Canada-Nunavut Home and Community Care and Mental Health and Addictions Services Funding Agreement

Table of Contents

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

Funding 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 -

THE GOVERNMENT OF NUNAVUT (hereinafter referred to as "Nunavut" or "Government of Nunavut") as represented by the Minister of Health herein referred to as "the territorial Minister")

REFERRED to collectively as the "Parties"

PREAMBLE

WHEREAS, on January 16, 2017 Canada and Nunavut 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 Nunavut agreed in November 2018 to postpone federal funding for one year, now to begin in 2019-2020, which will permit Nunavut to put in place its programs and initiatives for home and community care and mental health and addictions;

WHEREAS, Canada and Nunavut agreed to a Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the Common Statement, attached here to as Annex 1) on August 21, 2017, which articulated their shared vision to improve access to home and community care as well as 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 Nunavut agree that data collection and public reporting of outcomes is key to reporting results to Canadians on these health system priorities, and that the performance measurement approach taken will recognize and seek to address differences in access to data and health information infrastructure;

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

WHEREAS, Nunavut 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, assisted 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;

AND WHEREAS, the Government of Nunavut 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 Nunavut for activities to protect residents in long-term care settings through increased infection prevention and control measures;

NOW THEREFORE, Canada and Nunavut agree as follows:

1.0 Objectives

1.1 Building on Nunavut's existing investments and initiatives, Canada and Nunavut commit to work together to improve access to home and community care and strengthen access to mental health and addictions services (listed in the Common Statement, attached as Annex 1).

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

2.0 Action Plan

2.1 Nunavut 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 Nunavut's approach to achieving home and community care and mental health and addictions services objectives is set out in their six-year Action Plan (2017-18 to 2022-23), as set out in Annex 2.

2.3 Nunavut will 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, Nunavut 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, as well as accreditation costs associated with meeting long-term care standards.

2.5 Nunavut'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 term of this Agreement is four years, from April 1, 2019 to March 31, 2023 (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 Nunavut for expenditures that are incurred from December 1, 2020, to March 31, 2022.

3.3 Renewal of Bilateral Agreement

3.3.1 Nunavut'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 the bilateral agreement, subject to appropriation by Parliament, and Nunavut and Canada's agreement on a new action plan.

3.3.2 The renewal will provide Nunavut and Canada the opportunity to review and course correct, if required, and realign new priorities in future bilateral agreements based on progress made to date.

4.0 Financial Provisions

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

4.2 Allocation to Nunavut

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.

Home and Community Care

1. $600 million for the Fiscal Year beginning on April 1, 2018
2. $650 million for the Fiscal Year beginning on April 1, 2019
3. $650 million for the Fiscal Year beginning on April 1, 2020
4. $900 million for the Fiscal Year beginning on April 1, 2021

Mental Health and Addictions Services

1. $250 million for the Fiscal Year beginning on April 1, 2018
2. $450 million for the Fiscal Year beginning on April 1, 2019
3. $600 million for the Fiscal Year beginning on April 1, 2020
4. $600 million for the Fiscal Year beginning on April 1, 2021

Safe Long-term Care

1. $1 billion for the Fiscal Year beginning on April 1, 2021

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 Nunavut 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 annual population estimates from Statistics Canada; and,
• L   is the total population of Canada, as determined using 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 Nunavut 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 based on the formulas described in section 4.2.3, Nunavut's estimated share of the amounts will be:

Fiscal Year	Home and community care Estimated amount to be paid to NunavutFootnote * (subject to annual adjustment)	Mental health and addictions services Estimated amount to be paid to NunavutFootnote * (subject to annual adjustment)
2019-2020	$620,000	$260,000
2020-2021	$670,000	$470,000
2021-2022	$670,000	$620,000
2022-2023	$930,000	$620,000
Table Footnote 1 Amounts represent annual estimates based on StatCan 2017 population Return to footnote * referrer

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

Fiscal Year	Safe Long-Term Care Estimated amount to be paid to NunavutFootnote * (subject to annual adjustment)
2021-2022	$3,001,000
Table Footnote * For Home and Community Care and Mental Health and Addictions Services, amounts represent annual estimates based on StatCan 2017 population. For Safe Long-term Care Funding, amounts represent annual estimates based on StatCan 2021 population. Return to footnote * referrer

4.3 Payment

4.3.1 Canada's contribution for Home and Community Care and Mental Health and Addictions Services will be paid in approximately equal semi-annual installments as follows:

1. The first installment will be paid on or about April 15 of each Fiscal Year. The second installment will be paid on or about November 15 of each Fiscal Year.
2. The amount of the first installment will be equal to 50% of the notional amount set out in Article 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 Nunavut for the Fiscal Year as determined under sections 4.2.5 and 4.2.3.
4. The actual amount will be based on the Statistics Canada quarterly preliminary population estimates on July 1 of the preceding Fiscal Year. Canada will notify Nunavut of the actual amount of the first and 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 if Nunavut has failed to provide its annual financial statement for the previous Fiscal Year or to provide data and information related to home and community care and mental health and addictions to 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 Nunavut'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 Nunavut'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 Nunavut 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 Nunavut 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 Nunavut, Nunavut may retain and carry forward to the next Fiscal Year the amount of up to 10 percent of the contribution paid to Nunavut 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 Nunavut in that Fiscal Year, and use the amount carried forward for expenditures on eligible areas of investment incurred in that Fiscal Year. Any request by Nunavut 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 subsection is supplementary to the maximum amount payable to Nunavut under subsection 4.2.5 and 4.2.6 of this Agreement in the next 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 Nunavut, Nunavut may retain and carry forward up to 10 percent of funding provided in the last Fiscal Year of this Agreement for eligible areas of investment in the renewed bilateral agreement, subject to the terms and conditions of that renewed agreement. The new Action Plan for the renewed bilateral agreement will provide details on how any retained funds carried forward will be expended. Any request by Nunavut 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 Nunavut exceed the amount to which Nunavut 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, Nunavut shall repay the amount within sixty (60) calendar days of written notice from Canada.

