Canada-Alberta Home and Community Care and Mental Health and Addiction Services Funding Agreement

Table of Contents

• Funding Agreement
• Annex I - Common Statement of Principles on Shared Health Priorities
• Annex II - Action Plans
  • Alberta Action Plan on Home and Community Care and Mental Health and Addictions Services
  • Alberta Action Plan for Increased Infection Prevention and Control

Funding Agreement

BETWEEN:

REFERRED to collectively as the "Parties".

PREAMBLE

WHEREAS, on March 10, 2017 Canada and Alberta agreed to targeted federal funding over 10 years, beginning in 2017-18, for investments in home and community care and mental health and addictions, in addition to the existing legislated commitments through the Canada Health Transfer;

WHEREAS, Canada and Alberta agreed to a Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the "Common Statement"), attached hereto as Annex 1, on August 21, 2017, which articulated their shared vision to improve access to home and community care and mental health and addictions services in Canada;

WHEREAS, Canada authorizes the federal Minister to enter into agreements with the provinces and territories, for the purpose of identifying activities provinces and territories will undertake in home and community care and mental health and addictions services, based on a menu of common areas of action and in keeping with the performance measurement and reporting commitments, consistent with the Common Statement;

WHEREAS, Canada and Alberta agree that data collection and public reporting of outcomes is key to reporting results to Canadians on these health system priorities;

WHEREAS, the Government Organization Act authorizes the Alberta Minister to enter into agreements with Canada under which Canada undertakes to provide funding toward costs incurred by Alberta for the provision of home and community care and mental health and addictions initiatives;

WHEREAS, Alberta is responsible for the design and delivery of health care in Alberta. Alberta is also responsible for the planning, determining the objectives of, defining the contents of, setting the priorities for, and evaluating its programs and services in home and community care and mental health and addictions. In this respect, Alberta makes ongoing investments in home and community care and mental health and addictions services, consistent with its broader responsibilities for delivering health care services to its residents;

WHEREAS the Government of Canada makes ongoing investments in home and community care and mental health and addictions services for Indigenous communities and other federal populations.

WHEREAS, since March 2020, Canada has been in the midst of the COVID-19 global pandemic, which has disproportionately affected Canadians living in supportive care settings in the community, namely long-term care facilities, supportive living facilities, and seniors' residences where they receive continuing care services (hereinafter referred to as long-term care settings), and which is requiring provinces and territories to put in place stronger measures to reduce the risk of harm to residents of these facilities;

WHEREAS, the Government of Canada announced an investment of $19 billion to help provinces and territories to safely restart their economies and make Canada more resilient to possible future surges in cases of COVID-19, of which $740M is to support provinces and territories through 2020-21 with one-time investments for infection prevention and control, including in long-term care settings;

WHEREAS, on November 30, 2020, the Government of Canada committed to a further investment of $1 billion to support provinces and territories to protect residents in long-term care settings, given the continued serious risk to health of these vulnerable Canadians;

WHEREAS, Canada authorizes the federal Minister to enter into agreements with the provinces and territories, for the purpose of identifying activities provinces and territories will undertake to protect residents in long-term care settings through increased infection prevention and control measures and in keeping with performance measurements and reporting commitments;

WHEREAS, the Government Organization Act authorizes the provincial Minister to enter into agreements with the Government of Canada under which Canada undertakes to provide Safe Long-term Care funding toward expenditures incurred by Alberta for activities to protect residents in long-term care settings through increased infection prevention and control measures;

NOW THEREFORE, Canada and Alberta agree as follows:

1.0 Objectives

1.1 Building on Alberta's existing investments and initiatives, Canada and Alberta commit to work together to improve access to home and community care and strengthen access to mental health and addictions services, as further described in the Common Statement.

1.2 Further, Canada and Alberta commit to work together to further improve access to safe care through increased infection prevention and control in long-term care settings.

2.0 Action Plan

2.1 Alberta will invest federal funding for home and community care and mental health and addictions services provided through this Agreement in alignment with the selected action(s) from each menu of actions listed under home and community care and mental health and addictions in the Common Statement.

2.2 Alberta's approach to achieving home and community care and mental health and addictions services objectives is set out in its five-year Action Plan (2017-18 to 2021-22), as set out in Annex 2.

2.3 Alberta agrees to invest the federal Safe Long-term Care funding provided under this Agreement on infection prevention and control activities in long-term care settings in each of the following three areas:

• Retention measures for existing staff, including wage top-ups, and/or hiring of additional human resources (e.g. personal support workers, licensed practical nurses, cleaners);
• new infrastructure and renovations to existing infrastructure, such as ventilation of self- isolation rooms and single rooms; and,
• readiness assessments conducted in long-term care settings to prevent COVID infections and spread.

2.4 In addition, Alberta may also invest the federal Safe Long-term Care funding through this Agreement on infection prevention and control activities in long-term care settings in one or more of the following areas;

• strengthened infection prevention and control measures and training for existing staff;
• adequate supply of personal protective equipment for staff and visitors;
• rapid training programs to increase the number of supportive care workers, including training for students and workers from other sectors;
• enhanced screening and regular testing of staff and visitors to quickly detect, prevent or limit spread; and,
• additional inspectors and infection prevention and control specialists to support in- person inspections of all facilities.

2.5 Alberta's approach to achieving the objective of the Safe Long-term Care funding, as set out in section 1.2, in the areas identified above, is set out in Annex 2, as amended.

3.0 Term of Agreement

3.1 The Agreement, once signed by both Parties, shall be in effect from April 1, 2018 and will remain in effect until March 31, 2022, unless terminated earlier in accordance with section 10 of this Agreement (the "Term").

3.2 Subject to sections 4.4 and 4.5, the Safe Long-term Care funding provided under this Agreement may be used by Alberta for expenditures that are incurred from December 1, 2020, to March 31, 2022.

3.3 Renewal of Agreement

3.3.1 Alberta's share of the federal funding for 2022-23 to 2026-27, based on the federal commitment in Budget 2017 of $11 billion over ten years, will be provided upon the renewal of this Agreement, subject to appropriation by Parliament, and Alberta and Canada's agreement on, a new five-year action plan which is to be informed by the actions set out in Annex 2 and the Common Statement.

3.3.2 If both Parties ultimately agree to renew, Alberta and Canada may choose to review and, if required, agree to realign the action plan in a future agreement based on the priorities in the Common Statement.

4.0 Financial Provisions

4.1 The contributions made under this Agreement are in addition to and not in lieu of those that Canada currently provides to Alberta under the Canada Health Transfer to support delivering health care services within their jurisdiction.

4.2 Allocation to Alberta

4.2.1 In this Agreement, "Fiscal Year" means the period commencing on April 1 of any calendar year and terminating on March 31 of the immediately following calendar year.

4.2.2 Canada has designated the following maximum amounts to be transferred in total to all provinces and territories under this initiative on a per capita basis for the Term starting on April 1, 2018 and ending on March 31, 2022.

4.2.3 For home and community care and mental health and addictions services, annual funding will be allocated to provinces and territories on a per capita basis, for each Fiscal Year that an agreement is in place. The per capita funding for each Fiscal Year, are calculated using the following formula: F x K/L, where:

• F is the annual total funding amount available under this program (funding amount will change depending on Fiscal Year);
• K is the total population of the particular province or territory, as determined using annual population estimates from Statistics Canada; and
• L is the total population of Canada, as determined using annual population estimates from Statistics Canada.

For Safe Long-term Care, annual funding will be allocated to provinces and territories with a base amount of $2,000,000 for each province and territory, and the remainder of the fund allocated on a per capita basis. The total amount to be paid to Alberta will be calculated using the following formula: $2,000,000+(F- (N x 2,000,000)) x (K/L), where:

• F is the total one-time funding amount available under this initiative;
• N is the number of jurisdictions (all 13) that will be provided the base funding of $2,000,000;
• K is the total population of a particular province or territory, as determined using the July 1 2021 population estimates from Statistics Canada; and,
• L is the total population of Canada, as determined by the July 1 2021 population estimates from Statistics Canada.

4.2.4 For the purposes of the formula in section 4.2.3, the population of Alberta for each Fiscal Year and the total population of all provinces and territories for that Fiscal Year are the respective populations as determined on the basis of the quarterly preliminary estimates of the respective populations on July 1 of that Fiscal Year. These estimates are released by Statistics Canada in September of each Fiscal Year.

