Canada-Newfoundland and Labrador agreement to Work Together to Improve Health Care for Canadians (2023-24 to 2025-26)

Tables of contents

Funding agreement
Annex 1 – Common statement of principles on shared health priorities
Annex 2 – Shared pan-Canadian interoperability roadmap
Annex 3 – Headline common indicators
Annex 4 – Action plan

Funding agreement

(the "Agreement")

BETWEEN:

HIS MAJESTY THE KING IN RIGHT OF CANADA (hereinafter referred to as "Canada" or "Government of Canada") as represented by the Minister of Health and the Minister of Mental Health and Addictions and Associate Minister of Health (herein referred to as "the federal Ministers")

- and -

HIS MAJESTY IN RIGHT OF NEWFOUNDLAND AND LABRADOR (hereinafter referred to as "Newfoundland and Labrador" or "Government of Newfoundland and Labrador") as represented by the Minister of Health and Community Services and the Minister for Intergovernmental Affairs (herein referred to as "the provincial Ministers")

REFERRED to collectively as the "Parties", and individually as a "Party"

PREAMBLE

WHEREAS, on February 23, 2023, Canada and Newfoundland and Labrador announced an overarching agreement in principle on Working Together to Improve Health Care for Canadians, supported by almost $200 billion over ten years in federal funding, including $46.2 billion in new funding to provinces and territories;

WHEREAS, Canada has also announced a five per cent Canada Health Transfer (CHT) guarantee for the next five years, starting in 2023-24, which will be provided through annual top-up payments as required. This is projected to provide approximately an additional $17 billion over 10 years in new support. The last top-up payment will be rolled into the CHT base at the end of the five years to ensure a permanent funding increase, providing certainty and sustainability to provinces and territories;

WHEREAS, Working Together to Improve Health Care for Canadians includes a federal commitment of $25 billion in bilateral funding to provinces and territories over ten years focused on four shared health priorities:

expanding access to family health services, including in rural and remote areas;
supporting our health workers and reducing backlogs;
improving access to quality mental health, substance use, and addictions services; and
modernizing health systems with health data and digital tools.

WHEREAS, in the area of mental health, substance use, and addictions services, Working Together to Improve Health Care for Canadians also includes a commitment by Canada and Newfoundland and Labrador to continue to work to support collaboration on the Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the "Common Statement", attached hereto as Annex 1), supported by the federal Budget 2017 investment of $5 billion over 10 years;

WHEREAS, Newfoundland and Labrador has the primary responsibility for delivering health care services to its residents and supports diversity, equity, and the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+;

WHEREAS, Canada authorized the federal Ministers to enter into agreements with the provinces and territories, for the purpose of identifying activities that provinces and territories will undertake in respect of the four shared health priorities, and for funding in this Agreement associated with the federal investment for mental health, substance use, and addictions services consistent with the Common Statement (and menu of actions outlined in Annex 1);

WHEREAS, the Executive Council Act and the Intergovernmental Affairs Act authorizes the Government of Newfoundland and Labrador to enter into agreements with the Government of Canada;

WHEREAS, Canada undertakes to provide funding to Newfoundland and Labrador that will further help provide Newfoundlanders and Labradorians with improvements in health care associated with four shared health priorities, mental health, and substance use and addictions services consistent with the Common Statement; and

NOW THEREFORE, this Agreement sets out the terms between Canada and Newfoundland and Labrador as follows:

1.0 Key principles and collaboration

The key principles and commitment to collaboration agreed to in Working Together to Improve Health Care for Canadians are outlined below.

1.1 Canada and Newfoundland and Labrador acknowledge that this Agreement will mutually respect each government's jurisdiction, and be underpinned by key principles, including:

A shared responsibility to uphold the Canada Health Act that strengthens our public health care system;
Principles agreed to in the Common Statement (outlined in Annex 1);
Reconciliation with Indigenous Peoples, recognizing their right to fair and equal access to quality and culturally safe health services free from racism and discrimination anywhere in Canada, including through seamless service delivery across jurisdictions and meaningful engagement and work with Indigenous organizations and governments; and
Equity of access for under-served groups and individuals, including those in official language minority communities.

1.2 Canada and Newfoundland and Labrador acknowledge the importance of supporting health data infrastructure, data collection and public reporting, and will work together to improve the collection, sharing and use of de-identified health information, respecting federal/provincial/territorial privacy legislation, to improve transparency on results and to help manage public health emergencies, and to ensure Canadians can access their own health information and benefit from it being shared between health workers across health settings. This includes:

collecting and securely sharing high-quality, comparable information needed to improve services to Canadians, including disaggregated data on key common health indicators with the Canadian Institute for Health Information (CIHI);
adopting common interoperability standards (both technical exchange and content of data), including the Shared pan-Canadian Interoperability Roadmap (outlined in Annex 2), to improve Canadians' access to their health information in a usable digital format and support the exchange and analysis of health data within and across Canada's health systems in a way that protects Canadians' privacy and ensures the ethical use of data to improve the health and lives of people;
work to align provincial and territorial policies and legislative frameworks where necessary and appropriate to support secure patient access to health information, and stewardship of health information to support the public good, including improving care quality, patient safety, privacy protection, system governance and oversight, planning and research;
promoting health information as a public good by working with federal-provincial-territorial Ministers of Health to review and confirm overarching principles, which would affirm Canadians' ability to access their health information and have it follow them across all points of care. The existing Health Data Charter, as outlined in the Pan-Canadian Health Data Strategy would serve as the starting point for the discussion of these principles; and
collecting and sharing available public health data (e.g., vaccination data, testing data) with the Public Health Agency of Canada to support Canada's preparedness and response to public health events, building on commitments made as part of the Safe Restart Agreements.

1.3 Canada and Newfoundland and Labrador acknowledge they will work with other provinces and territories to streamline foreign credential recognition for internationally-educated health professionals, and to advance labour mobility, starting with multi-jurisdictional recognition of health professional licences.

1.4 Canada and Newfoundland and Labrador acknowledge a mutual intent to engage in a two-phased formal review process:

Phase 1: This review will be done in 2026 by a joint committee of Federal, Provincial, and Territorial health and finance officials to assess results and determine next steps for bilateral agreements related to improvements to home and community care, mental health, substance use, and addiction services associated with the Common Statement and long-term care; and
Phase 2: A formal five-year review of the healthcare plan outlined on February 7, 2023, recognizing the importance of long-term sustainability for provincial/territorial health systems. This review would consist of an assessment of both the bilateral agreements (herein) and the CHT investments (not included as part of this bilateral agreement). The review will be done by a joint committee of Federal, Provincial, and Territorial health and finance officials, commencing by March 31, 2027, and concluded by December 31, 2027, to consider results achieved thus far in the four shared health priority areas and will include:
1. an assessment of progress-to-date on public reporting to Canadians using the common indicators;
2. sharing of de-identified health information, and other health data commitments; and
3. current and forward-looking Federal, Provincial, and Territorial investments to support this plan.

2.0 Objectives

2.1 Canada and Newfoundland and Labrador agree that, with financial support from Canada, Newfoundland and Labrador will continue to build and enhance health care systems towards achieving some or all of the objectives of:

timely access to high-quality family health services, including in rural and remote areas;
a sustainable, efficient and resilient health workforce that provides Canadians timely access to high-quality, effective, and safe health services;
access to timely, equitable, and quality mental health, substance use, and addictions services to support Canadians' well-being; and
access to a patient's own electronic health information that is shared between the health professionals they consult to improve safety and quality of care, and which informs Canadians on how the system is working.

2.2 Canada and Newfoundland and Labrador agree that, with Budget 2017 financial support from Canada outlined in 5.2.2, Newfoundland and Labrador will continue to work to improve access to mental health, substance use, and addictions services consistent with the Common Statement (and menu of actions outlined in Annex 1).

3.0 Action plan

3.1 Newfoundland and Labrador set out in their Action Plan (attached as Annex 4) how the federal investment under this Agreement will be used, as well as details on targets and timeframes based on common headline indicators in priority areas where federal funds will be invested, as well as jurisdiction-specific indicators, for each of the initiatives.

3.2 Newfoundland and Labrador will invest federal funding as part of the 2017 commitment for mental health, substance use, and addictions services provided through this Agreement in alignment with the menu of actions listed in the Common Statement.

3.3 Newfoundland and Labrador will invest federal funding in some or all of the four shared health priority areas, without displacing existing planned spending in those areas.

3.4 In developing initiatives under this Agreement, Newfoundland and Labrador agrees to implement measures that also respond to the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+.

3.5 Newfoundland and Labrador's approach to achieving objectives is set out in their three-year Action Plan (2023-24 to 2025-26), as set out in Annex 4.

