Canada-Nunavut Home and Community Care and Mental Health and Addictions Services Funding Agreement

BETWEEN:

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 -

THE GOVERNMENT OF NUNAVUT (hereinafter referred to as “Nunavut” or “Government of Nunavut”) as represented by the Minister of Health herein referred to as “the territorial Minister”)

REFERRED to collectively as the “Parties”

PREAMBLE

WHEREAS, on January 16, 2017 Canada and Nunavut 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 Nunavut agreed in November 2018 to postpone federal funding for one year, now to begin in 2019-2020, which will permit Nunavut to put in place its programs and initiatives for home and community care and mental health and addictions;

WHEREAS, Canada and Nunavut 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 Nunavut 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, Nunavut authorizes the territorial Minister to enter into agreements with the Government of Canada under which Canada undertakes to provide funding toward costs incurred by the Government of Nunavut for the provision of health services which includes home and community care and mental health and addictions initiatives;

WHEREAS, Nunavut makes ongoing investments in home and community care and mental health and addictions services, consistent with its broader responsibilities for delivering health care services to its residents;

AND WHEREAS the Government of Canada makes ongoing investments in home and community care and mental health and addictions services for Indigenous communities and other federal populations.

NOW THEREFORE, Canada and Nunavut agree as follows:

1.0 Objectives

1.1 Building on Nunavut's existing investments and initiatives, Canada and Nunavut 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).

2.0 Action Plan

2.1 Nunavut will invest federal funding provided through this Agreement in alignment with the selected action(s) from each menu of actions listed under home and community care and mental health and addictions in the Common Statement.

2.2 Nunavut's approach to achieving home and community care and mental health and addictions services objectives is set out in their six-year Action Plan (2017-18 to 2022-23), as set out in Annex 2.  

3.0 Term of Agreement

3.1 The term of this Agreement is four years, from April 1, 2019 to March 31, 2023 (the Term).

3.2 Renewal of Bilateral Agreement

3.2.1 Nunavut'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 the bilateral agreement, subject to appropriation by Parliament, and Nunavut and Canada's agreement on a new action plan.

3.2.2 The renewal will provide Nunavut 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 Nunavut under the Canada Health Transfer to support delivering health care services within their jurisdiction.

4.2 Allocation to Nunavut

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

  1. $600 million for the Fiscal Year beginning on April 1, 2018
  2. $650 million for the Fiscal Year beginning on April 1, 2019
  3. $650 million for the Fiscal Year beginning on April 1, 2020
  4. $900 million for the Fiscal Year beginning on April 1, 2021

Mental Health and Addictions Services

  1. $250 million for the Fiscal Year beginning on April 1, 2018
  2. $450 million for the Fiscal Year beginning on April 1, 2019
  3. $600 million for the Fiscal Year beginning on April 1, 2020
  4. $600 million for the Fiscal Year beginning on April 1, 2021

4.2.3 Annual funding will be allocated to provinces and territories on a per capita basis, for each Fiscal Year that an agreement is in place. The per capita funding amounts for home and community care and for mental health and addictions services, for each Fiscal Year, are calculated using the following formula: F x K/L, where:

  • F is the annual total funding amount available under this program (funding amount will change depending on Fiscal Year);
  • K is the total population of the particular province or territory, as determined using annual population estimates from Statistics Canada; and
  • L is the total population of Canada, as determined using annual population estimates from Statistics Canada.

4.2.4 For the purposes of the formula in section 4.2.3, the population of Nunavut 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 formula described in section 4.2.3, Nunavut's estimated share of the amounts will be:

Fiscal Year Home and community care
Estimated amount to be paid to NunavutFootnote * (subject to annual adjustment)
Mental health and addictions services
Estimated amount to be paid to NunavutFootnote * (subject to annual adjustment)
Table Footnote 1

Amounts represent annual estimates based on StatCan 2017 population

Return to footnote * referrer

2019-2020 $620,000 $260,000
2020-2021 $670,000 $470,000
2021-2022 $670,000 $620,000
2022-2023 $930,000 $620,000

4.3 Payment

4.3.1 Canada's contribution will be paid in approximately equal semi-annual installments as follows:

  1. 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.
  2. 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.
  3. The amount of the second installment will be equal to the balance of Canada's contribution to Nunavut for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
  4. The actual amount will be based on the Statistics Canada quarterly preliminary population estimates on July 1 of the preceding Fiscal Year.  Canada will notify Nunavut of the actual amount of the first and second installment in each Fiscal Year as determined under the formula set out in sections 4.2.5 and 4.2.3.
  5. Canada shall withhold payment of the second installment for the Fiscal Year if Nunavut 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.
  6. 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.
  7. Payment of Canada's funding for each Fiscal Year of this Agreement is subject to an annual appropriation by Parliament of Canada for this purpose.