4.2.5 Subject to annual adjustment pursuant to updated data and based on the formulas described in section 4.2.3, Alberta's funding under this Agreement is anticipated to be (in millions of dollars):

Annual Funding for Home and Community Care and Mental Health and Addiction Services

Fiscal Year	Home and community care Estimated amount to be paid to AlbertaTable note* (subject to annual adjustment)	Mental health and addictions services Estimated amount to be paid to AlbertaTable note* (subject to annual adjustment)
2018-2019	70.06	29.19
2019-2020	75.9	52.54
2020-2021	75.9	70.06
2021-2022	105.09	70.06

4.2.6 Subject to annual adjustment based on the formulas described in subsection 4.2.3, Alberta's estimated share of the amounts will be:

Fiscal Year	Safe Long-Term Care Estimated funding amount for AlbertaTable note*
2021-2022	$115,145,216

4.3 Payment

4.3.1 Canada's contribution for home and community care and mental health and addictions services will be paid in two approximately equal installments as follows:

1. The first installment will be paid on or about April 15 of each Fiscal Year. The second installment will be paid on or about November 15 of each Fiscal Year.
2. The amount of the first installment will be equal to 50% of the notional amount set out in Article 4.2.5 as adjusted by Article 4.2.3.
3. The amount of the second installment will be equal to the balance of Canada's contribution to Alberta for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
4. Canada will notify Alberta at the beginning of the Fiscal Year of their notional amount. The notional amount will be based on the Statistics Canada quarterly preliminary population estimates on July 1 of the preceding Fiscal Year. Canada will notify Alberta of the actual amount of the second installment in each Fiscal Year as determined under the formula set out in sections 4.2.5 and 4.2.3.
5. Canada shall withhold payment of the second installment for the Fiscal Year until Alberta provides its annual financial statement for the previous Fiscal Year and provides data and information related to home and community care and mental health and addictions to the Canadian Institute for Health Information (CIHI) for the previous Fiscal Year in accordance with section 5.1.2.
6. The sum of both semi-annual installments constitutes a final payment and is not subject to any further adjustment once the second installment of that Fiscal Year has been paid.
7. Payment of Canada's funding for each Fiscal Year of this Agreement is subject to an annual appropriation by Parliament of Canada for this purpose.

4.3.2 Canada's contribution for Safe Long-term Care will be paid in approximately equal semi- annual installments as follows:

1. The first installment will be paid within 30 days of Canada's acceptance of Alberta's proposed approach and initiatives for the use of the Safe Long-term Care funding, as set out in Annex 2.
2. The second installment will be paid, following Alberta's fulfillment of the obligations identified in subsection 5.1.2, and amendment of Annex 2 in accordance with subsection 5.1.3.

4.3.3 Where Alberta fails to put in place a cost-recovery agreement as required pursuant to section 4.8, Canada shall deduct from the payment referred to in subsection 4.3.2(b) an amount equivalent to the amount of funding provided by Alberta to those facilities with whom they do not have the required cost-recovery agreements in place.

4.4 Carry Over

4.4.1 At the request of Alberta, Alberta may retain and carry forward to the next Fiscal Year, the amount of up to 10 percent of the contribution paid to Alberta for a Fiscal Year under subsection 4.2.5 and 4.2.6 that is in excess of the amount of the eligible expenditures actually incurred by Alberta in that Fiscal Year, and use the amount carried forward for expenditures on eligible expenditures incurred in that Fiscal Year. Any request by Alberta to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters.

4.4.2 For greater certainty, any amount carried forward from one Fiscal Year to the next under this section is supplementary to the maximum amount payable to Alberta under this Agreement in the following Fiscal Year.

4.4.3 In the event this Agreement is renewed in accordance with the terms of section 3.2.1, and at the request of Alberta, Alberta may retain and carry forward up to 10 percent of funding provided in the last Fiscal Year of this Agreement for eligible expenditures in the renewed 5-year agreement (2022-23 to 2026-27), subject to the terms and conditions of that renewed agreement. The new Action Plan (2022-23 to 2026-27) will provide details on how any retained funds carried forward will be expended. Any request by Alberta to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by the Parties via an exchange of letters.

4.5 Repayment of overpayment

4.5.1 In the event payments made to Alberta exceed the amount to which Alberta 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, Alberta shall repay the amount within sixty (60) calendar days of written notice from Canada.

4.6 Use of Funds

4.6.1 Canada and Alberta agree that funds provided under this Agreement will only be used by Alberta in accordance with the areas of action outlined in Annex 2.

4.7 Eligible Expenditures

4.7.1 Eligible expenditures for funds provided under this Agreement are the following:

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

4.7.2 Canada and Alberta agree that amounts paid to Alberta under the Safe Long-term Care Fund may be provided by Alberta to:

• publicly-owned long-term care settings;
• privately-owned not-for-profit long-term care settings; and,
• subject to section 4.8, privately-owned for-profit long-term care settings.

4.8 Cost Recovery

4.8.1 Where Alberta provides Safe Long-term Care funding to privately-owned, for-profit facilities in accordance with this Agreement, Alberta agrees to put in place cost-recovery agreements with these facilities and report on these agreements through amendments to Annex 2 by no later than March 31, 2022 in accordance with the requirements set out in subsection 5.1.3.

4.8.2 Where Alberta has cost-recovery agreements in place with one or more privately-owned for-profit facilities pursuant to subsection 4.8.1, Alberta agrees to invest all funds recovered through those agreements in accordance with the terms of this Agreement and the initiatives outlined in Annex 2.

5.0 Performance Measurement and Reporting to Canadians

5.1 Funding conditions and reporting

5.1.1 As a condition of receiving annual federal funding, Alberta agrees to participate in a Federal-Provincial-Territorial process through CIHI, to develop common indicators and to share relevant data to permit CIHI to produce annual public reports on pan-Canadian progress on home and community care and mental health and addictions services.

1. Alberta will designate an official or official(s), for the duration of this agreement, to work with CIHI and represent the interests of Alberta related to performance measurement and reporting for home and community care, as well as mental health and addictions services.
2. Sharing of data with CIHI is subject to an appropriate agreement between Alberta and CIHI to enable the sharing of information as required by this Agreement, and subject to applicable law.

5.1.2 As a condition of receiving annual federal funding, by no later than October 1 of each Fiscal Year during the Term of this Agreement, Alberta agrees to:

1. Provide data and information (based on agreed-to indicators through the FPT process) related to home and community care and mental health and addictions services in the province to CIHI annually. This will support CIHI to measure progress on the shared commitments outlined in the Common Statement and report to the public.
2. Provide to Canada an annual financial statement, with attestation from Alberta's accounting officer for the Ministry of Health, of funding received from Canada under this Agreement during the Fiscal Year compared against the action plan, and noting any variances between actual expenditures and Alberta's 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 eligible expenditures actually incurred by Alberta for home and community care and mental health and addictions programs and services;
   3. If applicable, the amount of any amount carried forward by Alberta 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.
3. For the Safe Long-term Care funding, the annual financial statement will also set out, for the previous fiscal year:
   1. The amount of the federal funding flowing to each facility, and the type of facility (as set out in 4.7.2);
   2. The estimated amount of funds to be recovered under cost-recovery agreements, where applicable, and the priority areas where those funds will be reinvested;

5.1.3 As a condition of receiving the second payment installment of the Safe Long-term Care funding, Alberta agrees to, by no later than March 31, 2022, amend Annex 2 to:

1. Provide up-to-date information on performance measures, targets and intended outcomes for the applicable three areas identified in section 2.3, and for any other areas in which Alberta has used Safe Long-term Care funding to support infection prevention and control, and interim results for each initiative.
2. Provide a breakdown of the facilities receiving funding under this Agreement, and specifically, identifying those privately-owned, for-profit facilities receiving funding pursuant to this Agreement and whether or not cost-recovery agreements are in place with them with respect to this funding;
3. Indicate the amount paid to each recipient operating a privately-owned, for-profit facility and describe the incremental impact that will be achieved through these investments;
4. Provide information on the estimated amount of funding to be recovered pursuant to the cost-recovery agreements; and,
5. Indicate how Alberta will use recovered funding to increase infection prevention and control pursuant to the terms of this Agreement.