4.6 Use of Funds

4.6.1 Canada and Nunavut agree that funds provided under this Agreement will only be used by Nunavut 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 Nunavut agree that amounts paid to Nunavut under the Safe Long-term Care Fund may be provided by Nunavut 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 Nunavut provides Safe Long-term Care Funding to privately-owned, for-profit facilities in accordance with this Agreement, Nunavut 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 Nunavut has cost-recovery agreements in place with one or more privately-owned for-profit facilities pursuant to subsection 4.8.1, Nunavut 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, Nunavut agrees to participate in a Federal-Provincial-Territorial process, including working with stakeholders and experts, through the Canadian Institute for Health Information (CIHI), to develop common indicators and to share relevant data in order to permit CIHI to produce annual public reports that will measure pan-Canadian progress on home and community care and mental health and addictions services.

1. Nunavut will designate an official or official(s), for the duration of this Agreement, to work with CIHI and represent the interests of Nunavut related to performance measurement and reporting for home and community care, as well as mental health and addictions services.

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, Nunavut agrees to:

1. Provide data and information (based on existing and new indicators) related to home and community care and mental health and addictions services to the Canadian Institute for Health Information annually. This will support the Canadian Institute for Health Information to measure progress on the shared commitments outlined in the Common Statement and report to the public.
2. Beginning in Fiscal Year 2020-2021, provide to Canada an annual financial statement, with attestation from Nunavut's Chief Financial Officer, 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 Nunavut's Action Plan (Annex 2):
   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 home and community care and mental health and addictions programs and services;
   3. If applicable, the amount of any amount carried forward by Nunavut under section 4.4; and
   4. If applicable, the amount of any surplus funds that is 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); and
   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, Nunavut agrees to, by no later than March 31, 2022 for any initiative that began in FY 2021-22, amend Annex 2 to:

1. Provide up-to-date information on performance measures, targets and intended outcomes for the three areas identified in section 2.3, and for any other areas in which Nunavut 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 Nunavut will use recovered funding to increase infection prevention and control pursuant to the terms of this Agreement.

5.1.4 Nunavut also agrees to amend Annex 2, by October 1, 2022 to provide any outstanding interim results and by March 31, 2023, 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 Nunavut will ensure that expenditure information presented in the annual financial statement is, in accordance with Nunavut's standard accounting practices, complete and accurate.

5.3 Evaluation

5.3.1 Responsibility for evaluation of programs rests with Nunavut in accordance with its own evaluation policies and practices.

6.0 Communications

6.1 Canada and Nunavut 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.

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 Nunavut shall 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 Nunavut website.

6.4 Canada, with prior notice to Nunavut, 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 Nunavut 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 bilateral agreements. Canada agrees to give Nunavut 10 days advance notice and advance copies of public communications related to the Common Statement, Safe Long-term Care Funding, bilateral agreements, and results of the investments of this Agreement.

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

7.0 Dispute Resolution

7.1 Canada and Nunavut 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 Nunavut 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 Nunavut, as the case may be, may notify the other party in writing of the failure or breach. Upon such notice, Canada and Nunavut will endeavour to resolve the issue in dispute bilaterally through their designated officials, at the Assistant Deputy Minister level (hereinafter the "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 Nunavut responsible for health, and if it cannot be resolved by them, then the respective Ministers of Canada and Nunavut most responsible for Health shall endeavour to resolve the dispute.

8.0 Amendments to the Agreement

8.1 The main text of this Agreement (not including attached annexes) 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 Nunavut, by Nunavut's Minister of Health.

8.2 Annex 2 may be amended at any time by mutual consent of the Parties. To be valid, any amendments to Annex 2 shall be in writing and signed, in the case of Canada, by their Designated Official, and in the case of Nunavut, by their Designated Official.

9.0 Equality of Treatment

9.1 During the term of this Agreement, if another province or territory, except the province of Quebec, negotiates and enters into a Home and Community Care and Mental Health and Addictions Services Agreement with Canada, or negotiates and enters into an amendment to such an agreement and if, in the reasonable opinion of Nunavut, any provision of that agreement or amended agreement is more favourable 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 Nunavut, if requested by Nunavut. This includes any provision of the Agreement except for the Financial Provisions set out under section 4.0. This amendment shall be retroactive to the date on which the Home and Community Care and Mental Health and Addictions Services Agreement or the amendment to such an agreement with the other province or territory, as the case may be, comes into force.

10.0 Termination

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

10.2 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 Nunavut after the date of effective termination.

11.0 Notice

11.1 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 by post 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

Email: marcel.saulnier@canada.ca

The address for notice or communication to Nunavut shall be:

Government of Nunavut
P.O. Box 1000 Stn 1000
Iqaluit, Nunavut
X0A 0H0
Attention: Deputy Minister, Health

12.0 General

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

12.2 This Agreement is based on the Common Statement of Principles on Shared Health Priorities, Annex 1, finalized on August 21, 2017.

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

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

12.5 If for any reason a provision of this Agreement that is not a fundamental term is found by a court of competent jurisdiction to be or to have become invalid or unenforceable, in whole or in part, it will be deemed to be severable and will be deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.

SIGNED on behalf of Canada by the Minister of Health at Ottawa this 28^th day of March, 2019.

The Honourable Ginette Petitpas Taylor, Minister of Health

SIGNED on behalf of Nunavut by the Minister of Health at Iqaluit this 15^th day of March, 2019.

The Honourable George Hickes, Minister of Health

Annex 1 to the Agreement

A Common Statement of Principles on Shared Health Priorities

Annex 2 to the Agreement

Nunavut's Action Plan

Introduction

The Government of Nunavut's Department of Health (Health) is responsible for the delivery of healthcare to 38,243 Nunavummiut^{Footnote 1}. Healthcare service delivery, including that for mental health and addiction services is challenging as the population is spread across a vast geography. Specifically, Nunavut accounts for 1/5 of Canada's land mass and there are 25 remote communities, accessible only by air, spread across three time zones and divided into three regions: the Qikiqtaaluk (or Baffin), the Kivalliq and the Kitikmeot. Most of Nunavut's population is Inuit (85%) and as such, providing home and community care, and mental health and addictions care that are culturally appropriate and incorporate Inuit values is a key priority for Health.

