ONTARIO HEALTH SERVICES INTEGRATION FUND. Integration Plan. Submitted by the Ontario Region HSIF Advisory Committee

ONTARIO HEALTH SERVICES INTEGRATION FUND Integration Plan Submitted by the Ontario Region HSIF Advisory Committee September 29, 2011

TABLE OF CONTENTS Executive Summary........ 3 A.HSIF ONTARIO REGION INTEGRATION PLAN: 4 Date and Contact Information...... 4 B. Ontario First Nations Health Landscape 4 1. First Nations Profile....... 4 First Nations Demographics..... 4 First Nations Communities..... 5 First Nations Organizations..... 5 First Nations Health Issues..... 6 2. First Nations Health Services...... 7 Health Canada, First Nations & Inuit Health Ontario Region. 7 Province of Ontario...... 7 3. Provincial Health Service Delivery...... 8 Provincial Services...... 8 Regional Health Authorities LHINs.... 8 Ontario Aboriginal Health Policy and Strategic Initiatives.. 9 4. Trilateral First Nations Health Senior Officials Committee... 9 C. Aboriginal Health Transition Fund: Lessons Learned 10 Key Accomplishments..... 10 Key Successes...... 11 Recommendations...... 11 Additional Comments..... 12 D. Ontario HSIF: Key Objectives and Priorities 13 HSIF Overview, Objectives and Principles..... 13 HSIF Implementation in Ontario..... 14 HSIF in Ontario: Priority Areas..... 14 E. Partner Engagement..... 17 F. Communication, Reporting and Dissemination.... 18 G. Soliciting, Development and Review of Proposals.... 19 H. Key Milestones Critical Path....... 21 I. Sustainability Plan........ 25 J. Evaluation Plan...... 25 APPENDIX A: TFNHSOC Terms of Reference APPENDIX B: TFNHSOC Schematic APPENDIX C: Minutes of June 29, 2011 Initial TFNHSOC Meeting Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 2

EXECUTIVE SUMMARY The Health Services Integration Fund (HSIF) is a five year, $80 million Health Canada initiative supporting collaborative planning and multi year projects aimed at better meeting the health care needs of First Nations, Inuit and Métis peoples 1 in Canada. It has long been recognized that closing the gap in health status between First Nations/Inuit/Métis and non Aboriginal people requires coordinated efforts by the multiple partners and jurisdictions involved in the planning and delivery of health services. HSIF is intended to improve the integration of health services. HSIF funding will be provided to projects that increase aggregated work and more comprehensive health planning between federal and provincial health systems. HSIF will move beyond support for small or localized community level projects and enable sustained system change through a focus on broader scale projects (e.g. intra provincial) which will encourage more collective First Nations engagement in health planning and delivery. HSIF will capitalize on the lessons learned and partnerships established through the Aboriginal Health Transition Fund (AHTF) which had separate funding streams for adaptation and integration activities, often resulting in fragmented work for First Nations projects. Broader scale projects under HSIF will be supported under one funding stream. From 2006 2011 AHTF funded 11 integration projects in Ontario Region which focused on activities to develop an Ontario First Nations trilateral public health relationship framework, an Ontario First Nations trilateral health promotion strategy, the successful amalgamation of a federal and provincial hospital into one hospital governed by a First Nations Regional Health Authority, identification of community needs with respect to substance abuse continuum of care, integrated electronic health record system business plan, continuum of care for the elderly, the development of an Ontario First Nations Strategic Health Plan and First Nations Capacity Building. Under HSIF, a multi party Advisory Committee has been established in Ontario to develop the following integration plan that draws on lessons learned from AHTF and defines priority areas in integrating health services within the province. The Advisory Committee will guide the establishment of multi year integration projects (broader in scope and reach than many funded under AHTF) aimed at improving integration and access to existing provincial and federal health services to better meet the health care needs of First Nations people in Ontario. The Ontario Region HSIF Integration Plan has been completed in accordance with the criteria prescribed in the First Nations and Inuit Health Branch HSIF Implementation Guide and template. Participants from First Nations, federal and provincial governments, have been interviewed and their feedback has been utilized to shape and inform this Plan. It is clear that all partners are committed to undertaking further work to enhance the integration of health services in Ontario in order to support improved health outcomes of First Nations people. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 3