5.1.4 Alberta also agrees to amend Annex 2, by October 1, 2022, to report, in accordance with the performance measures set out in Annex 2, on the outcomes and results achieved using the Safe Long-term Care funding.

5.2 Audit

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

5.3 Evaluation

5.3.1 Responsibility for evaluation of programs rests with Alberta in accordance with Alberta's own evaluation policies and practices.

6.0 Communications

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

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

6.3 In the spirit of transparency and open government, Canada will make this Agreement, including any amendments, publicly available on a Government of Canada website and Alberta agrees to make the results under this Agreement related to the Safe Long-term Care funding, as set out in Annex 2, publicly available on its Government of Alberta website.

6.4 Canada, with prior notice to Alberta, may incorporate all or any part or parts of the data and information in 5.1.2 and 5.1.3, or any parts of evaluation and audit reports made public by Alberta into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

6.5 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement, Safe Long-term Care Funding and this Agreement. Canada agrees to give Alberta 10 days advance notice and advance copies of public communications related to the Common Statement, Safe Long-term Care Funding, this Agreement, and results of the investments of this Agreement.

6.6 Alberta reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement, Safe Long-term Care Funding and this Agreement. Alberta agrees to give Canada 10 days advance notice and advance copies of public communications related to the Common Statement, Safe Long-term Care Funding, this Agreement, and results of the investments of this Agreement.

7.0 Dispute Resolution

7.1 Canada and Alberta are committed to working together and avoiding disputes through government-to-government information exchange, advance notice, early consultation, and discussion, clarification, and resolution of issues, as they arise.

7.2 If at any time either Canada or Alberta 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 Alberta, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Alberta will endeavour to resolve the issue in dispute bilaterally through their designated officials, at the Assistant Deputy Minister level (hereafter "Designated Officials").

7.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Canada and Alberta responsible for Health, and if it cannot be resolved by them, then the respective Ministers of Canada and Alberta most responsible for Health shall endeavour to resolve the dispute.

8.0 Amendments to the Agreement

8.1 This Agreement (not including 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 Canada's Minister of Health, and in the case of Alberta, by Alberta's Minister of Health.

9.0 Termination

9.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Alberta by giving at least 12 months written notice of its intention to terminate. Alberta 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.

9.2 As of the effective date of termination of this Agreement under section 10.1, Canada shall have no obligation to make any further payments to Alberta after the date of effective termination, and Alberta may reduce or cancel its commitments commensurately.

10.0 Notice

10.1 Any notice, information, or document provided for under this Agreement will be effectively given if delivered or sent by letter or email, postage or other charges prepaid. Except in periods of postal disruption, any notice mailed will be deemed to have been received eight calendar days after being mailed.

The address for notice or communication to Canada shall be:

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

Attention: Associate ADM, Strategic Policy

The address for notice or communication to Alberta shall be:

Intergovernmental Relations, Alberta Health
19th Floor, ATB Place
10025 Jasper Avenue NW
Edmonton, Alberta
T5J 1S6

Attention: Executive Director, Intergovernmental Relations

11.0 General

11.1 This Agreement, including Annexes 1 and 2, comprise the entire agreement entered into by the Parties with respect to the subject matter hereof.

11.2 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Alberta.

11.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Alberta shall be admitted to any share or part of this Agreement.

11.4 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.

11.5 Notwithstanding the dates of the signatures below, this Agreement to be effective as of April 1, 2018.

SIGNED on behalf of Canada by the Minister of Health at Ottawa this 28^th day of September, 2018.

The Honourable Ginette Petitpas Taylor, Minister of Health

SIGNED on behalf of Alberta by the Minister of Health at Edmonton this 1^st day of May, 2018.

The Honourable Sarah Hoffman, Minister of Health

Pursuant to the Government Organization Act

Intergovernmental Relations, Executive Council

Date: May 7, 2018

Annex 1 to the Agreement

A Common Statement of Principles on Shared Health Priorities

Annex 2 to the Agreement

Alberta action plan: Federal funding contributions for home and community care and mental health and addiction services

Introduction

The Government of Alberta is committed to a stable, accountable, high quality, person-centered and sustainable health system that emphasizes staying healthy and well, while also supporting equitable access to required care when needed. We are also committed to reducing the gap in health outcomes between Indigenous and non-Indigenous peoples through collaborative program design and delivery. As the population increases and demographics change, the demands for health services in Alberta continue to grow. There is an increased need for home and community care, as well as a coordinated and integrated mental health system. To help Albertans remain independent and active in their communities as they age or as their needs change, Alberta is shifting focus towards community-based care.

The Canada-Alberta Home and Community Care and Mental Health and Addiction Services Agreement will support Alberta towards achieving its vision for community-based health care. The vision for health in Alberta is where Albertans' health and wellbeing are improved through an integrated healthcare system that structures and plans around the diversity of individuals and their communities, and connects people to needed care and services regardless of who they are (ethnicity, language, gender, sex) or where they reside in the province. Achieving this vision requires a shift from a focus on higher-cost facility based care to more integrated community-based care and supports that are accessible to all Albertans closer to home.

Areas of action

This vision will be implemented through a multi-pronged approach involving a number of health system programs and areas such as home and community care, primary care, mental health and addiction services. The initiatives described in this action plan align with the areas of action outlined in the Common Statement of Principles for Shared Health Priorities.

Home and community care

Overview of current home and community care services in Alberta

Alberta's Home Care Program offers an array of health and support services to Albertans of all ages in their own homes and communities. In 2016/17, almost 119,000 Albertans received services from the home care program. Home care services are provided in a wide range of settings including: private homes or apartments, community settings (e.g. schools, public health clinics, adult day programs) and congregate living facilities (e.g. seniors' lodges, supportive living facilities). Of these 119,000 clients, approximately 70% were seniors, and 30% were children and adults under the age of 65.^Footnote1

Challenges in the provision of home and community care in Alberta are not dissimilar to challenges faced by other provinces and territories. For example, home care clients living in rural and remote areas, including Indigenous communities, do not have access to the variety or amount of home and community care services available to clients in urban and metropolitan areas. Home and community care can also place additional burden on friend and family caregivers, who are more often women^Footnote2, as they provide upwards of eighty to ninety percent of care in the home. Furthermore, demand for home and community care services is steadily increasing, with total client volume in Alberta rising nearly 20% from 2010/11 to 2016/17. This growing demand across the province is being driven by an aging population that is living longer, changing rates of chronic disease, and an expressed desire among Albertans to remain in their own homes and communities as they age or as their care needs change^Footnote3. The number of seniors in Alberta is expected to nearly double in the next twenty years from 550,000 in 2017 to more than 1 million by 2035^Footnote4. Overall, home care clients in Alberta are very satisfied with the quality of home and community care services they receive^Footnote5, but additional resources and strategic investments will be needed to maintain this quality over time as supporting clients with more complex care needs to remain in their own homes and communities will place further demands on caregivers and the system as a whole.

Plans and priorities for the next five years

To support Alberta's shift towards more community-based care, Alberta's Budget 2017 increased provincial funding for home and community care by $150 million, which included the $23.4 million in federal investments for home and community care in 2017-2018. The budget for home and community care in Alberta in 2017-18 was $2.02 billion. Additional provincial investment is planned to augment the federal investment over the next four years. The ultimate goal for this targeted investment is to help Albertans maintain their independence and avoid, or delay, the need for higher levels of care.

In recent years, the Ministry of Health has provided its provincial health authority, Alberta Health Services (AHS), with over $95 million in grant funding to develop, implement and evaluate home and community care initiatives aimed at supporting more Albertans with complex care needs to receive care in their homes and communities rather than in more costly facility-based settings such as hospitals or long-term care facilities. For example, a number of projects focused on the provision of interdisciplinary team-based care to home care clients with complex care needs related to chronic disease, aging or frailty. These initiatives were found to cause significant reductions in the use of emergency departments (25-40% reduction 6 months after intervention) and hospital admissions (33-52% reduction 6 months after intervention) among clients who received this specialized community care^Footnote6. The provision of additional adult day program spaces as well as enhanced community rehabilitation services were found to significantly increase client satisfaction with home and community care services and, in some cases, reduce the strain experienced by family caregivers^Footnote3. Evidence from these and other community-based Alberta initiatives have guided the selection of priorities for this federal investment. The selected initiatives also support the objectives of the recently released Alberta Dementia Strategy and Action Plan as well as AHS' Enhancing Care in the Community initiatives.

