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

Table of Contents

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 -

HER MAJESTY THE QUEEN IN RIGHT OF THE PROVINCE OF ONTARIO (hereinafter referred to as "Ontario" or "Government of Ontario") as represented by the Minister of Health, and the Minister of Long-Term Care (herein referred to as "the provincial Ministers")

REFERRED to collectively as the "Parties"

Preamble

  • WHEREAS, on March 10, 2017 Canada and Ontario 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 Ontario 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 Ontario 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 Ministry of Health and Long-Term Care Act authorizes the provincial Minister to enter into agreements with the Government of Canada under which Canada undertakes to provide funding toward costs incurred by the Government of Ontario for the provision of health services which includes home and community care and mental health and addictions initiatives;
  • WHEREAS, Ontario 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 long-term care homes, and which is requiring provinces and territories to put in place additional measures to reduce the risk of harm to residents of these homes;
  • 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 homes, given the continued serious risk to health of these 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 homes through increased infection prevention and control measures and in keeping with performance measurements and reporting commitments.
  • AND WHEREAS, the Ministry of Health and Long-term Care Act authorizes 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 Ontario for activities to protect residents in long-term care homes through increased infection prevention and control measures.

NOW THEREFORE, Canada and Ontario agree as follows:

1.0 Objectives

1.1 Building on Ontario's existing investments and initiatives, Canada and Ontario 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 Ontario commit to collaborate in order to further improve access to safe care through increased infection prevention and control in long-term care homes.

2.0 Action Plan

2.1 Ontario 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 Ontario'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 Ontario will invest the federal Safe Long-term Care Funding provided under this Agreement on infection prevention and control activities in long-term care homes in 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 and measures such as surveillance testing conducted in long- term care homes to prevent COVID infections and spread.

2.4 In addition, Ontario may also invest the federal Safe Long-term Care Funding through this Agreement on infection prevention and control activities in long-term care homes 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 homes.

2.5 Ontario’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 Ontario for expenditures that are incurred from December 1, 2020, to March 31, 2022.

3.3 Renewal of Bilateral Agreement

3.3.1 Ontario'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 Ontario and Canada's agreement on a new five-year Action Plan.

3.3.2 The renewal will provide Ontario 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 to and not in lieu of those that Canada currently provides to Ontario under the Canada Health Transfer to support delivering health care services within their jurisdiction.

4.2 Allocation to Ontario

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

Safe Long-term Care

  1. $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. The total amount to be paid to Ontario 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 July 1, 2021 annual population estimates from Statistics Canada; and,
  • L is the total population of Canada, as determined by the July 1, 2021 population estimates from Statistics Canada.

4.2.4 For the purposes of the formula in section 4.2.3, the population of Ontario 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 for home and community care and mental health and addiction services, Ontario's estimated share of the amounts will be:

Annual Funding for Home and Community Care and Mental Health and Addition Services
Fiscal Year Home and community care
Estimated amount to be paid to Ontariotable 1 note *
(subject to annual adjustment)
Mental health and addictions services
Estimated amount to be paid to Ontariotable 1 note *
(subject to annual adjustment)
2018-2019 $231,990,000 $96,660,000
2019-2020 $251,330,000 $173,990,000
2020-2021 $251,330,000 $231,990,000
2021-2022 $347,990,000 $231,990,000

Table 2 Notes

Table 1 Note *

Amounts represent annual estimates based on StatCan 2017 population

Return to table 1 note * referrer

4.2.6 Subject to annual adjustment based on the formulas described in subsection 4.2.3, Ontario’s estimated share of the amounts will be:

Fiscal Year

Safe Long-Term Care

Estimated funding amount for Ontario*

2021-2022 $379,575,486

For Safe Long-term Care Funding, amounts represent annual estimates based on StatCan 2021 population.

4.3 Payment

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:

  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 Ontario for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
  4. Canada will notify Ontario 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 Ontario 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.
  5. Canada shall withhold payment of the second installment for the Fiscal Year if Ontario 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.

4.3.2 Canada’s contribution for Safe Long-term Care will be paid in approximately equal semi- annual installments as follows:

  1. The first installment will be paid within 30 days of Canada’s acceptance of Ontario’s proposed approach and initiatives for the use of the Safe Long-term Care Funding, as set out in Annex 2.
  2. The second installment will be paid, following Ontario’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 Ontario fails to have 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 Ontario to those homes with whom they do not have the required cost-recovery agreements in place.

4.4 Carry Over

4.4.1 At the request of Ontario, Ontario may retain and carry forward to the next Fiscal Year the amount of up to 10 percent of the contribution paid to Ontario for a Fiscal Year under for home and community care and mental health and addictions services under subsection 4.2.5, and up to 10 percent of the contribution paid to Ontario for a Fiscal Year for Safe Long-term Care under subsection 4.2.6 that is in excess of the amount of the eligible expenditures actually incurred by Ontario 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 Ontario to retain and carry forward an amount exceeding 10 percent as set out in this subsection 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 Ontario 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 Ontario, Ontario 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 Ontario 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 Ontario exceed the amount to which Ontario is entitled under this Agreement, the amount of the excess is a debt due to Canada and, unless otherwise agreed to in writing by the Parties, Ontario shall repay the amount within sixty (60) calendar days of written notice from Canada.

4.6 Use of Funds

4.6.1 Canada and Ontario agree that funds provided under this Agreement will only be used by Ontario 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 Ontario agree that amounts paid to Ontario under the Safe Long-term Care Fund may be provided by Ontario to long-term care homes operated in accordance with the Long-Term Care Homes Act, 2007 (Ontario) or any successor legislation.

4.8 Cost Recovery

4.8.1 Where Ontario provides Safe Long-term Care Funding to municipal, non- profit and for- profit long-term care homes, in accordance with this Agreement, Ontario agrees to reconcile funding as per the terms of its current cost-recovery agreements with these homes and report on these agreements through amendments to Annex 2 by no later than March 31, 2023 in accordance with the requirements set out in subsection 5.1.4.

4.8.2 Where Ontario has cost-recovery agreements in place pursuant to subsection 4.8.1, Ontario agrees to invest 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, Ontario 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. Ontario will designate an official or official(s), for the duration of this agreement, to work with CIHI and represent the interests of Ontario 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, Ontario 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 2019-2020, 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 Ontario'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 Ontario 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.
  3. For the Safe Long-term Care Funding, the annual financial statement will also set out, for the previous Fiscal Year:
    1. The amount of the federal funding flowing to long-term care homes and how long- term care homes will use the funding for the intended purpose, in alignment with the Safe Long-term Care Fund (as set out in 4.7.2)

5.1.3 As a condition of receiving the second payment installment of the Safe Long-term Care Funding, Ontario agrees to, by no later than March 31, 2022, amend Annex 2 to:

  1. Provide up-to-date information on performance measures, targets and intended outcomes for the applicable three areas identified in section 2.3, and for any other areas in which Ontario has used Safe Long-term Care Funding to support infection prevention and control, and interim results for each initiative.
  2. Indicate the amount allocated by eligible expense category and describe the impact that will be achieved through these investments;
  3. Provide information on the estimated amount of funding to be recovered pursuant to the cost-recovery agreements; and,
  4. Indicate how Ontario will use recovered funding to increase infection prevention and control pursuant to the terms of this Agreement.