4.0 Term of agreement

4.1 This Agreement comes into effect upon the date of the last signature of the Parties and will remain in effect until March 31, 2026 ("the Term"), unless terminated in accordance with section 11 of this Agreement. Funding provided under this Agreement will cover the period April 1, 2023 to March 31, 2026.

4.2 Renewal of bilateral agreements

4.2.1 Upon signing renewed bilateral agreements, Newfoundland and Labrador will have access to the remainder of its share of the federal funding, subject to appropriation by Parliament, for:

2026-27, the allocation based on the federal commitment in Budget 2017 of $5 billion over ten years for mental health, substance use and addiction services; and
2026-27 to 2032-33, the allocation based on the federal commitment in Budget 2023 of $25 billion over ten years to support the Working Together to Improve Health Care for Canadians plan.

5.0 Financial provisions

5.1 The funding provided under this Agreement is in addition to and not in lieu of those that Canada currently provides under the CHT to support delivering health care services within the province.

5.2 Allocation to Newfoundland and Labrador

5.2.1 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.

5.2.2 Canada has designated the following maximum amounts to be transferred in total to all provinces and territories under this initiative based on the allocation method outlined in subsection 5.2.3 for the Term of this Agreement.

Working Together to Improve Health Care for Canadians

$2.5 billion for the Fiscal Year beginning on April 1, 2023
$2.5 billion for the Fiscal Year beginning on April 1, 2024
$2.5 billion for the Fiscal Year beginning on April 1, 2025

Budget 2017 mental health, substance use, and addictions services

$600 million for the Fiscal Year beginning on April 1, 2023
$600 million for the Fiscal Year beginning on April 1, 2024
$600 million for the Fiscal Year beginning on April 1, 2025

5.2.3 Allocation method

For the funding associated with Working Together to Improve Health Care for Canadians, annual funding will be allocated to provinces and territories on base ($5,000,000 if population is less than 100,000; $20,000,000 if population is between 100,000 and 500,000; and $50,000,000 if population is greater than 500,000) plus per capita basis. The final total amount to be paid to each jurisdiction will be calculated using the following formula: B + (F - ((N * 5,000,000) + (O * 20,000,000) + (S * 50,000,000)) x (K / L), where:
B is the base amount allocated to each province or territory based on population ($5,000,000 if population is less than 100,000; $20,000,000 if population is between 100,000 and 500,000; and $50,000,000 if population is greater than 500,000), as determined using annual population estimates on July 1^st from Statistics Canada;

F is the total annual funding amount available outlined under this program;

N is the number of provinces and territories with a population less than 100,000, as determined using annual population estimates on July 1^st from Statistics Canada;

O is the number of provinces and territories with a population between 100,000 and 500,000, as determined using annual population estimates on July 1^st from Statistics Canada;

S is the number of provinces and territories with a population greater than 500,000, as determined using annual population estimates on July 1^st from Statistics Canada;

K is the total population of Newfoundland and Labrador, as determined using annual population estimates on July 1^st from Statistics Canada; and

L is the total population of Canada, as determined using annual population estimates on July 1^st from Statistics Canada.
For funds associated with Budget 2017 Mental Health, Substance Use, and Addictions Services, annual funding will be allocated to provinces and territories on a per capita basis. The per capita funding for each Fiscal Year, is calculated using the following formula: F x K/L, where:

F is the annual total funding amount available under this program;

K is the total population of Newfoundland and Labrador, as determined using the annual population estimates on July 1^st from Statistics Canada; and

L is the total population of Canada, as determined using the annual population estimates on July 1^st from Statistics Canada.

5.2.4 Subject to annual adjustment based on the formulas described in section 5.2.3, Newfoundland and Labrador estimated share of the amounts will be:

Fiscal Year	Working Together to Improve Health Care for Canadians Estimated amount to be paid to Newfoundland and Labrador^{Footnote *} (subject to annual adjustment)	Budget 2017 Mental Health, Substance Use, and Addictions Services Estimated amount to be paid to Newfoundland and Labrador^{Footnote *} (subject to annual adjustment)
2023-2024	$77,220,000	$8,110,000
2024-2025	$77,220,000	$8,110,000
2025-2026	$77,220,000	$8,110,000
* Amount represent annual estimates based on Statistics Canada's July 1^st, 2022, population estimates. Return to footnote * referrer

5.3 Payment

5.3.1 Funding provided by Canada will be paid in semi-annual installments as follows:

In 2023-2024, the first installment will be paid within approximately 30 business days of execution of this Agreement by the Parties. The second installment will also be paid within approximately 30 business days of execution of this Agreement by the Parties, subject to 5.3.1.g.
Starting in 2024-2025, the first installment will be paid on or about April 15 of each Fiscal Year and the second installment will be paid on or about November 15 of each Fiscal Year.
The first installment will be equal to 50% of the notional amount set out in section 5.2.4 as adjusted by section 5.2.3.
The second installment will be equal to the balance of funding provided by Canada for the Fiscal Year as determined under sections 5.2.3 and 5.2.4.
Canada will notify Newfoundland and Labrador prior to the first payment of each 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. Prior to the second payment, Canada will notify Newfoundland and Labrador of the amount of the second installment as determined under sections 5.2.3 and 5.2.4.
Canada shall withhold payments if Newfoundland and Labrador has failed to provide reporting in accordance with 7.1.
Canada shall withhold the second payment in 2023-24 if Newfoundland and Labrador has failed to satisfy all reporting requirements associated with the preceding Canada – Newfoundland and Labrador Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23, specifically to:
1. continue to participate in a Federal-Provincial-Territorial process to improve reporting on and provide data to CIHI for the 6 common indicators to measure pan-Canadian progress on improving access to mental health, substance use, and addictions services; and
2. submit an annual financial statement, with attestation from Newfoundland and Labrador's Chief Financial Officer, of funding received the preceding Fiscal Year from Canada for mental health and addiction services under the Canada – Newfoundland and Labrador Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23 compared against the Expenditure Plan, and noting any variances, between actual expenditures and the Expenditure Plan.
The sum of both installments constitutes a final payment and is not subject to any further payment once the second installment has been paid.
Payment of Canada's funding for this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.

5.4 Retaining funds

5.4.1 For Fiscal Years 2023-24 through 2024-25, upon request, Newfoundland and Labrador may retain and carry forward to the next Fiscal Year up to 10 per cent of funding that is in excess of the amount of the eligible costs actually incurred in a Fiscal Year and use the amount carried forward for expenditures on eligible areas of investment. Any request to retain and carry forward an amount exceeding 10 per cent will be subject to discussion and mutual agreement in writing by their designated officials, at the Assistant Deputy Minister level (herein referred to as "Designated Officials"), and is subject to monitoring and reporting to Canada on the management and spending of the funds carried forward on a quarterly basis.

5.4.2 Any amount carried forward from one Fiscal Year to the next under this subsection is supplementary to the maximum amount payable to Newfoundland and Labrador under subsection 5.2.4 of this Agreement in the next Fiscal Year.

5.4.3 Upon request, Newfoundland and Labrador may retain and carry forward up to 10 per cent of funding provided in the last Fiscal Year of this Agreement for eligible areas of investment, to be noted in the new agreement and subject to the terms and conditions of that new agreement. The new Action Plan will provide details on how any retained funds carried forward will be expended. Any request by Newfoundland and Labrador to retain and carry forward an amount exceeding 10 per cent will be subject to discussion and mutual agreement in writing by their Designated Officials, and is subject to monitoring and reporting to Canada on the management and spending of the funds carried forward on a quarterly basis.

5.5 Repayment of overpayment

5.5.1. In the event payments made exceed the amount to which Newfoundland and Labrador is entitled under this Agreement, the amount of the excess is a debt due to Canada and, unless otherwise agreed to in writing by the Parties, Newfoundland and Labrador shall repay the amount within sixty (60) calendar days of written notice from Canada.

5.6 Use of funds

5.6.1. The Parties agree that funds provided under this Agreement will only be used by Newfoundland and Labrador in accordance with the initiatives outlined in Annex 4.

5.7 Eligible expenditures

5.7.1. Eligible expenditures under this Agreement are the following:

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

6.0 Performance measurement

6.1 Newfoundland and Labrador agrees to designate an official or official(s), for the duration of this Agreement to participate in a CIHI led Federal-Provincial-Territorial indicator process to:

Refine the eight common headline indicators (outlined in Annex 3);
Work to identify additional common indicators that are mutually agreed upon, including indicators focused on the health of Indigenous populations with acknowledgement of the role for Indigenous partners in this work;
Improve reporting on common indicators to measure pan-Canadian progress on improving access to mental health, substance use, and addictions services, associated with the commitment in the Common Statement; and
Share available disaggregated data with CIHI and work with CIHI to improve availability of disaggregated data for existing and new common indicators to enable reporting on progress for underserved and/or disadvantaged populations including, but not limited to, Indigenous peoples, First Nations, Inuit, Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+.