4.4 Carry Over

4.4.1 At the request of Nunavut, Nunavut may retain and carry forward to the next Fiscal Year the amount of up to 10 percent of the contribution paid to Nunavut for a Fiscal Year under subsection 4.2.5 that is in excess of the amount of the eligible expenditures actually incurred by Nunavut 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 Nunavut to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters. 

4.4.2 For greater certainty, any amount carried forward from one Fiscal Year to the next under this subsection is supplementary to the maximum amount payable to Nunavut under subsection 4.2.5 of this Agreement in the next Fiscal Year.

4.4.3 In the event this Agreement is renewed in accordance with the terms of section 3.2.1, and at the request of Nunavut, Nunavut 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 bilateral agreement, subject to the terms and conditions of that renewed agreement. The new Action Plan for the renewed bilateral agreement will provide details on how any retained funds carried forward will be expended. Any request by Nunavut to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters.

4.5 Repayment of overpayment

4.5.1 In the event payments made to Nunavut exceed the amount to which Nunavut 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, Nunavut shall repay the amount within sixty (60) calendar days of written notice from Canada.  

4.6 Use of Funds

4.6.1 Canada and Nunavut agree that funds provided under this Agreement will only be used by Nunavut in accordance with the areas of action outlined in Annex 2.

4.7 Eligible Expenditures

4.7.1 Eligible expenditures for funds provided under this Agreement are the following:

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

5.0 Performance Measurement and Reporting to Canadians

5.1 Funding conditions and reporting

5.1.1 As a condition of receiving annual federal funding, Nunavut 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.

  1. Nunavut will designate an official or official(s), for the duration of this Agreement, to work with CIHI and represent the interests of Nunavut 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, Nunavut agrees to: 

  1. Provide data and information (based on existing and new indicators) related to home and community care and mental health and addictions services to the Canadian Institute for Health Information annually. This will support the Canadian Institute for Health Information to measure progress on the shared commitments outlined in the Common Statement and report to the public.
  2. Beginning in Fiscal Year 2020-2021, provide to Canada an annual financial statement, with attestation from Nunavut'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 Nunavut's Action Plan (Annex 2):
    1. The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year;
    2. The total amount of funding used for home and community care and mental health and addictions programs and services;
    3. If applicable, the amount of any amount carried forward by Nunavut under section 4.4; and
    4. If applicable, the amount of any surplus funds that is to be repaid to Canada under section 4.5.

5.2 Audit

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

5.3 Evaluation

5.3.1 Responsibility for evaluation of programs rests with Nunavut in accordance with its own evaluation policies and practices. 

6.0 Communications

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

6.4 Canada, with prior notice to Nunavut, may incorporate all or any part or parts of the data and information in 5.1.2, or any parts of evaluation and audit reports made public by Nunavut into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

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

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

7.0 Dispute Resolution

7.1 Canada and Nunavut 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 Nunavut 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 Nunavut, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Nunavut 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 Nunavut responsible for health, and if it cannot be resolved by them, then the respective Ministers of Canada and Nunavut 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 Nunavut, by Nunavut's Minister of Health.

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 Nunavut, 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 Nunavut, 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 Nunavut, if requested by Nunavut. This includes any provision of the 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. 

10.0 Termination

10.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Nunavut by giving at least 12 months written notice of its intention to terminate. Nunavut 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 Nunavut after the date of effective termination.

11.0 Notice

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. 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:

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

Email: marcel.saulnier@canada.ca

The address for notice or communication to Nunavut shall be:

Government of Nunavut
P.O. Box 1000 Stn 1000
Iqaluit, Nunavut
X0A 0H0
Attention: Deputy Minister, Health

12.0 General

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 Nunavut.

12.4 No member of the House of Commons or of the Senate of Canada or of the Legislature of Nunavut 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 Ottawa this 28th day of March, 2019.