The funding provided through this Agreement will support and improve access to existing home and community care programs and services and help to scale and spread innovative initiatives over the next four years. Federal funding will augment the funding from Alberta for the programs and services listed in this action plan. These initiatives include:

1 Spreading and scaling evidence-based models of home and community care

a) Standardized basket of services

Description: Implementing a standard basket of home care services accessible by all Albertans regardless of where they reside in the province, including more intensive services and restorative care. This will include increasing basic home and community care services, particularly in rural and remote areas, as well as the provision of more intensive/restorative services and team-based care for clients with complex care needs. This may also include offering more client-directed funding options with more flexible funding limits. Keeping up with increasing demand growth will ensure home and community care services are available to all Albertans who require them.

The target population for this initiative is Albertans requiring home and community care services, particularly those in rural and remote areas of the province (including Indigenous communities) who have been chronically under-served. More intensive and/or restorative services will target clients at risk for hospitalization, or support clients to return safely to community more quickly after hospitalization.

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Spreading and scaling evidence based models of home and community care that are more integrated and connected with primary health care.

Federal contribution: Alberta anticipates spending in excess of $522.7 million over the five years included in this action plan to offer a more equitable and extensive basket of services to an ever increasing population of home and community care clients. Federal funding will contribute approximately 44 per cent of this planned expenditure.

Expected outcomes: A larger proportion of individuals will receive care and support within their homes and communities rather than in higher cost hospitals or facility-based continuing care. Fewer people will be assessed for facility-based continuing care while in hospital, and more people will be supported to return home and given a chance to rehabilitate prior to being assessed for facility-based continuing care.

b) Access to specialized, interdisciplinary programs, services and teams

Description: In response to existing programs that have been effective and well-received by Albertans, this initiative will increase access to specialized interdisciplinary programs, services and teams. This initiative will:

• Expand the Assess, Treat, Refer (ATR) community-based Emergency Medical System (EMS) program and EMS Urgent Response Teams. These innovative team-based care approaches involve EMS responding with the goal of treating clients with complex care needs in place and avoiding unnecessary transfers to emergency department (ED) or hospital. EMS teams also coordinate and collaborate with primary care providers and home care case managers.
• Expand Virtual Hospital and Integrated Care Teams for clients with complex chronic conditions (e.g. frail elderly, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF]). Specialized interdisciplinary care teams can provide care to clients with complex needs in community and are better positioned to coordinate with primary and acute care providers.
• Expand interdisciplinary community support teams that maximize health care workers' scopes of practice and coordinate with a client's primary care provider as necessary.

Specialized interdisciplinary team-based care such as the initiatives described above will support clients with complex care needs to avoid hospitalization or to return home more quickly after hospitalization. Better integration in health care service delivery can improve quality of care and reduce unnecessary use of more costly services.

The target population for this initiative is Albertans with complex and high needs (e.g. frailty, COPD, CHF, addiction or mental health issues, dementia, end of life).

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Spreading and scaling evidence based models of home and community care that are more integrated and connected with primary health care; and
• Enhancing access to palliative and end-of-life care at home or in hospices.

Federal contribution: Alberta anticipates spending ~$89 million over the next five years on the initiatives/programs described above. Federal funding will contribute to approximately 80 per cent of the planned expenditures.

Expected outcomes: With increased access to specialized interdisciplinary programs and services, we anticipate a reduction in hospital admissions/readmissions, as well as emergency department use, among program clients.

2 Enhancing access to palliative and end-of-life services

Description: This initiative will focus on the scale and spread of palliative and end-of-life services in home and hospice. Expansion of palliative home care and hospice services for clients throughout their health care journey allows clients to die in the place of their choice, in alignment with their goals of care. Currently some Albertans die in hospital while waiting for a hospice space. Making hospice spaces available to all Albertans who would prefer to receive care in a hospice setting would improve the quality of life for people in the final stages of their life.

The target population for this initiative will be all Albertans who require palliative and end-of-life care.

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Enhancing access to palliative and end-of-life care at home or in hospices.

Federal contribution: Alberta anticipates spending $35.6 million over and above current expenditures to enhance palliative home care programming and services to rural and remote parts of the province and to expand the number of hospice spaces. Federal funding for home and community care will fully fund this expansion.

Expected outcomes: With this initiative, we anticipate an increase in the number of Albertans receiving end-of-life care in community (in home and/or hospice), and a reduction in transfers to hospital by clients with an end-of-life prognosis.

3 Increasing support for caregivers through in-home respite and adult day programs

Description: Increase the provision of in-home respite services as well as basic and comprehensive adult day program (ADP) spaces. Adult day programs provide important socialization, physical activity, and monitoring for home and community care clients while simultaneously providing family caregivers with respite.

The work of unpaid family and friend caregivers in Canada has been valued at more than $25 billion per year^Footnote7, and the health system cannot afford to replace this care. In-home respite services can reduce the strain experienced by family and friend caregivers as a result of caregiving responsibilities, and can help families support home and community care clients to remain living at home as long as possible. ADPs are also a key form of respite services to support family and friend caregivers who provide the majority of care to Albertans with long-term health care needs. Comprehensive ADPs also offer programming for the monitoring and maintenance of the health and well-being of individuals with dementia or other complex health conditions to allow them to remain living in the community as long as possible. Clients and family caregivers report significantly improved quality of life from participation in comprehensive ADPs.^Footnote8

Target populations for this initiative include Albertans receiving care from family or friend caregivers, as well as caregivers at risk of burden from the stress of caregiving.

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Increasing support for caregivers.

Federal contribution: Alberta anticipates spending $15.4 million over and above current expenditures to enhance respite services and supports for informal caregivers. Federal funding for home and community care will fully fund this expansion.

Expected outcomes: This initiative will result in increased basic and comprehensive ADP spaces. It is expected to reduce hospital and emergency department usage among adult day program clients and also result in fewer caregivers reporting stress or burden.

Measurement and reporting

There will be several positive outcomes from the initiatives that have been listed as priorities for this federal investment. It is anticipated that home care clients with basic, and even the most complex, needs would be able access and receive the intensity of supports they and their caregivers require to remain safely at home for longer. As well, more Albertans who require palliative and end-of-life care will receive community-based supports so they can die in their place of choice. Previous evaluations of similar initiatives indicate that unnecessary use of higher cost health care services by home care clients can be avoided as a result of the more comprehensive and intensive supports available to them and their caregivers. Finally, it is anticipated that these initiatives will reduce caregiver burden and improve client and family experience and satisfaction with home and community care services.

Alberta Health will be engaged in collaborative work with AHS, the O'Brien Institute and the Health Quality Council of Alberta to measure and monitor the impact of Alberta's investment in home and community care. The following measures are among those being considered for evaluating the impact of the provincial and federal investment in home and community care:

• Home care client counts;
• Alternate Level of Care days for persons waiting in hospital for continuing care facility space;
• Percent of clients transitioned to facility-based continuing care, from the community rather than from acute care;
• 30 day unplanned readmission to hospital for home care clients;
• ED visits for home care clients;
• EMS transfers for home care clients;
• Number of adult day program spaces;
• Percent of clients whose caregivers are expressing continued distress;
• Overall client experience with home care.

Alberta is participating in the federal/provincial/territorial working group with the Canadian Institute for Health Information (CIHI), which is seeking to reach consensus on a focused set of common indicators for monitoring progress on health system priorities. Alberta will also continue to submit home and community assessment data to CIHI's Home Care Reporting System (HCRS) through the Alberta Continuing Care Information System (ACCIS).

Mental health and addiction

Overview of current mental health and addiction services in Alberta

Addiction and mental health conditions involve a complex interplay of genetics, personality, childhood experiences or trauma, and social determinants of health, resulting in a diverse range of needs. This complexity demands a high-functioning system to deliver and support a continuum of services. Services that are comprehensive, well-coordinated and integrated within Alberta Health Services (AHS) and with partner organizations and ministries are required to meet the needs of Albertans. Addiction and mental health services offered by AHS align with a tiered model of care. Clients and families receive care according to their needs along this continuum, stepping-up to higher levels of intensity as their needs for services increase and stepping-down to lower levels of intensity as their needs decrease.