A. HSIF ONTARIO INTEGRATION PLAN DATE & CONTACT INFORMATION Date: 2011/09/26 FNIHB Region: Contact Information: ONTARIO Yeshodara Naidoo, Health Services Integration Fund Coordinator/Senior Policy Analyst Regional Director s Office First Nations and Inuit Health Ontario Region, Health Canada 1547 Merivale Road, 3 rd Floor, Nepean ON K1A 0L3 Telephone: (613) 946 8981 e mail: yeshodara.naidoo@hc sc.gc.ca Deborah Wild, Senior Policy Advisor Regional Director s Office First Nations and Inuit Health Ontario Region, Health Canada 1547 Merivale Road, 3 rd Floor, Nepean, ON K1A OL3 Telephone: (613) 952 0138 e mail: Deborah.wild@hc sc.gc.ca B. ONTARIO FIRST NATIONS HEALTH LANDSCAPE 1. First Nations Profile Demographics Approximately 22 percent 2 of Canada s First Nations people reside in Ontario, more than any other region in Canada. In terms of the First Nations population in Ontario, Aboriginal Affairs and Northern Development Canada 3 reported 181,524 Registered Indians in this region as of December 2010, with 86,640 (48%) living on reserve. 4 This number grew significantly from 2003 when the total Registered Indian population in Ontario was 161,718 with 80,539 (49%) living on reserve 5. The Census found that the Ontario First Nations population (158,395 enumerated in 2006) 6 had grown roughly 20 percent in five years three times faster than the overall Ontario population growth rate of 6.6 percent for the period from 2001 to 2006. The Census also found that over 29 percent of Ontario s First Nations people are under age 15 compared to only 18 percent of non Aboriginal Ontarians 7. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 4

First Nations Communities There are 133 First Nations in Ontario. The First Nations communities are diverse in terms of size, location and proximity to urban centres; cultural and linguistic affiliation; and community infrastructure and development. One third of Ontario First Nations communities are geographically remote 8. Five of the twenty largest First Nations in Canada are located in Ontario. These are: Six Nations of the Grand River, the largest First Nation in Canada with a total population of almost 24,000; Mohawks of Akwesasne, the second largest with over 11,000; Mohawks of the Bay of Quinte with over 8,000;Wikwemikong with over 7,300;and Oneida with over 5,500.An additional sixteen First Nations in Ontario (both northern and southern) have total populations of between 2,000 and5,000 9.The vast majority of First Nations in Ontario (over 100) receive services through one of sixteen tribal councils 10. There are over thirty treaties impacting First Nations in Ontario 11. First Nations Organizations Most First Nations in Ontario are affiliated with one of following four Political Territorial Organizations, which provide representation and advocacy on behalf of their member First Nations: Anishinabek Nation (Union of Ontario Indians) The Anishinabek Nation represents39 First Nations in four strategic regions across northern and southern Ontario. Its Advisory Council on Health is a technical body with representation from the four regions that meets quarterly and brings issues forward to the Chiefs Committee on Health. Association of Iroquois and Allied Indians The Association of Iroquois and Allied Indians represents 8 First Nations in southern and northern Ontario. Its Health/Social Advisory Board also meets quarterly as a technical body and brings forward issues to a Chiefs Council. Grand Council Treaty #3 Grand Council of Treaty #3 represents 24 First Nations in northwestern Ontario (plus two in Manitoba). Health bodies include a Health Council and a Social Sustainability Chiefs Committee. Nishnawbe Aski Nation Nishnawbe Aski Nation represents 47 First Nations in northern Ontario from Manitoba to James Bay. Community and Tribal Council Health Directors bring forward issues to the NAN Health Policy and Planning Unit, Executive and Chiefs to address accordingly. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 5