The Honourable Ginette Petitpas Taylor, Minister of Health

SIGNED on behalf of Nunavut by the Minister of Health at Iqaluit this 15th day of March, 2019.

The Honourable George Hickes, Minister of Health

Annex 1 to the Agreement

A Common Statement of Principles on Shared Health Priorities

Annex 2 to the Agreement

Nunavut's Action Plan

Introduction

The Government of Nunavut's Department of Health (Health) is responsible for the delivery of healthcare to 38,243 NunavummiutFootnote 1. Healthcare service delivery, including that for mental health and addiction services is challenging as the population is spread across a vast geography. Specifically, Nunavut accounts for 1/5 of Canada's land mass and there are 25 remote communities, accessible only by air, spread across three time zones and divided into three regions: the Qikiqtaaluk (or Baffin), the Kivalliq and the Kitikmeot. Most of Nunavut's population is Inuit (85%) and as such, providing home and community care, and mental health and addictions care that are culturally appropriate and incorporate Inuit values is a key priority for Health.

The Government of Nunavut incorporates Inuit societal values into program and policy development, as well as into service design and delivery. The delivery of health services in Nunavut is based on a primary health care model. Nunavut's primary health care providers include family physicians, nurse practitioners, midwives, community health nurses, and other allied health professionals.

Differences in health status exist between Inuit residing in Nunavut and the general Canadian population. Specifically, Inuit are more likely to be daily smokers, experience food insecurity, and be overweight or obese. Rates of childhood maltreatment (i.e., physical and/or sexual abuse) are also higher among Inuit. Similarly, negative mental health outcomes such as binge drinking, depression, and suicide attempts and ideation occur more frequently among Nunavut's Inuit relative to other Canadians.Footnote 2 Suicide rates among Inuit in Nunavut between 1999-2014 were approximately 110 per 100,000 population, whereas the Canadian average is approximately 15 per 100,000 population.Footnote 3 These negative health outcomes are often the result of poor social determinants of health among Nunavut's Inuit. For example, a severe shortage of housing that contributes to overcrowding and homelessnessFootnote 4, food insecurity due to the high cost of foodFootnote 5, as well as lower educational attainment and socioeconomic statusFootnote 6. In addition, historical and intergenerational trauma as a result of colonization (e.g., residential school, dog slaughter, forced resettlement, the re-location of Inuit to sanitariums in the South for tuberculosis, among others), has had a significant impact on the well-being of Inuit.

Despite all of these challenges, Inuit in Nunavut continue to demonstrate resilience and strength. The communities across the territory are tight-knit and work together to solve issues and support one another. As well, many Inuit have a strong connection to the land and utilize the territory's natural resources in ways that benefit their family and community. There are also leaders within the community, such as EldersFootnote 7 who promote resilience and cultural continuity.

These strengths underscore the need to develop health services and programming that build on existing community resources and engage community members in program development and implementation. It is critical to be collaborative and culturally appropriate in order to support a sustained impact on access to mental health and addictions services, and home and community care.

Currently, through the Territorial Health Investment Fund (THIF) the Federal Government is supporting, among other things, Inuit workforce development by providing funding for training community based mental health and addictions outreach workers in Nunavut. Likewise, through the Northern Wellness Agreement, the Federal Government supports the frontline service delivery of the Home and Community care program, including care and training for Home Care Nurses in Nunavut. Together, these funding streams contribute to the objective of achieving a sustainable health system that supports the wellness of Nunavummiut.

This federal funding will complement and build on these existing initiatives. Specifically, in the priority area of improving access to mental health and addictions services, these federal funds will be used to provide mental health and addictions outreach workers the necessary resources to implement child and youth programming at the community level. For the priority area of improving access to home and community care, these federal funds will allow for the implementation of a standardized assessment tool which will increase access and enhance service delivery by ensuring services are tailored to an individual's specific needs.

Home and Community Care Services

Nunavut Overview

In Nunavut, the continuing care system consists of the Home and Community Care (HCC) Program, three Continuing Care Centres funded by the Department of Health, and three Elders' Home facilities.

Family members and friends from all generations are the first providers of care in the home in all Canadian jurisdictions, including Nunavut.  Government-provided service supplements existing care or, in rare cases, is the only support when there are no friends or family members available, willing, or able to provide care.

