Canada-Newfoundland and Labrador Emergency Treatment Fund Bilateral Agreement
BETWEEN:
HER MAJESTY THE QUEEN IN RIGHT OF CANADA (hereinafter referred to as “Canada” or “Government of Canada”) as represented by the Minister of Health (herein referred to as “the federal Minister”)
- and -
HER MAJESTY THE QUEEN IN RIGHT OF THE 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 (herein referred to as “the Newfoundland and Labrador Minister”) and the Minister for Intergovernmental and Indigenous Affairs
REFERRED to collectively as the “Parties”
PREAMBLE
WHEREAS, Canada and Newfoundland and Labrador agree that Canada is in the midst of an opioid crisis that has had a significant effect on many communities, that has claimed the lives of thousands of Canadians from all walks of life, that has had a devastating impact on many Canadian families, and the Emergency Treatment Fund is designed to augment treatment services through one-time funding in response to the opioid crisis;
WHEREAS, Canada and Newfoundland and Labrador agree that immediate action and collaboration is needed among governments to help reduce harms and deaths associated with problematic substance use, including opioids;
WHEREAS, the governments of Canada and Newfoundland and Labrador have committed to work together to further address the opioid crisis, in full respect of their respective jurisdictional responsibilities, and recognizing that the Government of Newfoundland and Labrador has the primary responsibility for the design and delivery of substance use disorder treatment and response services in Newfoundland and Labrador, the one-time Emergency Treatment Fund is intended to augment services and Newfoundland and Labrador will be required to sustain any ongoing initiatives as required;
WHEREAS, Canada has established a transfer payment program called the Emergency Treatment Fund to provide one-time funding to the provincial and territorial governments for the development and delivery of treatment services for problematic substance use, including opioids;
WHEREAS, Canada authorizes the federal Minister to enter into agreements with the provinces and territories, for the purpose of promptly and effectively responding to the opioid crisis and problematic substance use through the Emergency Treatment Fund;
AND WHEREAS, The Executive Council Act authorizes the Newfoundland and Labrador Minister to enter into agreements with the Government of Canada under which the Government of Newfoundland and Labrador undertakes to use the funding provided by Canada under the Emergency Treatment Fund for the provision of treatment services for problematic substance use, including opioids.
NOW THEREFORE, Canada and Newfoundland and Labrador agree as follows:
1.0 Purpose
1.1 The Parties are committed to protecting the health and safety of all Canadians through a compassionate and collaborative approach to addressing problematic substance use. The objective is to support single or multi-year projects that will improve access to evidence-based treatment services.
1.2 The purpose of this Agreement is to provide financial support from Canada to Newfoundland and Labrador to target treatment services for problematic substance use, including opioids. This funding will support single or multi-year projects that will build on and enhance existing initiatives, capacity, and priorities.
2.0 Emergency Treatment Services
2.1 Objectives
2.1.1 Canada and Newfoundland and Labrador agree that over the period of this Agreement, with financial support from Canada, Newfoundland and Labrador will address local, regional, and system priorities to reduce opioid-related harms and deaths by further building on and enhancing Newfoundland and Labrador treatment services and programs to improve the availability and accessibility of treatment for problematic substance use towards achieving the objectives of:
- Improving access to opioid dependency treatment in the province using multi-disciplinary teams, case managers, primary care providers and telemedicine. The proposed Hub and Spoke model will have four regional based Hubs that will provide consultation and support to the primary health care practitioners.
Newfoundland and Labrador approach to achieving these objectives is set out in its Action Plan attached as Annex 1.
2.2 Eligible Areas of Investment
2.2.1 Newfoundland and Labrador agrees to allocate funds provided by Canada under this Agreement in one or more of the following eligible areas of investment:
- support initiatives that will establish, build on, or enhance existing treatment approaches;
- encourage further implementation of innovative treatment solutions;
- recognize the importance of broader strategies to support access to treatment services by enhancing health care providers’ knowledge of best practices.
2.2.2 The types of initiatives for which Newfoundland and Labrador agrees to use the funding may include: enhancements or expansion of existing treatment approaches such as opioid agonist treatments (e.g., methadone, buprenorphine/naloxone), withdrawal management products (e.g., opioid agonist taper and alpha2-adrenergic agonists), oral Naltrexone, psychosocial treatment interventions, and counseling services; innovative treatment solutions such as wrap-around care and injectable agonist therapies; and, implementation strategies to enhance health care providers’ knowledge of best practices (alcohol, cannabis, and tobacco are excluded).