7.0 Reporting to Canadians

7.1 Funding conditions and reporting

7.1.1 By no later than October 1, in each fiscal year, with respect of the previous Fiscal Year, Newfoundland and Labrador agrees to:

Provide data and information annually to CIHI related to the new headline indicators, additional common indicators, and the mental health, substance use, and addictions services indicators identified as part of commitment made in the Common Statement.
Beginning in Fiscal Year 2024-25, report annually and publicly in an integrated manner to residents of Newfoundland and Labrador on progress made on targets outlined in Annex 4 (Action Plan) for headline indicators in the priority area(s) where federal funds are to be invested, and on jurisdiction-specific indicators for each of the initiatives tailored to their jurisdiction's needs and circumstances.
Beginning in Fiscal Year 2024-25, provide to Canada an annual financial statement, with attestation from Newfoundland and Labrador's Chief Financial Officer, of funding received the preceding Fiscal Year from Canada under this Agreement or the Previous Agreement compared against the Action Plan, and noting any variances, between actual expenditures and the Action Plan:
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 each of the shared health priority areas that are supported by the federal funds;
3. If applicable, the amount of any funding carried forward under section 5.4; and
4. If applicable, the amount of overpayment that is to be repaid to Canada under section 5.5.

7.1.2 Newfoundland and Labrador will provide quarterly reporting to Canada on the management and spending of the funds retained to the next Fiscal Year.

7.2 Audit

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

7.3 Evaluation

7.3.1 Responsibility for evaluation of programs rests with Newfoundland and Labrador in accordance with its own evaluation policies and practices.

8.0 Communications

8.1 The Parties 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.

8.2 Each Party will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.

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

8.4 Newfoundland and Labrador will make publicly available, clearly identified on Government of Newfoundland and Labrador website, this Agreement, including any amendments.

8.5 Canada, with prior notice to Newfoundland and Labrador, may incorporate all or any part of the data and information in 7.1, or any part of evaluation and audit reports made public by Newfoundland and Labrador into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

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

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

8.8 Canada and Newfoundland and Labrador agree to participate in a joint announcement upon signing of this Agreement.

8.9 Canada and Newfoundland and Labrador agree to work together to identify mutually agreeable opportunities for joint announcements relating to programs funded under this Agreement.

9.0 Dispute resolution

9.1 The Parties 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.

9.2 If at any time a Party 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, that Party may notify the other Party in writing of the failure or breach. Upon such notice, the Parties will endeavour to resolve the issue in dispute bilaterally through their Designated Officials.

9.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Canada and Newfoundland and Labrador responsible for health, and if it cannot be resolved by them, then the federal Minister(s) and Minister of Health and Community Services shall endeavour to resolve the dispute.

10.0 Amendments to the agreement

10.1 The main text of this Agreement may be amended at any time by mutual consent of the Parties. Any amendments shall be in writing and signed, in the case of Canada, by the federal Minister(s), and in the case of Newfoundland and Labrador, by the provincial Minister(s).

10.2 Annex 4 may be amended at any time by mutual consent of the Parties. Any amendments to Annex 4 shall be in writing and signed by each Party's Designated Official.

11.0 Termination

11.1 Either Party may terminate this Agreement at any time if the terms are not respected by giving at least 6 months written notice of intention to terminate.

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

11.3 Sections 1.0, and 8.0 of this Agreement survive for the period of the 10-year Working Together to Improve Health Care for Canadians plan.

11.4 Sections 5.4 and 7.0 of this Agreement survive the termination or expiration of this Agreement until reporting obligations are completed.

12.0 Notice

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

The address of the Designated Official for Canada shall be:

Assistant Deputy Minister, Strategic Policy Branch

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

Email: jocelyne.voisin@hc-sc.gc.ca

The address of the Designated Official for Newfoundland and Labrador shall be:

Assistant Deputy Minister of Corporate Services
Department of Health and Community Services
Government of Newfoundland and Labrador
P.O. Box 8700
1^st Floor, West Block Confederation Building
100 Prince Philip Drive
St John's, NL
A1B 4J6

Email: PatrickMorrissey@gov.nl.ca

13.0 General

13.1 This Agreement, including Annexes, comprises the entire Agreement entered into by the Parties.

13.2 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Newfoundland and Labrador.

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

13.4 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 severed and deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.

13.5 This Agreement may be executed in counterparts, in which case (i) the Parties have caused this Agreement to be duly signed by the undersigned authorized representatives in separate signature pages in accordance with the following signature process, which together shall constitute one agreement, and (ii) the Parties agree that facsimile signature(s) and signature(s) transmitted by PDF shall be treated as original signature(s). Electronic signature(s) may be accepted as originals so long as the source of the transmission can be reasonably connected to the signatory.

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Canada by the Minister of Health

The Honourable Mark Holland, Minister of Health

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Canada by the Minister of Mental Health and Addictions and Associate Minister of Health

The Honourable Ya'ara Saks, Minister of Mental Health and Addictions and Associate Minister of Health

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Newfoundland and Labrador by the Minister of Health and Community Services

The Honourable Tom Osborne, Minister of Health and Community Services

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Newfoundland and Labrador by the Minister for Intergovernmental Affairs

The Honourable Andrew Furey, Minister for Intergovernmental Affairs

Annex 1 – Common Statement of Principles on Shared Health Priorities

Common Statement of Principles on Shared Health Priorities

Annex 2 – Shared pan-Canadian interoperability roadmap

Figure 1. Text version below. — **Figure 1. 5-Year shared pan-Canadian interoperability roadmap**

Annex 3 – Headline common indicators

Headline common indicators
Shared health priority area	Indicator
Family health services	Percentage of Canadians who report having access to a regular family health team, a family doctor or nurse practitioner, including in rural and remote areas
Health workers and backlogs	Size of COVID-19 surgery backlog
Health workers and backlogs	Net new family physicians, nurses, and nurse practitioners
Mental Health and Substance Use	Median wait times for community mental health and substance use services
	Percentage of youth aged 12 to 25 with access to integrated youth services (IYS) for mental health and substance use
	Percentage of Canadians with a mental disorder who have an unmet mental health care need
Modern health data system	Percentage of Canadians who can access their own comprehensive health record electronically
Modern health data system	Percentage of family health service providers and other health professionals (e.g., pharmacists, specialists, etc.) who can share patient health information electronically

Annex 4 – Action plan

Overview

On February 23, 2023, the Government of Canada and the Government of Newfoundland and Labrador publicly agreed to new federal funding for investments in family health services, health workforce and backlogs, mental health and substance use, and modernized health data systems.

Over the 10-year period (2023-24 to 2032-33), the Government of Canada will invest approximately $805 million in federal funding to help improve health care for Newfoundlanders and Labradorians, which includes $32 million that was committed to mental health and substance use from the 2017 Statement of Principles on Shared Health Priorities. This Action Plan outlines how federal funding will be invested for the first three years of this 10-year period.

Ensuring the long-term sustainability of the health care system is an ongoing challenge in Newfoundland and Labrador. Much work is underway, and more is to come as the Province is taking action to address the retention and recruitment of health care professionals; improve the wait times for access to care; leverage new opportunities and technologies; and address the growing rates of mental health and substance use issues.

Health Accord NL was created in November 2020 to reimagine the health care system to best deliver services to people in communities across the province. It was mandated to deliver a 10-year Health Accord with short-, medium-, and long-term goals for a health care system that better meets the needs of Newfoundlanders and Labradorians. The Health Accord NL final reports were released in 2022 and contained 59 calls to action on improving specific social, economic, and environmental conditions affecting the population's health; providing better, more timely access to health care; and developing a more integrated, technologically-enhanced, and sustainable health system. Guided by Health Accord NL, the Government of Newfoundland and Labrador is driving meaningful change across the health care system that will improve access to primary care, shorten wait times, and provide integrated service delivery.

An agreement in principle to work together on shared health priorities was signed in February 2023 by the Governments of Newfoundland and Labrador, and Canada. This included a top up to support paediatric hospitals and emergency rooms, as well as a five per cent guarantee on the Canada Health Transfer for the next five years. The federal government's priorities closely align with provincial health priorities as evidenced by the provincial government's largest ever investment in health care in Budget 2023. The federal investment on these shared health priorities will complement work being led by the province to date. This action plan highlights the commitment to these shared health priorities underway as guided by Health Accord NL, and most importantly, how this work supports reimagining health care and improving the ability of Newfoundlanders and Labradorians to access care. Working together, the record investments build on the meaningful action that has been taken to ensure timely access to quality care, as well as enhances efforts to support valued health care professionals and global recruitment efforts.