In Nunavut, an individual may self-refer to the HCC program or be referred by a health care professional or a family member.  A standard comprehensive assessment is completed to determine the level of care and services that are required. Health also provides education and training opportunities to all employees in the HCC program. 

The HCC program provides health care and support services, based on assessed needs, in the comfort of an individual's home.  The main services provided by the HCC program in Nunavut include:

  • Acute Care Replacement: services provided to clients who are experiencing an acute illness, but who have the potential to return to a pre-illness level of functioning and self-care;
  • Chronic Disease Management: services provided to clients with advanced disease(s) who can be maintained at home, with ongoing home care services and family assistance;
  • Long-Term Care Replacement: services provided to home care clients with illness/disability to aid them to increase their level of functioning or self-care so that they can function without the supports of home care services;
  • Palliative Care: compassionate care offered to a person living with a progressive, life-threatening illness that does not respond to curative treatment. The primary objective is maintenance of the best possible quality of life.  Palliative care provides family support, prevention, assessment, and treatment of pain and other distressing symptoms, and integrates the psychological, social, cultural and spiritual aspects of care; and
  • Post-Hospital Care: short-term home care services, of an expected duration of 6 weeks or less, provided to stable clients who are post-surgical or have had an acute illness which has been diagnosed and treated.

The goals of the HCC program are to provide services to Nunavummiut, based on their assessed need, in order to promote independent living and support families in caring for people at home, in their community, rather than in a facility.

In Turaaqtavut (2018 mandate), the Government of Nunavut (GN) re-affirmed its commitments to strengthening self-reliance and community well-bring (Inuusivut) by:

  • Respecting our Elders and calling upon them to help us remember the past and use it to shape our future;
  • Valuing our Elders by listening to them, paying attention to their traditional knowledge, and meeting their needs for care in the territory; and
  • Investing with partners in infrastructure that enhances our well-being as individuals and communities, including facilities for Elder care and addictions in the territory.

HCC programming is available to all Nunavummiut. For fiscal year 2016/17, there were 940 home care clients, a 5% increase from the prior year. The majority of those receiving home care are 65 and older. According to the 2016 Census, there were 1,360 individuals aged 65 and older in Nunavut. This is a 67% increase from 2006. It is projected by 2030 the population aged 65 and older will triple. 

Priority Area for Investment

The GN and the Government of Canada share the priority of addressing access to appropriate services and supports in home and community to meet the needs of the growing population. A key component of this joint approach is being able to report and manage based upon a set of nationally agreed upon measures of performance. A barrier to Nunavut in supporting this federal investment is the lack of a consistent, evidence-based assessment tool to determine the service needs of Nunavut residents and provide the data needed to manage and report on the national measures of performance. Implementing the interRAI tool would directly support improved access and service delivery of home and continuing services by ensuring services are allocated to individuals based on their assessed care needs.  Implementing interRAI within LTC will also ensure that care is being delivered in the correct setting, such that individuals whose care needs can be met within the community, are provided the opportunity to return there with the appropriate supports in place.

Activity – InterRAI Assessment Tool Project (FY 2019-20-2022/23)

Acquisition and implementation of interRAI is a necessary component to enhancing the Government of Nunavut's ability to integrate home care services within the primary health care model, as well as to better identify and respond to the needs of Nunavummiut with increased investment in home care infrastructure.

InterRAI is an internationally-researched and recognized set of clinical assessment instruments compatible across multiple health care sectors. These tools are widely regarded as a best practice assessment tool, particularly in home care and continuing care service delivery areas. They are in use in many Canadian jurisdictions and have been accepted as the national standard and form the basis of the Canadian Institute for Health Information (CIHI)'s Home Care Reporting System (HCRS).

Nunavut will be utilizing the most recent versions of the RAI assessment tools that are being promoted by CIHI for home care and long-term care.  These tools will be compatible with CIHI's interRAI Reporting System (IRRS) that is being set up to manage interRAI data from the provinces and territories.

The project directly aligns with the activities in the Common Statement of Principles for

Shared Health Priorities by:

  • Enhancing home care infrastructure, such as digital connectivity, remote monitoring technology and facilities for community-based service delivery
  • Spreading and scaling evidence-based models of home and community care that are more integrated and connected with primary health care.

The GN currently does not use interRAI, nor does it submit data to the HCRS, resulting in a reduced understanding of the overall care needs of Nunavut residents, how our current resources are addressing these needs, and if we are adequately resourced to effectively support seniors to age in place in community. It will also help to validate when long term care admissions are required.