The Government of Nunavut incorporates Inuit societal values into program and policy development, as well as into service design and delivery. The delivery of health services in Nunavut is based on a primary health care model. Nunavut's primary health care providers include family physicians, nurse practitioners, midwives, community health nurses, and other allied health professionals.

Differences in health status exist between Inuit residing in Nunavut and the general Canadian population. Specifically, Inuit are more likely to be daily smokers, experience food insecurity, and be overweight or obese. Rates of childhood maltreatment (i.e., physical and/or sexual abuse) are also higher among Inuit. Similarly, negative mental health outcomes such as binge drinking, depression, and suicide attempts and ideation occur more frequently among Nunavut's Inuit relative to other Canadians.^{Footnote 2} Suicide rates among Inuit in Nunavut between 1999-2014 were approximately 110 per 100,000 population, whereas the Canadian average is approximately 15 per 100,000 population.^{Footnote 3} These negative health outcomes are often the result of poor social determinants of health among Nunavut's Inuit. For example, a severe shortage of housing that contributes to overcrowding and homelessness^{Footnote 4}, food insecurity due to the high cost of food^{Footnote 5}, as well as lower educational attainment and socioeconomic status^{Footnote 6}. In addition, historical and intergenerational trauma as a result of colonization (e.g., residential school, dog slaughter, forced resettlement, the re-location of Inuit to sanitariums in the South for tuberculosis, among others), has had a significant impact on the well-being of Inuit.

Despite all of these challenges, Inuit in Nunavut continue to demonstrate resilience and strength. The communities across the territory are tight-knit and work together to solve issues and support one another. As well, many Inuit have a strong connection to the land and utilize the territory's natural resources in ways that benefit their family and community. There are also leaders within the community, such as Elders^{Footnote 7} who promote resilience and cultural continuity.

These strengths underscore the need to develop health services and programming that build on existing community resources and engage community members in program development and implementation. It is critical to be collaborative and culturally appropriate in order to support a sustained impact on access to mental health and addictions services, and home and community care.

Currently, through the Territorial Health Investment Fund (THIF) the Federal Government is supporting, among other things, Inuit workforce development by providing funding for training community based mental health and addictions outreach workers in Nunavut. Likewise, through the Northern Wellness Agreement, the Federal Government supports the frontline service delivery of the Home and Community care program, including care and training for Home Care Nurses in Nunavut. Together, these funding streams contribute to the objective of achieving a sustainable health system that supports the wellness of Nunavummiut.

This federal funding will complement and build on these existing initiatives. Specifically, in the priority area of improving access to mental health and addictions services, these federal funds will be used to provide mental health and addictions outreach workers the necessary resources to implement child and youth programming at the community level. For the priority area of improving access to home and community care, these federal funds will allow for the implementation of a standardized assessment tool which will increase access and enhance service delivery by ensuring services are tailored to an individual's specific needs.

Home and Community Care Services

Nunavut overview

In Nunavut, the continuing care system consists of the Home and Community Care (HCC) Program, three Continuing Care Centres funded by the Department of Health, and three Elders' Home facilities.

Family members and friends from all generations are the first providers of care in the home in all Canadian jurisdictions, including Nunavut. Government-provided service supplements existing care or, in rare cases, is the only support when there are no friends or family members available, willing, or able to provide care.

In Nunavut, an individual may self-refer to the HCC program or be referred by a health care professional or a family member. A standard comprehensive assessment is completed to determine the level of care and services that are required. Health also provides education and training opportunities to all employees in the HCC program.

The HCC program provides health care and support services, based on assessed needs, in the comfort of an individual's home. The main services provided by the HCC program in Nunavut include:

• Acute Care Replacement: services provided to clients who are experiencing an acute illness, but who have the potential to return to a pre-illness level of functioning and self-care;
• Chronic Disease Management: services provided to clients with advanced disease(s) who can be maintained at home, with ongoing home care services and family assistance;
• Long-Term Care Replacement: services provided to home care clients with illness/disability to aid them to increase their level of functioning or self-care so that they can function without the supports of home care services;
• Palliative Care: compassionate care offered to a person living with a progressive, life-threatening illness that does not respond to curative treatment. The primary objective is maintenance of the best possible quality of life. Palliative care provides family support, prevention, assessment, and treatment of pain and other distressing symptoms, and integrates the psychological, social, cultural and spiritual aspects of care; and
• Post-Hospital Care: short-term home care services, of an expected duration of 6 weeks or less, provided to stable clients who are post-surgical or have had an acute illness which has been diagnosed and treated.

The goals of the HCC program are to provide services to Nunavummiut, based on their assessed need, in order to promote independent living and support families in caring for people at home, in their community, rather than in a facility.

In Turaaqtavut (2018 mandate), the Government of Nunavut (GN) re-affirmed its commitments to strengthening self-reliance and community well-bring (Inuusivut) by:

• Respecting our Elders and calling upon them to help us remember the past and use it to shape our future;
• Valuing our Elders by listening to them, paying attention to their traditional knowledge, and meeting their needs for care in the territory; and
• Investing with partners in infrastructure that enhances our well-being as individuals and communities, including facilities for Elder care and addictions in the territory.

HCC programming is available to all Nunavummiut. For fiscal year 2016/17, there were 940 home care clients, a 5% increase from the prior year. The majority of those receiving home care are 65 and older. According to the 2016 Census, there were 1,360 individuals aged 65 and older in Nunavut. This is a 67% increase from 2006. It is projected by 2030 the population aged 65 and older will triple.

Priority area for investment

The GN and the Government of Canada share the priority of addressing access to appropriate services and supports in home and community to meet the needs of the growing population. A key component of this joint approach is being able to report and manage based upon a set of nationally agreed upon measures of performance. A barrier to Nunavut in supporting this federal investment is the lack of a consistent, evidence-based assessment tool to determine the service needs of Nunavut residents and provide the data needed to manage and report on the national measures of performance. Implementing the interRAI tool would directly support improved access and service delivery of home and continuing services by ensuring services are allocated to individuals based on their assessed care needs. Implementing interRAI within LTC will also ensure that care is being delivered in the correct setting, such that individuals whose care needs can be met within the community, are provided the opportunity to return there with the appropriate supports in place.