5.1.4 Ontario also agrees to amend Annex 2, by March 31, 2023, to report:

  1. In accordance with the performance measures set out in Annex 2, on the outcomes and results achieved using the Safe Long-term Care Funding; and,
  2. The results of Ontario’s reconciling of funding as per the terms of its current cost- recovery agreements with homes, as outlined in 4.8.1.

5.2 Audit

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

5.3 Evaluation

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

6.0 Communications

6.1 Canada and Ontario 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 and Ontario may 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 Ontario website.

6.4 Canada, with prior notice to Ontario, 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 Ontario into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

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 Ontario 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 Ontario 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. Ontario 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 Ontario 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 Ontario 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 Ontario, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Ontario 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 Ontario responsible for health or long-term care, as appropriate, and if it cannot be resolved by them, then the respective Ministers of Canada and Ontario most responsible for Health or long-term care, as appropriate 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 Ontario, by Ontario’s Minister of Health and in the case of the Safe Long-term Care Fund, Ontario’s Minister of Long-Term Care.

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 Ontario, 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 Ontario, 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 Ontario, if requested by Ontario. 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.

10.0 Termination

10.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Ontario by giving at least 12 months written notice of its intention to terminate. Ontario 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 Ontario 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 Ontario shall be:

Ministry of Health and Long-Term Care
80 Grosvenor Street, 10th Floor, Hepburn Block
Toronto, Ontario
M7A 1R3

Email: patrick.dicerni@ontario.ca

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 Ontario.

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

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 this 23 day of January, 2019.

The Honourable Ginette Petitpas Taylor, Minister of Health

SIGNED on behalf of Ontario by the Minister of Health and Long-Term Care this 23 day of January, 2019.

The Honourable Christine Elliott, Minister of Health and Long-Term Care

Annex 1 to the Agreement

Common Statement of Principles on Shared Health Priorities

Annex 2 to the Agreement:

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

Introduction

Ontario's health care system serves over 13 million Ontarians at various stages of their lives. Ensuring that Ontarians can rely on the province's publicly funded health care system - when and where they need it - is a government priority.

Ontario has been focused on building capacity in community settings. Success to date has relied on the shift towards care provided in the home and community.

Ontario is committed to ensuring that the delivery of health care is fair and easier to access, particularly as the system supports an aging population. Strategic investments, pursuit of efficiencies, and health care transformation, will strengthen the continuum of care, while also building capacity in the community, including home care and mental health and addictions services.

Ontario's funding agreement with the federal government to improve access to home and community care and mental health and addictions services will support the significant investments Ontario is already making in these health priority areas.

Home and Community Care

Overview of Home and Community Care in Ontario

Home and community care services are provided through Ontario's 14 Local Health Integration Networks (LHINs).

Home and community care services support people who need nursing, personal support or other health supports in their homes, at school or in the community. With these supports, seniors and people of all ages with complex medical conditions can often stay in their own homes, or be cared for in the community longer. Home care can also help provide a smooth transition for people who need support after returning from a stay in hospital, rehabilitation or another health care setting.

The total number of home care clients has increased by almost 20 per cent in the past 10 years. The government has increased its investment in home and community care by approximately $250 million per year since 2013. These funding increases have helped to address rising demographic pressures from a growing and aging population; and help more people get the care they need at or close to home and in the community.

Ongoing funding of approximately $3 billion annually now provides about 670,000 clients and their families with greater access to home and community care services from health care professionals like registered nurses, physiotherapists, social workers, registered practical nurses and personal support workers. This investment also supports other important services, such as caregiver respite and palliative and end-of-life care, delivered in residential hospices, in patients' homes, and in hospitals.

Preparing for the Road Ahead: Case for Action

Ontario is facing a number of trends with significant implications for the home and community care sector. The increasing number of seniors in Ontario and increasing client complexity, along with changing client expectations and preferences, require continued transformation and investment in the home care sector to ensure that it continues to meet the needs of Ontarians.

Impact of aging on the health system compounded by the prevalence of chronic and complex diseases; home care clients are rising in acuity

  • Seniors (65 years and older) are the fastest growing age group in Ontario. In 2016, 16.4% of Ontario's population was 65 years or older. By 2041, it is projected that 25% of Ontario's population will be 65 years or older, almost doubling from 3 million seniors in 2016 to 4.6 million seniors.Footnote 1
  • From 2007-08 to 2016-17, the number of high needs seniors cared for by home care increased by 114% (from about 42,000 to about 90,000); this trend of more complex patients served by home and community care is expected to continue.Footnote 2
  • Complex clients with high needs often require more service than those traditionally supported at home, in particular personal support services, in order to continue living independently in their homes.Footnote 3

Changing client preferences and expectations

  • Clients and caregivers often note service delivery could be better coordinated and made more convenient for the client and family.Footnote 4

Increased public interest in palliative care

  • Not all Ontarians who would benefit from palliative home care are currently receiving it. Fewer than half (43.3%) of dying clients receive palliative home care services in the last month of their lives.Footnote 5

Increasing caregiver burnout and stress

  • Caregivers of long-stay home care patients who experienced distress, anger or depression, or who were unable to continue in that role, increased from 21.2% in 2012-13 to 43.4% in 2017-18.Footnote 6
Ontario's Vision

Ontario will continue improving the home care client experience today, while building a dynamic home care system prepared for the clients of tomorrow. Home care will provide the care people need effectively, while ensuring that home care is a reliable partner for our hospitals and primary care providers so we can reduce the pressure on hospitals and long-term care homes.

Ontario will leverage federal funding to invest $180 million in new funding in 2018 that will make available an estimated 2.8 million more hours of personal support, including caregiver respite; plus 284,000 more nursing visits; and 58,000 more therapy visits. These investments will provide clients and their families with expanded services to meet the needs of the rising number of seniors and others requiring home care, and the additional services required for home care clients with more complex needs. They will also help clients with complex needs leave the hospital and return home to appropriate home care when they are ready, and will help them avoid unnecessary emergency department visits and hospital readmissions.

Areas for Investment and Expected Outcomes

The following areas for investment will be supported by federal funding and are consistent with the Common Statement of Principles on Shared Health Priorities.

  1. Expanding Access to Home Care (includes palliative and end-of-life care)
  2. Caregiver Supports
  3. Information Technology

A description of specific initiatives under each area and their expected outcomes are provided below.

1. Expanding Access to Home Care

Ontario is investing to keep pace with the growing number of home care clients and to better respond to their needs. Of the $180 million new investment in home care in 2018, approximately half will support the growing number of home care clients based on modelling population growth and trends in service allocations. This funding will support all client types and services, including nursing, therapies, personal support and care coordination. The other half of this investment - $90 million - is intended to begin to enhance care for high needs clients.

Ontario is also expanding residential hospice capacity through capital and operating investments. In addition, the ministry is exploring other opportunities to enhance access to community-based palliative care, including the initiatives noted below.

Beginning in 2017-18, the ministry made new base funding investments to ensure urban Indigenous and First Nations people have access to more home and community care services. The total investment was approximately $10 million in 2017-18, increasing to approximately $19 million in 2018-19 and ongoing. This will ensure that First Nations and Indigenous people have access to more culturally appropriate care and improved outcomes. Funding is intended to support Indigenous communities as they direct new funding to areas most in need while recognizing historical barriers to access to health care, particularly in the north. The allocation of the home and community care investment is based on a dialogue and partnership between the ministry and Indigenous organizations.