Implementing interRAI in Nunavut will require working with the vendor of the Meditech EMR currently used within Nunavut to ensure a seamless integration of the interRAI assessment and care plan data into the overall electronic health record.  The implementation of interRAI will first focus on the Regional Centres before rolling out to the other communities in each Region.  Some of the factors that will determine the sequence include size of community, home care program vacancies, and informatics support. A training plan will be an important part of implementation and will be key to supporting its ongoing utilization.

When implemented, interRAI will facilitate consistent evidence-based assessment and care planning for HCC clients, allow for the timely communication of pertinent client data and information between service providers across the continuum of care throughout the territory, enable consistent tracking and reporting of data, and assist in decisions regarding effective resource utilization. This is important for Nunavut communities where limited resources are available but the disparities in health are high.

The following table outlines the funding allocation for interRAI Assessment Tool.

Funding Allocations
Home and Community Care
Activities 2017-18Footnote * 2019-20 2020-21 2021-22 2022-23 Total
Table 1 Footnote 1

2017-18 funds already provided through legislation.

Return to footnote * referrer

Table 1 Footnote 2

Allocations are notional. Funding allocations are subject to annual adjustment based on the formula described in section 4.2.3 of the Agreement. The budgeted amount for these areas will need to be flexible as bilateral funding is adjusted based on annual population estimates.

Return to footnote ** referrer

Table 1 Footnote 3

Section 4.4.1 of the Agreement provides that, if required, Nunavut may retain and carry forward to the next Fiscal Year unexpended federal funds, subject to certain conditions.

Return to footnote *** referrer

Home and Community Care Services $200,000          
interRAI Assessment Tool Planning and Implementation   $620,000 $670,000 $670,000 $930,000 $3,090,000

Performance Measurement

A monitoring and evaluation plan for the interRAI implementation will be developed and implemented to measure progress enabling the project to be efficiently managed.

Nunavut is participating in the development of common indicators with CIHI and other jurisdictions that will measure improvements in access to home and community care services. When feasible, the Government of Nunavut will be reporting on the national indicators developed with CIHI, in addition to those specific to Nunavut.  The data will be used to inform clinical, administrative, and policy decision making and will assist with resource allocation in home and community care that will help better meet client needs.

 

Summary of Expected Results
Home and Community Care Expected Results
Outputs Output indicators Outcomes Outcome indicators Target by 2022/23

interRAI is implemented in Home and Community Care and Long-term Care facilities in the Territory

Access to standardized primary and secondary data to inform clinical, administrative, and policy decision making

# of communities that are using interRAI

# of long-term care facilities that are using interRAI

# and % of homecare and long-term care facility clinical staff that have completed interRAI training

% of home care clients that have been assessed using interRAI

% of long-term care facility residents that have been assessed using interRAI

Increased ability to conduct best practice assessments through sustainable interRAI use

Enhanced distribution and utilization of home and community care resources

Allocation of resources meets the needs of home care clients

# of home care and long-term care facility staff that are trained to use interRAI

# of home care and long-term care facility staff that are using interRAI

# of days between client assessment and first home visit

# of days between identification of need for placement and actual placement date

Reporting on HCC indicators to CIHI to monitor quality of care

Percentage of communities where home care is delivered that are using interRAI

Access to standardized primary and secondary data to inform clinical, administrative, and policy decision making

interRAI system is ready for implementation to support access to standardized primary and secondary data to inform clinical, administrative, and policy decision making

Mental Health and Addictions Services

Nunavut Overview

The Government of Nunavut is committed to the delivery of quality Mental Health and Addictions services across Nunavut. The primary objective of mental health and addictions treatment is to promote healthy and resilient Nunavummiut by providing access to quality clinical expertise and culturally relevant services, across the continuum of care and as close to home as possible.

Individuals and families seeking care in Nunavut often require support for many complex psychosocial issues. For that reason, the Department of Health is working towards achieving a fully integrated mental health and addictions system, so that individuals and families can access comprehensive care at any point in the system. This method is best practice and creates a holistic approach to mental health, addictions, and suicide prevention assessment, treatment and services.  Supporting the mental health and addictions workforce is a central focus of the current service system. Currently, this workforce is primarily comprised of mental health nurses, mental health consultants and community based mental health and addictions outreach workers. Present efforts in training focus on supporting these workers in understanding the key aspects for the identification, intervention and treatment of problematic substance use, mental health issues and concurrent disorders.