2.2.3 Treatment services specifically to address alcohol, cannabis, and tobacco are excluded from this funding.
2.2.4 Types of eligible expenditures may include:
- Operating costs;
- Capital costs;
- Training, professional development and related investments;
- Information technology and related investments; and,
- Other costs that in the opinion of the Parties are essential for the completion of the project and achievement of results.
2.2.5 Canada and Newfoundland and Labrador also agree to promote, define, and deliver identifiable innovative approaches to treatment service delivery.
3.0 Period of Agreement
3.1 This Agreement shall come into effect upon the last signature being affixed and will remain in effect until March 31, 2023, unless terminated in writing by Canada or Newfoundland and Labrador , in accordance with the terms and conditions set out in section 11. Funding provided under this Agreement, in accordance with section 4, will cover the period from April 1, 2018 to March 31, 2023.
3.2 Canada and Newfoundland and Labrador concur that the purpose of this time-limited, one-time Agreement is to help Newfoundland and Labrador more rapidly ramp up or otherwise augment treatment initiatives in light of the opioid crisis, and that ongoing funding for enhanced initiatives established under this Agreement are to be sustained by Newfoundland and Labrador.
4.0 Financial Provisions
4.1 The funding provided under this Agreement is in addition to, and not in lieu of, that which Canada currently provides to Newfoundland and Labrador through the Canada Health Transfer in order to support health care services within Newfoundland and Labrador. Furthermore, this funding is in addition to and not in lieu of those funds that Canada has already provided to address problematic substance use and the opioid crisis.
4.2 Allocation to Newfoundland and Labrador
4.2.1 Canada has designated the following maximum one-time amount of funding to be transferred in total to all provinces and territories under this Agreement: $150,000,000 for the period starting on April 1, 2018 and ending on March 31, 2023.
4.2.2 The final total amount to be paid to Newfoundland and Labrador will be calculated using the following formula:
(F –G x 500,000) x (0.33K/[N-P] + 0.33L/Q + 0.33M/R), where:
F is the total one-time funding amount available under this initiative;
G is the number of provinces and territories receiving only the minimum baseline funding (i.e., provinces and territories for which this funding allocation formula results in an allocation of less than $500,000);
K is the total population of Newfoundland and Labrador, as determined using the 2017 population estimates from Statistics Canada;
L is the number of apparent opioid-related deaths in Newfoundland and Labrador as determined using 2016 data from the Public Health Agency of Canada’s National Report on apparent Opioid-Related Deaths in Canada (based on P/T reporting);
M is the number of opioid poisoning hospitalizations in Newfoundland and Labrador as determined using 2016-17 data from the Canadian Institute for Health Information’s Annual Report on Opioid-Related Harms (based on P/T reporting);
N is the total population of Canada as determined using the 2017 population estimate from Statistics Canada;
P is the total population of province and territories receiving only the minimum baseline funding, as determined using the 2017 population estimate from Statistics Canada;
Q is the total number of apparent opioid-related deaths in Canada, as determined using 2016 data from the Public Health Agency of Canada’s National Report on Apparent Opioid-Related Deaths in Canada; and,
R is the total number of opioid poisoning hospitalizations in Canada as determined using 2016-17 data from the Canadian Institute for Health Information’s Annual Report on Opioid-Related Harms (based on P/T reporting).
4.2.3 Newfoundland and Labrador agrees to match Canada’s contribution at a 1:1 ratio, with the exception of the first $250,000 in federal funding, for which no cost-matching is required. Newfoundland and Labrador’s matching contribution shall be the equivalent to Canada’s contribution less $250,000 and, as outlined in Annex 1, can include eligible expenditures made specifically for treatment related to problematic substance use as of January 1, 2016. Newfoundland and Labrador agrees to make reasonable efforts to ensure that previous and ongoing funding from Canada under, pursuant to, or through other programs or agreements shall not be used to match Canada’s contribution under this Agreement.
4.2.4 Based on the formula described in section 4.2.2, Newfoundland and Labrador’s estimated share of the amounts identified in section 4.2.1 will be:
| Fiscal Year | Amount to be paid to Newfoundland and Labrador | Amount to be paid by Newfoundland and Labrador |
|---|---|---|
| 2018-2019 | $1,563,961 | $2,650,000 |
4.3 In this Agreement, “Fiscal Year” means the period commencing on April 1 of any calendar year and terminating on March 31 of the immediately following calendar year.