Initiatives supported by federal funds

Theme: Family health services

Transform how family health services are delivered so they are patient-centred and delivered through integrated, team-based models of care

Newfoundland and Labrador is committed to establishing province-wide Family Care Teams, with interprofessional team-based care central to this commitment. Team-based care has been shown to improve continuity of care, timely access, chronic disease management and health outcomes, provider satisfaction and work-life balance, and reduce emergency department visits, hospitalizations, and entry to long-term care. As well, a team-based, family care model helps all practitioners better utilize their skills and work to their full scope of practice. Building and strengthening Family Care Teams is an essential starting point for transformation of a rebalanced health system as outlined in Health Accord NL. Currently, there are 11 Family Care Teams in various stages of implementation throughout the Province. Supported by federal investment over the next year, the Province plans to grow the number of teams by another eight. These teams will be integrated with other system changes such as strengthening hospital services and the creation of a provincial integrated air and road ambulance system. Implementation of Family Care Teams will continue into 2024 and 2025.

Changes in the way health providers are compensated and work together to utilize technologies are priorities for a team-based approach. Introducing a blended capitation model for family physician payment is also foundational in developing Family Care Teams. This model will be delivered in collaboration with community services to provide sustainable, appropriate, equitable, and person-focused care that supports the needs of patients/clients. The blended capitation model requires new and modified information technology systems to facilitate the new method of payment for family physicians.

Primary health care across Newfoundland and Labrador has been strained with the loss of primary care providers in community-based clinics. There is a need to increase the number of family physicians practicing in the Province to fully implement the new model of care. The Family Practice Programs are designed to support physicians by removing financial barriers associated with opening or joining a family practice. The two Family Practice Programs that federal investments will support include the Family Practice Start-Up Program and the New Family Physician Income Guarantee. The Family Practice Start-Up Program includes $150,000 for recipients to open or join a family practice, and stay for a five-year return-in-service agreement. The New Family Physician Income Guarantee ensures recipients have their income guaranteed to be the equivalent to a salaried physician for their first two years of service by providing financial support dependent on fee-for-service billings and Newfoundland and Labrador Health Services sources of income.

Newfoundland and Labrador has high rates of children and youth with medically complex needs. A more integrated approach is needed to respond to health care needs of children and youth and improve health outcomes. Federal funding will be allocated to support the implementation of one model of Child and Youth Community Health Services for the Province. This model will utilize a central intake and a streamlined organizational structure with an interprofessional team across all children- and youth-serving Government departments to support improving health outcomes for this population.

Within the population of children and youth with complex needs are those who enter into protective care who have often experienced adverse childhood events such as poverty, trauma, parental mental illness and/or exposure to family violence. These adverse events are recognized risk factors for poor physical and mental health outcomes, and children and youth in care often have complex needs that require significant services and supports from multiple health providers. Additionally, children and youth in care experience additional systemic barriers that affect their ability to access appropriate services in a timely way, which often results in disrupted and inequitable care, further exacerbating the complexity of their needs. Within the Child and Youth Community Health Services model, a province-wide clinic targeted and resourced with interprofessional clinicians will be implemented to provide health support to children and youth in alternate care. These services will integrate mental and physical health care services under one program structure. Supported by federal funding, the multi-disciplinary team of professionals with the addition of a clinical occupational therapist, speech language pathologist, clinical dietitian, nurse practitioner, social worker, mental health counsellor, and behaviour management specialist helps implement an integrated continuum of care. These two initiatives will address the needs of children and youth while aligning with Health Accord NL recommendations.

As Family Care Teams are established across the Province, providing equitable access to urgent care is also imperative to the provision of quality and accessible health care. An urgent care model will be established in health centres across the Province, utilizing a principles-based and criteria-based approach as outlined in Health Accord NL. The criteria will include distance between the site and the nearest hospital emergency department, geography, size of the catchment population and availability of health care providers to reflect population needs.

The purpose of urgent care centres is to alleviate the increasing demands at emergency departments, by treating patients presenting with primary health and urgent medical issues. Urgent care centres will provide extended-hour access for unexpected, non-life-threatening health concerns that require same-day or next-day access. Treatment will be available for patients unattached to a primary care provider and for those who may be attached but cannot receive timely access to address their concern. Urgent care centres will be part of the continuum of care, which will allow the right care to be delivered to the right patient at the right location.

Urgent care teams will include nurses (nurse practitioners, registered nurses and licensed practical nurses), emergency medicine physicians, family medicine physicians, X-ray technologists, medical laboratory technologists, along with managers and clerical staff. Additional diagnostic equipment (e.g., X-ray, ultrasound, laboratory equipment, monitors) and newly-leased infrastructure will be required to implement urgent care centres. This costing considers projected inflation/amortization rates and 10-year lease agreements and incorporates the specified infrastructure requirements to provide urgent care services.

Given the ongoing need for more family physicians, funding allocations for Family Care Teams, Family Practice Programs, child and youth care programs and urgent care teams will help address the needs of Indigenous peoples and other underserved and disadvantaged populations by providing better access to primary care services. Improved access to primary care and supports for children and youth, particularly those with complex needs, aligns with priorities identified by provincial Indigenous Governments and Organizations (IGOs). Family Care Teams will also be well positioned to help improve the social determinants of health, such as housing and food security, another priority outlined by provincial IGOs.

To support activities within the Family Health Services initiative, federal funding will be allocated to the following areas to:

Create additional Family Care Teams across the Province, which includes the cost of technology to support teams with the appropriate provision for information sharing, virtual care, and patient engagement and communication.
Increase the annual budget for Family Practice Programs to further remove the financial barriers associated with opening or joining a family practice throughout the Province. This will enable two calls for applications (spring and fall) that are necessary to capture physicians looking to remain in the Province after completing residency, as well as physicians looking to return to the Province to practice. It will also support long-term planning for early-career physicians.
Support nine full-time equivalent (FTE) required positions to implement the Child and Youth Community Health Services Model.
Support new FTE positions to address the complex needs of children and youth in alternate care and allow for expansion to all areas of the Province.
Support the creation of an urgent care centre in St. John's. Federal funding for urgent care centres will be allocated toward expenses for additional staffing and new capital equipment.

Family health services
Initiatives	2023-24	2024-25	2025-26	Total
i. Transform how family health services are delivered so they are patient-centred and delivered through integrated, team-based models of care
Family care transformation	$ 10.26 M	$ 8.50 M	$ 1.00 M	$ 19.76 M
Child and youth model	$ 0.87 M	$ 1.73 M	$ 1.73 M	$ 4.33 M
Urgent care	$ 1.94 M	$ 2.58 M	$ 2.58 M	$ 7.10 M
Total	$ 13.07 M	$ 12.81 M	$ 5.31 M	$ 31.19 M

Theme: Health workforce and backlogs

Institute models of care that address surgical backlogs and increase access to health services
Improving quality and access to care and enhancing health innovation and efficiency was a pillar of Health Accord NL. Following the release of its Calls to Action, work was completed to find ways to increase service capacity within tertiary care sites. The COVID-19 pandemic presented many challenges and service interruptions, which continue to affect surgical wait times as illness amongst staff and patients have affected service delivery. One area identified was to increase operating room space to help address surgical backlogs for women's health and paediatric services.

Joint replacements have long been considered an inpatient-only surgical procedure. This has changed in recent years and the number of procedures performed on an outpatient basis is steadily increasing. Outpatient or same-day joint replacement surgery eliminates the need for an inpatient post-operative hospital stay, as patients mobilize shortly after surgery and return home the same day. To address the increasing demand for joint replacements, Newfoundland and Labrador Health Services plans to introduce a same-day outpatient joint replacement surgery initiative within the Western Zone with a goal to increase the number of inpatient joint replacement surgeries in that region by 130 annually. In the Eastern Rural Zone, orthopaedic surgeries at Carbonear General Hospital are being expanded by staffing four additional inpatient beds and utilizing travelling orthopaedic surgeons to perform these procedures. Hospitalist physicians will be required for post-operative recovery. It is expected that 160 hip/knee replacements can be accommodated annually utilizing this model.

To help address surgical backlogs and increase access to health care services, federal funding will be allocated to:
- Enhance staffing of FTE registered nurses, clerical staff, and supplies to operationalize additional operating room capacity in women's health and paediatric services.
- Enhance staffing by four FTE health care worker positions to perform 130 additional (or 100 inpatient, 30 same-day) joint replacement surgeries. These positions include a registered nurse, physiotherapist, social worker, supporter worker/rehabilitation assistant and clerk.
- Recruit health care workers and purchase surgical supplies/equipment to implement orthopaedic surgery expansion at Carbonear General Hospital.
Institute innovative team-based models of care that maximize health care worker competencies allowing professionals to work to their full scope of practice, and provide support to address demands and reduce health care worker burden
New ways of providing services are needed across all dimensions of health care delivery to support a robust system that evolves with changing service needs of the population. The Province is committed to developing innovative models of care to relieve the burden on the broader primary care workforce and transform health care delivery into a sustainable model. Federal investments will help support implementation of new models of care across the province.