Alberta spent over $850 million in 2016-17 to support addiction and mental health initiatives across the province. Alberta's Budget 2017-18 committed a $15 million increase for addiction and mental health and support, including funding to support the implementation of the recommendations of the Valuing Mental Health Report. Funding for mental health and addiction services in the province is provided to Alberta Health Services and community based services that provide addiction and mental health prevention and promotion, community based treatment, and specialized services. Two examples of priorities include expansion of the Opioid Dependence Program (ODP) and the Mental Health Capacity Building Program (MHCB). ODP services are currently located in all Zones throughout the province. For children and youth, the MHCB is made up of 37 programs in Alberta serving children and youth under age 19 years, and their families, located in 85 communities, 182 schools and 74 additional outreach schools.

As the single health authority in the province, AHS employs more than 9,000 Addiction and Mental Health (AMH) staff and contracted employees. Addiction and mental health services are provided in approximately 104 acute care hospitals and psychiatric facilities, 107 emergency departments and urgent care centers, 236 AMH community clinics, and 39 addiction residential and detoxification facilities. Further, AHS and its contracted services provide approximately 3,304 beds located in addiction, community mental health, psychiatric and acute care settings. Primary care physicians, private providers, non-governmental organizations and self-help groups also provide addiction and mental health care and supports throughout the province.

In 2015/16, over 130,000 clients were treated in AHS community/outpatient addiction and mental health services. In 2016/17, there were over 28,000 mental health and substance use discharges from acute care hospitals and psychiatric facilities, as well as over 102,000 visits to emergency departments and urgent care centres for mental health or substance use problems. Over 930,000 individuals in Alberta consulted a physician for addiction and mental health services during the 2016/17 fiscal year. Tele-mental health served 11,179 clients in 2016/17, and during the same period, there were 18,573 mental health related calls to the Mental Health Helpline and Health Link and 13,511 calls to the Addiction Helpline. Service volumes have been increasing across these sectors of the care continuum.

Although many Albertans are served through the existing addiction and mental health service system, recent reports that have highlighted gaps in available services. The Gap Analysis of Public Mental Health and Addiction Programs (GAP-MAP), 2014 report analyzed service gaps in adult addiction and mental health services, compared to population need. This report concluded that approximately 1 in 10 adults in Alberta had an unmet addiction and mental health service need because they either did not receive any services or received an insufficient amount of service. The report also concludes that the system invests the majority of resources in inpatient, crisis and residential services and operates on a reactive, acute model of care; it also indicates that mental health services are comparatively better resourced than addiction services and a large majority of resources are dedicated to services for adults. Further, community support services are not well integrated into addiction and mental health services.

Similarly, the Office of the Auditor General concluded that mental health services in Alberta need to be improved in their 2015 follow-up audit of mental health services. More specifically, they found that care planning and delivery was disjointed with limited coordination across service settings, programs and providers. The OAG highlighted housing supports as a key area for greater investment and coordination. Most recently, the government of Alberta sponsored a review of the mental health service system in 2015. Valuing Mental Health: Report of the Alberta Mental Health Review Committee (the Report), released in early 2016, reported that addiction and mental health services were difficult to access and navigate, were fragmented, and often did not meet the needs of vulnerable populations (e.g., children and youth, Indigenous peoples, persons with complex needs).

AHS monitors the performance of its services through a series of public and internal performance measures. These measures also suggest that clients may have difficulty accessing services. The proportion of children offered an appointment with a mental health therapist within 30 days decreased from 85% in 2015/16 to 81% in 2017/18, while the number of enrolments increased from 8,913 to 9,387 (5% increase). Likewise, wait times for adult addiction outpatient services are significantly longer in rural and remote areas of the province, compared to urban areas which often offer walk-in intake services. Overall, 1 out of 10 adults waited more than 15 days for outpatient addiction services in 2016/17. In addition, a significant proportion of available bed days in acute psychiatric units (approximately 15% in 2016/17) are used by clients who could be in alternative level of care (ALC). The most common reason why clients are designated as ALC is because they are waiting for services in the community.

Taken together this suggests that Alberta's addiction and mental health service system would benefit greatly from resourcing to enhance service integration and care coordination, expand access to services to meet growing demands, and make improvements for specific sectors of the service continuum and populations (e.g. services for children and youth).

Plans and priorities for the next five years

One strategy to support the vision for community-based health care is the creation of a Primary Care Network governance structure. On June 19, 2017, the Minister established a Provincial Primary Care Network (PCN) Committee by Ministerial Order. The Provincial PCN Committee will provide governance, leadership, strategic direction and priorities for the PCNs. It will provide a forum for PCNs, through their zonal leadership, to raise opportunities and issues to the provincial level. Zone Committees will work to align planning across PCNs in their zone, create and implement a zone-wide service plan, optimize service delivery for populations across zones, and create efficiencies through shared services. These committees will be instrumental in ensuring Albertans have access to AMH services in primary care settings and will promote greater integration of primary care and specialty addiction and mental health services.

Enhancing community-based programs is supported in the Valuing Mental Health (VMH): Next Steps (June 2017) document, which outlines actions to respond to recommendations made in the Report. To achieve the transformational change that the Committee's report calls for, actions focus on improving system continuity through coordinating and integrating services across health and with community service providers, and supporting those who are most likely to experience vulnerabilities.

Stakeholders, who provided feedback into development of VMH: Next Steps, recognized that while actions must serve all Albertans, particular focus should be given to groups who are underserved including:

• Children, youth and families;
• People with multiple and complex needs;
• People seeking addiction services; and
• Indigenous Peoples and communities.

As the largest organization responsible for the delivery of health care services in the province, AHS is tasked with leading the operationalization of Alberta Health's vision of enhancing care in the community, improving the integration of health and social services, and ensuring the needs of the four priority target populations identified in VMH: Next Steps are met. To achieve this, AHS Addiction and Mental Health has four strategic directions and each play an important role in enhancing delivery of addiction and mental health services:

1. Provide community treatment services to Albertans in need (e.g., promotion and prevention, specialized community services, primary care, and follow-up/transition from inpatient and hospital-based care).
2. Provide addiction and mental health supports in home care and supportive living environments.
3. Enhance appropriate use of crisis and emergency service (e.g., help people who would otherwise use crisis/emergency services instead access services in their home and community).
4. Provide specialized interventions for complex and high-risk populations (e.g., provide services in community settings, provide transitional/follow-up support for people moving from specialized facility-based care to the community).

The funding provided through this Agreement will support and improve access to existing mental health and addiction programs and services. Federal funding will be augmented by funding from Alberta for the programs and services listed in this action plan. These initiatives include:

1 Community-based addiction and mental health services

Description: Alberta currently has well-established core community health addiction and mental health services, including community-based follow-up from specialized services or inpatient services. An example of these services includes the expansion of Inpatient Psychiatric Staffing in St. Paul to provide comprehensive care to patients with complex needs on the acute care unit ($0.7 million per annum). Alberta also provides a range of emergency, crisis and outreach services to Albertans at risk of or in crisis, often in partnership with local agencies and police forces. An example is the Assertive Outreach Teams in the North Zone to serve patients with severe and persistent mental illness who present at Emergency Departments (ED) and require further support and follow-up ($0.5 million per annum).

In accordance with Alberta's vision towards community-based health care and in alignment with the AHS addiction and mental health strategic directions, this initiative will improve and increase access to community-based addiction and mental health services. This will include:

• Implementing evidence-informed models of community care by translating research, introducing innovations and supporting the spread of effective models of care. The increase of evidence-based models of care will improve access and transition between services. An example of this type of service includes the addition of the North Zone Aboriginal Travel Teams.
• Increasing access to community treatment services, including specialized community services and follow-up from emergent or crisis situations (e.g., discharge from acute care/emergency care, disasters or community crises). Example of this type of service includes the addition of outreach services for the homeless in Central Zone.
• Enhancing the appropriate use of crisis and emergency services, to support Albertans at risk of or in process of emergent or crisis situations. Initiatives will be based on population need, in order to provide addiction and mental health patients and their families focused care in the most appropriate service setting.

Increasing availability of community-based services will help meet growing demands and reduce wait times for services. This initiative will support Albertans who are at risk for or have addiction and mental health concerns, those who require treatments, or those who are met with crisis or emergency situations. An example of this program is the North Zone Indigenous Travel Team, which has been funded to recruit two addiction and mental health outreach teams to provide access to culturally appropriate services in high needs communities ($0.7 million per annum).