As a result of this engagement and to reflect the nation-to-nation approach to reconciliation, investments are being made directly by the ministry to Indigenous organizations and First Nations communities. Funding can be used for any eligible home care and community service under the Home Care and Community Services Act, 1994.

Federal funding will support:

  • Increased base investment to align home care services with needs resulting in the following estimated new services:
    • 2,541,000 more hours of personal support;
    • 464,000 more nursing visits; and
    • 95,000 more therapy visits.

With more effective delivery, home care will be able to provide more care.

  • Enhanced support for palliative and end-of-life care, including:
    • Additional supports for palliative and end-of-life care in the community, including both in home care and services in congregate settings such as residential hospices.
    • Implementation of cross-sector models of palliative and end-of-life care.
  • New base funding to improve access to home care services in Indigenous communities across Ontario. This includes funding for 125 First Nations communities and three urban Indigenous organizations with service delivery sites across Ontario. Funding is intended to complement, not replace, federal funding for home care services and LHIN-funded services.

This aligns with the following actions in the Common Statement of Principles on Shared Health Priorities:

  • Spreading and scaling evidence-based models of home and community care that are more integrated and connected with primary health care;
  • Enhancing access to palliative and end of life care at home or in hospices.

Expected Outcomes

  • Increased care for those who need it, such as people with complex needs.
  • Increased number of patients dying in the setting of their choice.
  • Higher quality care for clients and a better experience for both clients and caregivers.
  • Improved integration and coordination of home and continuing care with primary care and acute care.
  • More complex clients are transitioned from hospital to home; prevent or delay admission to long-term care homes.
  • Reduced use of hospitals for people in the final weeks of life as palliative care improves in the community and clients develop advance care plans.
  • Improved access to home and community care services in First Nations and Métis communities.
2. Caregiver Supports

Ontario is expanding caregiver education and training. In 2018, the province established an arm's-length organization to improve the caregiving experience by providing a centralized place where caregivers can go to seek a range of supports and services. The organization will also provide oversight and guidance over the implementation of caregiver initiatives; will play a role in helping to identify gaps in caregiver services and supports within and between LHINs; and will facilitate solutions to fill these gaps.

The ministry will also work with LHINs and the Ministry of Children, Community and Social Services (MCCSS) to improve transitions and enable coordination of services and increase linkages with the developmental disabilities sector.

Federal funding will support:

  • Additional caregiver supports, including education, training and resources (e.g., link to peers in their community and development of programs where there are gaps).
  • Enhanced support to navigate existing services and resources (e.g. guidance on the most appropriate services and assistance to find services and organizations).
  • Additional caregiver in-home respite through an increase in base investments in home and community services. This is on top of other respite and caregiver supports allocated in the context of the broader expansion of access to home and community care and associated increases in service amounts for some clients and families.

This aligns with the following action in the Common Statement of Principles on Shared Health Priorities:

  • Increasing support for caregivers.

Expected Outcomes

  • Reduced caregiver distress and improved caregiver capacity.
  • Continued ability of caregivers to deliver about $10 billion worth of care each year.
  • Delayed long-term care home admissions due to reduced caregiver distress.
  • Caregivers are provided with a single point of access to information, referral and navigation services so they can get the support they require to care for themselves and their loved ones.
3. Information Technology (IT)

The public increasingly expects that the digital innovations that provide convenience in their daily lives are adopted and utilized in health care. Clients and families seek the ability to understand what services they can expect from home and community care using digital tools including for self-assessment; to view and schedule their care provider appointments; to collaborate with their care team with access to their care plan and plain language summary of assessment; and to adopt virtual care tools including telemedicine and remote monitoring devices in their homes that are flexible to their needs.

Care providers are seeking to better support the clients they serve with strengthened IT systems that improve care planning by ensuring providers have the information they need to provide the best client care and can work effectively with other partners in the health system.

Federal funding will support:

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

This aligns with the following actions in the Common Statement of Principles on Shared Health Priorities:

  • 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; and
  • Increasing support for caregivers.

Expected Outcomes

  • Patients and caregivers are able to be partners in managing their health needs.
  • Improved integration of care teams.
  • Improved communication with clients and caregivers.
  • Improved quality of care, particularly in rural and remote communities.
Expenditure Plan 2017-18 to 2021-22
Funding Breakdown by Initiative 2017/18table 2 note *
($M)
2018/19table 2 note **
($M)
2019/20table 2 note **
($M)
2020/21table 2 note **
($M)
2021/22table 2 note **
($M)
Total
($M)
1. Expanding Access to Home Care, includes palliative and end-of-life care 57.07 211.99 226.33 226.33 322.99 1,044.71
2. Caregiver Supports 20.00 20.00 20.00 20.00 20.00 100.00
3. Information Technologytable 2 note *** 0.00 0.00 5.00 5.00 5.00 15.00
Total Federal Funding for Ontario - Home and Community Care 77.07 231.99 251.33 251.33 347.99 1,159.71
Table 2 Notes
Table 2 Note *

Funding already provided through legislation

Return to table 2 note * referrer

Table 2 Note **

Allocations are notional. Funding allocations are subject to annual adjustment based on the formula described in section 4.2.3 of the Agreement.

Return to table 2 note ** referrer

Table 2 Note ***

Decisions regarding palliative information technology allocations are to be determined.

Return to table 2 note *** referrer

Data Collection and Common Indicators

Performance and outcome data for home care is collected through a number of sources:

  • Data from Resident Assessment Instrument - Home Care (RAI-HC) assessments.
  • Client Health and Related Information System (CHRIS), an IT system used by Ontario's LHINs for home and community care.
  • Client and Caregiver Experience Evaluation Survey (via telephone). This is currently being reviewed with the aim of updating the survey by 2019.

Health Quality Ontario (HQO) also reports health system indicators publicly on its website (http://www.hqontario.ca/System-Performance/Home-Care-Performance).

As of March 29, 2018, the 11 public indicators on their website are:

System Performance Indicators
Theme Measures
Home care clients waiting for services
  • Clients receiving nursing services within five days
  • Clients with complex needs receiving personal support within five days
Care and client experience in home care
  • Client experience with home care
  • Home care clients with communication problems
  • Home care clients who fell
  • Home care clients with pressure ulcers
  • Home care clients who did not receive a flu vaccine
  • Home care clients with incontinence
Getting care elsewhere
  • Hospital readmissions for new home care clients
  • Emergency department visits by home care clients
  • Moving to a long-term care home

Health Quality Ontario, working with an expert panel, is in the process of reviewing and updating the publicly reported home care indicators to ensure that they continue to meet the criteria of strong public reporting indicators.

As part of this and future indicator review cycles, new or revised indicators will be included to understand:

  • Adequacy of service provided.
  • Whether patients are able to have more days at home - including, as part of end of life care, potentially using measures of patients discharged from hospital with home support, and unplanned emergency department visits by home care clients in the last month of life.
  • The balance between patients served by home and community care, as opposed to long-term care, potentially using measures such as the number of high needs clients being served in the community (measured by MAPLe score which is derived from RAI-HC assessments).
  • Caregiver distress and interventions that reduce it.

Ontario has worked closely with the CIHI-PTFootnote 7 Working Groups for Performance Measurement of FPT Shared Health Priorities to develop common indicators in home and community care. Ontario will continue to work with CIHI to refine and implement the selected indicators.

Consistent with the announcement made by FPT health ministers on June 29, 2018, Ontario approves of the set of common indicators, which were developed with the Canadian Institute for Health Information to measure pan-Canadian progress in home and community care.