4.4 Payment
4.4.1 Canada’s contribution under this Agreement as set out in 4.2.4 will be paid within approximately 30 business days of both Parties’ signatures being affixed to this Agreement.
4.4.2 Newfoundland and Labrador must spend the entire amount of Canada’s contribution by no later than March 31, 2023.
4.4.3 Newfoundland and Labrador must spend the entire amount of Newfoundland and Labrador’s matching contribution by no later than March 31, 2023.
4.4.4 Payment of Canada’s contribution under this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.
4.5 Repayment of overpayment
4.5.1 Canada and Newfoundland and Labrador agree that every effort will be made to ensure that the calculation of Canada’s contribution installment to Newfoundland and Labrador will be accurate.
4.5.2 In the event payment made to Newfoundland and Labrador 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 Newfoundland and Labrador shall repay the amount to Canada within 90 calendar days of written notice from Canada.
4.6 Repayment of unmatched funds
4.6.1 In the event that Newfoundland and Labrador does not clearly demonstrate that funds have been cost-matched to the federal funding on a 1:1 ratio less $250,000 by March 21, 2023 in accordance with section 4.2.3, including funding announced as of January 1, 2016, Newfoundland and Labrador agrees to repay the unmatched funds to Canada within 90 calendar days of written notice from Canada.
4.7 Use of Funds
4.7.1 Canada and Newfoundland and Labrador agree that funds provided under this Agreement will only be used by Newfoundland and Labrador in accordance with the areas for investment outlined in section 2.0 of this Agreement and detailed in Annex 1.
5.0 Accountability and Reporting
5.1 Action Plan
5.1.1 Newfoundland and Labrador has completed and shared its Action Plan for the years 2018-19 to 2022-23 of federal funding with Canada, as set out in Annex 1. Upon signature of this Agreement by both Parties, Newfoundland and Labrador will publicly release its Action Plan which:
- Provides an overview of the opioid crisis and treatment for problematic substance use in Newfoundland and Labrador;
- Identifies specific priority areas for investment and objectives, which builds upon the progress to date in delivering treatment services;
- Highlights those investments Newfoundland and Labrador will make in a cost-shared manner equivalent to the federal contribution less $250,000 including initiatives implemented as of January 1, 2016;
- Outlines the indicators and specific targets that Newfoundland and Labrador will use to track progress and report on annually according to their planned investments.
5.1.2 The Action Plan may be amended by Newfoundland and Labrador with mutual consent from Canada in a manner consistent with the spirit and intent of this Agreement if deemed necessary by Newfoundland and Labrador to reflect shifts in approach necessitated by changing circumstances or priorities. Such amendments will be done in accordance with section 9.1 and will be made publicly available in accordance with section 7.2.
5.2 Reporting
5.2.1 Within 90 days of both Parties signing this Agreement, Newfoundland and Labrador agrees to:
- Provide all available baseline data on the agreed-to indicators; and
- Describe any initiatives being undertaken in Fiscal Year 2018-2019 as outlined in the Action Plan.
5.2.2 Beginning in Fiscal year 2019-20 and by no later than October 1 of the subsequent Fiscal Year during the Period of this Agreement, Newfoundland and Labrador agrees to:
- Report to Canada annually on the results and expenditures of the Emergency Treatment Fund allocation until March 31, 2023. The report shall show separately the results attributable to the funding provided by Canada under this Agreement and results attributable to funding provided by Newfoundland and Labrador.
- Provide to Canada an audited financial statement of revenues received from Canada under this Agreement during the preceding Fiscal Year
- The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year.
- The total amount of funding used for programs and services under section 2.2.
- If applicable, the amount of any amount carried forward by Newfoundland and Labrador under section 4.6
- If applicable, the amount of any surplus funds that are to be repaid to Canada under section 4.5.
The financial statement shall be prepared in accordance with Canadian Generally Accepted Accounting Principles and the audit shall be performed by the Newfoundland and Labrador Auditor General or his/her delegate, or by an independent public accounting firm registered under the laws of Newfoundland and Labrador and shall be conducted in accordance with Canadian Generally Accepted Auditing Standards.