Activity - InterRAI assessment tool Project (FY 2019-20-2022/23)

Acquisition and implementation of interRAI is a necessary component to enhancing the Government of Nunavut's ability to integrate home care services within the primary health care model, as well as to better identify and respond to the needs of Nunavummiut with increased investment in home care infrastructure.

InterRAI is an internationally-researched and recognized set of clinical assessment instruments compatible across multiple health care sectors. These tools are widely regarded as a best practice assessment tool, particularly in home care and continuing care service delivery areas. They are in use in many Canadian jurisdictions and have been accepted as the national standard and form the basis of the Canadian Institute for Health Information (CIHI)'s Home Care Reporting System (HCRS).

Nunavut will be utilizing the most recent versions of the RAI assessment tools that are being promoted by CIHI for home care and long-term care. These tools will be compatible with CIHI's interRAI Reporting System (IRRS) that is being set up to manage interRAI data from the provinces and territories.

The project directly aligns with the activities in the Common Statement of Principles for

Shared Health Priorities by:

• Enhancing home care infrastructure, such as digital connectivity, remote monitoring technology and facilities for community-based service delivery
• Spreading and scaling evidence-based models of home and community care that are more integrated and connected with primary health care.

The GN currently does not use interRAI, nor does it submit data to the HCRS, resulting in a reduced understanding of the overall care needs of Nunavut residents, how our current resources are addressing these needs, and if we are adequately resourced to effectively support seniors to age in place in community. It will also help to validate when long term care admissions are required.

Implementing interRAI in Nunavut will require working with the vendor of the Meditech EMR currently used within Nunavut to ensure a seamless integration of the interRAI assessment and care plan data into the overall electronic health record. The implementation of interRAI will first focus on the Regional Centres before rolling out to the other communities in each Region. Some of the factors that will determine the sequence include size of community, home care program vacancies, and informatics support. A training plan will be an important part of implementation and will be key to supporting its ongoing utilization.

When implemented, interRAI will facilitate consistent evidence-based assessment and care planning for HCC clients, allow for the timely communication of pertinent client data and information between service providers across the continuum of care throughout the territory, enable consistent tracking and reporting of data, and assist in decisions regarding effective resource utilization. This is important for Nunavut communities where limited resources are available but the disparities in health are high.

The following table outlines the funding allocation for interRAI Assessment Tool.

Funding allocations
Home and Community Care

Activities	2017-18Footnote *	2019-20	2020-21	2021-22	2022-23Footnote **	Total
Total Federal Fund Received	$200,000	$621,650	$668,485	$673,051	$927,226	$2,783,186
Home and Community Care Services	$200,000	-	-	$941,941	-	$1,141,941
interRAI assessment tool planning and implementation	-	$156,546	$575,452	$50,522	$930,000	$1,712,520
Virtual Care (Workflow Standardization)	-	-	-	$28,804	-	$28,804
Total Expenditure	$200,000	$156,546	$575,452	$1,021,267	$930,000	$2,883,265
Carry-Forward to be Spent the Next Fiscal YearFootnote ***	-	$465,104	$558,137	$212,026	-	-

Performance measurement

A monitoring and evaluation plan for the interRAI implementation will be developed and implemented to measure progress enabling the project to be efficiently managed.

Nunavut is participating in the development of common indicators with CIHI and other jurisdictions that will measure improvements in access to home and community care services. When feasible, the Government of Nunavut will be reporting on the national indicators developed with CIHI, in addition to those specific to Nunavut. The data will be used to inform clinical, administrative, and policy decision making and will assist with resource allocation in home and community care that will help better meet client needs.

Summary of expected results
Home and Community Care expected results

Outputs	Output indicators	Outcomes	Outcome indicators	Target by 2022/23
interRAI is implemented in Home and Community Care and Long-term Care facilities in the Territory Access to standardized primary and secondary data to inform clinical, administrative, and policy decision making	# of communities that are using interRAI # of long-term care facilities that are using interRAI # and % of homecare and long-term care facility clinical staff that have completed interRAI training % of home care clients that have been assessed using interRAI % of long-term care facility residents that have been assessed using interRAI	Increased ability to conduct best practice assessments through sustainable interRAI use Enhanced distribution and utilization of home and community care resources Allocation of resources meets the needs of home care clients	# of home care and long-term care facility staff that are trained to use interRAI # of home care and long-term care facility staff that are using interRAI # of days between client assessment and first home visit # of days between identification of need for placement and actual placement date Reporting on HCC indicators to CIHI to monitor quality of care Percentage of communities where home care is delivered that are using interRAI Access to standardized primary and secondary data to inform clinical, administrative, and policy decision making	interRAI system is ready for implementation to support access to standardized primary and secondary data to inform clinical, administrative, and policy decision making

Mental health and addictions services

Nunavut overview

The Government of Nunavut is committed to the delivery of quality Mental Health and Addictions services across Nunavut. The primary objective of mental health and addictions treatment is to promote healthy and resilient Nunavummiut by providing access to quality clinical expertise and culturally relevant services, across the continuum of care and as close to home as possible.

Individuals and families seeking care in Nunavut often require support for many complex psychosocial issues. For that reason, the Department of Health is working towards achieving a fully integrated mental health and addictions system, so that individuals and families can access comprehensive care at any point in the system. This method is best practice and creates a holistic approach to mental health, addictions, and suicide prevention assessment, treatment and services. Supporting the mental health and addictions workforce is a central focus of the current service system. Currently, this workforce is primarily comprised of mental health nurses, mental health consultants and community based mental health and addictions outreach workers. Present efforts in training focus on supporting these workers in understanding the key aspects for the identification, intervention and treatment of problematic substance use, mental health issues and concurrent disorders.

