INAN Committee Report

Government Response to the 17th Report of the Standing Committee on Indigenous and Northern Affairs

“The challenges of delivering continuing care in First Nations communities”

INTRODUCTION

The Government of Canada thanks the members of the Standing Committee on Indigenous and Northern Affairs for their valuable study on continuing care in First Nations communities. The Government would also like to thank the witnesses from across the country who participated in this important study. The Committee’s recommendations align with many of the actions the Government has proactively been taking to address the various challenges associated with continuing care in First Nations communities.

Canada recognizes the importance of supporting seniors and persons living with chronic illness or disabilities to remain in their communities for as long as possible, so they can receive the culturally safe and appropriate care they need, surrounded by their families and loved ones. The Government currently provides funding for home and community care, palliative care, and assisted living services to support over 30,000 First Nations to receive the care they need, when and where they need it.

The Government is working with partners to improve access to a coordinated continuum of care for seniors and those living with chronic illness, as well as ensuring that the services provided are culturally appropriate. Budget 2017 investments in home and palliative care in First Nations communities provide a solid foundation to advance many of the Committee’s recommendations. Recent investments in on reserve housing for First Nations provide further support for seniors and persons living with chronic illness or disabilities to remain, not only in their communities, but in their homes for longer, where they can continue to receive the services and supports they require.

The Government is also considering additional investments as outlined in the most recent Budget. Budget 2019 proposes to invest $35 million in 2019‑20 to ensure the Assisted Living Program continues to help meet the needs of seniors and people with disabilities; and $8.5 million over two years to work with First Nations and Inuit communities on developing a new and more holistic long‑term care strategy.

Inclusion of palliative care in the First Nations and Inuit Home and Community Care program (Recommendation 1)

The Government of Canada recognizes the importance of palliative care as a key element of the continuum of services for First Nations living within their own homes and communities. Budget 2017 announced significant new investments in home and palliative care services for First Nations and Inuit – $184.6 million over five years and $69.1 million ongoing – representing a 76% increase in annual funding in this area. This funding will support a number of enhancements to the First Nations and Inuit Home and Community Care program, including the provision of palliative care services. Offering palliative care services, including culturally appropriate palliative care assessments and training, will allow clients to remain in their home community for care rather than having to seek treatment in larger, and often unfamiliar, urban centres.

The increased funding provided through Budget 2017 will support the following key activities: extending home and community care services hours beyond the current core hours to help address increasing demand and meet the needs of clients with significant care needs that extend into evenings and weekends, including respite and short-term critical care; increasing the number of community-based staff, or increased wages for existing staff, in order to improve the recruitment and retention of qualified health professionals; the provision of allied health services (e.g., physiotherapy, occupational therapy, podiatry); and, the purchase of specialized medical equipment and supplies to meet program and client needs.

The Government has developed a Framework on Palliative Care in Canada, which was released in December 2018. Further engagement is currently underway with National Indigenous Organizations towards the development of a distinctions-based framework on palliative care for Indigenous peoples.

In-home respite care (Recommendation 2)

The significant new investments provided through Budget 2017 for the First Nations and Inuit Home and Community Care Program are enabling First Nations and Inuit communities to address respite care needs by extending the hours of service to meet the needs of clients with care requirements in evenings and on weekends. Some communities are also planning enhancements that will provide pediatric respite and personal support worker services. These new investments are also enabling communities to improve the recruitment and retention of qualified health care providers.

Respite care for children (up to the age of majority, 18 or 19 in most jurisdictions) is also funded through Jordan’s Principle. Jordan’s Principle ensures all First Nations children can access the health, social and educational support, products, services and supports they need, when and where they need them. Non-medical respite care is also funded through Indigenous Services Canada’s Assisted Living Program.

Budget 2017 investments will also enable improvements to data collection, reporting, analysis and monitoring. This will help broaden the understanding of ongoing respite care needs and allow the Government to refine its approach to respite care funding and service delivery.

Long-term care facilities (Recommendation 3)

The Government has focused its investments on ensuring First Nations and Inuit remain in their homes and communities for longer, by providing home-based medical and non-medical care through the First Nations and Inuit Home and Community Care and Assisted Living programs, and through infrastructure funding to communities to support housing improvements.

Budget 2016 provided $416.6 million over two years to improve on reserve housing conditions, reduce overcrowding and increase health and safety. This was in addition to approximately $143 million annually provided by the Government to First Nations to support a range of housing needs. In addition, Budget 2018 provided dedicated support for a distinctions-based housing strategy for First Nations ($600 million over three years). These investments to improve on reserve housing, coupled with increased funding for the First Nation and Inuit Home and Community Care program, will enable individuals with continuing care needs to remain in their homes and communities longer.