New models of service delivery include exploring and implementing new positions within multidisciplinary health care teams and enabling all team members to work to their full scope of practice to address the health needs of Newfoundlanders and Labradorians. The Province is implementing a pilot program to utilize physician assistants where there are high patient volumes and vacancies that affect service delivery. Physician assistants are advanced practice clinicians who practice medicine under the supervision of a licensed physician. They have a broad scope of practice and can work in any clinical setting to extend physician services, complement existing services, and aid in improving patient access to health care. The pilot program will run for three years, and will be monitored for indicators of success and will conclude with a program evaluation.

Improving access to midwifery care is another area of focus that the Province is committed to implementing in the public health care system. Adding midwives to obstetrical teams will help contribute to more sustainable obstetrical services by increasing the complement of service providers for maternal-child health. Currently, the only registered midwifery services are provided in the Central Zone of the Province in the Town of Gander. The Province plans to make this service available in six of the current 10 obstetrical sites. This will require increasing the workforce to 20 FTE midwives by 2027. The benefits of expanding midwifery services include increasing access to quality primary care providers for birthing people during the childbearing years and their newborns, improving physical and mental health outcomes and client satisfaction, and increasing stability to obstetrical services that may be facing physician and/or nursing shortages. Increasing midwifery services has also been identified as a priority for some provincial IGOs as a means to access culturally safe maternal-child health care.

The Province worked with the regulatory body for pharmacists to expand the scope of pharmacist services as a means to assist with the growing pressure on the health care system to ensure timely access to primary care services. This initiative aims at increasing access to health services for all residents by providing treatment for selected ailments and conditions. Allowing a pharmacist to assess and prescribe for additional identified ailments/conditions and for hormonal contraceptives, as well as allowing prescription extensions up to 12 months, will relieve pressure for non-urgent services on the health system and on primary care providers. The Province will cover the assessment fees for nine select ailments/conditions and hormonal contraceptives, as well as the prescription renewal service fee, which should reduce the demand for primary care provider visits.

Newfoundland and Labrador has the highest burden of cardiovascular disease in the country. Recognizing the disparity in cardiovascular health outcomes, Health Accord NL recommended creating a Cardiac Centre of Excellence to provide an organized hub of tertiary services within a spoke network enabling equitable access to cardiac care. The Province has since established the Newfoundland and Labrador Cardiovascular and Stroke Institute (the Institute) to provide equitable provincial access to cardiovascular diagnostics and intervention using a phased-in approach. The Institute demonstrates a strong commitment to quality health care in the Province and will immediately provide Newfoundlanders and Labradorians with new ways to access cardiovascular and stroke care services.

To support innovative models of health care delivery, federal funding will be allocated to:
- Pilot a program with four physician assistant positions within multidisciplinary health care teams, including salaries along with necessary relocation expenses and signing bonuses to attract out-of-province physician assistants.
- Salary and benefits for midwifery positions and start-up and other related costs for service expansion. Through federal funding, the Province aims to increase the workforce to 17 FTE midwives by 2025-26 across all health zones in province.
- Expenses related to the expansion of minor ailments for which pharmacists can prescribe and prescription extensions. Treatment of minor ailments at a local pharmacy provides appropriate and timely access to health care for individuals across the province.
- Base funding for the Newfoundland and Labrador Cardiovascular and Stroke Institute, which includes four permanent staffing positions, an aircraft retainer, space rental for cardiac rehabilitation, system/technical requirements and one-time funding for staffing.
Increase the supply of the health workforce by increasing the number of training, residency, and practicum spots for health professionals
Health care facilities throughout the province continue to experience high demand for various health care providers. Beginning in September 2023, the Province will have expanded the number of seats available to Newfoundland and Labrador residents in Memorial University's Undergraduate Medical Education Program. Five additional spaces will be available to eligible residents, bringing the total available seats to 65. Memorial University's Faculty of Medicine accepts 80 students annually into the four-year undergraduate program, including three seats reserved for Indigenous students. While increasing the number of reserved seats for students from Newfoundland and Labrador will provide an opportunity for more learners from this province to study at home, the Province is also working on increasing the number of international medical graduates in the province by increasing pathways for them to train and work in Newfoundland and Labrador. This will be achieved by adding five seats for International Medical Graduates to the Family Medicine Residency Program at Memorial University. Doing so will help improve the likelihood that more trainees will stay in the province to practice as a family physician upon completion of their residency training, as a return-in-service agreement is required.

Health care facilities throughout the province continue to experience high demands for registered nurses. A suite of measures has been implemented to expand the supply of nursing professionals, such as increasing the number of seats in the B.Sc. Nursing Program by 25 per cent by implementing a rural education program with remote teaching. Implementing a Bachelor of Science (B.Sc.) Nursing Practice Course grant supports the increased seat capacities of the B.Sc. Nursing Program and provides financial assistance to B.Sc. Nursing students.

The Province is seeking to address the vacancy rates of licensed practical nurses and personal care attendants. Both professions play an integral role in the health care system, particularly in long-term care. The vacancy rate for licensed practical nurse positions throughout the province is approximately 15 per cent. High vacancy rates in health care impact workloads of others. The need for licensed practical nurses is significant, particularly in rural areas, as new demands have been introduced with the construction of new long-term care facilities in the province. An additional 92 seats were distributed across several College of the North Atlantic (CNA) sites for the 2022-23 academic year to help increase the supply of licensed practical nurses in the province. To help address the current shortage of practical nurses and anticipated future supply needs, the Centre for Nursing Studies (CNS) will offer its Licensed Practical Nursing program in Jamaica, for residents who wish to be employed in Canada. The program was previously offered in 2009 with great success. Seat capacity will be 40 students in each of three community colleges, totaling 120 seats. The Nursing Department of the three Jamaica Colleges will deliver the five-semester program in collaboration with the CNS. The Nursing Council of Jamaica will approve all clinical placements prior to their use in the Licensed Practical Nursing program. The faculty of the Colleges, in consultation with the CNS, will coordinate clinical teaching and assume responsibility for implementation, monitoring and evaluation. The Colleges will supply the physical space, clinical placement, and human and support resources to deliver the CNS Licensed Practical Nursing program curriculum. Educating students internationally is part of a multi-pronged approach to address health workforce shortages. The proposed program aligns with broader initiatives on health workforce and backlogs, as well as the Province's immigration and multiculturalism priorities.

Addressing the vacancy rate for personal care attendants, which is currently at 13 per cent, is also a priority. Keyin College, through its partnership with the CNS, has developed an International Personal Care Attendant Pilot Program. The program facilitates international students to register for their studies with Keyin College, apply for their Post Graduate Work Permit through CNS, and gain employment with Newfoundland and Labrador Health Services upon completion. Currently, a Health Professional Bursary Program is available for graduates of personal care attendant programs. The $5,000 bursary includes a two-year return-in-service agreement with Newfoundland and Labrador Health Services upon completion of the program. Expanding the Health Professional Bursary to the International Personal Care Attendant Pilot Program will provide financial support to international personal care attendants graduating in the first year of the program, with the same two-year return-in-service agreement with Newfoundland and Labrador Health Services, thereby contributing further to the talent supply of personal care attendants in the province. It is estimated that the three-year pilot project will graduate 37 students in its first year and 95 students in the second and third years, for a total of 227 students.

To help increase the supply of the health workforce, federal funding will be allocated to:
- Expand the number of seats available to Newfoundland and Labrador residents in Memorial University's Undergraduate Medical Education Program.
- Increase opportunities for International Medical Graduates to complete their postgraduate training in the province. Funding will support operating and distribution costs, travel expenses, academic and administrative salaries, contracted services, capital costs and clinical skill assessment for the International Medical Graduates residency expansion.
- Operationalize the B.Sc. Nursing Practice Course Grant by funding the seat increases.
- Support the Licensed Practical Nursing program in Jamaica, including consulting and coordinating services and program delivery expenses, such as travel to Jamaica for program implementation and monitoring, and a financial bursary of $5,000 per student with a two-year return-in-service agreement..
- Ensure the $5,000 Health Professional Bursary is available to each student graduating in the first year of the International Personal Care Attendant Pilot Program.
Increase the number of targeted incentive programs for difficult to fill positions and increase programs designed to increase retention of health care workers, including programs to support career development
Given the worldwide shortage of health care workers, the sustainability of community and hospital services, particularly in rural areas, is a concern. Recruitment and retention of providers is multi-faceted and is linked directly to work-life balance, workload, and burnout. Health Accord NL highlights the need for creating a strategic recruitment plan that will ensure health care providers are in place to offer stable, direct care and services to patients, clients, residents, and families in a rebalanced health and social system, while at the same time providing work-life balance for employees.