Health is dedicated to increasing mental health and addictions treatment capacity across the territory, with a focus on community-based services and supports. The Government of Nunavut is working towards the well-being and self-reliance of Nunavummiut and communities. As such, a major objective of mental health and addictions treatment is to provide Inuit culturally informed wellness practices. To achieve this, the mental health and addictions program is focusing on hiring and developing a local Inuit workforce who can support clients in their recovery from addictions, mental illness, or both. For those who require more complex care, which cannot be provided in Nunavut, pre-treatment and reintegrating into the community have been essential areas of focus for mental health and addictions treatment in the territory.

Some examples of key successes of Health in the area of Mental Health and Addictions include:

• Continued focus on mental health and addiction workforce development. This includes developing the Mental Health and Addictions Outreach Worker (MHAOW) program.
  • The purpose of this position is to support mental health and addictions services by empowering clients and community members to actively participate in mental wellness; the MHAOW delivers programs, provides education, fosters strong community partnerships, incorporates Inuit knowledge and values, and assists children, youth, adults, and elders in accessing services.
  • The MHAOW program is prioritizing the hiring of local Inuit whose knowledge of their community and the diverse mental health needs are invaluable to the success and sustainability of services.
  • The MHAOW program includes an extensive orientation and training plan, which is currently being finalized. Training includes foundational skills-based courses specific to mental health, addictions, counselling, and community program development and training will be piloted in 2018-19.
• The Out-of-Territory (OOT) office provides residential placements for individuals and families who present with specialized needs that cannot be met in Nunavut. The OOT office identifies clients' needs in order to match them with a service that will best meet their needs. This office also conducts thorough facility reviews for quality assurance and to allow for a better understanding of which facilities might best serve certain client groups.
• A continued focus on building mental health and addictions supports in-territory for individuals with serious mental health or addiction related issues, such as the successful operation of two in-territory mental health residential facilities in Iqaluit and Cambridge Bay. In Iqaluit, the facility has 16 beds with an occupancy rate of approximately 85% and in Cambridge Bay, the facility has 10 beds with an occupancy rate of approximately 95%.

Despite some of the successes of the mental health and addictions program, there are significant service gaps that remain across Nunavut's communities. Specifically, health human resource issues, such as high turnover rates, burnout due to vicarious trauma, and vacancies and challenges in recruiting to remote communities. These issues contribute to Health's ongoing reliance on transient professionals (e.g., locums, agency nurses etc.) who often cannot provide the continuity in care or culturally sensitive services that Nunavummiut dealing with mental health and addictions issues deserve. Additionally, rates of mental health and addictions issues are high, and this is particularly felt among youth in the territory. This is due to the fact that close to 50% of the territory's population is under the age of 25^{Footnote 8}, coupled with the vulnerable nature of this period of development to the negative impacts of trauma and adverse events. The result of these service issues are driving high health care expenditures in the areas of:

• Emergency room visits for acute emotional and problematic substance use issues;
• Hospitalization for self-injury;
• Medevac expenses;
• Out-of-territory assessment, stabilization and treatment; and
• Treatment of secondary outcomes such as assault, domestic violence, and sexual abuse.

Priority areas for investment

The following project will address gaps in the current mental health and addictions service system in the areas of 1) the lack of a high quality integrated mental health and addictions service delivery at the community level and 2) the need to develop human resource capacity, particularly in the areas of children and youth mental health care.

The projects directly align with the activities in the Common Statement of Principles for Shared Health Priorities by:

• expanding access to community-based mental health and addiction services for children and youth (age 10-25).

The projects proposed for this federal funding are complementary to ongoing initiatives under THIF funding which is being utilized to help grow and train the mental health workforce. This federal funding will be used to support these newly developed resources by providing them funding to deliver programs and services for children and youth.

Project priority area: Expanding access to community mental health and addiction services for children and youth

Health is working to expand the mental health workforce, but there still remains a need for significant financial support in the areas of program delivery, professional development and support, and external supports.

Program delivery:

The Department of Health recognizes that community-based programs play a critical role in improving the wellbeing of young Nunavummiut by addressing a broad spectrum of mental health related issues. Several communities are currently delivering a variety of programs with great success, yet continuous funding challenges threaten their longevity, and many more communities are lacking youth-specific programs completely. The need for sustained and community-based programs specific to child and youth mental health and addictions has been raised by many Nunavummiut as a key component to expanding access.

Presently, there are several successful programs being delivered by mental health workers in each region, such as sewing programs in Kivalliq, mentorship programs in Kitikmeot, and land camps in Qikiqtaaluk. One of the greatest strengths of these programs is that the majority started as projects developed entirely at a community level. They offer culturally appropriate activities geared towards meeting the unique wellness needs of each community. Moreover, from a mental health perspective, the department has observed how impactful these programs are for youth and their families. The programs give youth opportunities to build connections with their peers, develop healthy coping skills, reduce anxiety and depression, and feel more hopeful. Additionally, the programs are vital in helping youth access further mental health services. The mental health workers facilitating the programs are able to connect with youth in safe environments which foster trusting, therapeutic relationships, and allow the youth to feel more comfortable discussing mental health concerns.

The youth mental health workers across the territory have identified financial security as the primary factor in supporting program sustainability. Typically, the process of securing funding falls entirely on the individual who wishes to facilitate the program. Though each program varies, facilitators usually require money for acquiring materials, resources, food, renting space, and compensating additional community members such as artists and Elders. If they are able to find potential dollars, they often report programs starting late in the fiscal year due to lengthy application processes. Moreover, most funding is limited to a one-year plan as per fiscal year restrictions. As a result, workers receive funding and may have only a few months before the fiscal year ends; thus, they are not able to effectively deliver their program and are often discouraged from continuing it. Having available funding which could be carried over each year and allocated from within our own department would support the ongoing facilitation and success of these programs. Furthermore, it would allow for more opportunities to develop new programs as our mental health workforce expands.

The objective of this project is to support community-driven projects and develop a model in which the strengths of these programs are recognized and shared across the territory. Funding may be used to designate a Program Coordinator who focuses specifically on assessing, developing, and delivering youth programs. This model would support the scaling up of successful community-level initiatives and would facilitate adaptations to ensure relevancy, cultural appropriateness, and best practices are upheld. Previous experience of the Mental Health and Addictions program indicates that communities wishing to implement new programs are more successful and the funding is used more effectively when they are provided relevant examples that can be tailored to their unique needs.

