Canada-Nova Scotia 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 PROVINCE OF NOVA SCOTIA (hereinafter referred to as "[Nova Scotia]" or "Government of Nova Scotia") as represented by the Minister of Health herein referred to as "the provincial Minister")

REFERRED to collectively as the "Parties"

PREAMBLE

WHEREAS Canada and Nova Scotia 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 Nova Scotia 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 Nova Scotia 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 Nova Scotia has the primary responsibility for the design and delivery of substance use disorder treatment and response services in Nova Scotia. The one-time Emergency Treatment Fund is intended to augment services and Nova Scotia 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;

WHEREAS, Section 6 of Chapter 376 of the Revised Statutes of Nova Scotia, 1989, the Public Services Act authorizes the provincial Minister of Health and Wellness to enter into an agreement with the Government of Canada under which the Government of Nova Scotia 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;

AND WHEREAS, Nova Scotia is responsible for the provision of treatment services including to Indigenous populations accessing treatment services off-reserve.

NOW THEREFORE, Canada and Nova Scotia 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 Nova Scotia 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 Nova Scotia agree that over the period of this Agreement, with financial support from Canada, Nova Scotia will address local, regional, and system priorities to reduce opioid-related harms and deaths by further building on and enhancing Nova Scotia's treatment services and programs to improve the availability and accessibility of treatment for problematic substance use towards achieving the objectives of:

1. Increasing access to evidence-based Opioid Use Disorder (OUD) treatment;
2. Reducing wait times and wait lists for OUD treatment.

Nova Scotia's 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 Nova Scotia 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 Nova Scotia 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 Nova Scotia 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 Nova Scotia, 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 Nova Scotia concur that the purpose of this time-limited, one-time Agreement is to help Nova Scotia 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 Nova Scotia.

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 Nova Scotia through the Canada Health Transfer in order to support health care services within Nova Scotia. 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 Nova Scotia

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 Nova Scotia 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 [province/territory], as determined using the 2017 population estimates from Statistics Canada;

L is the number of apparent opioid-related deaths in [province/territory] 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 Nova Scotia[province/territory] 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 Nova Scotia 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-sharing is required. Nova Scotia'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. Nova Scotia 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, Nova Scotia's estimated share of the amounts identified in section 4.2.1 will be:

Table 1: Nova Scotia's Share of Amounts Identified in Section 4.2.1

Amount to be paid to Nova Scotia	Matching amount to be paid by Nova Scotia for OUD treatment
$3,160,108	$2,910,108

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 Nova Scotia must spend the entire amount of Canada's contribution by no later than March 31, 2023.

4.4.3 Nova Scotia must spend the entire amount of its 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 Nova Scotia agree that every effort will be made to ensure that the calculation of Canada's contribution installment to Nova Scotia will be accurate.

4.5.2 In the event payment made to Nova Scotia exceeds the amount to which Nova Scotia is entitled under this Agreement, the amount of the excess is a debt due to Canada and Nova Scotia 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 Nova Scotia 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, Nova Scotia 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 Nova Scotia agree that funds provided under this Agreement will only be used by Nova Scotia 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 Nova Scotia 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, Nova Scotia will publicly release its Action Plan which:

1. Provides an overview of the opioid crisis and treatment for problematic substance use in Nova Scotia;
2. Identifies specific priority areas for investment and objectives, which builds upon the progress to date in delivering treatment services;
3. Highlights those investments Nova Scotia will make in a cost-shared manner equivalent to the federal contribution less $250,000 including initiatives implemented as of January 1, 2016;
4. Outlines the indicators and specific targets that Nova Scotia will use to track progress and report on annually according to their planned investments.

5.1.2 The Action Plan may be amended by Nova Scotia with mutual consent from Canada in a manner consistent with the spirit and intent of this Agreement if deemed necessary by Nova Scotia 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, Nova Scotia agrees to:

1. Provide all available baseline data on the agreed-to indicators; and
2. Describe any initiatives being undertaken in Fiscal Year 2018-2019 as outlined in the Action Plan at Annex 1.

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, Nova Scotia agrees to:

1. Report to the people of Nova Scotia and 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 Nova Scotia.
2. Provide to Canada an audited financial statement of revenues received from Canada under this Agreement during the preceding Fiscal Year including:
   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 programs and services under section 2.2.
   3. If applicable, the amount of any amount carried forward by Nova Scotia under section 4.4; and
   4. If applicable, the amount of any surplus funds that are to be repaid to Canada under section 4.5 and 4.6.
   The financial statement shall be prepared in accordance with Canadian Generally Accepted Accounting Principles and the audit shall be performed by the Nova Scotia Auditor General or his/her delegate, or by an independent public accounting firm registered under the laws of Nova Scotia and shall be conducted in accordance with Canadian Generally Accepted Auditing Standards.