Newfoundland and Labrador has committed to health workforce planning, including the development of initiatives to assist with the recruitment and retention of health professionals to provide effective and sustainable services to the people of the province. For this, the Province implemented a number of incentives to address health workforce shortages, focusing on the key role of workforce supply on the sustainability of the health care system and transformation of health care delivery. Further, four programs to support health professional recruitment and retention province-wide will be developed. These programs include an Employee Referral Program that will be designed to improve recruitment and retention by providing current employees with an opportunity to assist with recruitment efforts by referring individuals to work in select health care occupations in Newfoundland and Labrador Health Services. The second will be a Physicians Recruiting Physicians Program designed to allow existing physicians in the province to play an active role in the recruitment of new physicians. The third will be a Community Recruitment and Retention Program designed to assist communities and municipalities with recruitment and retention efforts for health care professionals within their communities. Lastly, the fourth will be an Employee Wellness Incentive designed for current employees in select health occupations aimed at providing an incentive towards wellness.

The Province recognizes the valuable and important work that health care professionals do, in all areas of the province, and continues to actively engage health professional regulatory bodies, advocacy associations, and unions to identify issues and improve current working conditions to retain health professionals. Recognizing the importance of health care provider retention in a competitive global environment, the Province is implementing a suite of initiatives focused on retention of health care workers, including opportunities to support career development.

The Supervised Practice Experience Program (SPEP) for Nurses aims to support re-entry of nurses and internationally educated nurses in obtaining employment as a registered nurse or licensed practical nurse in Newfoundland and Labrador. This initiative encourages eligible nurses to complete their currency of practice in the province as part of the overall recruitment and retention strategy. Currency of practice hours prevents many nurses from re-entering the profession, or internationally educated nurses from obtaining licensure for entry to practice as a registered nurse or licensed practical nurse in Newfoundland and Labrador. As part of the program, the College of Registered Nurses of Newfoundland and Labrador and College of Licensed Practical Nurses of Newfoundland and Labrador will grant an Interim License with Conditions to eligible participants. This license will allow them to gain currency of practice hours to be eligible for licensure and enter practice as a registered nurse or licensed practical nurse. Return-in-service agreements will be required.

Part-time, Non-Stipendiary Clinical Faculty Members at Memorial University's Faculty of Medicine play an important role in delivering training to medical learners in rural areas. These faculty members provide clinical bedside teaching to undergraduate and postgraduate medical learners during scheduled clinical placements, mainly at rural sites throughout the province. They are appointed through recommendation, from a clinical discipline, to oversee and evaluate a learner during a rotation. They are remunerated for their services upon completion of the learner's evaluation. On average, higher rates of payment are available in other parts of Canada compared to the remuneration schedule at Memorial University for these clinical faculty members who are essential to deliver rural training opportunities. To achieve national parity in the remuneration rates provided to these clinical faculty members, and to increase the number of these faculty members willing to accept learners on rural placements, the annual funding for Appointed Part-time, Non-Stipendiary Clinical Faculty Members will be increased to $250 per student, per week.

In 2019, the Province directed the four former Regional Health Authorities to convert all hospital ambulance services to Advanced Life Support care. Achieving this directive required a 50 per cent Advanced Care Paramedic (ACP) staffing complement, or one ACP and one Primary Care Paramedic (PCP), per service. The CNA ACP program was designed and funded to train ACPs in Newfoundland and Labrador in 2019 so that learners could still work with their ambulance service as a PCP. As Newfoundland and Labrador Health Services learners graduate from the program and become registered as ACPs, their former PCP positions will be eliminated and converted to ACP positions. The program is on a voluntary basis and uptake was challenged due to the high cost of travel to complete the program. The Province designed a travel assistance program to address concerns of travel costs for CNA's ACP program. The program provides employees enrolled in the ACP program at CNA with the opportunity to avail of financial assistance in the form of a reimbursement of travel expenses.

In an effort to support human resource management, the Province will also utilize federal funding to expand ServiceNow (HR System). This initiative aims to consolidate distinct and inadequate existing HR solutions, make HR service enhancements, and position for the future of health care. It is designed to automate all HR service workflows to replace current manual processes, while also leveraging the current investment in ServiceNow for IT service management automation. Existing systems require significant time and resources to operate and maintain, and significant enhancement requests are ill suited on legacy technologies, which require custom development for implementation, requiring additional support and maintenance.

Access to quality care is impacted by health professional vacancies. Provincial IGOs have identified accessing care closer to home as a priority. Provincial recruitment and retention efforts will have positive impacts on all areas of the province, including in Indigenous communities. The Province is preparing to co-develop an Indigenous Recruitment Incentive with IGOs to fill vacancies in Indigenous communities and communities with large Indigenous populations, as well as increase the number of Indigenous health care professionals in the health system.

To support recruitment and retention of health care workers, including programs to support career development, federal funding will be allocated to:
- Implement province-wide recruitment and retention programs.
- Cover the implementation of the SPEP in partnership with the College of Registered Nurses of Newfoundland and Labrador, along with a return-in-service agreement with Newfoundland and Labrador Health Services.
- Increase remuneration received by Part-time, Non-Stipendiary Clinical Faculty Members at Memorial University's Faculty of Medicine, an increase of $400,000 annually.
- Implement the travel assistance program for those in the ACP program at CNA.
- Support implementation of the ServiceNow (HR System) to approximately 20,000 users through software licensing and professional services.

Health workforce and backlogs
Initiatives	2023-24	2024-25	2025-26	Total
i. Institute models of care that address surgical backlogs and increase access to health services
Models of care to address surgical backlogs and increase access to health services	$ 2.69 M	$ 4.39 M	$ 4.39 M	$ 11.47 M
Subtotal	$ 2.69 M	$ 4.39 M	$ 4.39 M	$ 11.47 M
ii. Institute innovative models of care that maximize health care worker competencies allowing professionals to work to their full scope of practice, and provide support to address demands and reduce health care worker burden
New models for Physician Assistants and Midwifery	$ 1.25 M	$ 2.93 M	$ 3.62 M	$ 7.80 M
Innovative model for Cardiovascular and Stroke Care	$ 2.98 M	$ 2.48 M	$ 2.48 M	$ 7.94 M
Scope change for pharmacists	$ 8.24 M	$ 8.24 M	$ 8.24 M	$ 24.72 M
Subtotal	$ 12.47 M	$ 13.65 M	$ 14.34 M	$ 40.46 M
iii. Increase the supply of the health workforce by increasing the number of training, residency, and practicum spots for health professionals
Enhancing training capacity	$ 0.78 M	$ 0.78 M	$ 0.78 M	$ 2.34 M
International training pathways	$ 2.29 M	$ 3.00 M	$ 2.40 M	$ 7.69 M
Subtotal	$ 3.07 M	$ 3.78 M	$ 3.18 M	$ 10.03 M
iv. Increase the number of targeted incentive programs for difficult to fill positions and increase programs designed to increase retention of health care workers, including programs to support career development
Incentives for recruitment and retention	$ 5.73 M	$ 0.28 M	$ 0.28 M	$ 6.29 M
Career development for nurses, Advanced Care Paramedics and physicians	$ 1.04 M	$ 0.54 M	$ 0.54 M	$ 2.12 M
Human resource technology	$ 1.60 M	$ 1.00 M	$ 1.00 M	$ 3.60 M
Subtotal	$ 8.37 M	$ 1.82 M	$ 1.82 M	$ 12.01 M
Total	$ 26.60 M	$ 23.64 M	$ 23.73 M	$ 73.97 M

Theme: Mental health and substance use

Expand access to integrated mental health and substance use services to address the specific needs of special populations
Mental health, sometimes paired with addictions, consistently ranks among the greatest health concerns for the public. Health Accord NL approached "health" as an inclusive term including physical and mental health. Before Health Accord NL's Calls to Action, an intensive review of the provincial mental health and addictions system began in 2015, which resulted in the public release of Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador (Towards Recovery) in 2017. From both Towards Recovery and Health Accord NL, the Provincial Government committed to implementing a comprehensive, evidence-based, recovery-focused, person-centred system for mental health and addictions services integrated into Family Care Teams.

As part of Towards Recovery, the Province, in partnership with the former Regional Health Authorities, launched new mental health teams throughout the Newfoundland and Labrador. These Flexible Assertive Community Treatment (FACT) teams utilize an evidence-based comprehensive biopsychosocial model that provides treatment of illness and symptoms, hands-on assistance with daily living activities and recovery support for individuals, usually over the age of 18 years, with serious mental illness and concurrent disorders. Whereas Assertive Community Treatment (ACT) teams provide a shared-care approach with every team member fully involved in each person's care and treatment, FACT may provide care and treatment by the full team or by individual team members at any given time, depending on the treatment level intensity (low or high) required by individuals. Currently there are 13 FACT teams and two ACT teams, strategically located across the province to best respond to community needs. These teams work collaboratively with all aspects of the continuum of care in the health system. Furthermore, these teams also support individuals with other social determinants of health such as housing and employment.