Professional development and support

Mental health workers in Nunavut experience extraordinary challenges in their professions; most report high levels of stress, feelings of isolation and helplessness, and having a need for more support. Consequently, the department has high turn-over rates amongst frontline staff, which greatly impedes program development and creates significant gaps in services. As mentioned above (MHAOW program), the department has been approved to receive funding for a number of new mental health worker positions across the territory. With this funding, there is potential to hire one or two workers in each community who can support child and youth mental health initiatives. However, Health requires additional funding for professional development and support.

The Department of Health will support our child and youth workers by providing more resources and facilitating peer support networks. For instance, Health will use this funding for hosting annual summits in which employees can meet in person to share successes and challenges while receiving support from mental health and addictions staff and each other. From a long-term perspective, Health would also like to use this funding to develop a website specific to child and youth mental health, which can act as a resource hub for clients and an ongoing support forum for professionals. As internet capabilities are improving in Nunavut, more and more youth and families are going online to find information. Health would like to support youth and their families to find relevant information on mental health and addictions topics online. This would include educational resources on mental health and addictions illnesses, tools for coping, and links to services or other resources in their community, Nunavut, and Canada. All materials posted would be developed or adapted to ensure they are culturally appropriate and translated.

External supports

The Government of Nunavut recognizes the importance of providing quality mental health care within the territory. For acute cases, however, clients often need to leave their community to receive care in Iqaluit or outside of the territory. Thus, the Department of Health relies on external partners who can offer services remotely in order to meet the needs of communities at a local level.

For children and youth, the SickKids Tele-link Program has been a major provider for psychiatric consultations and follow-up assessments. With this program, children and youth throughout Nunavut are able to receive psychiatric support from within their community. This funding will be used to continue the program. In addition to psychiatric services, the SickKids Tele-link Program also offers professional to professional consultations and educational seminars, providing further opportunities for the department to meet professional development objectives.

This funding will be used to support new projects and initiatives with nationwide partners. For example, a pilot project is currently being discussed amongst members from various helpline organizations looking to improve access to services in remote Nunavut communities. Kids Help Phone, First Nations and Inuit Hope for Wellness Helpline, and Kamatsiaqtut Helpline are working with our department on developing strategies for serving children and youth who face barriers when accessing help. The pilot project would begin in one or two communities and would extend territorially depending on evaluation and need. There will be costs associated with travel, telecommunications, resource development and program management.

Performance measurement

A monitoring and evaluation plan for the projects will be developed and implemented during the 2019/2020 fiscal year. This plan will measure the progress and success of program implementation both qualitatively and quantitatively. The evaluation will concentrate on project-specific indicators (see Table 2: Expected Outcomes). Ongoing evaluation over the course of the project timeline will allow for program adaptations as needed. Where possible, priority will be given to indicator measurement that aligns with the indicators developed through CIHI's common indicator project. Although Nunavut does not have a standardized data collection system for mental health and addiction health related indicators, Nunavut participated in CIHI's project for the development of common indicators and is working towards being able to report on them.

Funding allocations

Table 1
Mental health and addictions

Activities	2017-2018Footnote *	2019-20	2020-21	2021-22	2022-23Footnote **	Total
Total Federal Funding Received	$100,000	$259,021	$466,361	$621,278	$618,147	$2,066,660
Mental health and addiction services	$100,000	-	-	-	-	$100,000
Program delivery	-	$13,406	$156,179	$487,996	$300,000	$957,581
Professional development and support	-	$41,832	$62,349	$153,259	$150,000	$407,440
External service provision (e.g. contracted services)	-	$16,495	$38,500	$10,904	$100,000	$165,899
Evaluation	-	-	-	-	$70,000	$70,000
Total Expenditure	$100,000	$71,733	$257,028	$652,159	$620,000	$1,700,920
Carry Forward to be Spent the Next Fiscal YearFootnote ***	-	$187,288	$396,621	$363,634	-	-
Table 1 Footnote 1 2017-18 funds already provided through legislation. Return to footnote * referrer Table 1 Footnote 2 Allocations are notional. Funding allocations are subject to annual adjustment based on the formula described in section 4.2.3 of the Agreement. The budgeted amount for these areas will need to be flexible as bilateral funding is adjusted based on annual population estimates. Return to footnote ** referrer Table 1 Footnote 3 Section 4.4.1 of the Agreement provides that, if required, Nunavut may retain and carry forward to the next Fiscal Year unexpended federal funds, subject to certain conditions. Return to footnote *** referrer

Table 2
Mental health and addictions expected results^{Footnote 9}

Initiatives	Outputs	Output indicators	Outcomes	Outcome indicators	Target by 2022
Expand access to community mental health and addiction services for children and youth.	Program Delivery Professional Development and Support External Service Provision	Number of programs running (e.g., % increase in number of programs running) Number of individuals attending Workforce retention (e.g., pre-/post- implementation retention) Number of clients accessing services	Increased capacity to address mental health and addictions issues amongst children and youth at a community level	To be established when the monitoring and evaluation plan is developed in 2019.	To be established when the monitoring and evaluation plan is developed in 2019.

Nunavut - Action Plan for Increased Infection Prevention and Control

I. Overview

Background

In Nunavut, long-term care programs and services include long-term care and care provided to seniors (55+) with a chronic illness, physical disability, or cognitive impairment, based on assessed need. Programs and services consist of:

• The Home and Community Care Program, which is included under long-term care as Nunavummiut often decline residential long-term care because it is not accessible in their community, region or in territory. As a result, a significant proportion of long-term care is provided through home care service delivery and is dependent on the availability of community resources.
• Two Elders' Homes, which operate as assisted living facilities, each with an 8-bed capacity. They are owned by the Government of Nunavut with non-profit operators contracted to provide care. These facilities are mandated to provide Level 2-3 care. However, Level 4 care is also provided as residents' age-in-place.
• Three Continuing Care Centres (CCC's), which are long-term care facilities that are owned and operated by the Government of Nunavut's Department of Health (Health) to provide Level 4 care. Two centres have 10 beds and one centre has 8.
• Out of territory placement for Nunavummiut with dementia-related illnesses that cannot be managed in a territorial facility and when there is no capacity in territory.

