Implementation Agreement on the March 10, 2017, Asymmetrical Agreement – Home and Community Care and Mental Health and Addictions Services

BETWEEN:

THE GOVERNMENT OF CANADA, represented by the Minister of Health (hereinafter referred to as “Canada”)

- and -

THE GOVERNMENT OF QUEBEC, represented by the Minister of Health and Social Services and Minister Responsible for Canadian Relations and the Canadian Francophonie (hereinafter referred to as “Quebec”)

PREAMBLE

WHEREAS the Government of Canada and the Government of Quebec recognize the importance of increasing early intervention with regard to mental disorders and addictions and share the common objective of improving access to home and community care services within the context of the aging population;

WHEREAS on September 16, 2004, the Prime Minister of Canada and the Premier of Quebec signed a health agreement entitled Asymmetrical Federalism that Respects Quebec's Jurisdiction, which notably allows for the existence of agreements and arrangements adapted to Quebec’s specificity;

WHEREAS in recognition of Quebec’s jurisdiction with regard to health and social services and the Government of Quebec’s exercise of full control over the planning, organizing and managing of services within its territory, enabling it to implement its own health plans and priorities, the Government of Canada and the Government of Quebec agreed, on March 10, 2017, to an asymmetrical agreement based on the principles of the asymmetrical agreement of September 2004, including targeted federal funding over 10 years, beginning in 2017-2018, for investments in home and community care and mental health and addictions services, in addition to the existing legislated commitments through the Canada Health Transfer;

WHEREAS this asymmetrical agreement of March 10, 2017, recognizes that the Government of Quebec itself will continue to report to the Quebec population on the use of all the funding for health and will continue to collaborate with the other governments with regard to the sharing of information and best practices;

WHEREAS Canada authorizes the federal Minister to enter into agreements with the provinces and territories for the purpose of facilitating the formulation, coordination and implementation of any program or policy within the mandate of the federal Minister;

NOW THEREFORE, Canada and Quebec agree as follows:

1.0 Definition

The following expression used in this Agreement will have the scope defined below:

“Agreement” means this Implementation Agreement on the March 10, 2017, Asymmetrical Agreement – Home and Community Care and Mental Health and Addictions Services.

“Fiscal Year” means the period commencing on April 1 of any calendar year and ending on March 31 of the immediately following calendar year.

2.0 Objectives

2.1 Canada and Quebec agree that the goal of this Agreement is to establish the terms and conditions for the payment of Canada’s contributions to the funding for home and community care and mental health and addictions services for Fiscal Years 2018-19 to 2021-22.

2.2 To this end, the two parties agree that Quebec will identify its priorities and will be responsible for designing, implementing, assessing and adapting its policies and programs with regard to home and community care and mental health and addictions services.

3.0 Areas of Investment: Home and Community Care and Mental Health and Addictions Services

3.1 Quebec is responsible for establishing the vision, priorities and objectives for home and community care and mental health and addictions services.

3.2 The funds transferred by Canada to Quebec under this Agreement will be used to support Quebec’s objectives and priorities with regard to home and community care and mental health and addictions services, including those identified by Quebec as examples in Appendix 1.

4.0 Term of the Agreement

4.1 The term of this Agreement is four years, from April 1, 2018, to March 31, 2022.

4.2 Agreement Renewal

4.2.1 This Agreement will be renewed under similar conditions for the period from 2022-23 to 2026-27 in order to ensure federal funding for this period, provided that Quebec sends an updated Appendix 1 identifying examples of Quebec’s objectives and priorities with regard to home and community care and mental health and addictions services for the renewal period. 

5.0 Financial Provisions

5.1 The contributions made under this Agreement are in addition to and not in lieu of those that Canada currently provides to Quebec under the Canada Health Transfer to support the delivery of health care services.

5.2 Allocation to Quebec

5.2.1 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.

Fiscal year Home and community care services Mental health and addictions services
2018-2019 $600M $250M
2019-2020 $650M $450M
2020-2021 $650M $600M
2021-2022 $900M $600M

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

  • F is the annual total funding available under this program (funding amount will change depending on Fiscal Year);
  • K is the total population of the 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.

5.2.3 For the purposes of the formula in section 5.2.2, the population of Quebec for each Fiscal Year and the total population of all provinces and territories for the Fiscal Year in question are the respective populations as determined on the basis of the quarterly preliminary estimates of the respective populations on July 1 of the same Fiscal Year. These estimates are released by Statistics Canada in September of each year.

5.2.4 Subject to annual adjustment based on the formula in section 5.2.2, Quebec’s estimated share of the amounts will be:

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

Amounts represent annual estimates based on the 2017 Census

Return to footnote * referrer

2018-2019 $137.20M $57.17M
2019-2020 $148.64M $102.90M
2020-2021 $148.64M $137.20M
2021-2022 $205.80M $137.20M

5.3 Payment

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

  1. The first installment will be paid on or about April 15 of each Fiscal Year. The second installment will be paid on or about November 15 of each Fiscal Year.
  2. The amount of the first installment will be equal to 50% of the notional amount set out in Article 5.2.4 as adjusted by Article 5.2.2.
  3. The amount of the second installment will be equal to the balance of Canada’s contribution to Quebec for the Fiscal Year as determined under sections 5.2.4 and 5.2.2.
  4. Canada will notify Quebec of the notional amount at the beginning of the Fiscal Year. The notional amount will be based on Statistics Canada’s quarterly preliminary population estimates on July 1 of the preceding Fiscal Year. Canada will notify Quebec of the actual amount of the second installment for each Fiscal Year, as determined under the formula set out in sections 5.2.4 and 5.2.2.
  5. 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.
  6. 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.