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Spreading evidence-based models of community mental health care and culturally-appropriate interventions that are integrated with primary health services.

Federal contribution: It is anticipated that $33.9 million of the federal funding will be used to build upon these community services and enhance innovative approaches to improve service access. This funding will provide additional support towards enhanced follow-up in the community, and enhanced crisis support and outreach services, in order to reduce avoidable admissions to acute care or emergency care for vulnerable Albertans or for those in - or at risk of - crisis.

Expected outcomes: The demand for mental health and addiction services is growing in the province, which results in Albertans having long wait times for services, not receiving services, or receiving an insufficient amount of service. We anticipate that providing increased access to services in the community will result in more individuals served for an addiction or mental health need over the fiscal year. This will result in fewer people requiring acute care admissions for an addiction or mental illness.

2 Mental health and addiction services for children and youth

Description: Alberta currently provides a spectrum of community addiction and mental health services to children and youth. Services include prevention / promotion, outreach, and scheduled and non-scheduled services (e.g., walk in), within the continuum of addiction and mental health services. The Mental Health Capacity Building (MHCB) Program works in schools and communities to promote positive mental health in children, youth and families and supports community members who work with children and youth ($10.4 million per annum). There are currently 37 programs in 85 communities and 182 schools with an outreach to 74 additional schools, throughout Alberta. Of the 37 Programs, 28 are located in rural and remote geographic areas in Alberta with a formalized connection for 14 of those rural programs to Indigenous communities. The focus of the program is mental health promotion, prevention, early and brief intervention for children, youth and families by: raising awareness, reducing stigma, building personal and interpersonal skills, supporting positive community norms, and intervening early to help children, youth and families who are at risk for addiction and mental health issues. A primary role for MHCB is to assist in connecting children, youth and families to treatment services when they need them.

There are currently a range of crisis and emergency services in conjunction with acute care sites, emergency departments, local schools and other child-serving community agencies across Alberta. The province also currently provides highly specialized services in community and residential care settings for children and youth with acute mental illness or addiction issues. For example, the Protection of Children Abusing Drugs (PCHAD) program, under a protection order, allows a child to be confined up to 10 days for detoxification, stabilization and assessment at 4 protective safe houses in Alberta with a total of 25 beds ($1.1 million enhancement per annum).

Federal funding will provide additional services in key targeted areas to improve wait times for children and youth at high risk or experiencing complex addiction and mental health issues. Studies show that half of those who develop mental health disorders show symptoms by age 14^Footnote9, which may be linked to a number of root causes and social determinants of health. This initiative will improve community care on the addiction and mental health continuum for children, youth and families. Areas of focus will include:

• Community-based mental health services for children and youth, such as promotion and prevention, specialized community services, and follow-up from emergent or crisis situations (e.g., discharge from acute care/emergency care, disasters or community crises). Examples of this type of service include the addition of the AHS operated Rutherford Clinic in the Edmonton Zone.
• Crisis and emergency services to support children, youth and families at risk of, or in the process of, emergent or crisis situations. Based on population need, initiatives will provide AMH patients and their families focused care in the most appropriate service setting.
• Intensive and specialized interventions for high-risk children and youth. This will involve partnering with stakeholders (e.g., schools, social services) to support children and youth with significant mental health and addiction concerns. Examples of this type of service include the addition of a youth mental health day program in the North Zone.

This initiative will focus on both prevention and treatment, as it supports children and youth either at risk of, or currently experiencing, mental illness or addiction. Enhancing community mental health and addiction services for children and youth will support individuals before they reach a crisis point. Focusing intensive and specialized interventions for high-risk youth, as well as increasing access to crisis and emergency services, will provide help when it is needed. This will benefit their families, the community and the province. It will also reduce or prevent acute care admissions for mental health or addiction. Target populations will include children or youth at risk for experiencing mental health concerns, those at risk of or in crisis situations and those with acute and/or severe mental illness and addiction.

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Expanding access to community-based mental health and addiction services for children and youth (age 10-25), recognizing the effectiveness of early interventions to treat mild to moderate mental health disorders.

Federal contribution: It is anticipated that $76.2 million of the federal funding will be used to support: community day programs and residential services for children and youth at risk for serious mental health or addiction issues (such as the Rutherford Clinic in the Edmonton Zone, which provides assessments and treatments for children and youth with mental health issues, and works with primary care providers); a youth mental health day program in the North Zone, which partners with three surrounding school districts to support children and youth with significant mental health concerns ($0.8 million per annum); and the expansion of PChAD Beds in the Calgary Zone ($1.1 million per annum).

Expected outcomes and results: These initiatives will reduce the wait times for children and youth seeking mental health services. We anticipate an increase in the number of clients served for mental health or addiction services during the fiscal year. In the long-term, increasing access to these services will result in healthier and happier children, and will reduce later-stage expenses, such as hospital stays and social services.

3 Specialized addiction and mental health services

Description: Addiction and mental health conditions involve a complex interplay of factors, including social determinants of health. This complexity demands a high-functioning system to deliver and support a continuum of services. Alberta currently provides supportive services in order to meet the complex needs of Albertans. For example, individuals covered by Persons with Developmental Disabilities (PDD), who have concurrent mental illness, are provided with enhanced housing opportunities to help them transition from Alberta Hospital in Edmonton ($0.6 million per annum).

In order to better meet the needs of those seeking specialized addiction and mental health services, this initiative will include:

• Increased housing and home-based supports to assist recovery for people with AMH needs. This initiative will improve AMH supports to Albertans who are in the housing continuum. Initiatives ensure that AMH supports are available to the most vulnerable Albertans in the community without reliance on acute or facility based care. Examples of this type of service include the addition of housing supports for chronically homeless in the North Zone and women in the sex trade in the Edmonton Zone.
• Increased availability of intensive interventions to improve short-term, acute, and intensive care options on the AMH continuum. Examples of this type of service include assertive outreach teams in the North Zone, enhanced detoxification services in the Central and South Zones, the addition of satellite homes for transition from Claresholm Care Centre in the Calgary Zone, the addition of ultra-short stay beds in the Calgary Zone, and expansion to inpatient staffing and beds in the North Zone.
• Increased specialized care options for complex and high-risk adult populations. This will cover an array of vulnerable populations which crosses a variety of conditions (e.g., severe depression, schizophrenia, dementia and aggressive behaviour) that require tailored, short or longer term services. Examples of this type of service include the addition of a rehabilitation facility in the Calgary Zone, a Person with Developmental Disabilities enhanced home in the Edmonton Zone, and a home for the not criminally responsible in the Calgary Zone.

This initiative will improve access to supportive housing options for adults challenged by homelessness and/or complex needs, and increase availability of specialized or intensive care for high-risk adult populations. The target population for this initiative is adults with complex or severe addiction and/or mental health needs, recognizing vulnerable or underserved populations.

These investments align with the agreed-to Common Statement of Principles on Shared Health Priorities by:

• Expanding availability of integrated community-based mental health and addiction services for people with complex needs.

Federal contribution: Alberta currently provides community supports for those vulnerable Albertans who require transitional housing but also need addiction and mental health support to maintain community living. It is anticipated that $123.5 million of the federal funding will be used to expand these community addiction and mental health supports provided to vulnerable Albertans (e.g., homeless), needed to maintain their ability to live in the community while reducing acute care and emergency service demands. Alberta funds a range of intensive interventions across the province. Federal funding will augment this provincial investment, by adding intensive care options to the foundational intensive services across the province in a number of areas where there is clear need for improved intense service needs (e.g., rural areas, detox services). For example, enhanced detoxification services will be added to Central and South Zones with the opportunity to convert social detox beds to medical detox beds ($3.7 million for two years).

Alberta is also funding a range of community and institutional specialized services across the province, supporting the high volume of Albertans with high risk and complex mental health care needs. Federal funding will augment the provincial investments, by increasing the range and type of specialized services offered across the province in key strategic areas. This will in turn decrease the burden on the acute care and emergency services across the province. For example, a Mental Health Rehabilitation Facility for patients with severe and persistent illness is being planned for the Calgary Zone in association with a contracted service provider ($6.2 million per annum).