5.2.3 Canada, with prior agreement from Nova Scotia, 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 Nova Scotia will ensure that expenditure information presented in the annual report is, in accordance with Nova Scotia standard accounting practices, complete and accurate.

5.4 Evaluation

5.4.1 As per established policies and processes with respect to program effectiveness, Nova Scotia may evaluate programs and services receiving funds provided under this Agreement and make public the results of any such evaluations.

6.0 Long-Term Collaboration

6.1 Canada and Nova Scotia 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 Nova Scotia 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.

7.5 Nova Scotia 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 Nova Scotia 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 Nova Scotia 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 Nova Scotia, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Nova Scotia 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 Nova Scotia, and if it cannot be resolved by them, then the federal Minister and Nova Scotia Minister of Health and Wellness shall endeavor to resolve the dispute.

9.0 Amendments to the Agreement

9.1 This Agreement, including the attached Annex 1, 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 Nova Scotia, by the Nova Scotia Minister of Health and Wellness.

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 Nova Scotia, 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 Nova Scotia, if requested by Nova Scotia. 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 Nova Scotia by giving at least 12 months written notice of its intention to terminate. Nova Scotia 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.

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 Nova Scotia after the date of effective termination.

11.3 As of the effective date of termination of this Agreement under section 11.1, Nova Scotia 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 Nova Scotia agrees to return any federal funding not cost-matched by Nova Scotia 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, 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:

70 Colombine Drive
Ottawa, Ontario, K1A 0K9

The address for notice or communication to Nova Scotia shall be:

Denise M. Perret, Q.C
Deputy Minister of Health and Wellness
1894 Barrington Street,
Barrington Tower
PO Box 488
Halifax NS B3J 2R8
Email: Denise.Perret@novascotia.ca

13.0 General

13.1 This Agreement, including Annex 1, comprise 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 Nova Scotia.

13.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Nova Scotia 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.

13.5 This Agreement is drafted in English at the request of the Parties. Les parties ont convenu que le présent Accord soit rédigé en anglais.

Signed on behalf of Canada by the Minister of Health at Ottawa, Ontario this 12^th day of March, 2019.

The Honourable Ginette Petitpas Taylor, Minister of Health

Signed on behalf of Nova Scotia by the Minister of Health at Halifax, Nova Scotia this 14^th day of March, 2019.

The Honourable Randy Delorey, Nova Scotia, Minister of Health

Annex 1 — Nova Scotia Action Plan

Overview of the opioid crisis and treatment in Nova Scotia

Opioid misuse and overdose are a public health and safety concern across the country and Nova Scotia is no exception. Substance use-related disorders are leading causes of death, emergency department and hospital visits, and increased health care costs in Nova Scotia.

There are two aspects to the opioid crisis in Nova Scotia: over-prescription of opioids for pain treatment resulting in increased dependency and addiction; and the increasing appearance of highly potent illegal synthetic opioids in the illicit drug supply. Opioids contribute to approximately two-thirds of all acute drug toxicity deaths in the province with hydromorphone and methadone being the most common opioids involved. Detections of non-pharmaceutical fentanyl and other illegally produced opioids in seized street drugs are becoming more frequent in the province.

Data obtained from the NS Medical Examiner Service shows that between the years 2011-2017, there have been 417 acute opioid toxicity deaths in Nova Scotia. In 2018, there were 42 confirmed and 17 probable opioid toxicity deaths in the province.

Recognizing the need to act to prevent a bigger crisis, Nova Scotia carried out a planning process to identify actions to tackle the immediate and long-term effects of opioid use and overdose in the province. In October 2016, the government established a provincial leadership committee, co-chaired by the Department of Health and Wellness and the Department of Justice. The purpose of this committee, and the seven working groups reporting to it, was to develop Nova Scotia's Opioid Use and Overdose Framework. The framework and action plan were released in July 2017 outlining the government's plan to reduce the effects of opioid use and overdose by focusing on 5 main areas:

• understanding the issue
• prevention
• harm reduction
• treatment and prescribing practices
• criminal justice and law enforcement

As key components of the action plan, the province has made investments to stabilize needle-exchange programs and develop models of safer consumption, expand access to life-saving naloxone, and to increase access to opioid-use disorder (OUD) treatment.

Overview of Treatment Services in Nova Scotia

In Nova Scotia, treatment programs are delivered through the Nova Scotia Health Authority (NSHA) Mental Health and Addictions program of care which has the operational responsibility for four specialized, publicly-funded OUD treatment programs with multiple sites, and provides funding to Direction 180, a non-government organization operating a low-threshold OUD treatment program in Halifax.