Note that with the mutual consent of the parties to this Agreement, Annex 2 for Home and Community Care may be revised to reflect indicator development, for more effective reporting; and to align with annual provincial budgets.

Mental Health and Addictions

Overview of Mental Health and Addictions in Ontario

Mental health and addictions (MHA) issues have emerged as one of the most serious health and social challenges facing families, children and youth. The Ministry of Health and Long-Term Care is committed to promoting positive mental health and well-being by building a comprehensive mental health and addiction system that ensures children, youth, and adults in Ontario receive appropriate services where and when they need them.

The ministry does this by setting provincial policy direction for publicly funded mental health and addictions services. This includes provincial funding and planning for:

  • Prevention and promotion activities for mental health and addictions issues;
  • Mental health and addictions services in community settings, including residential programs and specialized mental health services such as eating disorders;
  • OHIP physician billing for primary care and psychiatry as well as mental health staff in inter-professional care teams, and;
  • Acute mental health services in a hospital.

The ministry's current annual mental health and addictions system spending is over $4 billion per year. This supports 241 children and youth mental health organizations, 380 community mental health and addictions agencies, care provided at 60 general hospitals with mental health and addictions designated beds and 4 stand-alone psychiatric hospitals.

MHA services delivered outside of in-patient hospital programs and primary care settings are referred to as "community-based" MHA services. The ministry funds community-based mental health and addictions programs and services through the province's 14 Local Health Integration Networks. Additionally, the ministry provides almost 17,000 units of supportive housing for people living with mental health and addictions issues, and other vulnerable people.

The ministry is also working with stakeholders, including service providers, to implement a comprehensive set of policies and programs to address opioid addiction and overdose. Since 2017, commitments related to Ontario's Opioid Strategy are underway to combat the devastating impact that the opioid crisis has had on individuals, families, and communities across the province. Ontario's response has been focused on improving the treatment of pain, enhancing addictions treatment and services, expanding access to harm reduction and supplies, and improving surveillance and reporting of opioid overdoses. This includes investments to expand access to withdrawal management and residential and community treatment services for young people and adults living with addictions in Ontario.

The system also includes problem gambling programs that serve adults and youth with gambling problems and their families, prevention, community counselling and residential treatment.

Preparing for the Road Ahead: Case for Action

The ministry is developing a comprehensive and connected multi-year mental health and addictions strategy to address key challenges in Ontario's MHA system. There are countless indications of the emergence of MHA as one of the most serious health and social issues facing the province, for example:

  • Two-million Ontarians visit their family doctor every year for MHA-related reasons.Footnote 8
  • About 158,000 people visited an emergency department for MHA-related reasons in 2016-17, representing a steady increase each year from 113,000 visits in 2008-09.Footnote 9
  • Up to 70% of young adults with serious mental health issues report that their symptoms began in childhood/adolescence.Footnote 10
  • In 2016-17, 130,000 unique clients (children and youth) were served in children and youth mental health agencies, a 7% increase from the previous year.
  • In 2017, there were 1,261 recorded opioid-related deaths. This is a 45% increase from the number of deaths in 2016.Footnote 11
  • 19% of Ontarians experience a substance use disorder in their lifetime. Opioids, alcohol, and cannabis are the three most commonly misused substances.Footnote 12
  • 40% increase in psychosis related to cannabis use. Cannabis legalization is expected to result in an increased need for early psychosis intervention services for youth.Footnote 13
  • Youth 18-24 have the highest rates of high risk drinking, alcohol dependence, cannabis use and non-medical opioid use. Youth-specific treatment is limited and withdrawal management services (detox) are non-existent.Footnote 14
  • Access to some evidence-based publicly funded services (e.g., psychotherapy, developmentally appropriate youth addictions programs) is severely limited.
  • Additional supports for cost effective prevention, promotion and early intervention initiatives, when treatment is often most effective, are needed to meet demand.
  • The presence of serious mental illness in the prison population is more than four times higher than in the broader community.
  • There is a significant demand for mental health and addictions supportive housing across the province with upwards of 90,000 additional units needed to meet demand.

There are necessary system changes that must take place to improve people's experience accessing services and to improve oversight and accountability within the system. Some of the biggest issues currently facing our mental health and addictions system include:

  • High Wait Times and Limited Service Capacity - Demand for mental health and addictions services exceeds funding and service gaps exist for critical services (e.g. supportive housing, youth addictions).
  • Barriers to Access - Ontarians do not know what services are available or where to get help due to a lack of transparency about the service system and poor coordination between primary care, hospitals, schools, and community-based services.
  • Uneven Service Quality - The quality of services varies from provider to provider and from region to region. Services are not always based on the best evidence and current professional thinking.
  • Lack of Data - Ontarians, service providers and system planners do not have access to the information they need, limiting effective oversight and accountability and scaling of best practices.
  • Fragmented System - The care continuum is highly fragmented, spanning from hospitals to primary care to community agencies. Poor coordination across the parts of the continuum results in inefficiencies and poor client experience as people struggle to navigate this complex service space.

An all-party Select Committee on MHA (2010), the Auditor General of Ontario (2016-17) and front-line system leaders have all recommended similar actions to build a comprehensive mental health and addictions treatment system. For example, all three of these groups highlighted the importance of investing in services as a key component of system renewal.

  • The Select Committee called on the government to invest in peer support, child and youth services, services for Indigenous people, supportive housing, mental health and justice programs, and mobile crisis intervention teams to reduce wait times.
  • The Auditor General called on the government to invest in supportive housing and child and youth mental health services.
  • Front-Line and System Leaders called on the government to invest in prevention and promotion, structured psychotherapy, youth addictions and supportive housing.
Ontario's Vision

Ontario's government has committed to match federal funding from this bilateral agreement for a total investment of $3.8 billion over 10 years. The investment will create an Ontario where everyone is fully supported in their journey toward mental wellness thanks to a comprehensive and connected mental health and addictions treatment system - a system where Ontarians with mental illness and/or addictions can recover with the support of high-performing, high-quality, accessible, effective and recovery-oriented services.

Ontario has been working to identify how and where to target new investments by the province, matched together with federal funding, to improve the mental health and addictions sector as demand for these services continue to increase.

Accordingly, Ontario is developing and will implement a multi-year plan for a comprehensive and cost effective mental health and addictions treatment system that includes action on client experience and outcomes, access, service quality, and resource optimization. The four key outcomes of the government's commitment on MHA will include:

  • People: Services that improve client experience and outcomes.
  • Access: A comprehensive, streamlined and connected treatment system gives Ontarians the services and supports they need, when and where they need them.
  • Quality: The same, high-quality services and supports, no matter where you are in the province.
  • Resource Optimization: A strategic approach that deploys funds across the entire mental health and addictions service continuum, with a focus on upstream prevention and resource optimization (and addresses hallway health care).

There is an urgent need to put capacity into the system where there are critical service gaps while the details of the multi-year strategy are being developed. Priority areas have been identified through consultations with front-line providers, the public and by reviewing evidence; and will benefit from new provincial and federal investments.

  • Reduce wait times for community services;
  • Enhance opioids and addiction services;
  • Create additional supportive housing;
  • Build capacity for child and youth mental health; and
  • Invest in services for indigenous people.

As the multi-year plan is still in development, out-year funding allocations may be revised during the term of this agreement.

Areas for Investment and Expected Outcomes

The following areas for investment will be supported by federal funding and are consistent with the Common Statement of Principles on Shared Health Priorities.