Within the Newfoundland and Labrador Health Services Labrador-Grenfell Zone, the Mental Health and Addictions Program has seven FTEs, and two temporary FTE positions on the north and south coast of Labrador. These positions include registered nurses and social workers. Historically, these positions have been difficult to fill, resulting in chronic vacancies that are affecting the ability to deliver in-person services in communities. Staff from other areas of the region travel to the communities during times of crisis which in turn has left those areas without service or limited services for periods of time. Following a period of long-term vacancy, a trial for a rotational position for Natuashish was implemented. This trial has been successful in providing consistent and stable services to the community. The clinician works six days a week at 11.25 hours a day. The clinician is also able to respond to an after-hours crisis, if needed. Given the success of this trial in Natuashish, the goal is to establish rotational positions for mental health and addictions for other north and south coast communities in Labrador.

Towards Recovery included a recommendation to construct a six-bed mental health unit in Happy Valley-Goose Bay. Opening of this new unit will help address an identified need in the region for access to mental health services for some of the most remote areas of Labrador, reducing the need to travel to the Island portion of the province. Funding will support annual operational funding for the new six bed mental health unit at the Labrador Health Centre in Happy Valley-Goose Bay for salaries, including 17.4 FTEs (15.4 FTE for resident care services and two FTE for support services) and supplies, which includes drugs, utilities, linen and food expenses.

To expand access to mental health and substance use services, federal funding will be allocated to:
- Continue offering the FACT and ACT programs with required health care provider positions in these teams to help treat illness, assist with daily living tasks, and provide recovery supports for those with serious mental health illness and concurrent disorders.
- Fund the transportation costs from St. John's to Happy Valley-Goose Bay for nine staff every six weeks to establish rotational position(s) for mental health and addictions professionals to provide consistent and stable services to remote and Indigenous communities.
- Support annual operational funding for the new six-bed mental health unit at the Labrador Health Centre in Happy Valley-Goose Bay to provide equitable access to in-patient treatment closer to home for rural, remote, and Indigenous communities.
All provincial IGOs have identified mental health and addictions as a priority, with specific priority initiatives including improving access to mental health services, implementing treatment programs closer to home to respond to the rising prevalence of addictions issues, and the need for increasing awareness of provincial supports available for community members. The new mental health unit in Happy Valley-Goose Bay and rotational mental health and addictions positions for coastal Labrador will greatly benefit Labrador Indigenous populations to address mental health and addictions concerns.
Continue implementation of 2017 Bilateral Agreement Action Plan
On December 23, 2016, the Government of Canada and the Government of Newfoundland and Labrador publicly agreed to new federal funding for investments in home and community care, including mental health and addictions. Considerable inroads were made with the support from the federal investment, enabling completion of many Towards Recovery recommendations. These recommendations included actions to promote positive health and well-being and prevent mental illness; focus on individuals' preferences and strengths; decrease wait times and improve access to services; enhance provider collaboration; address stigma and discrimination; and support people in need of services when and where they need it most.

Improving access to community-based services remains a priority and implementation of such services is aimed at reducing hospitalizations and offering supports across the full continuum of care as outlined in the Provincial Stepped Care Model. Federal funds will be allocated to continue delivery of these services, including maintaining existing and scaling up FACT/ACT teams to support individuals living in the community who are dealing with significant mental health issues, mobile crisis response teams, increasing individual and group access to psychological therapies including dialectical behaviour therapy, and continue investment in e- Mental health services.

Another continued priority includes improving access to services for substance use in response to the opioid crisis being experienced across the country. An Opioid Action Plan was implemented, of which a key component was to implement a provincial Take-Home Naloxone Kit Program to increase capacity for opioid overdose response. Federal funding will be allocated to fund services and programs, including funding peer support workers in community organizations and expanding peer support programs for those in recovery from additions, and in partnership with community-based groups, continued to expand the needle exchange program throughout the province.

Implementation of e-Mental health initiatives also remains a high priority. Newfoundland and Labrador is known nationally and internationally as a leader in this field and hosts a robust suite of online mental health and addictions supports, located on bridgethegapp.ca, for people province-wide, which includes programs such as Strongest Families, MindwellU, BreathingRoom™ and Therapy Assistance Online to name a few. Federal funding will be allocated to further innovate service delivery models to improve the way services are delivered by deploying innovative technology. Federal funding will also maintain four e-Mental health care providers with expertise in the delivery of services through technology.

All provincial IGOs have raised mental health and addictions as a priority. The initiatives identified for funding will greatly benefit Labrador, and FACT/ACT teams will have province-wide benefits. Furthermore, the priority areas identified in previous agreements will continue as priorities and will support Indigenous populations across the province.

Mental health and substance Use
Initiatives	2023-24	2024-25	2025-26	Total
i. Expand access to integrated mental health and substance use services to address the specific needs of special populations
FACT/ACT teams and mental health and addictions rural and remote positions	$ 4.62 M	$ 4.62 M	$ 4.62 M	$ 13.86 M
New Mental Health Facility	$ 1.93 M	$ 1.93 M	$ 1.93 M	$ 5.79 M
Community Mental Health	$ 5.00 M	-	-	$ 5.00 M
Subtotal	$ 11.55 M	$ 6.55 M	$ 6.55 M	$ 24.65 M
ii. Continue implementation of 2017 Bilateral Agreement Action Plan
2017 Bilateral Agreement	$ 8.10 M	$ 8.10 M	$ 8.10 M	$ 24.30 M
Subtotal	$ 8.10 M	$ 8.10 M	$ 8.10 M	$ 24.30 M
Total	$ 19.65 M	$ 14.65 M	$ 14.65 M	$ 48.95 M

Theme: Modernizing health data systems

Invest in policies, technology, people, and processes to improve data collection, reporting and analytics to drive system improvements and ensure data can be shared with patients and across the health system
Health Accord NL identified that modern digital tools and techniques such as virtual care, interoperability and integration, and clinical decision support, will be key enablers to strengthening health care services, in addition to one provincial, modern, integrated air and road ambulance system with a central medical dispatch. Calls to Action from Health Accord NL recommended immediate planning and investment in a modern, integrated, provincial Health Information System (HIS) and prioritizing virtual care improvements.

As improvements to primary care are made by implementing Family Care Teams, the Electronic Medical Record (EMR), eDOCSNL, will be a critical technology enabler for this work. This will allow standardized documentation and data collection while sharing appropriate clinical information across care settings. The Province has been successfully deploying the Med Access EMR solution since 2016. The EMR serves health care providers across the province, particularly in primary care, by providing vital documentation and practice management tools to family physicians and providing data for secondary use to help guide health system decision-making and improvement in primary care clinics across the province. The EMR is also vital to implementing the new blended capitation payment model. Fully funding the Provincial EMR program will remove a financial burden for physicians and increase uptake.

A modernized and integrated provincial HIS that encompasses the full continuum of care is vital to the transformation of health care delivery across the province. Health Accord NL recommended ensuring that care providers are supported by an inclusive and integrated HIS from the moment individuals are admitted to health care facilities. The current system does not communicate with the modern EMR used in primary care, nor does it allow for integration of other community care and social systems. Modernizing the Provincial HIS will improve cyber security and enable modern health functions including e-ordering, e-scheduling, e-prescribing, e-referrals, secure messaging, and electronic notes. Engagement with provincial IGOs showed initiatives towards modernizing health systems and access to health data are shared priorities. Ensuring that information systems are inclusive to everyone in the province will help support timely and appropriate care, as well as enable appropriate data collection to support health care planning into the future. Access to quality data will support benchmarking and performance management, and as a result, more informed decision-making and accountability for the health care system.

Many initiatives recommended in Health Accord NL and underway in the province require modernizing virtual care technology and the delivery of services such as additional videoconferencing equipment and peripheral devices (e.g., examination camera, e-stethoscopes). For example, as part of virtual care deployments provincially, the e-stethoscope will be used in emergency departments, urgent care settings, the neonatal intensive care unit (NICU), pre-admission processes, and primary health care to do virtual patient assessments. To ensure streamlined service, federal funding will be allocated to yearly licensing renewals as well as equipment. Virtual care enables care to be provided closer to home, which was a priority identified by some provincial IGOs.

The Province has experienced challenges in staffing of both physicians and registered nurses in emergency services and primary care settings across the region, which was further impacted by the COVID-19 pandemic. Consequently, many rural hospital emergency departments have had temporary closures and diversions to larger hospitals. In response, the Province adapted its current model of care in some smaller hospitals to provide patient assessment by a physician using virtual technology. The model is designed so that a physician can provide virtual emergency care from a different location. The virtual physician collaborates with staff on site to treat patients in their community and support transfer to a larger centre if further care is required.