Independent First Nations There are currently thirteen First Nations that are not politically affiliated with any of the PTOs. By this non affiliation, the Independent First Nations have politically agreed, in the holistic interests of all of their respective communities and respecting their Independent First Nation status, to jointly take proaction on issues of fundamental concern. The Independent First Nations (IFN) Health Network is made up of the Health Directors or Representatives of the thirteen Independent First Nations. The IFN Health Network is a technical advisory and working group which reports its recommendations and activities on health initiatives to the Chiefs of the Independent First Nations. Other First Nations There are currently two First Nations in Ontario that are not associated with any of the above PTOs or the Independent First Nations. First Nations Health Issues First Nations health status in Ontario is poor in comparison to non First Nations populations. The 2002/2003 Ontario First Nations Regional Health Survey (RHS) 12 echoed the findings of numerous reports detailing the prevalence of chronic health conditions such as diabetes, hypertension, arthritis, heart disease and cancer among First Nations individuals 13. Other data indicate that over 20,000 Aboriginal people in Ontario suffer from depression, anxiety disorders and/or substance abuse 14. A significant barrier to First Nations access to health services in Ontario is a lack of health human resource availability, particularly in remote communities. FNIH OR recently cited data from Sioux Lookout and Moose Factory Zones indicating a 35 percent nursing vacancy rate. A study comparing Ontario s 2002/2003 RHS findings with national population health data noted that only 65 percent of Ontario First Nation respondents had contact with a general practitioner or family physician, while the rate was 81 percent for Ontario respondents, despite significantly higher chronic health conditions among First Nations people. First Nations in Ontario generally have limited access to specialized services such as physiotherapists, eye specialists and dentists 15. Furthermore, according to First Nations, federal and provincial representatives who were consulted in the preparation of The Examination of Funding for Health Programs and Services to First Nations in Ontario (Lemchuk Favel, September 2011), programs and services in Ontario, both on reserve and outside of the communities, were not adequately meeting the needs of the First Nations population. Gaps include: mental health and addictions; chronic disease diagnosis and management; acute diseases/accidents and illnesses; active and engaged parenting; children s programs and services; youth programs and services; continuity of care/provision of essential services and specialized care; infrastructure; culturally appropriate services; transitional assistance and wellness education and preventative health care 16. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 6

2. First Nations Health Services Health Canada: First Nations & Inuit Health, Ontario Region (FNIH OR) First Nations and Inuit Health Ontario Region (FNIH OR) is responsible for ensuring primary care and public health services across 133 First Nations communities in Ontario. FNIH OR also manages the Non Insured Health Benefits (NIHB) Program for First Nations individuals registered to Ontario First Nations communities. FNIH OR funds First Nations Provincial and Territorial organizations as well as First Nations communities to implement a diverse set of health promotion and disease prevention programs, including governance and consultation. It also provides direct health services, such as nursing and environmental health, to First Nations communities. To better organize operations and maintain effective relationships with First Nations, FNIH OR is structured according to four geographic zones: Moose Factory, Southern Ontario, Thunder Bay and Sioux Lookout. The September 2011 Examination of Funding for Health Programs and Services to First Nations in Ontario, commissioned by FNIH OR, provides a financial analysis of the 2009 2010 health care expenditures for First Nations in Ontario. These include health programs and services funded by federal and provincial governments which address the health needs of First Nations living on or off reserve. During 2009 10, $1.7 billion was expended of which $1.2 billion or 74.4% were provincial expenditures and $0.4 billion or 25.6% were from federal sources 17. By residency, federal expenditures were more heavily weighted to on reserve First Nations and provincial expenditures were weighted to the First Nations off reserve population. The Public Health Agency of Canada works closely with the provinces and territories to improve the health of Canadians and is responsible for addressing public health emergencies and infectious disease outbreaks in Canada. It ensures linkages and coordination between various levels of government and organizations to ensure efficient, effective pandemic preparedness. In responding to a pandemic or threat of a pandemic in First Nations communities or any community, PHAC facilitates coordinated responses, communications and information sharing. PHAC also provides project based funding to Aboriginal persons living off reserve in Ontario in three program areas related to child and youth health: The Community Action Program for Children (CAPC), the Canada Prenatal Nutrition Program and Aboriginal Head Start for Urban and Northern Centres (AHSUNC). Province of Ontario Several Provincial Ministries are engaged in the delivery of health services: the Ministry of Health and Long Term Care, Ministry of Aboriginal Affairs, Ministry of Health Promotion & Sport, Ministry of Child & Family Services, Ministry of Community & Social Services and the Ministry of Intergovernmental Affairs. A number of First Nations communities in Ontario supplement their community health programs and services by delivering provincially supported health initiatives such as those funded through the Aboriginal Healing and Wellness Strategy (see description of Provincial Health Service Delivery below). Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 7