  1. Child and youth community-based mental health and addictions services
  2. Community-based core mental health and addictions services
  3. Integrated community-based mental health and addictions services for people with complex needs

A description of specific initiatives under each area and their expected outcomes are provided below.

1. Child and Youth Community-based Mental Health and Addiction Services

Children and youth in Ontario continue to face barriers accessing mental health and addictions services. There has been a 56% increase in hospitalizations and 53% increase in emergency department visits for mental health and addictions care for children and youth; and rates of emergency department visits are highest in Ontario for ages 18 to 24.Footnote 15

Transitional aged youth (16-25 years) face additional challenges as they move from child and youth to adult services. Often, services are not available due to wait listsFootnote 16 or services are not developmentally appropriate or acceptable to youth.

A Youth Services System Review and mapping exercise in 2016 identified developmentally appropriate withdrawal management services as a key service gap, along with community and residential treatment services. Many leaders in the sector have long advocated for the province to make significant investments in a range of youth addictions services.

Additional resources are especially needed to help intervene early and prevent illness. For example, Ontario does not have any prevention or early intervention services for disordered eating for children and youth, yet rates of diagnosable eating disorders among adolescent girls and young women is as high as 5%. More males also have body image problems and disordered eating. As well, clinicians are reporting earlier onset, with children as young as seven years presenting at eating disorders treatment programs.Footnote 17

Ontario has recently revised its public health standards to include mental health promotion. While Ontario's public education system is leading the way for mental health promotion in schools, there is no similar initiative in post-secondary institutions, and capacity across the province to deliver these services to older youth is limited.

To help address these challenges, this area of investment aims to expand access to children and youth community-based mental health and addictions services as well as targeted mental health promotion, prevention and early intervention services that are evidence-based, and culturally and developmentally appropriate.

Federal funding will support:

  • Child and youth mental health services to reduce wait times by enhancing community-based child and youth mental health services and supports, including cost-effective early intervention services, as well as intensive treatment services.
  • Strengthening youth addictions services by adding developmentally appropriate withdrawal management services for youth; increasing capacity for residential treatment services for youth in areas of the province that do not currently have those services; and enhancing developmentally appropriate community treatment.
  • Implementing a new province-wide Eating Disorders Early Intervention Program that will use targeted prevention, mental health promotion, early identification and early intervention services to address body image, disordered eating and early-stage eating disorders in children, youth and young adults.
  • Build on campus mental health and addictions supports by providing dedicated funding for postsecondary institutions to partner with community-based mental health and addictions providers and public health agencies to improve access and create more integrated mental health and addictions supports for postsecondary students.
  • Enhancing capacity to respond to the needs of students in schools through expansion of early identification and assessment of student and improve linkages to services in the community when needed.
  • Enhancing integrated services for youth through Youth Wellness Hubs, community centres where youth aged 12 to 25 have walk-in access to mental health and addictions services, as well as other services, including primary care.

This aligns with the following actions in the Common Statement of Principles on Shared Health Priorities:

  • Expanding access to community-based mental health and addictions services for children and youth (aged 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 health needs.

Expected Outcomes

  • Increased capacity to respond to the mental health needs of children and youth.
  • Increased access to addictions services across Ontario for youth.
  • Improved addiction treatment outcomes by providing developmentally appropriate services to youth.
  • Reduction in the anticipated increased burden on the health system following the legalization of cannabis.
  • Greater personal, social and economic benefits including improved wellbeing by intervening at this age than with interventions later in the lifespan.
  • Decreased risk of morbidity and premature mortality, reducing the large economic burden of untreated MHA issues on the health system.
  • Prevention, early identification and intervention in disordered eating and eating disorders will result in higher rates of treatment success and improved well-being.
2. Community-based Core Mental Health and Addiction Services

Ontario is committed to addressing critical service gaps and maintaining an ongoing focus on prevention, promotion and early intervention. The most impactful return on investment lies in promoting wellness, preventing mental illness and addictions, and intervening early when problems arise. However, work still needs to be done to address gaps between the demand for services and what is available. While the province currently spends approximately $1.6B for community mental health and addictions services, and in 2017 invested more than $140M over three years to address these gaps, additional investments will support the expansion of services to fill critical service gaps across the lifespan, including addictions services, early psychosis intervention and inequities in health services for diverse and marginalized populations.

Federal funding will support:

  • Increasing access to structured psychotherapy and counselling support programs for people with mild to moderate anxiety and depression by expanding three evidence-based modalities of structured psychotherapy, including online, self-guided support programs, and in-person therapy; as well as enhancing supports for individuals receiving social assistance.
  • Expanding addictions services for adults, with a focus on addressing opioids, alcohol and cannabis, including treatment for poly-substance use and concurrent (mental health and addictions) disorders. Services will include additional staffing for community and residential withdrawal management and treatment services, as well as peer support services. Service enhancements would address service gaps across the province and increase equitable access to addiction services.
  • Increasing access to Early Psychosis Intervention (EPI) programs, which are specialized community programs that serve people between the ages of 14 and 35 who are experiencing symptoms of psychosis and have received no treatment, or have received less than 12 months of treatment for psychosis. Federal funds will add capacity, including new staffing resources, to EPI programs across the province, fill gaps where services do not currently exist, and allow for comprehensively supporting EPI clients with cannabis and other substance use issues.
  • Expanding programs for priority populations by increasing existing services and creating new services targeted at priority populations in their regions, including racialized, immigrant, refugee, French-speaking, and LGBTQ2S populations.

This aligns with the following actions in the Common Statement of Principles on Shared Health Priorities:

  • Spreading evidence-based models of community mental health care and culturally-appropriate interventions that are integrated with primary health services;
  • Expanding availability of integrated community-based mental health and addiction services for people with complex health needs; and,
  • 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.

Expected Outcomes

  • Increased access to a wide variety of adult addictions services across Ontario.
  • Increased availability of peer support services in the community MHA sector.
  • Increased access to publicly-funded structured psychotherapy services.
  • Increased access to services for those experiencing cannabis/opioid use disorder and poly-substance use issues.
  • Increased capacity to meet the anticipated increase in demand for Early Psychosis Intervention services related to cannabis legalization.
  • Decreased rates of hospitalization for young people with psychosis.
  • Reduced pressures on unplanned emergency visits and other higher-cost components of the health system through early intervention.
  • Decreased risk of morbidity and premature mortality, reducing the large economic burden of untreated mental health and addictions issues on the health system.
3. Integrated Community-based MHA Services for People With Complex Needs

Poverty, homelessness, mental health concerns and needs, and addictions lead many people into conflict with the law. In fact, people with mental health issues are over-represented in the justice and corrections system; and are over-represented in courts and tend to have burdensome judicial and mental health histories. At the same time, there is an ongoing need for supportive housing as a permanent solution to homelessness - especially for people with mental health and addictions issues.

Furthermore, existing pediatric and adult eating disorders intensive programs across the province are very limited, with only five sites across Ontario, with none in the north. Investments will be made to support significant expansion in the availability and access to integrated-community mental health and addiction services for people with complex health and social needs.

Federal funding will support:

  • Increasing capacity of mental health and justice teams to respond to people with mental health and addictions issues by supporting Mobile Crisis Rapid Response, expanding hostel outreach programs, and hiring more case managers to work with people with mental health and addictions issues who are involved with police or the justice system. Ontario will also build capacity to better support police and first responders through expansion of mental wellness programs.
  • Increasing supports in supportive housing units: Supports, such as daily living supports and case management, are essential for people with serious mental health and addictions issues to live as independently as possible in permanent affordable housing. Federal funds will support the development and provision of new supports for clients with mental health and addictions issues.