5.2.3 Canada, with prior agreement from Newfoundland and Labrador, may incorporate all or any part or parts of the said report into any public report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.
5.3 Audit
5.3.1 Newfoundland and Labrador will ensure that expenditure information presented in the annual report is, in accordance with Newfoundland and Labrador standard accounting practices, complete and accurate.
5.4 Evaluation
5.4.1 Responsibility for evaluation with respect to program effectiveness rests with Newfoundland and Labrador in accordance with its own evaluation policies and practices.
6.0 Long-Term Collaboration
6.1 Canada and Newfoundland and Labrador agree to share and release data as available, and to share knowledge, research and information on effective and innovative practices in treatment programs, to further support the development of and reporting on outcomes.
7.0 Communications
7.1 Canada and Newfoundland and Labrador 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.
7.2 Canada will make publicly available up-to-date Emergency Treatment Fund bilateral agreements entered into with all provinces and territories, including any amendments, on a Government of Canada website.
7.3 Each government will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.
7.4 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the bilateral agreements. Canada agrees to give Newfoundland and Labrador 10 days advance notice and advance copies of public communications related to this Agreement, and results of the investments of this Agreement.
7.5 Newfoundland and Labrador reserves the right to conduct public communications, announcements, events, outreach and promotional activities about this bilateral agreement. Newfoundland and Labrador agrees to give Canada 10 days advance notice and advance copies of public communications related to this Agreement, and results of the investments of this Agreement.
8.0 Dispute Resolution
8.1 Canada and Newfoundland and Labrador are committed to working together and avoiding disputes through government-to-government information exchange, advance notice, early consultation, and discussion, clarification, and resolution of issues, as they arise.
8.2 If at any time either Canada or Newfoundland and Labrador is of the opinion that the other Party has failed to comply with any of its obligations or undertakings under this Agreement or is in breach of any term or condition of the Agreement, Canada or Newfoundland and Labrador, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Newfoundland and Labrador will endeavor to resolve the issue in dispute bilaterally through their designated officials at the Assistant Deputy Minister level (hereinafter “Designated Officials”).
8.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Health for Canada and Newfoundland and Labrador, and if it cannot be resolved by them, then the federal Minister and Newfoundland and Labrador Minister shall endeavor to resolve the dispute.
9.0 Amendments to the Agreement
9.1 This Agreement, including the attached annex, may be amended at any time by mutual consent of the Parties. To be valid, any amendments shall be in writing and signed, in the case of Canada, by the federal Minister, and in the case of Newfoundland and Labrador, by the Newfoundland and Labrador Ministers.
10.0 Equality of Treatment
10.1 During the term of this Agreement, if another province or territory, except the province of Quebec, negotiates and enters into an Emergency Treatment Fund agreement with Canada, or negotiates and enters into an amendment to such an agreement and if, in the reasonable opinion of Newfoundland and Labrador, any provision of that agreement or amended agreement is more favorable to that province or territory than the terms set forth in this Agreement, Canada agrees to amend this Agreement in order to afford similar treatment to Newfoundland and Labrador, if requested by Newfoundland and Labrador. This includes any provision of the bilateral agreement except for the Financial Provisions set out under section 4.0. This amendment shall be retroactive to the date on which the Emergency Treatment Fund Agreement or the amendment to such an agreement with the other province or territory, as the case may be, comes into force.
11.0 Termination
11.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Newfoundland and Labrador by giving at least 12 months written notice of its intention to terminate. Newfoundland and Labrador may terminate this Agreement at any time if the terms of this Agreement are not respected by Canada by giving at least 12 months written notice of its intention to terminate. The date at least 12 months after written notice of termination will be the “effective date of termination”.
11.2 As of the effective date of termination of this Agreement under section 11.1, Canada shall have no obligation to make any further payments to Newfoundland and Labrador.
11.3 As of the effective date of termination of this Agreement under section 11.1, Newfoundland and Labrador will repay federal funds on a pro-rated basis after the date of effective termination.
11.4 As of the effective date of termination of this Agreement under section 11.1 Newfoundland and Labrador agrees to return any federal funding not cost-matched by Newfoundland and Labrador consistent with section 4.2.3 and section 4.7.1.
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 or email, postage or other charges prepaid. Any notice that is delivered will have been received in delivery; and, except in periods of postal disruption, any notice mailed will be deemed to have been received eight calendar days after being mailed.
