller rural communities experience financial vulnerability. While the vast majority of residents are Caucasian and English speaking, NL will ensure equal access to opportunities arising from this funding for all residents. NL will also consider and address barriers created due to language, culture and gender differences.
- These initiatives will benefit all residents in LTC, PCHs and CCHs, including Indigenous people and individuals living in rural communities. Though training and education, homes will explore opportunities to raise awareness about diversity and inclusion, including language, culture, and gender, and the impact this may have on IPAC measures.
- HEC established the LTC+ Program to provide eligible homes with seed funding and coaching to identify improvement objectives for pandemic response, as well as, coaching to implement their improvements. LTC homes in Eastern Health are enrolled in this program. All residential care homes will be are encouraged to participate. The additional ICP resources will support other care homes to participate in this program.
- In addition to the measures outlined to specifically address infection prevention and control measures, NL is committed to participating in federal, provincial and territorial work to inform the development of national standards.
Additional human resources will build on existing initiatives to support infection prevention and control, contribute to safe working environments for staff and support recruitment and retention of staff.
1. Infection Prevention and Control Human Resources ($660,000)
- Dedicate six FTE (ICPs) for the residential care homes as follows: 2.5 FTE Eastern Health, 1 FTE Central Health, 2 FTE Western Health, 0.5 FTE Labrador-Grenfell Health. ICPs will be responsible for the development, implementation, evaluation, and maintenance of a comprehensive infection control program in residential care homes. These activities include education, consultation, policy/program development, outbreak management, monitoring, and quality improvement.
- Positions will partially support private care homes, but will be RHA employees.
2. Pandemic Coordinator ($115,000)
- This position will oversee communication to LTC homes, PCHs and CCHs in the Eastern Health region. Eastern Health has 17 of 41 LTC sites, 43 of 89 PCHs and all 12 CCHs. Responsibilities of the coordinator would include education, auditing of processes, communication of new information and liaison with other departments such as IPAC, Public Health, LTC Program, PCH Program and CCH Program.
- The position will partially support private care homes, but will be an Eastern Health employee.
3. Provincial Safe LTC Fund Coordinator ($115,000)
- In consultation with a broad group of internal and external stakeholders, including RHA staff, Department of Health and Community Services staff and private service providers, this position will be responsible for implementation of all elements of the Safe LTC Fund.
- The position will support all residential care homes and the RHAs, but will be a Department of Health and Community Services employee.
1. Infrastructure Initiatives:
Funding will be used across 40 publicly owned and operated LTC homes for various infrastructure initiatives. Together these initiatives will improve infection prevention and control in homes and make these spaces safer for residents, staff and visitors. The action plan will be updated to identify homes that have benefited from initiatives.
1. Infrastructure upgrades (LTC- Public sector) ($10,960,000)
- Ventilation Upgrades: Many LTC sites have aging infrastructure and do not have adequate ventilation.
- Furniture replacement to meet best practices in IPAC.
- Improvements to clean and soiled utility rooms.
- Surface upgrades, including removal of wood surfaces, replacement and repair of hand rails.
- The RHAs repair and renovation budget requests for LTC homes far exceeds funding available through Safe LTC. Funds will therefore be allocated to the RHAs on a per bed basis in consultation with regional infrastructure and IPAC staff to identify most urgent needs related to infrastructure upgrades identified above. In addition to the funding available through Safe LTC, the RHAs will continue to fund other infrastructure upgrade.
2. Outdoor Recreation Space for Residents and Families ($1,000,000).
- The installation of accessible and sheltered structures will increase resident's access to outdoor recreational spaces. This will support increased quality of life for residents and support family visitation. At an estimated cost of $50,000 per sheltered space, up to 20 homes will be supported to install structures. This will expand on other initiatives implemented to support family visitation during the pandemic such as improvements to outdoor spaces and virtual visitation.