5.4  Repayment of overpayment

In the event that payments made to Quebec exceed the amount to which Quebec is entitled under this Agreement, the excess amount is a debt due to Canada and shall be repaid to Canada upon receipt of a notice to this effect and by the deadline specified in the notice.

6.0 Distribution and Information Sharing

6.1 For a number of years, Quebec has been sharing its health information, expertise and best practices with other governments in Canada and intends to continue this practice.

6.2 Quebec agrees to ensure transparency with regard to the objectives of this Agreement and will continue to do its own reporting to the Quebec population on the use of all funding for healthcare in accordance with its own reporting practices and indicators and will recognize the federal funding obtained under this Agreement. 

6.3 Quebec is responsible for the evaluation of its programs in accordance with its own evaluation policies and practices.

6.4 Quebec will use comparable indicators for the purposes of comparing health and social services with other provinces and territories. 

6.5 Quebec will participate, as an observer, in the work of the Canadian Institute for Health Information to develop a set of common indicators for home care and mental health and addictions services.

6.6 Quebec will ensure that the information on expenditures indicated in the yearly financial statements is complete and accurate and complies with Quebec accounting practices.

7.0 Communications

7.1 Canada and Quebec agree on the importance of communicating with citizens about the objectives of this Agreement in an open and transparent manner through appropriate public information activities.

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

7.3 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Agreement. Canada agrees to give Quebec 10 days advance notice and advance copies of communications related to the results of the investments of this Agreement.

7.4 Quebec reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Agreement. Quebec agrees to give Canada 10 days advance notice and advance copies of communications related to the results of the investments of this Agreement.

7.5 Canada, with prior notice to Quebec, may, if properly cited, incorporate parts of reports containing data and information or any parts of evaluation and audit reports made public by Quebec into any public report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

8.0 Dispute Resolution

8.1 Canada and Quebec 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.

8.2 If at any time, either Canada or Quebec 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 Quebec, as the case may be, may notify the other Party in writing. Upon such notice Canada and Quebec will endeavour to resolve the issue in dispute bilaterally through their designated officials.

8.3 If a dispute cannot be resolved by the designated officials, the dispute will be referred to the deputy ministers responsible for health for Canada and Quebec, and if it cannot be resolved by them, then the respective ministers with the highest levels of responsibility for health for Canada and Quebec shall endeavour to resolve the dispute.

9.0 Amendments to the Agreement

Canada and Quebec can agree, by mutual consent and in writing, to any amendment to the Agreement. Such amendment will come into effect on such date as may be decided by 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 Quebec, by Quebec’s Minister of Health and Social Services and the Minister Responsible for Canadian Relations and the Canadian Francophonie.

10.0 Appendix

The Appendix to this Agreement is an integral part of this Agreement.

11.0 Termination

11.1  Canada may terminate this Agreement at any time if it is demonstrated that the terms and conditions of this Agreement are not met by Quebec by giving at least 12 months written notice of its intention to terminate. Quebec may terminate this Agreement at any time if it is demonstrated that the terms of this agreement are not met by Canada by giving at least 12 months written notice of its intention to terminate.

11.2  As of the effective date of termination of this Agreement, under section 11.1, Canada shall have no obligation to make any further payments to Quebec.

12.0 Notice

12.1  Any notice, information, or document provided for under this Agreement will be considered as received if delivered or sent by mail, with postage or other charges prepaid. Any notice that is delivered will have been received in delivery; and, except in periods of postal disruption, any notice mailed by post will be deemed to have been received eight calendar days after being mailed.

12.2  The address for notice or communication to Canada shall be:

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

Email: marcel.saulnier@canada.ca

The address for notice or communication to Quebec shall be:

Ministère de la Santé et des Services sociaux
1075 Sainte-Foy Road
Quebec City, Quebec G1S 2M1

1005 Sainte-Foy Road, 1st Floor
Quebec City, Quebec G1S 4N4

Email: luc.castonguay@msss.gouv.qc.ca

13.0 General

13.1 This Agreement constitutes the entire agreement entered into by the parties with respect to the subject matter hereof.

13.2 This Agreement shall be governed and interpreted in accordance with the laws of Quebec.

13.3 No member of the House of Commons or of the Senate of Canada or of the National Assembly of Quebec shall be admitted to any share or part of this Agreement, or to any benefit arising therefrom.

13.4 If for any reason a provision of this Agreement that is not a fundamental term of the agreement between the Parties is found by a court of competent jurisdiction to be 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.

IN WITNESS WHEREOF, the authorized representatives of Canada and Quebec have signed this agreement in triplicate.