The address for notice or communication to Canada shall be:
Health Canada
70 Colombine Drive
Brooke Claxton Building
Ottawa, Ontario, K1A 0K9
Email: suzy.macdonald@canada.ca
The address for notice or communication to Newfoundland and Labrador shall be:
Department of Health and Community Services
Government of Newfoundland and Labrador
P.O. Box 8700
1st Floor West Block, Confederation Building
100 Prince Philip Drive
St. John’s, NL
A1B 4J6
Email: michaelharvey@gov.nl.ca
13.0 General
13.1 This Agreement, including Annex 1, comprises the entire agreement entered into by the Parties with respect to the subject matter hereof.
13.2 This Agreement shall be interpreted according to 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 deemed to be severable and will be deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.
SIGNED on behalf of Canada by the Minister of Health at Winnipeg, Manitoba this 28th day of June, 2018.
The Honourable Ginette Petitpas Taylor, Minister of Health
SIGNED on behalf of Newfoundland and Labrador by the Minister of Health and Community Services at Winnipeg, Manitoba this 28th day of June, 2018.
The Honourable John Haggie, Minister of Health and Community Services
SIGNED on behalf of Newfoundland and Labrador by the Minister for Intergovernmental and Indigenous Affairs at Winnipeg, Manitoba this 28th day of June, 2018.
The Honourable Dwight Ball, Minister for Intergovernmental and Indigenous Affairs
Annex 1 to the Agreement
Newfoundland and Labrador Action Plan for the Emergency Treatment Fund
Introduction
Access to opioid dependence treatment (ODT) in Newfoundland and Labrador is hindered by stigma, limited numbers of primary health care providers involved in care, and geographical barriers. Newfoundland and Labrador has approximately 24 physicians and two nurse practitioners who prescribe opioid agonist maintenance treatment (OAMT). Further, only one third of community pharmacists are registered to dispense opioid agonist medications. There are people throughout the province who are required to travel two hours daily to a community pharmacy to receive their required treatment.
Treatment services are currently provided by the provincial Opioid Treatment Centre located in St. John’s, a methadone clinic in Corner Brook, and through private fee for service physicians in the province.
There are two adult addictions treatment centres in Newfoundland and Labrador. The Grace Centre located in Harbour Grace and the Humberwood Centre located in Corner Brook. Both centres are part of a continuum of care for adults impacted by addictions. In addition, the Hope Valley Centre located in Grand Falls - Windsor is for youth with addictions issues.
The ODT Working Group was established in October 2017 as a part of ‘Towards Recovery: The Mental Health and Addictions Action Plan for Newfoundland and Labrador’. The Working Group is comprised of community organizations, persons with lived experience, regional health authorities (RHAs), and health care providers (including physicians, nurses, pharmacists, and mental health and addictions staff). The primary focus of the working group has been the review and approval of a provincial proposal for ODT. This action plan outlines the approach to improve access to treatment of opioid use disorder throughout the province.
Overview
According to the Newfoundland and Labrador Centre for Health Information, in 2016, there were 18 apparent opioid-related deaths in Newfoundland and Labrador. Further, there were 57 hospital admissions involving opioid poisoning. There was an increase in these rates for 2017 with 33 apparent opioid related deaths and 84 hospital admissions involving opioid poisoning.
The Provincial Government has responded by implementing an Opioid Action Plan. Components of the plan include:
- Implementing a Provincial Prescription Monitoring Program focused on prescription drugs with high potential for abuse. The Provincial Pharmacy Network was also created, which had all community pharmacies connected in late May 2017;
- Implementing a provincial Take Home Naloxone Kit program to increase capacity for Opioid Overdose response; and,
- Providing open access to Suboxone under all provincial drug programs in December 2016, thereby removing the requirement for special authorization.
From June 2017 to April 2018, 2409 individuals received methadone or buprenorphine/naloxone prescriptions in the province; 71 per cent of these individuals reside in the Eastern Health region.
Priority Areas for Investment
Federal funding will be directed towards a new provincial model for ODT, one that consists of a Hub and Spoke model of care. The proposal has incorporated harm-reduction, recovery focused and person-centred approaches. The ultimate goal of this proposal is to improve access to ODT in the province using multi-disciplinary teams, case managers, primary care providers and telemedicine.