Canada recognizes the current gap regarding long-term care facilities on reserves. Further engagement and analysis is required to develop a suitable approach to this issue that would support self-determination and the transformation of quality long-term care services in First Nations communities. In June 2018, the Canadian Institutes of Health Research held a “Best Brains Exchange” titled, Building a Foundation for a Long-Term Care Strategy in Indigenous Communities in Canada . The event brought together First Nations, Inuit and Métis leaders, federal/provincial/territorial government decision makers and researchers/experts and supported focused discussion on the topic of long-term care needs for Indigenous people, including a review of the latest evidence and innovative approaches. The Government will continue to work collaboratively with First Nations, Inuit and Métis to define their long-term care priorities and needs and to explore new models of care.

Culturally appropriate programming and service delivery (Recommendations 4, 5 and 6)

Culturally appropriate programming and service delivery in long-term care facilities, and in‑home and community-based care is an essential component of supporting the health and wellbeing of Indigenous peoples. The Government of Canada has successfully partnered with provinces, territories, academic institutions and professional organizations to develop or adapt curricula to include an Indigenous-specific cultural competency component for health professionals.

Canada is also supporting the Canadian Indigenous Nurses Association to develop online orientation sessions for nurses working with Indigenous peoples in both urban and northern settings and to revise existing curricula on cultural competency to reflect the Truth and Reconciliation Calls to Action. The Government is also collaborating with the Royal College of Physicians and Surgeons of Canada and Indigenous partners on the development of an approach to enhancing cultural safety in physician practice. Canada will continue to work in collaboration with these and other partners on the further development and implementation of training for Indigenous and non-Indigenous health professionals providing continuing care on reserve.

Through the First Nations and Inuit Home and Community Care and Assisted Living programs, the Government supports culturally appropriate services through a community-based care model that provides comprehensive, culturally sensitive and responsive services that are unique to the health and social needs of First Nations and Inuit. Both programs support nutrition, meal planning and meal preparation as part of the home care available on reserve, including incorporating traditional foods where available. Through the Government of Canada’s flexible funding approach, First Nations communities have designed strengths-based, community-driven approaches that integrate traditional healing practices across a range of program areas. The benefits of traditional healing go far beyond health; it is an important part of cultural identity and community connectedness for First Nations.

The Government is also supporting promising practices where organizations have developed models that integrate culturally appropriate care into the health system. For instance, the Meno Ya Win Health Centre in Sioux Lookout, Ontario is using the Traditional Healing, Medicine, Foods and Supports Program as a model for integrating First Nations cultural care, including serving traditional Anishnabe foods, with hospital-based services. Canada will continue to work with First Nations, provinces and territories, and other partners to encourage the implementation of culturally appropriate care and services in long-term care facilities and on reserve programs.

Access to post-secondary health education (Recommendation 7)

The Government of Canada recognizes the continued need to increase representativeness of Indigenous health care workers in the health care system and to address health human resources needs in First Nations communities, particularly for rural and remote communities. The challenges related to training and retention of health professionals on reserve are complex and are related to numerous factors including wage parity, funding shortfalls, and geographic isolation. The Government agrees with the Committee that a local First Nations health workforce is essential and has positive impacts on community well-being and health.

Canada supports access to post-secondary health education and occupational training through several key programs. The Aboriginal Health Human Resources Initiative works to increase the number of Indigenous people entering health careers, as well as to provide training to community-based workers and health managers delivering health services in First Nations communities. The initiative is delivered through two streams. The first is the provision of bursaries and scholarships for Indigenous students pursuing post-secondary studies in health and dental fields through Indspire, an Indigenous-led national charity. A program evaluation found that through Indspire, a total of 3,064 scholarships and bursaries were awarded between 2013-14 and 2017-18, helping approximately 765 Indigenous students per year to participate in post-secondary studies leading to health careers. The second stream of the Initiative provides funding to ensure that community‑based health workers and managers are trained and certified, in order to improve the quality and consistency of healthcare services provided in First Nations communities. One example under this second stream is support for the First Nations Health Managers Association to offer a certification program leading to the Certified First Nations Health Manager professional designation. In 2018, 36 First Nations individuals graduated from the certification process, a record number, bringing the total number of individuals with the designation to 175.

As well, the Post-Secondary Student Support Program provides financial assistance to First Nations students who are enrolled in eligible post-secondary programs, including community college and certificate programs, undergraduate programs, and advanced or professional degree programs. In 2017-18, the Government of Canada invested $90 million over two years in the Post-Secondary Student Support Program and the University College Entrance Preparation Program for First Nations and Inuit students. This funding will support over 4,600 students. In the context of the Post‑Secondary Education Review announced in Budget 2017, the Government is working with First Nations leadership towards a strategic vision of First Nations-directed regional strategies supporting post-secondary education based on a combination of student support and locally‑tailored programs and services, supported by governance capacity.

In addition, the University and College Entrance Preparation Program provides financial assistance to First Nations students enrolled in university or college entrance programs to help them obtain the academic level required to enter a degree program. This program aims to increase the number of First Nations students with the academic level required for entrance into post-secondary programs.