3. Infrastructure/ Equipment Upgrade Grant Program ($2,550,000).
- Private, for-profit homes can apply for funding through the Infrastructure and Equipment Upgrade Grant Program. This funding will support 89 PCHs, 12 CCHs and 1 LTC home across the province. Homes can apply to the appropriate RHA for funding based on established criteria including initiatives to support enhanced infection prevention and control, including infrastructure and equipment upgrades, equipment to support symptom monitoring, or initiatives to enhance resident quality of life such as, outdoor visitation spaces or equipment for virtual visitation.
- Through Safe Restart, PCHs and CCHs were supported in their immediate needs to manage the COVID-19 pandemic. Funding from Safe LTC Fund will build on this support and allow homes to make infrastructure improvements such as equipment and surface upgrades and build capacity in best practices in IPAC including environmental health and outbreak management which will benefit residents now and in the future.
Initiatives in Three Main Priority Areas
|Staff retention measures and hiring additional human resources||N/A||$890,000||$890,000|
|New infrastructure and renovations||$3,850,000||$10,660,000||$14,510,000|
|Readiness assessmentTable 5 Footnote **||Cost included in other initiatives|
|By Facility Category||Facilities||2020-21||2021-22||Total|
|Publicly funded facilities/ residences||Human Resources|
|1 FTE||Labrador-Grenfell Health||N/A||$66,000||$66,000|
|0.5FTE||Pandemic Coordinator, Eastern Health||N/A||$115,000||$115,000|
|Provincial Safe LTC Fund Coordinator, Department of Health and Community Services||N/A||$115,000||$115,000|
|Infrastructure Upgrades Only|
|Eastern Health – 16 homes||$2,156,000||$4,381,600||$6,537,600|
|Central Health – 12 homes||$770,000||$1,722,000||$2,492,000|
|Western Health – 8 homes||$731,500||$1,550,900||$2,282,400|
|Labrador-Grenfell Health – 4 homes||$192,500||$455,500||$648,000|
|Total support for publicly funded facilities/residences||$3,850,000||$9,000,000||$12,850,000|
|Private not-for profit facilities/ residences||Total support for private funded facilities/residences||N/A||N/A||N/A|
|Private for-profit facilities/ residences||Human Resources|
|ICP resources indicated above will provide support to private homes, but will be employees of the RHAs, funding for these positions will not be allocated to private, for-profit homes directly.||N/A||N/A||N/A|
|Infrastructure Grant ProgramTable 5 Footnote ***|
|101 PCHs and CCHs and one private, for-profit LTC home will be eligible to apply for the grant program: Eastern Health – 43 PCH, and 12 CCH and 1 private LTC home||N/A||$1,402,500||$1,402,500|
|Central Health – 26 homes||N/A||$637,500||$637,500|
|Western Health – 16 homes||N/A||$408,000||$408,000|
|Labrador-Grenfell Health – 4 homes.||N/A||$102,000||$102,000|
|Total support for private for-profit facilities/residences||N/A||$2,550,000||$2,550,000|
|Golden Heights Manor||$751,700|
|Bonavista Protective Community Residence||$80,000|
|Blue Crest Nursing Home (Grand Bank)||$671,500|
|U.S. Memorial Health Centre (St. Lawrence)||$118,000|
|Placentia Health Centre (Lion's Manor)||$811,300|
|St. Patrick's Mercy Home||$502,600|
|Pleasant View Towers||$160,000|
|Dr. Albert O'Mahony Memorial Manor (Clarenville)||$41,400|
|St. Lukes Homes||$1,478,800|
|Agnes Pratt Home||$1,202,900|
|Valley Vista Senior's Home (Springdale)||$524,000|
|Baie Verte Peninsula Health Centre||$331,000|
|Dr. Hugh Twomey Health Centre (Botwood)||$310,000|
|Fogo Island Health Centre||$53,000|
|Connaigre Peninsula Health Centre||$94,000|
|A.M. Guy Health Centre (Buchans)||$54,000|
|North Haven Manor (Lewisporte)||$75,000|
|Notre Dame Bay Memorial Health Centre (Twillingate)||$222,800|
|Dr. Charles LeGrow Health Centre (Port-aux-Basques)||$30,000|
|Calder Health Care Centre||$20,000|
|Corner Brook Long Term Care Facility||$554,000|
|Western Long Term Care Home||$52,000|
|Bonne Bay Health Centre (Norris Point)||$15,000|
|Rufus Guinchard Health Centre (Port Saunders)||$25,000|
|Bay St. George Long Term Care Facility||$1,364,000|
|Labrador South Health Centre (Forteau)||$180,000|
|Labrador West Health Centre||$10,000|
|Happy Valley-Goose Bay Long Term Care Facility||$305,000|
|John M. Gray Home (St. Anthony)||$205,000|
|Total funding allocated directly to facilities:||$11,960,000|
II. Cost Recovery in For-Profit Facilities/Residences
- Through the Infrastructure and Equipment Upgrade Grant Program, funding will be allocated based on application and approval process. Funds will be reimbursed following submission of receipts and proof that initiatives have been implemented. The grant program will begin spring 2021 with distribution of funding completed by March 31, 2022. Private, for-profit homes will be required to enter into an agreement for the terms of funding and distribution of funds.