Expansion of the OUD treatment programs is a key component of the NS opioid framework. Enhanced funding over the past two fiscal years has added an additional 250 treatment spaces through increased capacity at main treatment sites and the establishment of four new satellite treatment clinics. In addition, through enhanced collaboration with primary care providers, there is increased ability to transfer stabilized patients from OUD treatment programs to primary care for ongoing maintenance treatment. The result has been elimination or substantial reduction in wait lists and wait times for OUD treatment across Nova Scotia. As of December 18, 2018, there are 2,129 Nova Scotians receiving Opioid Agonist Therapy from NSHA Mental Health and Addictions and Direction 180 and 22 Nova Scotians on a waitlist for opioid dependency treatment.

While progress has been made in enhancing access to OUD treatment, the demand is expected to continue to rise with administrative data from NSHA Mental Health and Addictions showing a 20% increase in individuals accessing OUD treatment from 2010-2015. Additionally, individuals 19 years of age and older admitted to in-patient withdrawal management services across the province in 2015-16 reported opioids as the second most presenting problem (31%) at the time of admission. Extrapolating trends from the 2017 Canadian Alcohol Tobacco and Drugs Survey to the Nova Scotian population, it is estimated that around 3,434 Nova Scotians may be misusing prescription opioids, which exceeds the number of individuals accessing specialized treatment even without considering the number of Nova Scotians abusing illicit opioids.

Ongoing provincial funding will sustain current gains in enhancing access to OUD treatment and the federal Emergency Treatment Funding (ETF) will build on these provincial investments and allow further enhancements to OUD treatment programs as part of the ongoing response to the opioid crisis.

Nova Scotia Priority Areas for Investment

Nova Scotia has identified the following actions as priority areas for investment for the Emergency Treatment Fund (ETF). These actions meet the criteria for eligible services as per the ETF agreement (clause 2.2.1): building on or enhancing existing treatment approaches; and strategies to enhance access to treatment services.

1. Enhance Existing Treatment Approaches

Existing treatment approaches in Nova Scotia include specialized Opioid Use Disorder (OUD) treatment programs offered through the Nova Scotia Health Authority at ten main treatments sites and satellite clinics.

The OUD treatment programs include assessment, treatment planning, relapse prevention and supportive counselling provided by a team of health care professionals. The treatment includes community -based opioid agonist therapies, buprenorphine/naloxone and methadone. Nova Scotia's OUD programs provide access points and flexible outpatient and community-based options for individuals across the province facing barriers to access due to geography, limited transportation and the ongoing nature of OUD treatment.

Provincial investments over the past two fiscal years have resulted in the addition of 250 treatment spaces through increased capacity at the main treatment sites and the establishment of four new satellite treatment clinics across the province, many of which serve surrounding rural areas (Bridgewater, New Germany, Caledonia, Antigonish). As of December 18, 2018, there are 2,129 Nova Scotians receiving opioid agonist therapy from these programs and there has been an elimination or significant reduction in waitlists and wait-times across the province.

New federal funding will be used to incrementally add up to 200 new treatment spaces for individuals in need of treatment and open a new satellite clinic. This will allow Nova Scotia to meet the anticipated ongoing demand for OUD treatment in areas of the province where there are substantive gaps in access.

2. Enhance Access to Treatment Services (e.g., training modules, ER protocols)

Federal funding will be used to support the following actions:

1. Build capacity in primary care to provide office-based OUD treatment by implementing a telephone addictions specialist consultation service and a practice support program for addictions treatment in primary care.

OUD is recognized as a chronic, relapsing health condition that has the potential to be in sustained remission with appropriate treatment. The research literature is clear that OUD can be treated safely, effectively and economically within primary care, particularly for clients who have reached clinical and pharmacological stability. Primary care is therefore an important setting for delivering accessible, continuous, comprehensive, and coordinated evidence-based treatment that includes Opioid Agonist Treatment with buprenorphine/naloxone as well as psychosocial support.

NSHA Primary Health Care, in collaboration with NSHA Mental Health and Addictions and community partners, will develop learning and quality improvement initiatives to increase the capacity of primary care providers and collaborative family practice teams to integrate the management of OUD into primary care practice across Nova Scotia.