The proposed Hub and Spoke model will have four regional based Hubs that will provide consultation and support to the primary health care practitioners (Spokes). This model will strive to establish a network of practitioners in the area of ODT. The four RHA-based Hubs will serve as the regional consultants and subject matter experts on opioid use disorder and treatment. Hubs will be responsible for coordinating the care of individuals with complex addictions and co-occurring substance use and addictions and mental health conditions across the health and substance use and addictions treatment systems of care. Hubs will provide “rapid access” to medication assisted treatments, provide care through the period of initial stabilization if necessary, coordinate referrals to ongoing care, and provide consultation and support to ongoing care. The initiation of medication-assisted treatments may be conducted using telehealth.
Hubs will be located in the four regions of the province: Eastern, Central, Western and Labrador-Grenfell. The current Opioid Treatment Centre located in St. John’s will be transformed to the Eastern Hub, while the other three Hubs will be in more rural areas of the province. The Hubs will provide support to primary care practitioners and others in treating persons with addictions. Subsequently this will build capacity in primary care and address barriers for persons without access to a prescribing practitioner. Through building a network of practitioners, this helps to unify the approach to ODT in the province and offer security and stability to people in the event that a practitioner leaves the area. Hubs may be comprised of addictions counselors, psychologist, peer support, pharmacist, licensed practical nurse, and prescribing practitioners (physicians or nurse practitioners).
Spokes will be comprised of a prescribing physician or nurse practitioner and the collaborating health and addictions professional who monitor adherence to treatment, coordinate access to recovery supports and community services, and provide care coordination and case management services. The Spokes will be located throughout the province, therefore increasing access to treatment in both urban and rural areas. The plan is for all primary health care providers who prescribe OAMT to become Spokes. This model will support a foundation for high quality primary care with embedded multidisciplinary support services, better coordination and transitions of care.
The model also includes the establishment of a Provincial ODT Centre of Excellence, for which Health Canada has provided $1.3 million to Eastern Health over three years under the Substance Use and Addiction Program (SUAP). This Centre of Excellence will be tasked with the development of learning initiatives and knowledge exchange for health care providers and community organizations.
The model will promote the increased utilization of telehealth services, and the development and greater integration, connection, and support for primary health practitioners. Since primary health care is often the first point of contact for individuals, increasing involvement with these practitioners has the potential to significantly increase access for mental health and addictions services.
Given the limited numbers of community pharmacies that provide OAMT services, a working group was formed to explore alternative means for people to access Suboxone. This group is determining the legislative and regulatory requirements needed for regional health authorities to be involved in the outpatient dispensing of Suboxone. It is proposed that in communities where there is no access to a community pharmacy, a hospital pharmacy will dispense Suboxone to an outpatient clinic where a registered nurse will administer the medication. This will allow for people to receive treatment closer to their home.
The implementation of the provincial ODT program will involve the establishment of the Provincial Centre of Excellence in 2018, the four Hubs over the next two fiscal years, and the Spokes in 2019-20. As there are other provincial initiatives occurring under the ‘Towards Recovery Action Plan’, there are likely opportunities for collaboration with other resources, such as the new Assertive Community Treatment/Flexible Community Treatment Teams (ACT and FACT teams).
Expected Outcomes
This proposed model of provincial ODT service delivery will see a substantial increase in capacity and utilization of effective telemedicine and telehealth modalities. Telemedicine technology helps to fill a gap in services in the province and offsets patients having to potentially travel long distances to access these services. As clinical specialists at the Hub level interact with primary care clinicians in local communities (spokes), this will increase the capacity of best practice ODT services, build a network of providers, and reduce gaps in service delivery in underserved areas of the province.
The Hub and Spoke model will require a transformation in the way persons with opioid use disorder are cared for in Newfoundland and Labrador. This model, which is based in the core principles of harm reduction, will provide easy and rapid access to treatment as people can be referred to Hubs by emergency departments, primary care providers, or addictions specialists. Once stabilized on appropriate opioid agonist medication, people will be transferred back to their primary care physician or nurse practitioner for ongoing care. The model will provide ongoing support to people through addictions counselling, peer support and case management, as well as needed mentoring to primary care providers with resources, consultation and training to care for persons with addictions.