Health is dedicated to increasing mental health and addictions treatment capacity across the territory, with a focus on community-based services and supports. The Government of Nunavut is working towards the well-being and self-reliance of Nunavummiut and communities. As such, a major objective of mental health and addictions treatment is to provide Inuit culturally informed wellness practices. To achieve this, the mental health and addictions program is focusing on hiring and developing a local Inuit workforce who can support clients in their recovery from addictions, mental illness, or both. For those who require more complex care, which cannot be provided in Nunavut, pre-treatment and reintegrating into the community have been essential areas of focus for mental health and addictions treatment in the territory.  

Some examples of key successes of Health in the area of Mental Health and Addictions include:

  • Continued focus on mental health and addiction workforce development. This includes developing the Mental Health and Addictions Outreach Worker (MHAOW) program.
    • The purpose of this position is to support mental health and addictions services by empowering clients and community members to actively participate in mental wellness; the MHAOW delivers programs, provides education, fosters strong community partnerships, incorporates Inuit knowledge and values, and assists children, youth, adults, and elders in accessing services.
    • The MHAOW program is prioritizing the hiring of local Inuit whose knowledge of their community and the diverse mental health needs are invaluable to the success and sustainability of services.
    • The MHAOW program includes an extensive orientation and training plan, which is currently being finalized. Training includes foundational skills-based courses specific to mental health, addictions, counselling, and community program development and training will be piloted in 2018-19.
  • The Out-of-Territory (OOT) office provides residential placements for individuals and families who present with specialized needs that cannot be met in Nunavut. The OOT office identifies clients' needs in order to match them with a service that will best meet their needs. This office also conducts thorough facility reviews for quality assurance and to allow for a better understanding of which facilities might best serve certain client groups. 
  • A continued focus on building mental health and addictions supports in-territory for individuals with serious mental health or addiction related issues, such as the successful operation of two in-territory mental health residential facilities in Iqaluit and Cambridge Bay. In Iqaluit, the facility has 16 beds with an occupancy rate of approximately 85% and in Cambridge Bay, the facility has 10 beds with an occupancy rate of approximately 95%.

Despite some of the successes of the mental health and addictions program, there are significant service gaps that remain across Nunavut's communities. Specifically, health human resource issues, such as high turnover rates, burnout due to vicarious trauma, and vacancies and challenges in recruiting to remote communities. These issues contribute to Health's ongoing reliance on transient professionals (e.g., locums, agency nurses etc.) who often cannot provide the continuity in care or culturally sensitive services that Nunavummiut dealing with mental health and addictions issues deserve. Additionally, rates of mental health and addictions issues are high, and this is particularly felt among youth in the territory. This is due to the fact that close to 50% of the territory's population is under the age of 25Footnote 8, coupled with the vulnerable nature of this period of development to the negative impacts of trauma and adverse events. The result of these service issues are driving high health care expenditures in the areas of:

  • Emergency room visits for acute emotional and problematic substance use issues;
  • Hospitalization for self-injury;
  • Medevac expenses;
  • Out-of-territory assessment, stabilization and treatment; and
  • Treatment of secondary outcomes such as assault, domestic violence, and sexual abuse.

Priority Areas for Investment

The following  project will address gaps in the current mental health and addictions service system in the areas of 1) the lack of a high quality integrated mental health and addictions service delivery at the community level and 2) the need to develop human resource capacity, particularly in the areas of children and youth mental health care. 

The projects directly align with the activities in the Common Statement of Principles for Shared Health Priorities by:

  • expanding access to community-based mental health and addiction services for children and youth (age 10–25).

The projects proposed for this federal funding are complementary to ongoing initiatives under THIF funding which is being utilized to help grow and train the mental health workforce. This federal funding will be used to support these newly developed resources by providing them funding to deliver programs and services for children and youth.

Project priority area: Expanding access to community mental health and addiction services for children and youth

Health is working to expand the mental health workforce, but there still remains a need for significant financial support in the areas of program delivery, professional development and support, and external supports.