A key Health Accord NL recommendation was the creation of a single integrated provincial ambulance service using dynamic deployment from a provincial medical dispatch centre. The financial requirements to implement a single integrated ambulance system include several components, one of which is the expansion of the current Medical Communications Centre to an accredited Central Medical Dispatch Centre, coordinating province-wide emergency response and inter-facility transports.

As outlined above, Newfoundland and Labrador is leading innovative practices and service delivery virtually to address important gaps and needs in mental health and addictions. To help further integrate e-mental health within the health care system further efforts will be undertaken to embed e-mental health tools within the provincial EMR and Personal Health Record, bringing critical measurement-based care data and learning to both providers and citizens.

The initiatives in this shared priority will benefit all residents across the province. As these initiatives are implemented, the opportunities for virtual care will help support underserved populations across the province, in particular bringing care closer to home. Implementation of a new HIS will support improved data, including disaggregated data, to support future universal and targeted health program planning. The Province continues to work with IGOs to advance implementation of an Indigenous Administrative Data Identifier in the health system, which will allow identification of the health records of Indigenous peoples. Implementation of the Identifier will be carried out in a manner that acknowledges and affirms Indigenous data sovereignty and data governance principles. With the Identifier implemented, the HIS will further enable and streamline access to Indigenous health data to support better planning, delivery, and evaluation of programs and services for Indigenous peoples.

To help modernize health systems, federal funding will be allocated to:
- Increase resources to fully cover the operating cost of the Provincial EMR. The Provincial EMR program has already enrolled over 720 providers across the province, advancing primary health care reform and enabling a large portion of the population to have a digital patient chart in eDOCSNL. Federal funding will help maximize physician participation in the EMR program. This is expected to decrease administrative burden of family physicians in the province.
- Modernize the provincial HIS, which is antiquated, incomplete, and disconnected. The current system has meant a continued reliance on paper-based records and manual processes (e.g., mail, fax) for conveying information across care settings and services. In many instances, important patient/client/resident information is simply unavailable at the point-of-care, resulting in information gaps and inefficient coordination of care.
- Support for expenses related to virtual care solutions to increase access to health care through virtual means. This includes adding resources to operationalize the virtual emergency room service delivery model in rural sites that have had to close temporarily and divert care to urban centre.
- Fund virtual care technology upgrades for new virtual programs including eStethoscope, which is used in emergency, urgent care, NICU, pre-admission, and primary health care settings to do live patient assessments. Such programs help improve access to services in rural and remote communities.
- Fund costs related to implementation of a province-wide Central Medical Dispatch Centre.

Modernizing health data systems
Initiatives	2023-24	2024-25	2025-26	Total
i. Invest in policies, technology, people, and processes to improve data collection, reporting and analytics to drive system improvements and ensure data can be shared with patients and across the health system
eDOCSNL Provincial Electronic Medical Record (EMR) program	$ 1.00 M	$ 1.00 M	$ 1.00 M	$ 3.00 M
Modernizing the provincial HIS	$ 15.00 M	$ 23.87 M	$ 31.28 M	$ 70.15 M
Virtual care initiatives	$ 6.01 M	$ 6.01 M	$ 6.01 M	$ 18.03 M
Central medical dispatch centre	$ 4.00 M	$ 3.35 M	$ 3.35 M	$ 10.70 M
Total	$ 26.01 M	$ 34.23 M	$ 41.64 M	$ 101.88 M

Overall funding allocations
	2023-24	2024-25	2025-26	TOTAL
Family health services	$ 13.07 M	$ 12.81 M	$ 5.31 M	$ 31.19 M
Health workers and backlogs	$ 26.60 M	$ 23.64 M	$ 23.73 M	$ 73.97 M
Mental health and substance use	$ 19.65 M	$ 14.65 M	$ 14.65 M	$ 48.95 M
Modernizing health data systems	$ 26.01 M	$ 34.23 M	$ 41.64 M	$ 101.88 M
Total for shared health priorities	$ 85.33M	$ 85.33M	$ 85.33M	$ 255.99M

Indicators, targets, and timeframes

The Canadian Institute for Health Information (CIHI) in collaboration with the federal, provincial, and territorial governments through the Shared Health Priorities Advisory Council outlined eight common headline indicators for each of the shared health priorities. The headline indicators are listed below. These indicators will be reported publicly by CIHI annually. These indicators, will be further refined by the Shared Health Priorities Advisory Council and Newfoundland and Labrador is committed to identifying administrative data for this purpose.


Headline Indicator	Baseline	Target	Timeframe
Family Health Services
Percentage of Canadians who report having access to a regular family health team, a family doctor or nurse practitioner, including in rural and remote areas1	88 per cent	90 per cent	March 2026
Health Workforce and Backlogs
Size of COVID-19 surgery backlog	21 per cent change in number of surgeries done monthly between March 2020 and September 2022, compared with 2019	Exceed the number of surgeries completed monthly compared to 2019	March 2026
Net new family physicians, nurses, and nurse practitioners2	13 per 10,000 net new family physicians 4 per 10,000 net new nurse practitioners 114 per 10,000 net new nurses	Increase net new family physicians, nurses, and nurse practitioners	March 2026
Mental Health and Substance Use
Median wait times for community mental health and substance use services3	33 days	32 days	March 2026
Percent of youth aged 12 to 25 with access to integrated youth services (IYS) for mental health and substance use	1 active site	At least two sites	March 2026
Percent of Canadians with a mental disorder who have an unmet mental health care need4	6 per cent	5 per cent	March 2026
Modernizing Health Data Systems
Percentage of Canadians who can access their own comprehensive health record electronically	9 per cent	At least 30 per cent	March 2026
Percentage of Family Health Service providers and other health professionals (e.g., pharmacists, specialists, etc.) who can share patient health information electronically	22 per cent for Atlantic Canada	Up to 35 Family Care Teams who can share patient health information electronically	March 2026
Footnote 1 The Canadian Community Health Survey (CCHS) underwent major redesign in 2022, including updated content and methodology. These changes will result in a revised baseline. Based on these changes, Newfoundland and Labrador's target is tentative and may be revised based on 2022 and 2023 data. Return to footnote 1 referrer Footnote 2 Target to be identified once provincial health human resource report is released. Return to footnote 2 referrer Footnote 3 On April 1, 2023, Newfoundland and Labrador transitioned to a single provincial health authority and will be adopting a new provincial Health Information System in the near team. Wait time data collection varied across the former regional health authorities. Provincial changes will impact the current baseline and as such, Newfoundland and Labrador's target is tentative and may be revised to reflect the reporting changes. Return to footnote 3 referrer Footnote 4 The Canadian Community Health Survey (CCHS) underwent major redesign in 2022, including updated content and methodology. These changes will result in a revised baseline. Based on these changes, Newfoundland and Labrador's target is tentative and may be revised based on 2022 and 2023 data. Return to footnote 4 referrer

In addition to the headline indicators, provincial indicators have also been developed with associated targets and timeframes for initiatives included in this plan. These targets will be publicly reported annually.


Indicator	Baseline	Target	Timeframe
Family Health Services
Number of Family Care Teams	As of April 1, 2023, 8 Family Care Teams underway, and 11 under development	Up to 35 Family Care Teams initiated	March 2026
Number of residents rostered to a Family Care Team	As of April 1, 2023, 28,267 people rostered to Family Care Team	Between 100,000 and 200,000 people rostered to a Family Care Team	March 2026
Health workforce and backlogs
Percentage of non-urgent surgeries meeting benchmark (hip/knee replacements, 182 days)	As of December 31 in quarter 3, 2022, 39 per cent of hip replacement surgeries performed within 182 days; and 40 per cent of knee replacement surgeries performed within 182 days	Greater than 50 per cent non-urgent surgeries (hip/knee replacements) meeting benchmark of 182 days	March 2026
Net new Physician Assistants	Zero as of April 1, 2023	Pilot project to add 4 new physician assistants	March 2026
Number of seats in education training programs for physicians	35 as of April 1, 2023	5 seats per year resulting in 10 new graduates with return in service agreements in family medicine	March 2026
Mental health and substance use
Number of individuals attached to FACT/ACT teams	As of April 1, 2023, 1,167 people were attached to a FACT/ACT team	Up to a 30 per cent increase	March 2026
Number of Doorways locations across the province	As April 1, 2023, 69 sites across the province	Increase Doorways by 5	March 2026
Modernizing Health Data Systems
Transformation plan for a new health information system	Planning is underway	Begun implementation of the plan across all health care sites	March 2026

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Date modified:: 2024-03-25