This aligns with the following actions in the Common Statement of Principles on Shared Health Priorities:

  • Expanding availability of integrated community-based mental health and addiction services for people with complex health needs.

Expected Outcomes

  • Fewer contacts with the justice system and reduced incarcerations and recidivism among individuals with MHA issues currently involved with the justice system.
  • Mental health and addictions supports for clients in supportive housing units.
  • Improved access to supports for suitable, affordable housing and housing stability for people with mental health and addictions issues.
  • Reduced homelessness for those with MHA issues.
  • Increased capacity to support clients with high acuity, chronic, complex and/or severe needs in relation to their eating disorders, and reduced use of expensive, private health care providers by Ontarians.
  • Decreased wait lists for intensive specialized eating disorders services, freeing up outpatient and community services for clients with less intense service needs.
  • Decreased wait lists will also result in lowered rates of premature mortality among those with eating disorders, particularly those with Anorexia Nervosa.
  • Increased presence of Indigenous voices in planning, delivery and coordination of MHA services along the patient journey.
  • Improved patient experience.
  • Improved access to care and better transitions between care providers.
  • Ability to address spiritual needs and provide culturally safe care.
Expenditure Plan 2017-18 to 2021-22
Funding Breakdown by Initiative 2017/18table 4 note *
($M)
2018/19table 4 note **
($M)
2019/20table 4 note **
($M)
2020/21table 4 note **
($M)
2021/22table 4 note **
($M)
Total
($M)
1. Child and Youth Community-based MHA Services (e.g. early psychosis intervention, youth addictions treatment) 15.49 33.20 66.82 74.85 74.85 265.21
2. Community-based Core MHA Services (e.g. counselling and psychotherapy, adult addictions treatment) 17.65 49.14 73.15 78.72 78.72 297.38
3. Integrated community-based MHA services for people with complex needs (e.g. supportive housing, justice supports) 5.4 14.32 34.02 78.42 78.42 210.58
Total Federal Funding for Ontario - Mental Health and Addictions 38.54 96.66 173.99 231.99 231.99 773.17
Table 4 Notes
Table 4 Note *

Funding already provided through legislation.

Return to table 4 note * referrer

Table 4 Note **

Allocations are notional. Funding allocations are subject to annual adjustment based on the formula described in section 4.2.3 of the Agreement.

Return to table 4 note ** referrer

Data Collection and Common Indicators

Performance and outcome data is collected and reported through various sources including:

  • Ontario Health Care Reporting System (OHRS) - All health service organizations' financial and statistical data is stored in a central database that is standardized, comparable, reliable, timely and usable. Yet data quality and integrity has been compromised by varying interpretations of reporting standards.
  • Ontario Mental Health Reporting System (OMHRS) - analyzes and reports on information submitted to CIHI (about all individuals receiving adult mental health services in acute care, as well as some individuals receiving services in youth inpatient beds and selected facilities in other provinces). OMHRS includes information about mental and physical health, social supports and service use, as well as care planning, outcome measurement, quality improvement and case-mix funding applications. OMHRS comprehensive data is collected using the Resident Assessment Instrument - Mental Health (RAI-MH) version 2.0, a standardized clinical instrument used to regularly assess those receiving inpatient mental health care.

Ontario is also working to improve the quality of data collection and reporting across the mental health and addictions system through various initiatives, including:

  • Ontario's multi-year Mental Health and Addictions Data-Digital Strategy which aims to standardize, streamline, and centralize data that would address a continuum of purposes, from enabling integrated care and improving collaboration among providers to supporting service planning and system transformation. A performance measurement framework for Ontario's MHA system is also in development, leveraging the work of the Mental Health and Addictions Leadership Advisory Council.
  • The Mental Health and Addictions Access to Care Initiative (ATC) - a partnership among specialty psychiatric hospitals - aims to address significant gaps in access to care by using data from four hospitals to track specific wait times, identify service gaps, and build a structure for public reporting and accountability. The ATC project has been extended for another year to refine wait-time priority indicators (including data definitions and standardization), commence benchmarking activities and refine data quality. The ATC Wait Times results will be incorporated into the Data Strategy's performance measurement products as well.
  • The Ministry of Children, Community and Social Services has partnered with CIHI to develop a system to facilitate data collection and reporting on a subset of children and youth accessing clinical services. This system will help identify system impacts and facilitate evaluation of services and outcomes.
  • MCCSS is also collecting data in an aggregate form via its contracting reporting process known as the Transfer Payment Budget Package. Starting in 2018-19 and tracking for a completed roll-out in 2020-21, a data repository and business intelligence solution will be implemented that will enable the collection, analyses and reporting of client level service data from MCCSS funded agencies providing core child and youth mental health services.

Ontario is planning to develop and implement a provincial mental health and addictions performance measurement framework with a set of vertical, "cascading" indicators across each level of the MHA system (e.g., provincial, regional, provider-level, program-level, client-level) to measure performance and outcomes of the system, including the initiatives outlined above. This framework will also align with the development of the shared priorities indicators being led by CIHI.

Consistent with the announcement made by FPT health ministers on June 29, 2018, Ontario approved the set of common indicators, which were developed with the Canadian Institute for Health Information to measure pan-Canadian progress against priorities tied to federal funding under the current agreement.

Note that, with the mutual consent of the parties to this Agreement, Annex 2 for Mental Health and Addictions may be revised to reflect indicator development, for more effective reporting; and to align with annual provincial budgets.

Ontario Action Plan for Increased Infection Prevention and Control

I. Context and current status

Background

In Ontario, long-term care (LTC) homes provide on-site 24-hour nursing care and assistance with activities of daily living for those who can no longer live in their own home safely. All LTC homes across the province are licensed, inspected and funded by the Ontario Ministry of Long-Term Care. Residents also pay a fee (called a co- payment), at a rate set by the government, which helps pay for accommodation and non-care staff and utilities.

The LTC sector is home to approximately 70,000 residents. These residents are supported by over 100,000 LTC staff, which includes nurses, personal support workers, physicians, nurse practitioners, and other staff (e.g., food preparation, housekeeping, etc.). There are 626 LTC homes in Ontario of which 355 are for-profit homes, 171 are non-profit homes, and 100 are municipal homes. Each LTC home has a unique resident population and offers a wide array of services, with some homes, such as Francophone and Indigenous-led homes, offering tailored services to meet the needs of residents of a particular religion, ethnic origin, or linguistic origin. LTC homes also vary in size and bed availability, with 247 small homes (0-96 beds), 234 medium homes (97-160 beds), and 145 large homes (more than 160 beds) located across the province.

All LTC home licensees in Ontario are treated equally and are obligated to meet the same standards of care, services, and accountability. These standards of care and services are set out in the Long-Term Care Homes Act, 2007 (LTCHA) and its associated Regulation 79/10, which establish the legislative and regulatory requirements that LTC home licensees must meet.

In October 2021, the Government of Ontario introduced the Providing More Care, Protecting Seniors, and Building More Beds Act, 2021, which received Royal Assent on December 9, 2021. Subject to approvals, the current LTCHA will be repealed and replaced by the Fixing Long-Term Care Act, 2021 (FLTCA). Once proclaimed and in force, the FLTCA will regulate the LTC sector and, as part of the Ontario government’s plan to fix LTC, ensure that every resident experiences the best possible quality of life, supported by safe, high-quality care.