Nunavut's long-term care division provides services, including respite and palliative care, to Nunavummiut aged 55 and over. There are usually between 20-25 Nunavummiut awaiting long-term care placement. In total, there are 44 long-term care beds in Nunavut, with five beds reserved for respite and palliative care needs. Patients within these facilities range from ages 30 to 94, and the majority of patients are Inuit. All facilities regularly operate at capacity and currently there are 34 residents in care in territory and 43 Nunavummiut in long-term care out of territory. The delivery of programs and services rely on health staff, agency contracted staff, and non-profit providers. There are no user fees for home and long-term care in Nunavut. A breakdown of ownership and level of care of the five facilities is provided below:

Facilities	Ownership	Level of care
Arviat Elders Home	Inuit owned, non-profit, GN-contracted	Assisted living for elders (level 2-3 care)
Iqaluit Elders Home	Inuit owned, non-profit, GN-contracted	Assisted living for elders (level 2-3)
Cambridge Bay Continuing Care Centre	GN-owned and operated	Long-term care (level 4)
Gjoa Haven Continuing Care Centre	GN-owned and operated	Long-term care (level 4)
Igloolik Continuing Care Centre	GN-owned and operated	Long-term care (level 4)

Health is responsible for overseeing long-term care delivery in Nunavut. While the delivery of long-term care strives to achieve accreditation standards, participation in an accreditation program is currently not a requirement for long-term care facilities. Nunavut faces great challenges with recruiting and retaining nurses due to the remote and isolated nature of the territory, as well as a lack of human resources in other areas. High vacancy levels and high staff turnover make it very challenging to achieve and maintain accreditation.

The Home and Continuing Care standards, policies, procedures are currently being reviewed and updated and are expected to be rolled out this coming fall. This work is being completed with the guidance and support of Nunavut's Chief Nursing Office to ensure consistency across different departmental divisions and to ensure the appropriate education and training is provided in the policy roll out.

Challenges in the long-term care sector

Nunavut experiences unique challenges and issues due to the remoteness of the territory. For instance, its 25 communities are only accessible by plane and are not connected by road or rail.

Similar to the acute care sector, staffing is the greatest challenge faced in long-term care with significant issues related to the recruitment and retention of qualified staff. The long-term care sector also faces challenges in providing timely and consistent education and training to para-professional front-line staff.

Since early 2020, the Department of Health has been responding to the COVID-19 pandemic. In April 2020, a series of checklists were developed for long-term care settings in the territory to prepare for, prevent, and respond to an outbreak. Staff successfully used the checklists to reduce the impact of the pandemic on residents in long-term care settings.

The recent COVID-19 outbreaks in Nunavut have highlighted the need for increased staff training across the territorial health system, including in long-term care settings. Nunavut's Long-term Care Action Plan, which was developed in response to the pandemic and updated in November 2020, is currently being updated to support safe long-term care. The purpose of this document is to inform the development of training material on COVID-19 for staff working in Elders' Homes and Continuing Care Centres. It updates existing material and brings guidance for long-term care together to facilitate review.

Lack of capacity and resources to provide quality care is an ongoing challenge and affects Nunavut's Home and Community Care program, which supports Nunavummiut to age in place. Although this program operates Monday to Friday, 8:30 am to 5 pm, it faces significant staffing challenges related to nursing staff, as well as para-professional staff. As such, families play a significant role in the delivery of community care across the territory.

Long-term care facilities are located in only 5 of Nunavut's 25 communities, which is an issue for most Nunavummiut as they prefer to receive care in their communities and regions. Having to relocate Nunavummiut, who are majorly Inuit, has serious implications given the historical and ongoing traumas Inuit face because of the traumatic impact of residential schools and forced relocation. The three continuing care centres, which provide high-level long-term care, are located in Cambridge Bay (8 beds); Gjoa Haven (10 beds); and Igloolik (10 beds). The two Elders Homes, which provide assisted living, are located in Arviat (8 beds) and Iqaluit (8 beds).

While there have been efforts to expand residential long-term care capacity within the territory, costs to build and operate facilities in the north impacts Nunavut's ability to implement needed infrastructure updates. A five-year plan guiding long-term care capacity development includes the following:

• 2024 opening of the 24-bed Long-term Care Centre in Rankin Inlet;
• Cambridge Bay to follow in 2024/25 with 24 beds; and,
• Iqaluit in 2024/25 with 48 beds.
• Please note that the LTC facilities for Iqaluit and Cambridge Bay are pending the approval of Territorial capital funding.

Impact of the COVID-19 pandemic on long-term care delivery

Challenges related to long-term care delivery in Nunavut have been exacerbated by the COVID-19 pandemic, as elsewhere in Canada.

Staffing has posed significant challenges as many nursing positions are filled with agency nurses, due to substantial vacancies and recruitment and retention challenges. In the context of the pandemic, it is significantly more challenging to recruit nurses given Nunavut's remoteness and isolation. Furthermore, health and safety requirements for outbreak responses and measures for infection prevention and control increased the number of staff required to provide long-term care. Staff testing positive for COVID-19 at facilities have posed great challenges and even resulted in the temporary closure of one of the Elders homes, due to staff shortages.

The deployment of staffing resources to support pandemic planning and response has impacted the delivery of home care services. During times of community outbreak, home care visits were suspended, which created a loss of care continuity and increased the burden on clients and their families and caregivers.

At the same time, families were hesitant to have family members placed outside of their communities, creating additional strain for caregivers. To prevent the spread of COVID-19, families were restricted from visiting their loved ones in long-term care facilities, creating further stress for both those in care and their families.

Efforts to mitigate the impact of COVID-19 in long-term care

To ensure safe long-term care delivery during the pandemic, all long-term care facilities were required to:

• Complete staffing contingency plans, ensuring that in the event of a community outbreak there is adequate back-up staff on the ground;
• Order and ensure an adequate supply of PPE, take inventory and track supply with a pandemic inventory form, and submit the form to the territorial division; and
• Adhere to visitor guidelines, allowing for 2 visitors per resident at a time, except during outbreaks when visitation was suspended.