Expected outcomes and results: There is a growing demand for these services in Alberta. We anticipate that increasing access to these services will result in an increased number of clients served each fiscal year.

Measurement and reporting

Alberta continues to monitor a number of measures that help inform us about the performance of our health system and support priority setting and local decision-making. The measures track our performance using a broad range of indicators that span the continuum of care. Alberta's current or potential measures in relation to mental health and addiction include:

• Percentage of mental health patients with unplanned readmissions within 30 days of leaving hospital
• Percentage of children (age 0-17 years) offered scheduled community mental health treatment within 30 days from referral
• Emergency department separations for adult and youth (in key / select targeted areas)
• Acute care admissions for adult and youth (in key / select targeted areas)
• Community addiction and mental health service volumes (scheduled and non-scheduled community services; adult and youth)
• Service volumes within intensive and specialty care programs
• Acute care length of stay in key areas of the AMH continuum

Alberta is participating in the federal/provincial/territorial working group with CIHI, which is seeking to reach consensus on a focused set of common indicators for monitoring progress on mental health and addiction services. If Alberta finds that the common CIHI indicators do not adequately align with the initiatives identified in this action plan, Alberta may identify other indicators. Measures will be analyzed in relation to the specific clinical and geographic area(s) where the initiative(s) are occurring. The identification of key performance indicators will be coordinated provincially between Alberta Health and AHS, and in consultation with provincial stakeholders.

Once indicators are agreed to, a schedule for data collection and reporting will be established. This will be coordinated provincially and consolidated into a provincial report that speaks to the overall impact of service enhancements to the continuum of addiction and mental health services in Alberta.

Anticipated expenditure plan for federal funding in home and community care and mental health and addictions^{Footnote 1Footnote 2}

Initiative name	Expenditures per Fiscal Year ($)
	2017-18	2018-19	2019-20	2020-21	2021-22	Total
Expenditures per fiscal year ($)
Standardized basket of services	13,840,606	41,860,000	47,700,000	47,700,000	76,890,000	227,990,606
Access to specialized, interdisciplinary programs, services and teams	6,200,000	16,300,000	16,300,000	16,300,000	16,300,000	71,400,000
Enhancing access to palliative and end-of-life services	3,200,000	8,100,000	8,100,000	8,100,000	8,100,000	35,600,000
Increasing support for caregivers through in-home respite and Adult Day Programs	200,000	3,800,000	3,800,000	3,800,000	3,800,000	15,400,000
Total	23,440,606	70,060,000	75,900,000	75,900,000	105,090,000	350,390,606
Mental Health and Addiction Services
Community-based addiction and mental health services	2,277,921	4,190,775	9,808,614	8,808,614	8,808,614	33,894,538
Mental health and addiction services for children and youth	2,300,000	4,294,536	19,075,240	25,248,573	25,248,573	76,166,922
Specialized addiction and mental health services	7,142,382	20,704,689	23,656,146	36,002,813	36,002,813	123,508,843
Total	11,720,303	29,190,000	52,540,000	70,060,000	70,060,000	233,570,303
Footnote 1 Subject to annual adjustment as per section 4.2 and potential carry-over amounts as per section 4.4. Return to footnote 1 referrer Footnote 2 Amounts listed indicate federal funding contributions. Alberta Health Services may spend in excess of these amounts for particular programs/services. Return to footnote 2 referrer

Alberta action plan for increased infection prevention and control

I. Context and current status

Background

Alberta's continuing care system offers a spectrum of health and personal care services and accommodation settings to support safety, independence and quality of life for Albertans of any age. Any Albertan can receive continuing care services, no matter their age, diagnosis or the length of time they need support. Eligibility for publicly funded health care services is based on a professional assessment of a person's unmet needs for care. Continuing care services include assistance with dressing, eating and bathing, meal preparation, respite, wound care, medication administration, and various other health care and support services. The demand for continuing care is expected to rise by 62 per cent over the next 10 years as Alberta's population ages.

In Alberta, publicly funded continuing care settings include continuing care homes (long- term care and designated supportive accommodations).

• As of March 31, 2021, approximately 91 per cent of residents living in the 27,716 continuing care home spaces are seniors.
• In 2016/17, 9% of residents in Alberta's long-term care facilities (nursing homes and auxiliary hospitals) were under 65 years of age, while 80% were 75 years of age or older.
• At that time 62% of long-term care facility residents were female while 38% were male.
• The most common languages spoken by these residents were English (89.5%); Chinese (1.9%); Italian (0.6%); Cantonese (0.6%) and Polish (0.5%).

Alberta has a mixed model of publicly and privately operated (both for-profit and not-for- profit) continuing care homes that provide access to high quality continuing care supports and services and provide choice to residents and their families. As of March 31, 2021, Alberta Health Services (AHS), Alberta's single provincial health authority, operated 30% (108) of publicly funded continuing care home sites, not-for-profit organizations operated 35% (126), and for-profit organizations operated 35% (124).

Continuing care homes are governed by several pieces of legislation, which include the Nursing Homes Act, the Hospitals Act, the Supportive Living Accommodation Licensing Act and subsequent standards that operators must comply with, including:

• Supportive Living Accommodation Standards - Set requirements for operators in the delivery of quality accommodation services to residents for all licensed supportive living accommodations (including designated supportive living).
• Long-Term Care Accommodation Standards - Set requirements in the delivery of quality accommodation services to residents for all long-term care facilities (includes nursing homes and auxiliary hospitals).
• Continuing Care Health Service Standards : Apply to all publicly funded health and personal care services provided to continuing care clients in home care and continuing care homes, and set minimum requirements for the provision of health care.

The Government of Alberta monitors all licensed supportive living and all long-term care accommodations at least annually to verify their compliance and investigate complaints relating to the Accommodation Standards. Additionally, Alberta Health Services and the Ministry of Health regularly audit compliance of continuing care homes in accordance to the Continuing Care Health Services Standards. Public reporting on compliance to standards is posted online.

During the COVID-19 pandemic, the Government of Alberta has been conducting additional inspections to identify compliance of continuing care homes to the Chief Medical Officer of Health Orders. Inspections include criteria such as screening processes; infection prevention and control; COVID-19 outbreak policies and management; enhanced cleaning; and quality of care monitoring. Alberta Health Services is also working to support operators in complying with the orders and monitors the status of any outbreak. Alberta Health Services follows up with facilities to determine whether they have adequate staffing to continue to meet client care needs.

The Government of Alberta is also modernizing the continuing care legislative framework to reflect the current environment and to address issues and concerns revealed by the COVID-19 pandemic. The new Continuing Care Act, which passed first reading in the legislature on March 28, 2022, will remove unnecessary restrictions; enable improvements for continuing care residents and clients, their families, support staff, and operators; increase clarity regarding continuing care services; and, support health system accountability and sustainability. Additionally, the new legislative framework removes barriers to implementing other transformative initiatives in the sector.

The Government of Alberta has recently completed a comprehensive review of continuing care homes. The Facility Based Continuing Care Review final report was released in May 2021, and includes 42 recommendations for system-wide improvements that would benefit residents and families, improve the work environment for staff, and increase system sustainability. The report also took into account Alberta's experience with the COVID-19 pandemic and includes recommendations specific to that experience as well. Based on the report's findings, the Government of Alberta is looking at innovative ways to provide Albertans with more choices of continuing care services, with a focus on increasing home and community care services and supports. Alberta has already implemented several recommendations including improving public reporting on continuing care inspections; phasing out ward rooms in facility-based continuing care; and allocating capital grant funding to support Indigenous communities and organizations. Actions to implement recommendations will continue for several years to come.

Actions taken since spring 2020

Continuing care homes have been disproportionately affected by the COVID-19 pandemic, since older adults are at greater risk of requiring hospitalization or dying if they are diagnosed with COVID-19. As of March 19, 2022, 8,393 residents and 9,551 staff in continuing care homes had tested positive for COVID-19 in Alberta; 1,362 residents and seven staff have died, and 73% of continuing care homes have had at least one resident or staff case.

The experiences of residents, families, staff, and operators during the pandemic highlighted many challenges and opportunities, including significant impacts to resident quality of life and mental health, impacts to family and friend caregivers due to the visitor restrictions, and workforce challenges which led to staff burnout and impacted quality of care.