Program Delivery:

The Department of Health recognizes that community-based programs play a critical role in improving the wellbeing of young Nunavummiut by addressing a broad spectrum of mental health related issues. Several communities are currently delivering a variety of programs with great success, yet continuous funding challenges threaten their longevity, and many more communities are lacking youth-specific programs completely. The need for sustained and community-based programs specific to child and youth mental health and addictions has been raised by many Nunavummiut as a key component to expanding access.

Presently, there are several successful programs being delivered by mental health workers in each region, such as sewing programs in Kivalliq, mentorship programs in Kitikmeot, and land camps in Qikiqtaaluk. One of the greatest strengths of these programs is that the majority started as projects developed entirely at a community level. They offer culturally appropriate activities geared towards meeting the unique wellness needs of each community. Moreover, from a mental health perspective, the department has observed how impactful these programs are for youth and their families. The programs give youth opportunities to build connections with their peers, develop healthy coping skills, reduce anxiety and depression, and feel more hopeful.  Additionally, the programs are vital in helping youth access further mental health services. The mental health workers facilitating the programs are able to connect with youth in safe environments which foster trusting, therapeutic relationships, and allow the youth to feel more comfortable discussing mental health concerns. 

The youth mental health workers across the territory have identified financial security as the primary factor in supporting program sustainability. Typically, the process of securing funding falls entirely on the individual who wishes to facilitate the program. Though each program varies, facilitators usually require money for acquiring materials, resources, food, renting space, and compensating additional community members such as artists and Elders. If they are able to find potential dollars, they often report programs starting late in the fiscal year due to lengthy application processes. Moreover, most funding is limited to a one-year plan as per fiscal year restrictions. As a result, workers receive funding and may have only a few months before the fiscal year ends; thus, they are not able to effectively deliver their program and are often discouraged from continuing it. Having available funding which could be carried over each year and allocated from within our own department would support the ongoing facilitation and success of these programs. Furthermore, it would allow for more opportunities to develop new programs as our mental health workforce expands.  

The objective of this project is to support community-driven projects and develop a model in which the strengths of these programs are recognized and shared across the territory. Funding may be used to designate a Program Coordinator who focuses specifically on assessing, developing, and delivering youth programs. This model would support the scaling up of successful community-level initiatives and would facilitate adaptations to ensure relevancy, cultural appropriateness, and best practices are upheld. Previous experience of the Mental Health and Addictions program indicates that communities wishing to implement new programs are more successful and the funding is used more effectively when they are provided relevant examples that can be tailored to their unique needs.

Professional Development and Support

Mental health workers in Nunavut experience extraordinary challenges in their professions; most report high levels of stress, feelings of isolation and helplessness, and having a need for more support. Consequently, the department has high turn-over rates amongst frontline staff, which greatly impedes program development and creates significant gaps in services. As mentioned above (MHAOW program), the department has been approved to receive funding for a number of new mental health worker positions across the territory. With this funding, there is potential to hire one or two workers in each community who can support child and youth mental health initiatives. However, Health requires additional funding for professional development and support.

The Department of Health will support our child and youth workers by providing more resources and facilitating peer support networks. For instance, Health will use this funding for hosting annual summits in which employees can meet in person to share successes and challenges while receiving support from mental health and addictions staff and each other. From a long-term perspective, Health would also like to use this funding to develop a website specific to child and youth mental health, which can act as a resource hub for clients and an ongoing support forum for professionals. As internet capabilities are improving in Nunavut, more and more youth and families are going online to find information. Health would like to support youth and their families to find relevant information on mental health and addictions topics online. This would include educational resources on mental health and addictions illnesses, tools for coping, and links to services or other resources in their community, Nunavut, and Canada. All materials posted would be developed or adapted to ensure they are culturally appropriate and translated.

External Supports

The Government of Nunavut recognizes the importance of providing quality mental health care within the territory. For acute cases, however, clients often need to leave their community to receive care in Iqaluit or outside of the territory.  Thus, the Department of Health relies on external partners who can offer services remotely in order to meet the needs of communities at a local level.

For children and youth, the SickKids Tele-link Program has been a major provider for psychiatric consultations and follow-up assessments. With this program, children and youth throughout Nunavut are able to receive psychiatric support from within their community. This funding will be used to continue the program. In addition to psychiatric services, the SickKids Tele-link Program also offers professional to professional consultations and educational seminars, providing further opportunities for the department to meet professional development objectives.