Nunavut has initiated several measures that align with the three priorities of the Safe Long-term Care Fund, for instance:

• Additional staff was hired to ensure back-up staff were on the ground in an affected community in the event of an outbreak at a long-term care facility.
• Nunavut also strengthened infection prevention and control measures by ensuring that there is an adequate supply of PPE for staff and visitors.
• Visitors and staff are required to complete enhanced screening and regular testing to quickly detect, prevent and limit spread of COVID-19.

Nunavut will be utilizing infection prevention and control consultant resources to help monitor, measure, and teach infection prevention and control best practices.

Funding provided through the Safe Long-term Care Fund will help offset the increased expenditures to ensure pandemic preparedness, adequate infection control, and infection prevention in long-term care sites. This will include an assessment of gaps and a determination of where more measures are required.

II. Areas of focus and initiatives

The Safe Long-term Care Fund is to support jurisdictions to increase infection protection and control in each of the three areas highlighted in the Fall Economic Statement:

• 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.

The main expenditures to support COVID-19 preparedness in long-term care facilities in Nunavut have included:

• Staffing costs to ensure the availability of services - including costs associated with travel, accommodation and overtime.;
• The procurement and supply of PPE.

Initiatives

1. Retention measures

   During the pandemic, additional staff were hired to ensure back-up staff were on the ground in an affected community in the event of an outbreak at a long-term care facility. Nunavut has also initiated rapid training programs for supportive care workers, including training for students and workers from other sectors.

   Funding for this initiative will include paying overtime for nurses and additional nurses/staff required for safe care to help ensure appropriate staffing ratios for provision of safe care. This will help offset the costs associated with necessary staffing overtime and the costs of extra staff required to be on the ground in affected communities should an outbreak occur in the communities. Federal funds may also be used to hire additional staff, including personal support workers and cleaning professionals, for back up in the event of additional community outbreaks to ensure enhanced cleaning measures.

2. Infrastructure and renovations

   Infrastructure updates to Nunavut's long-term care facilities will include the installation of new air purification units to ensure optimal infection prevention. Nunavut will use federal funding to purchase air purification systems for existing and new facilities to enhance IPAC measures and to ensure optimal air quality and minimize risk of virus transmission inside facilities (2022/23).

   To enhance air purification in all five facilities would require significant renovations that would disrupt and displace the residents. Purchasing individual air purification systems will provide each resident with increased air quality and further decrease their chance of getting COVID-19, as well as other airborne illnesses.

3. Strengthened infection, prevention and control measures: PPE and equipment

   Nunavut has strengthened infection prevention and control measures by ensuring that there is an adequate supply of PPE for staff and visitors. Visitors and staff are required to complete enhanced screening and regular testing to quickly detect, prevent, and limit spread of COVID-19. Additional inspectors and infection, prevention and control specialists have also been hired to support in-person inspections of all facilities.

   Federal funds will also support the procurement of additional PPE stock to ensure resident and staff protection against COVID-19. As well, funding will be used to enhance IPAC materials for facilities, such as copper fixtures, hand washing sinks, and negative pressure rooms to mitigate surface virus transmission.

4. Readiness assessments

   Nunavut will be utilizing infection prevention and control consultant resources to help monitor, measure, and teach infection prevention and control practices.

Projected funding allocation by initiative and facility

Priority area	2021-22	2022-23	Total
Staff retention measures and hiring additional human resources	$1,500,500	$1,200,500	$ 2,701,000
New infrastructure and renovations	N/A	$200,000	$ 200,000
Strengthened Infection, Prevention and Control Measures: PPE and equipment	N/A	$100,000	$ 100,000
Readiness Assessments	N/A	N/A	N/A

Projected funding allocation by initiative and facility part 2

Priority area		2021-22	2022-23	Total
By facility category	Facilities
Publicly funded facilities/ residences	Cambridge Bay Continuing Care Centre	$ 333,500	$ 333,500	$ 667,000
	Gjoa Haven Continuing Care Centre	$ 333,500	$ 333,500	$ 667,000
	Igloolik Continuing Care Centre	$ 333,500	$ 333,500	$ 667,000
	Total support for publicly funded facilities/residences	$ 1,000,500	$ 1,000,500	$ 2,001,000
Private not-for profit facilities/ residences	Arviat Elders Home	$ 250,000	$ 250,000	$ 500,000
	Iqaluit Elders Home	$ 250,000	$ 250,000	$ 500,000
	Total support for privately funded facilities/residences	$ 500,000	$ 500,000	$ 1,000,000

III. Performance measurement and expected results

Note your approach for measuring results in the following chart, including specific performance output measures and targets that your jurisdiction will use to track progress for each of the initiatives

Main priority areas

Priority areas	Performance measure	Target / Outcomes	Interim results	Results
Staff retention measures: Wages and salaries Hiring additional human resources	Number of staff hired New collective agreement	X new employees hired Collective agreement ratified	7 LPNs hired between April and September 2022. Collective agreement ratified on August 8, 2022	40 LPNs hired between April 2022 and March 2023. Collective agreement ratified on August 8, 2022.
New infrastructure and renovations	Number of air purifiers being purchased for all facility resident rooms and common areas	50 air purifiers purchased, contributing to a reduced risk of contamination and closure of facilities.	65 HEPA units procured and installed.	65 HEPA units procured and installed.
Strengthened infection, prevention and control measures: PPE and equipment	Percentage of staff and visitors having access to PPE Percentage of rooms equipped with copper fixtures	100% of staff and visitors have access to PPE 100% of rooms are equipped with copper fixtures	100% of staff and visitors have access to PPE. Fixtures being procured.	100% of staff and visitors have access to PPE. Fixtures have been procured and are being installed.
Readiness assessments	Number of infection prevention and control readiness assessments completed.	5 infection prevention and control readiness assessments completed.	In progress.	5 infection prevention and control readiness assessments have been completed.