Actions taken since spring 2020

COVID-19 created unprecedented challenges across the LTC sector and disproportionately affected residents and staff in LTC homes. The Ontario Ministry of Long-Term Care’s top priority during the pandemic has been, and continues to be, safeguarding the health, safety, and well-being of LTC residents and staff.

The Ontario government has taken swift, decisive action to optimize safety within LTC homes, reduce the risk of COVID-19 entry and spread, and support LTC homes in addressing outbreaks. This included enacting emergency orders and temporary regulatory amendments, and issuing and updating guidance documents and provincial directives for the LTC sector.

Specifically, these orders, documents, and directives focused on optimizing safety within LTC homes by:

  • Identifying enhanced measures related to physical distancing, cohorting, visiting, resident absences, and group social activities.
  • Deploying health professionals to homes experiencing critical staffing shortages, increasing flexibility in staffing, making it easier for qualified staff to be hired, and limiting staff to a single LTC home or other healthcare setting.
  • Setting out the quarantine (i.e., isolation) and diagnostic testing requirements for existing residents, new admissions, and transfers, and restricting the use of ward rooms with limited exceptions.
  • Requiring surveillance testing and active screening for everyone attending to LTC homes.
  • Identifying personal protective equipment (PPE) requirements including the use of masks, gowns, respirators, eye protection, etc., and providing free access to a provincial supply.
  • Ensuring access to and promotion of COVID-19 immunization through education and vaccine requirements, onsite vaccine clinics, and the promotion of best practices (e.g., giving staff paid time off to get vaccinated).

The Ontario Ministry of Long-Term Care has allocated over $2.5 billion in COVID-19 emergency funding for the LTC sector to assist LTC homes in the fight against COVID- 19 and equip them with the supports they need at different stages of the pandemic.

Federal investments have supported some of these actions, including the $740M provided to support vulnerable populations through the September 2020 Safe Restart Agreement.

Specifically, since March 2020, Ontario has made the following investments to facilitate equitable improvements in infection prevention and control in LTC homes:

  • $1.19 billion in the 2021-22 provincial budget and subsequent in-year investments including:
    • $540 million for additional prevention and containment support.
    • $106 million to continue to support homes as a result of restrictions on admissions and reduced occupancy.
    • $100 million for the Investing in Canada Infrastructure Program to support COVID-19 resilience infrastructure projects that reinforce safe physical distancing and retrofitting projects.
    • $23 million for the Specialized Care Centre operated by Toronto Grace Health Centre to provide additional LTC surge capacity in the General Toronto Area.
    • $61.4 million for minor capital repairs and renovations in LTC homes to improve infection prevention and control (IPAC). Potential renovations included minor renovations to support physical distancing, plumbing or water supply cleaning, or repairing or replacing furniture and equipment that cannot be fully cleaned.
    • $30 million for IPAC personnel and training.
    • $328.7 million additional investment in 2021-22 for prevention and containment including:
      • $277 million to support increased measures for preventions and containment in response to the omicron variant.
      • $51.7 million to address prevention and containment shortfalls from 2020-21.
  • $1.37 billion in 2020-21 including:
    • $786 million to support incremental costs related to staffing, protective equipment, and other prevention and containment measures.
    • $230.6 million to continue to protect the safety and well-being of all residents and staff and help stabilize operations in LTC homes and address critical needs across the sector. This includes:
      • $128 million to reimburse LTC homes for lost revenue as a result of restrictions on admissions and reduced occupancy due to COVID-19.
      • $11.2 million to extend the High Wage Transition Fund to March 31, 2021, ensuring that gaps in LTC staffing could continue to be addressed during the pandemic.
      • $61.4 million for minor capital repairs and renovations in LTC homes to improve IPAC.
      • $20 million for IPAC personnel and an additional $10 million for infection and prevention control training.
    • $130 million for emergency surge capacity and other initiatives such as the deferral of co-payments and the provincial portion of the temporary pandemic pay provided to non-management staff in LTC homes.
      • Ontario invested over $91.8 million to provide a temporary pandemic pay increase of $4 per hour, as well as a $250 lump sum amount for every 100+ hours worked in identified four-week periods.
      • Approximately 100,000 eligible staff that worked onsite in LTC homes received this increase between April 24, 2020 and August 13, 2020.
      • This investment has been enabled by funding support from the federal government, which covered approximately 3/4 of the total pandemic pay cost, while the provincial government covered the remaining amount.
    • $16 million to establish a Specialized Care Centre operated by Toronto Grace Health Centre to provide additional LTC surge capacity in the Greater Toronto Area.
    • $3 million to support the Independent COVID-19 Commission for Long- Term Care.
    • $42 million to LTC homes to ensure adherence to critical testing and screening requirements, including the hiring of third parties to support screening.
    • $167 million initially invested to provide a temporary wage increase for a 26-week period between October 1, 2020 to March 31, 2021.
  • Since October 1, 2020, Ontario has also invested over $1.3 billion to temporarily enhance wages for personal support workers and direct support workers who deliver publicly funded personal support services or direct support services in LTC, home and community care, public hospitals, and social services. This investment has helped stabilize, attract and retain the workforce needed to provide a high level of care, especially during the COVID-19 pandemic.

In addition to the above investments, Ontario addressed the impact of COVID-19 on LTC homes by partnering with the Federal government to deploy Canadian Armed Forces and Canadian Red Cross to over 20 LTC homes in immediate need of staffing supports. Ontario has also made it a priority to vaccinate vulnerable populations, including LTC residents and those who care for them.

The Ontario Ministry of Long-Term Care is committed to continuing to support long-term care homes and use lessons learned from the pandemic, to inform measures and new investments.

These additional federal investments will support prevention and containment efforts in Ontario’s 626 long-term care homes.

II. Priority areas for investment

The Safe Long-term Care Fund will be used to support staffing, staff retention and IPAC initiatives in Ontario’s 626 LTC homes under the province’s Prevention and Containment program. As part of this program, the Ontario Ministry of Long-Term Care is providing eligible LTC homes with financial relief to offset extraordinary costs incurred in the fight against COVID-19, while maintaining quality care and services for their residents. Eligible homes can use these funds to support any necessary incremental expenditures across several categories as follows.

Under the Prevention and Containment Program, every LTC home receives funding to support incremental expenditures necessary to prevent and contain the spread of COVID-19. The ministry has continuously refined the funding approach to ensure that the funding deployed aligns closely to the needs of each long-term care home. For instance the funding flowed has considered adjustments for homes classification (layout and design standards), size and outbreak status. LTC homes are unable to derive any surplus, revenue, or profit from the Prevention and Containment Program.

In addition, the Infection Prevention and Control Minor Capital program supports long- term care homes in completing urgent minor capital upgrades and improvements directly linked to improved infection prevention and control practices for the safety of their residents, staff and families. In 2021-22 the ministry provided up to $61.4 million through the Infection Prevention and Control Minor Capital Program to provide air conditioning in long-term care homes as part of a $246 million commitment in Budget 2021: Protecting People’s Health and Our Economy to improve living conditions in long- term care homes.