As more people have barrier-free access to opioid dependence treatment, it is anticipated that there will be a reduction in health care costs through the reduction in emergency department visits, hospital admissions, and HIV and Hepatitis C infections. It has been shown that when opioid use disorder is treated, there is a reduction in concurrent disorders, medical complications and health costs. There will also be reduced societal costs including crime rates, violence, and lost employment. Financial savings will also be realized by providing services closer to home for people. It is anticipated that there will be reduced distances between people requiring opioid agonist medication treatment and their service providers. This initiative is expected to improve access to treatment services throughout the province by expanding and providing treatment services more locally.
Monitoring and Evaluation
The implementation of this proposed model will require a robust evaluation framework designed to evaluate the success of the model in addressing the primary goals of this initiative. Implementation of a rigorous evaluation process will also assist in determining future service adjustments and recommendations for enhancements. The purpose of these measures is to capture information on clinical outcomes, experience of care outcomes, and quality of care outcomes specific to the provision of the provincial Hub and Spoke model. The development of an evaluation framework with specific outcomes and indicators will be conducted according to the performance monitoring approach in place for Towards Recovery Action Plan project teams.
Success can be measured by indicators such as:
- rate of opioid-related deaths
- rate of opioid-related emergency department visits
- rate of opioid-related hospital admissions
- number of primary care practitioners (physicians and nurse practitioners) who prescribe OAMT
- number of community pharmacies providing OAMT services
- number of people receiving treatment for opioid use disorder
- percentage of people who receive services within # days of referral
- number of take home naloxone kits distributed
It is difficult to estimate an accurate number of people in the province who are in need of ODT. In the Canadian Alcohol and Drug Use Monitoring Survey in 2012, among users of opioid pain relievers, 5.2% (or 243,000 Canadians representing 0.9% of the total population) reported abusing them. This would translate to approximately 4800 people in our province who abused opioids. It is noteworthy that approximately half of this number of people received prescriptions of OAMT from June 2017 to April 2018.
Budget and Financial Requirements
The proposed model will incorporate existing regional health authority-based staff currently working in existing ODT services. The model will require the addition of new health care staff to both the Hub designated providers and the Spoke teams of health care professionals to provide a full continuum of ODT service delivery. Other budget considerations include the infrastructure costs for telemedicine and physical space.
| ODT Program Component | 2018-19 | 2019-20 | 2020-21 | 2021-22 | 2022-23 |
|---|---|---|---|---|---|
| Reallocation of Existing Resources | $1.03M | $2.06M | $2.06M | $2.06M | $2.06M |
| New Resources Required | $1.78M | $3.55M | $3.55M | $3.55M | $3.55M |
| Centre of Excellence (SUAP)* | $0.43M | $0.43M | $0.43M | $0.43M | $0.43M |
| Total | $3.24M | $6.04M | $6.04M | $6.04M | $6.04M |
| Funding Sources | 2018-19 | 2019-20 | 2020-21 | 2021-22 | 2022-23 |
|---|---|---|---|---|---|
| GNL Newfoundland and Labrador | $2.65M | $5.26M | $5.26M | $5.69M | $5.69M |
| Health Canada Emergency Treatment Fund | $0.16M | $0.35M | $0.35M | $0.35M | $0.35M |
| Health Canada SUAP FundingTable 3 Footnote * | $0.43M | $0.43M | $0.43M | - | - |
| Total | $3.24M | $6.04M | $6.04M | $6.04M | $6.04M |
|
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Nearly 40 per cent of the total provincial budget is allocated to health care. In 2016-17, RHAs spent approximately 6 per cent ($134.2 million) of their total expenditures on mental health and addictions. This does not include other public expenditures, such as MCP and prescription drugs. There is a commitment by this province to increase provincial mental health and addictions budget to nine per cent. Ongoing funding requirements for the ODT program will come from this added funding.
| Name of Initiative | Description | Expected Results | Performance Measurement | Expenditure Plan for Emergency Treatment Fund | ||||
|---|---|---|---|---|---|---|---|---|
| 2018-19 | 2019-20 | 2020-21 | 2021-22 | 2022-23 | ||||
Provincial ODT Program |
A hub and spoke model of care that improves access to ODT using multi-disciplinary teams, case managers, primary care providers, and telemedicine. |
Improved access to services across the province. Increase capacity for health care professionals to be involved in ODT. |
Average wait times for ODT after referral % of population accessing OAMT # of people accessing OAMT # of prescribers of OAMT # of pharmacies involved in ODT |
0.16M |
0.35M |
0.35M |
0.35M |
0.35M |
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