Two initiatives have been identified for Emergency Treatment Fund (ETF) funding to enhance access to ongoing OUD treatment in primary care and will facilitate the transfer of stabilized patients from specialized OUD treatment programs to primary care. It is expected that this will contribute to increased access to treatment for all Nova Scotians, including vulnerable populations such as incarcerated individuals, youth and adults, and First Nations, ultimately normalizing OUD treatment within primary health care settings throughout Nova Scotia. The federal ETF will greatly enhance our capacity by supporting the implementation of these initiatives:

• Telephone Consultation Service: This includes addictions medicine specialists who will provide telephone-based consultation to primary care providers throughout the province. The specialists will be available to physicians, nurse practitioners and other providers to consult on opioid use disorder treatment and prescribing.
  The telephone consultation service will support providers to provide opioid agonist treatment to patients with OUD. The consultant calls will increase the provider's knowledge capacity in treating OUD. This will allow more Nova Scotians in rural and remote areas to access treatment in their communities.
• Practice Support Program: This will support physicians and primary care teams through education along with care pathways, tools and resources aligned with the logical ways a primary care practice functions.
  Physician, Nurse Practitioner and Social Work consultants will provide content knowledge and practical expertise. A professional practice leader will be part of the project team and function as the ongoing primary health care resource to maintain up to date content, coordinate education for providers, facilitate linkages between the primary health care system and mental health and addiction program, and monitor quality.

2. Provide training and education on OUD to emergency room staff across the province to facilitate rapid referral for treatment.

Despite overwhelming evidence that emergency department counselling and medical interventions are effective, they are essentially left out of mental health and addictions care pathways. In an effort to enhance system capacity to increase timely and equitable access to a continuum of services and supports for individuals and families experiencing harms associated with OUD, the NSHA Mental Health and Addictions program, in collaboration with the IWK, will partner with NSHA Program of Care (POC) to develop curriculum for training and education of emergency department staff to build capacity to identify and provide initial management and referral of OUD in Emergency POC.

Training will:

• increase access to evidence that informs practice in Emergency Departments (EDs)/Collaborative Emergency Centers (CECs) by enhancing knowledge and competencies of emergency department staff to improve service delivery, related to treatment, to patients presenting with OUD; and
• increase uptake of evidence-informed information leading to changes in OUD treatment and apply best practices approaches.
  The objective is to provide a more comprehensive approach to treatment. Topics to be covered will include harm reduction (e.g. take-home naloxone), screening and rapid assessment, inter-disciplinary approach, and stigma. Education materials aimed at increasing awareness and knowledge will include two-hour online pre-training guide, six hour in-class material, take-home resources, and evaluation materials.

The federal funding will be used to support the implementation of this program. The program aims to provide training to an estimated 1,350 ED/CEC staff over the first two-years.

3. Nova Scotia Expenditure Plan

Note: Nova Scotia will provide matching funding that exceeds the requirements of the agreement in 2017-2020 and federal funding will be spent in 2018-2023.

Table 2: Nova Scotia Expenditure Plan

Initiatives	Expenditure Plan
	2018-19	2019-20	2020-21	2021-22	2022-23
Enhanced existing treatment approaches
Treatment spaces	$250,000	$304,025	$304,025	$304,025	$304,025
Enhanced access to treatment services
Tele-consult service		$102,000	$102,000	$102,000	$102,000
OUD program of care		$165,500	$165,500	$165,500	$165,500
Emergency room training		$156,000	$156,000	$156,000	$156,000
Total Expense		$727,525	$727,525	$727,525	$727,525

Table 3: Nova Scotia's Matching Investment

Initiatives	Nova Scotia's Matching Investment
	2017-18	2018-19	2019-20	2020-21
Enhanced existing treatment approaches Treatment spaces	$799,000	$1,100,000	$1,000,000	$1,000,000

Table 4: Performance Measurement

Description	Expected Results	Performance Measurement	Expenditure Plan Outline how the federal funding will be allocated, by fiscal year					Totals
Continue to enhance access to Opioid Use Disorder Treatment through NSHA Mental Health and Addictions programs that includes specialized OUD programs and satellite clinics.	Reduce wait-times for OUD treatment Reduce or eliminate wait-list for OUD treatment Increase access to OUD treatment	Decrease in average wait-time for access to OUD treatment in NS # of people on waitlist for opioid treatment in NS # of people accessing publicly funded OUD treatment in NS	2018-19	2019-20	2020-21	2021-22	2022-23	$1,466,100
			$250,000	$304,025	$304,025	$304,025	$304,025
Implement a telephone addictions specialist consultation service	Increased capacity in primary care for OUD treatment Increased knowledge of ER providers around OUD	# of primary care providers using the telephone consultation service # of people transferred from MHA to primary care # of providers trained in emergency rooms on OUD # of referrals from ER to MHA OUD treatment programs		$102,000	$102,000	$102,000	$102,000	$408,000
Develop an OUD program of care				$165,500	$165,500	$165,500	$165,500	$662,000
Provide training on OUD in emergency rooms to facilitate rapid referral for treatment				$156,000	$156,000	$156,000	$156,000	$624,000
Total $3,160,100