This funding will be used to support new projects and initiatives with nationwide partners. For example, a pilot project is currently being discussed amongst members from various helpline organizations looking to improve access to services in remote Nunavut communities. Kids Help Phone, First Nations and Inuit Hope for Wellness Helpline, and Kamatsiaqtut Helpline are working with our department on developing strategies for serving children and youth who face barriers when accessing help. The pilot project would begin in one or two communities and would extend territorially depending on evaluation and need. There will be costs associated with travel, telecommunications, resource development and program management.

Performance Measurement

A monitoring and evaluation plan for the projects will be developed and implemented during the 2019/2020 fiscal year. This plan will measure the progress and success of program implementation both qualitatively and quantitatively. The evaluation will concentrate on project-specific indicators (see Table 2: Expected Outcomes). Ongoing evaluation over the course of the project timeline will allow for program adaptations as needed. Where possible, priority will be given to indicator measurement that aligns with the indicators developed through CIHI's common indicator project. Although Nunavut does not have a standardized data collection system for mental health and addiction health related indicators, Nunavut participated in CIHI's project for the development of common indicators and is working towards being able to report on them.

Funding Allocations

Table 1
Mental Health and Addictions
Activities 2017-18Footnote * 2019-20 2020-21 2021-22 2022-23 Total
Table 1 Footnote 1

2017-18 funds already provided through legislation.

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Table 1 Footnote 2

Allocations are notional. Funding allocations are subject to annual adjustment based on the formula described in section 4.2.3 of the Agreement. The budgeted amount for these areas will need to be flexible as bilateral funding is adjusted based on annual population estimates.

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Table 1 Footnote 3

Section 4.4.1 of the Agreement provides that, if required, Nunavut may retain and carry forward to the next Fiscal Year unexpended federal funds, subject to certain conditions.

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Program Delivery $100,000 $140,000 $230,000 $300,000 $300,000 $970,000
Professional Development and Support $40,000 $100,000 $150,000 $150,000 $440,000
External Service Provision (e.g. Contracted Services) $50,000 $90,000 $100,000 $100,000 $340,000
Evaluation $30,000 $50,000 $70,000 $70,000 $220,000
Total   $260,000 $470,000 $620,000 $620,000 $2,070,000
Table 2
Mental Health and Addictions Expected ResultsFootnote 9
Initiatives Outputs Output Indicators Outcomes Outcome Indicators Target by 2022

Expand access to community mental health and addiction services for children and youth.

Program Delivery

Professional Development and Support

External Service Provision

Number of programs running (e.g., % increase in number of programs running)

Number of individuals attending

Workforce retention (e.g., pre-/post- implementation retention)

Number of clients accessing services

Increased capacity to address mental health and addictions issues amongst children and youth at a community level

To be established when the monitoring and evaluation plan is developed in 2019.

To be established when the monitoring and evaluation plan is developed in 2019.

Footnotes

Footnote 1

Nunavut Bureau of Statistics Retrieved from: https://www.gov.nu.ca/sites/default/files/nunavut_and_canada_population_estimates_statsupdate_third_quarter_2017.pdf

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Footnote 2

2007/2008 Inuit Health Survey

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Footnote 3

Government of Nunavut. Office of the Chief Coroner. (2015). Report to the Department of Justice.

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Footnote 4

Nunavut Housing Corporation. (2016). The Blueprint for Action on Housing: Implementation Plan for the GN Long-Term Comprehensive Housing and Homelessness Strategy.  

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Footnote 5

Shirin Roshanafshar and Emma Hawkins. Health at a Glance: Food Insecurity in Canada (Ottawa, ON: Statistics Canada, March 25, 2015).

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Footnote 6

Inuit Tapiriit Kanatami (2016). Suicide Prevention Strategy, p. 17

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Footnote 7

In Nunavut, seniors and Elders, are often used interchangeably.  The term “senior” refers to an adult who has reached the age of eligibility stipulated by a program or service. This reflects the fact that care needs change with age and chronic disease progression, rather than with community status.  The term “Elder” refers to an individual with a role and status in his or her community that is not linked to age. In this action plan, both terms are used. 

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Footnote 8

Statistics Canada. (2017). Census Profile. 2016 Census. Statistics Canada Catalogue no. 98-316-X2016001. Ottawa. 

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Footnote 9

Note the specific indicators, output indicators are subject to change following further development of the evaluation and monitoring plan in 2019/20.

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