Clarifying jurisdictional roles and responsibilities (Recommendations 8 and 9)

The delivery of health care services to First Nations is an area of shared jurisdiction. Provinces and territories provide universal insured health services, such as physician and hospital services, to all residents, including First Nations, Inuit, and other Indigenous peoples. The Government of Canada funds or directly provides health programs and services for First Nations and Inuit that supplement those provided by provinces and territories.

The Government recognizes the jurisdictional challenges that exist for First Nations communities regarding the delivery of home and community care, palliative care and long-term care services on reserves. These jurisdictional challenges have led to inconsistencies in access to continuing care services and facilities across provinces and territories. Canada is exploring models of health transformation that will advance innovative approaches such as the Tripartite Framework Agreement on First Nation Health Governance in British Columbia which was signed in 2011. The First Nations Health Authority is now responsible for the design and delivery of First Nations health programs and services on a province-wide basis. Building on this work, the Government is investing in First Nations health transformation in other provinces, including Ontario, Quebec, Manitoba and Saskatchewan, towards a goal of First Nations-designed, delivered and controlled health systems. In addition, through Jordan’s Principle, Canada is ensuring that children receive the services they need, when and where they need them, regardless of jurisdiction.

Canada is committed to supporting better alignment between federal and provincial/territorial health systems and increased First Nations’ control over health services to create a health system that is responsive to community needs. The Government recognizes that a coordinated continuum of services is essential to ensuring that seniors and those living with chronic illness or disability have access to the services they need. Further engagement is required with partners, including First Nations and provinces and territories, to develop a suitable approach that addresses current challenges. Within the federal suite of programs and in the context of the broader service transformation underway within the new Department of Indigenous Services Canada, the Government is examining the potential for other service alignments and integrated service components that would lead to improved service coordination.

The 2018 Framework on Palliative Care in Canada notes the importance of culturally appropriate palliative care for First Nations. Engagement toward the development of a distinctions-based approach to palliative care for Indigenous peoples, reflecting the specific and unique priorities of First Nations, Inuit and Métis, is currently underway.

Integrated data collection protocol (Recommendation 10)

Data collection is integral to determining strengths, abilities, and needs within communities and populations. Funding provided for the First Nations and Inuit Home and Community Care program through Budget 2017 will support improved data collection, reporting, monitoring and analysis capabilities that will help decision making at the community-level, provide tangible outcome measurements and, improve interoperability with provincial records systems.

As indicated in the Committee’s report, governance of health information must be respectful of First Nations jurisdiction over data and respect the principles of First Nations ownership, control, access, and possession (OCAP®). Canada continues to work collaboratively with First Nations, provinces and territories to improve First Nations health information while respecting the privacy of all Canadians, and the importance of information governance for Indigenous peoples in particular.

In some parts of the country, such as British Columbia, Alberta, Ontario, and the Atlantic provinces, there have already been considerable advancements in multilateral partnerships, producing Information Sharing Agreements that will significantly close the data gap between First Nations and other provincial residents. The Government of Canada also supports the First Nations Regional Health Survey, which is First Nations-governed and has been implemented explicitly in keeping with the First Nations principles of OCAP®. The survey is coordinated by the First Nations Information Governance Centre and supports First Nations self-determination in research. It has demonstrated to governments and the research community how the principles of OCAP® can be successfully executed.

Canada is also committed to using data to more effectively address the broader socio-economic gaps that exist for First Nations people. In July 2016, a Memorandum of Understanding was signed by the Minister of Crown-Indigenous Relations and the National Chief of the Assembly of First Nations. The Memorandum called for parties to jointly produce options and recommendations, including appropriate metrics and indicators for closing socio-economic gaps between First Nations and non-Indigenous Canadians. A National Outcome-Based Framework is being developed as a result of this agreement and is intended to be a key mechanism of mutual accountability to ensure the new fiscal relationship is delivering results by measuring progress in closing the socio-economic gaps between all First Nations and non-Indigenous Canadians – a shared responsibility. It is also intended as a co-developed dashboard with high-level common outcomes and indicators that could lead to periodic joint reporting on progress in reducing socio-economic gaps at the national and regional levels. The Framework would also be a key tool to help drive the important shift from compliance to outcomes based reporting.

CONCLUSION

The Government thanks the Committee for its interest in this subject and the important recommendations provided. The investments provided through recent federal Budgets are providing a solid foundation to address these recommendations. However, Canada recognizes that further work is required. The funding proposed in Budget 2019 would ensure the Assisted Living Program continues to help meet the needs of seniors and people with disabilities, and support engagement with First Nations and Inuit communities on a new and more holistic long‑term care strategy to meet the needs of First Nations and Inuit individuals living with chronic illnesses and disabilities now and in the future.

The Government is committed to working with Indigenous partners, as well as with provinces and territories, to continue advancing this work so that Indigenous seniors and those living with chronic illness or disabilities have access to the services they need, when and where they need them.