SIGNED on behalf of Canada on the 17th day of September 2018
Ginette Petitpas Taylor
Minister of Health

SIGNED on behalf of Quebec on the 22nd day of August 2018
Gaétan Barrette
Minister of Health and Social Services

Jean-Marc Fournier
Minister Responsible for Canadian Relations and the Canadian Francophonie

Annex 1 – Examples of home, community, mental health and addiction care services

Home and Community Care Services

$1.3 billion for home support services in 2016-2017

  • As of March 31, 2017, more than 339,000 people were receiving approximately $13.8 million in home support services provided by health and social services network establishments.

Increase the number of people receiving home support services and enhance services to better meet their needs

  • To consolidate home support services, Quebec undertook to increase the number of people receiving home support services and enhance services to better meet their needs.
  • To allow people to remain in their homes as long as possible, a range of care and services, such as professional care and services, including nursing, nutrition, basic rehabilitation (physiotherapy, occupational therapy, etc.), respiratory therapy, and psychosocial services will be more readily available in quantity and quality.
  • Home assistance services will also be more accessible, including personal and household assistance services.
  • Quebec also plans to increase the number of hours of service during times where people require more intensive services, to ensure their condition can be stabilized and avoid unnecessary emergency room visits or hospitalizations.

A process aimed at improving the organization of home care and services is under way and is expected to improve care and services by promoting the adoption of best practices in home care across all establishments in the health and social services network. More specifically, the following objectives are expected in the coming years:

  • The percentage of users who have assessments and care plans will increase;
  • The extent of implementation of the components of the integrated services for adults network (RSIPA) will increase;
  • Emergency room visits by people aged 65 and over for management level-4 and -5 priorities will decrease;
  • Clinical progress tools will be implemented;
  • The RSIPA data counter will be made available and information will be provided allowing for database matching and patient service trajectory tracking including costs;
  • Clinical/administrative data quality will improve.

Mental Health and Addiction Services

In 2016-2017, $119,305,662 was spent on health and social services for addiction-related issues.

In 2016-2017, 45,067 different users received specialized addiction services free of charge through addiction rehabilitation centres in Quebec.

As part of the 2017-2018 economic update, the government announced $11 million in funding, annualized to $20 beginning in 2018-2019, to support the implementation of the 2018-2028 Interdepartmental Action Plan on Addiction.

In addition, the March 2018 Quebec Economic Plan confirmed an additional $15 million to support the Opioid strategy. This means that a total of $35 million in additional recurring funding will be invested in preventing, reducing and treating the effects of psychoactive substance use, compulsive gambling and Internet addiction.

The 2018-2028 Interdepartmental Action Plan on Addiction

The 2018-2028 Interdepartmental Action Plan on Addiction includes actions aimed at preventing, reducing and treating the effects of psychoactive substance use, compulsive gambling and Internet addiction. It includes 7 directions, 18 objectives and 70 actions, to be carried out by 14 departments and a number of government agencies, aimed at taking consistent and complementary action across the spectrum of psychoactive substance use, gambling and Internet use. More specifically, the following objectives are expected in the next few years:

  • Access to treatment for opioid addiction and intoxication and withdrawal management services will improve across all Quebec regions;
  • Cyber addiction services will be offered in all integrated centres with a Quebec addiction rehabilitation centre mission;
  • Responding addiction professionals will be deployed in all Quebec regions to improve neighbourhood addiction service access, integration and complementarity;
  • Access to addiction rehabilitation services will improve and reach an additional 4,500 people per year.

Mental Health

The mental health program has been in intensive development for a number of years. The 2015-2020 Action Plan on Mental Health, called Faire ensemble et autrement (working together in a new way) includes 40 measures across a range of areas, from defending users’ and families’ rights to participate in the reorganization of psychiatric services in Quebec to developing new care and service modalities, particularly for young people aged 12 to 35.

In December 2017, Quebec also announced the launch of the most ambitious psychotherapy access program in Canada. Inspired by the Improving Access to Psychological Therapies program, the initiative will apply a set of clinical guidelines developed by the National Institute for Health and Care Excellence to the most common mental illnesses (e.g., depression, anxiety disorders), as well as a number of more serious conditions (e.g., bipolar affective disorder).

During the first year, substantial amounts have been earmarked to support the plan and open new avenues for services, including:

  • $35 million to set up the Quebec psychotherapy program (Programme québécois de psychothérapie pour les troubles mentaux – des autosoins à la psychothérapie (PQPTM);
  • $30 million to improve accommodation and community retention services to prevent psychiatric hospitalizations and reduce psychiatric ward stays;
  • $15 million to consolidate assertive community treatment (ACT) and variable intensity support (VIS) services;
  • $15 million to enhance access to psychologists for youth (ages 0-18);
  • $10 million to consolidate first psychotic episode services for young people aged 12 to 35;
  • $1 million to enhance community crisis services;
  • $0.6 million to broaden the range of support services to establishments that provide mental health services from the Centre national d’excellence en santé mentale (CNESM), the only clinical expertise centre of its type in Canada, version 2.0 of the U.S. Technical Assistance Centres that support ACT and VIS practice in several U.S. states.
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