Similarly, the Infection Prevention and Control (IPAC) professionals and training funding supports homes in hiring and retaining IPAC professionals and in the training and education of long-term care (LTC) home personnel on IPAC best practices to protect residents, staff and the community. In 2021-22, this funding comprised of two components- $20M to support IPAC capacity in LTC homes, including retaining IPAC professionals and $10M to fund IPAC training for LTC home personnel. This $30M investment for 2021-22 reflects the government’s previous commitment to continuing funding announced in the 2020 Fall Preparedness Plan for Health, Long-Term Care and Education, and as included as part of the 2021 Ontario Budget under Chapter 1: Ontario’s Action Plan- Protecting People’s Health and Our Economy.

IPAC initiatives are a key component of Ontario’s plan to Fix Long-Term Care, which aims to ensure that every long-term care home resident experiences the best possible quality of life, supported by safe, high-quality care. The new Fixing Long-Term Care Act, 2021 will be coming into force, subject to approvals, as the sector continues to recover from the pandemic and in the context of the considerable change that has taken place over the past two years.

Initiatives

The Safe Long-term Care Funding will be used to support the following Prevention and Containment initiatives across all 626 LTC homes:

  1. 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) ($236 million). These measures include staffing recruitment and retention strategies related to:
    • Overtime pay, additional costs to convert part-time staff to full-time and costs to backfill staff on sick leave.
    • Hiring of new staff to carry out the added workload for essential services and/or to replace workers who are sick or in isolation.
  2. Strengthened IPAC measures and training. This includes ($39 million):
    • Implementing IPAC measures based on clinical evidence, and/or advice from a physician or other regulated health care practitioners with IPAC expertise.
    • Providing hotel or other accommodation to staff to help reduce travel pressures or potential exposure for their families.
    • Supporting virtual care and services for LTC home residents and staff.
  3. Adequate supply of personal protective equipment for staff and visitors ($45 million). This includes:
    • Cleaning, equipment, and operating supplies beyond typical levels for the home.
  4. Other incremental costs required for a rapid response to prevent and contain COVID-19 in the home ($60 million). This includes:
    • Regular testing of staff and visitors to quickly detect, prevent or limit spread
    • 24/7 active screening of LTC home staff and visitors and anyone else entering the LTC home for COVID-19.
    • Costs of COVID-19 testing and vaccine administration.
    • Other incremental costs required for a rapid response to prevent and contain COVID-19 in the home

III. Breakdown of initiative spending and cost recovery

As noted above, all of Ontario’s LTC homes (i.e., municipal, for profit or independent not for profit), are treated equitably and subject to the same stringent accountability requirements, which include detailed rules related to the purpose for which funding can and cannot be used, as well as regular reporting intervals and associated reconciliation policies.

The Ontario Ministry of Long-Term Care requires long-term care homes to submit quarterly financial reports and maintain detailed financial records for all incremental costs incurred, as they may be subject to an audit.

As with all funding provided to LTC homes, the Ontario Ministry of Long-Term Care will continue to use existing cost-recovery mechanisms such as its in-year and/or annual reconciliation processes to reconcile Safe Long-term Care funding. Specifically, the Ontario Ministry of Long-Term Care will rely on the existing funding policy for the Ontario Prevention and Containment program which sets out the purpose for which funding can be used, and the details related to reconciliation. For example, under the Prevention and Containment program, in the event that there is a difference between the incremental prevention and containment funding allocated to long-term care homes and the actual incremental expenses incurred for prevention and containment efforts, the Ontario Ministry of Long-Term Care could recover the excess funding based on the financial reporting required from the homes. Any further unspent funds at the time of annual reconciliation will be returned to the Ontario Ministry of Long-Term Care.

Initiatives
Funding allocation by initiative
Priority area 2021-22Footnote 1 Total

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).

$236M

$236M
Strengthened infection prevention and control measures and training

$39M

$39M
Adequate supply of personal protective equipment for staff and visitors

$45M

$45M
Other incremental costs required for a rapid response to prevent and contain COVID-19 in the home

$60M

$60M
Footnote 1

Per provision 4.4, Ontario may seek to retain and carry over a percentage of the 2021-22 funding that is in excess of the actual amount of eligible expenditures incurred by Ontario into fiscal year 2022-23 to assist with ongoing prevention and containment costs incurred by the sector, pending discussion and mutual agreement with Health Canada.

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IV. Performance measurement and expected results

Priority areas Performance measure Target / Outcomes Results to date

Results (to be reported in FY 2022-23)Footnote 1

  • Staff support/retention measures:
    • Wages and salaries
    • hiring additional human resources
    • Other
  • Strengthened infection prevention and control measures and training
  • Adequate supply of personal protective equipment for staff and visitors
  • Enhanced screening and regular testing of staff and visitors to quickly detect, prevent or limit spread
  • Actual spending to date by small, medium and large homes
  • Expenditures by expense categories: For example, expenditures related to staffing, PPE, cleaning, rapid antigen testing, and testing adherence
  • Incremental paid hours related to staffing expenses
All LTC homes are supported to comply with provincially set COVID-related requirements and to effectively manage outbreaks as needed

Based on the Q1- Q3 Prevention and Containment Expenditures Report the Ministry has received the following data on Prevention and Containment spending:

  • Small homes reported spending approx. $133M; Medium sized homes reported spending approx. $274M; Large homes reported spending approx. $271M.
  • The total spending for the sector by category was approx. $422M for staffing (62%); $80M for PPE costs (12%); $108M for screening (16%); and $69M for supplies, equipment, and all other expenses (10%)
  • 16.6 million incremental paid hours were added with this investmentFootnote 2
TBD
Footnote 1

Updated results are to be provided by the jurisdiction and will be posted publicly by way of amendments to the Action Plan.

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Footnote 2

Please note that this figure must be interpreted with caution as there may be data integrity concerns

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Footnotes

Footnote 1

Aging with Confidence: Ontario's Action Plan for Seniors, November 2017

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Footnote 2

Home Care Database, 2017

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Footnote 3

Thriving at Home: A Levels of Care Framework to Improve the Quality and Consistency of Home and Community Care for Ontarians, Levels of Care Expert Panel, 2017

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Footnote 4

Bringing Care Home, Expert Group on Home and Community Care, 2015

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Footnote 5

Bringing Care Home, Expert Group on Home and Community Care, 2015

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Footnote 6

Health Quality Ontario (HQO), 2016

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Footnote 7

Canadian Institute for Health Information-/Provincial/Territorial (CIHI-PT)

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Footnote 8

HQO and ICES, 2015

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Footnote 9

MOHLTC data.

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Footnote 10

Health Canada, 2006.

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Footnote 11

Office of the Chief Coroner for Ontario

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Footnote 12

CANSIM Table 13-10-0465-01 Mental health indicators (formerly table 105-1101 table): https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310046501&pickMembers%5B0%5D=
1.8&pickMembers%5B1%5D=2.1&pickMembers%5B2%5D=3.1

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Footnote 13

Busko, M. (2007). Cannabis Use Linked With Risk for Psychosis in Later Life. http://www.schizophreniaandsubstanceuse.ca/sitepages/news1.html

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Footnote 14

Canadadian Centre on Substance Use and Addiction: http://www.ccdus.ca/Eng/topics/Monitoring-Trends/Canadian-Drug-Trends/Pages/default.aspx.

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Footnote 15

ICES, 2017.

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Footnote 16

As reported by ConnexOntario and DATIS.

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Footnote 17

Reported in McVey, et al., Preventing Eating-Related and Weight-Related Disorders, 2012.

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