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2018 to 2022 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

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:

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;

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:

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:

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 1 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 OntarioTable 2 Note *
2021-2022 $379,575,486
Table 2 note *

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

Return to footnote * referrer

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:

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

Changing client preferences and expectations

Increased public interest in palliative care

Increasing caregiver burnout and stress

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:

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

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

Expected Outcomes

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:

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

Expected Outcomes

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:

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

Expected Outcomes

Expenditure Plan 2017-18 to 2021-22
Funding Breakdown by Initiative 2017/18Table 3 Note *
($M)		 2018/19Table 3 Note **
($M)		 2019/20Table 3 Note **
($M)		 2020/21Table 3 Note **
($M)		 2021/22Table 3 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 3 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 3 Notes
Table 3 Note *

Funding already provided through legislation

Return to table 3 note * referrer

Table 3 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 3 note ** referrer

Table 3 Note ***

Decisions regarding palliative information technology allocations are to be determined.

Return to table 3 note *** referrer
Data Collection and Common Indicators

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

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:

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:

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:

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:

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.

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:

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.

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:

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

Expected Outcomes

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:

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

Expected Outcomes

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:

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

Expected Outcomes

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.

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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.

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Data Collection and Common Indicators

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

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 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:

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:

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
  • 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

Interim Results (March 2022)

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 1

Final Results

Based on the Q1- Q4 Prevention and Containment Expenditures Report the Ministry has received the following data on Prevention and Containment spending:

  • Small homes reported spending approx. $150M; Medium sized homes reported spending approx. $306M; Large homes reported spending approx. $305M.
  • The total spending for the sector by category was approx. $476M for staffing (63%); $78M for PPE costs (10%); $116M for screening (15%); and $91M for supplies, equipment, and all other expenses (12%)

18.7 million incremental paid hours were added with this investmentFootnote 1
Footnote 1

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: https://www.ontario.ca/page/aging-confidence-ontario-action-plan-seniors

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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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