III. Performance Measurement and Expected Results
|Priority Area||Performance Measure||Target / Outcomes||Reporting and ResultsTable 6 Footnote 1|
Staff retention measures:
# FTE human resources added Number of readiness assessments completed in PCHs and CCHs Number of initiatives identified for Infrastructure Grant Program
All FTE positions filled 100 per cent of homes that apply for the Infrastructure and Equipment Grant Program complete a Readiness assessment
100 per cent of homes with approved applications implement initiatives as outlined in the application
Improved IPAC measures Increased compliance with IPAC standards Improved communication Improved policy and process development Increased resident and family satisfaction
Interim Report (February 2022)
All FTE positions have been filled with the exception of: Provincial LTC Fund Coordinator, 0.5 FTE ICP in EH, recruitment is underway for both positions.
ICPs have formed a provincial network and meet regularly to collaborate, share resources and support implementation of actions to improve infection prevention and control measures.
ICPs are working closely with PCHs and CCHs to complete needs assessment survey, develop an educational plan for staff, develop audit tools for hand hygiene and environmental services, strengthen monitoring activities, and review and improve outbreak protocols. With the onset of Omicron and the first occurrence of COVID-19 outbreaks in residential care homes in NL, ICPs have provided significant support to care homes including leading outbreak management activities.
New infrastructure and renovations
Percentage of public LTC homes completing infrastructure upgrades Percentage of private homes receiving funding through grant program Percentage of private homes implementing initiatives to improve infrastructure
75 per cent of homes implement improvements in IPACTable 6 Footnote *
75 per cent of private homes are supported through the grant programTable 6 Footnote **
100 per cent of homes with approved applications implement initiatives as outlined in the application
Improved IPAC measures Increased compliance with IPAC standards Improved communication Improved policy and process development Increased resident and family satisfaction
Interim Report (February 2022)
Almost 90% of public LTC home will receive some funding. The remaining LTC homes are newer facilities and do not require significant infrastructure and equipment upgrades.
For the Infrastructure and Equipment Grant Program, a policy and application form has been developed and shared with private service providers in December 2021. Homes are eligible for reimbursement of 75 per cent of costs up to the following maximums:
Applications have been delayed owing to ongoing management of a significant number of outbreaks in residential care.
Number of readiness assessments completed in PCHs and CCHs All public LTC homes participate in HEC's LTC+ Program
100 per cent of homes that apply for the Infrastructure and Equipment Grant Program complete a readiness assessment
100 per cent of public LTC homes participate in HEC LTC + Program
Interim Report (February 2022)
ICPs have supported some gap analysis and readiness assessments in PCHs and CCHs. This will continue as new applications for the Infrastructure and Equipment Grant Program are completed.
All homes in EH region (16 homes) participate in HEC LTC+ program. HEC LTC+ is closed to new applicants, however NL will continue to explore other opportunities for collaboration with HEC.
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