Alberta was allocated $86.3M under the Safe Restart agreement related to Vulnerable populations, some of which supported the COVID-19 response in continuing care. This funding was fully allocated and used prior to December 2020. Funding specific to Alberta's continuing care homes went to:

• Provide support for continuing care and lodge operators, including enhanced staffing, extra cleaning supplies, lost accommodation revenue, and paid student practicum positions; and
• Support seniors and other vulnerable Albertans in continuing care homes, home care or palliative care, and persons with disabilities living in congregate care settings, by:
  • Increasing staffing support;
  • Covering one-time pandemic preparedness costs for non-wage measures for infection prevention and control; and,
  • Supporting with enhanced staffing, Personal Protective Equipment (PPE), and cleaning supplies and lower accommodations/rental income.

Early in the pandemic, additional COVID-19 safety requirements, including limits and restrictions placed on visitors to these facilities, were implemented to reduce the spread of disease and prevent hospitalization and death of residents. These restrictions were necessary to help protect lives, but also placed emotional and financial burdens on residents, families, staff, and operators.

In Spring 2020, the Government of Alberta provided funding to support operators' implementation of Chief Medical Office of Health Orders through a number of different initiatives, including:

• Since March 2020, $12 million per month to protect staff and residents in contracted continuing care homes from COVID-19, and to help with the extra costs associated with preventing and managing outbreaks (e.g., screening visitors, housekeeping staff, cleaning supplies, reimburse continuing care homes for lost revenue as a result of restrictions on admissions and reduced occupancy due to COVID-19). This funding continues to current date;
• Since April 2020, $5 million per month for increased health-care aide (HCA) staffing levels. This funding continues to current date;
• As of April 2020, $4 million per month to provide an additional $2 per hour for wages for HCAs, which continues to be funded to date; and,
• $2.9 million from Spring 2020 to Spring 2022 to help support paid HCA student practicums (at a wage of $15/hour and up to 240 hours per placement).

In July 2020, Alberta's Chief Medical Officer of Health released a revised visitor policy for licensed supportive living, long-term care and hospice settings. This revised policy responded to the growing evidence about the negative impacts of longstanding visitor restrictions, including input heard through virtual town hall meetings with continuing care and hospice residents, families, staff and operators. The revised visitor policy included a safer approach for visits with residents, recognizing the importance of designated family and support people, and incorporated a site-based risk assessment process for social visitors.

In December 2020, Alberta's government rolled out a rapid testing pilot project at long- term care and designated supportive living facilities in the Edmonton Zone and Calgary Zone using dedicated mobile testing centres. The program was expanded in February 2021 to provide thousands of rapid tests to operators of all long-term care and supportive living facilities in Alberta to routinely screen their asymptomatic staff. By the end of March 2021, Alberta's government had distributed more than 1.8 million rapid tests to targeted facilities and industries across the province. This included hospitals, assessment centres, long-term care and supportive living facilities, oil sands companies, and private businesses including meat packing plants, airports and veterinary clinics. Additionally, Alberta's government provided $12.8 million in funding between December 2020 and June 2021 to train and hire more than 930 comfort care aides. Comfort care aides provided assistance for a range of needs, including companionship, enrichment activities, assisting with mobile communication devices to support engagement with families and loved ones, and assisting with basic personal care, cleaning and screening.

In February 2021, Alberta's government announced $68.5 million to support operators of non-contracted licensed supportive living, contracted and non-contracted home care, hospices, and residential addiction and mental health treatment centres, with costs associated with the pandemic. This funding helped operators pay for increased staffing, additional cleaning supplies and personal protective equipment. Alberta's government also announced the joint federal-provincial Critical Worker Benefit program to recognize Alberta's critical workers, including health care workers in continuing care and addiction and mental health settings. Through this program, a one-time payment of $1,200 was provided to approximately 380,000 workers in health care, social services, education and private sectors. This included approximately 113,000 eligible health care workers in a range of settings - acute care, home care, hospice, mental health and addiction, and continuing care facilities.

In September 2022, Alberta's government announced $22 million over two years in additional funding to provide wage increases to certified HCAs. The additional funding will provide a pay increase of $2 an hour for 13 months for HCAs working in home care agencies contracted with Alberta Health Services. The purpose of providing this increase in funding rates is to help retain current and recruit additional staff, which will allow more Albertans to be cared for in their own homes.

II. Priority areas for investment

Initiatives

1. Staff retention measures and hiring additional human resources

   1. Health Care Aide Support Funding - Funding is being provided to public and not-for-profit continuing care home operators to provide an additional $2 per hour for HCA wages in contracted homes and to increase HCA staffing levels. As of September 2021, 149 sites are being funded. Approximately 10,000 HCAs will receive the additional $2 per hour for wages.

      HCAs provide personal care and support services for the older adults, persons living with disabilities, acute conditions or those living with chronic illnesses. Some clients supported by HCAs require short-term help, while others need ongoing support. In their role, HCAs:

      1. Work under the direct or indirect supervision of a regulated health professional, such as a nurse.
      2. Provide basic health services, physical and/or emotional support for clients who have medical conditions or major functional limitations; they also support clients to remain as independent as possible.
      3. Provide care within the community, in a hospital or in continuing care homes.
   1. HCAs provide 90% of the frontline care in continuing care. Many HCA positions are casual (25%) or part-time (38%), and many HCAs work multiple jobs. 70% of health care aides are female and 75% are age 50 or younger.

2. Strengthened infection prevention measures
   1. COVID-19 Incremental Funding - Funding is being provided to not-for- profit continuing care home operators to support increased requirements/expectations in responding to the pandemic. This includes funding for:
      1. Additional staffing to ensure care services are maintained, personnel to screen visitors and monitor and test residents and staff, and enhanced cleaning protocols;
      2. Additional cleaning supplies for enhanced cleaning protocols and PPE for staff and residents; and,
      3. Reduced occupancy within shared rooms to lower risks of infection between residents. As of September 2021, 149 sites are being funded.

III. Breakdown of initiative spending and cost recovery / Cost sharing

Initiatives
Funding allocation by initiative and facility
Priority area	2020-21	2021-22	Total
Staff retention measures and hiring additional human resources	$15,575,000	$46,725,000	$62,300,000
Strengthened infection prevention measures	$18,875,000	$56,625,000	$75,500,000
By facility category	2020-21	2021-22	Total	Amount to be recovered for reinvestment
Total support for publicly funded facilities/residences (public and private not-for-profit operators only)	$34,450,000	$103,350,000	$137,800,000Footnote *	N/A

IV. Performance measurement and expected results

Priority Areas	Performance Measure	Target / Outcomes	ResultsFootnote 1 Footnote 2
Staff retention measures: HCA wage top up increasing HCA hours	Incremental additional HCA paid hours	Increase in the number of additional HCA paid hours	Results to Date (March 31, 2021) Based on the December 1, 2020 to March 31, 2021 Incremental COVID-19 Reporting, the Ministry has received the following data: Approx. 497,000 additional HCA paid hours Approx. 227,000 additional incremental hours for nursing and allied care staff $7.7M for cleaning supplies and PPE $6.7M for additional hospitality staffing $5.7M for other staffing (door screener, security, etc.) Final Results (Fall 2022) Based on the December 1, 2020 to March 31, 2022 Incremental COVID-19 Reporting, the Ministry has received the following data: Approx. 1,029,000 additional HCA paid hours Approx. 510,000 additional incremental hours for nursing and allied care staff $14.0M for cleaning supplies and PPE $14.5M for additional hospitality staffing $14.5M for other staffing (door screener, security, etc.)
Strengthened infection prevention measures increasing HCA, nursing and allied care hours total funding used for cleaning supplies total funding provided for hospitality staffing (food services, house-keeping) total funding provided for other staffing (door screener, security, etc.)	Incremental additional nursing and allied care paid hours Total incremental funding used for cleaning supplies and PPE Total incremental funding provided for hospitality staffing (food services, housekeeping) Total incremental funding provided for other staffing (door screener, security, etc.)	Increase in the number of additional incremental hours for nursing and allied care staff Increase in cleaning supplies and PPE Increase in hospitality staffing (food services, housekeeping) Increase in other staffing (door screener, security, etc.) Public and not-for-profit continuing care homes are supported to comply with provincially set COVID-related requirements and to effectively manage outbreaks as needed