3. Provincial Health Service Delivery Provincial Services Provincial delivery of health care services is guided by the provisions of the Canada Health Act. Services include physicians, Emergency Services, PharmaCare Program, Provincial Laboratory Program, Provincial Travel Grant, Public Health(see below) and other Provincial Programs. First Nations in Ontario access insured services through the provincial government. Those health related goods and services that are not insured by provinces and territories or private insurance plans come under the Non Insured Health Benefits program 18. Public health programs and services in Ontario are delivered through 36 public health units, each governed by a local Board of Health. The public health units are jointly funded by the provincial and municipal governments on a 75%:25% basis. Boards of Health may enter into service provision agreements with First Nations who pay a per capita share of the municipal share (e.g. a percentage of the 25% share) in return for direct service 19. A 2009community engagement process with over one hundred First Nations in Ontario in relation to public health gaps identified a lack of, or deficiencies in broader health services such as ambulance response times, access to primary care physicians, limitations on NIHB coverage for prescription drugs, and access to mental health services. In relation to public health specifically, they cited frustration about the limited access to good health data for planning purposes at the local level; the need for greater attention on chronic disease and obesity prevention (diabetes was frequently mentioned); concern about the need to maintain and, in some cases, create emergency plans for the community; lack of adequate dental services; and the absence of supports or ongoing funding at a sufficient level for a number of basic areas of programming such as child and maternal health 20. Regional Health Authorities LHINs The fourteen Local Health Integration Networks in Ontario were established in 2007 21. The LHINs have the mandate to plan, fund and integrate health care services offered by Hospitals, Long Term Care, Community Care Access Centres, Community Health Centres, Mental Health and Addiction services and Community Support Services. All 14 LHINs develop a three year Integrated Health Services Plan that outlines planning priorities for the LHIN. Overall policy direction for the provincial health care system and strategic priorities is set by the Ministry of Health and Long Term Care. (Of note, the public health units are separate from the LHINs and the public health units are jointly funded by the provincial and municipal governments). The Community Care Access Centres within each LHIN region have aligned their boundaries with the LHINs and there are now 14 CCACs across the province of Ontario. The LHINs are working together through the Provincial Aboriginal LHIN Network (PALN) to focus on cross LHIN collaboration on initiatives; knowledge transfer and communication; and Aboriginal community engagement and planning for an integrated health care system. In relation to Aboriginal health the LHINs overall objective is to learn about Aboriginal health care issues across the province and share information between the LHINS on Aboriginal health planning priorities and community Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 8

engagement initiatives. Key themes emerging from the provincial Aboriginal LHIN planning group that require further attention include: improving access to and integration of Mental Health and Addiction programs and services; better management of Chronic diseases (diabetes, arthritis, respiratory, cardiac and cancer); improving access to culturally appropriate care across care settings; and improving data accuracy to better understand health status, use of health care services and health and well being of Aboriginal people. Ontario Aboriginal Health Policy and Strategic Initiatives In Ontario an Aboriginal health policy was jointly developed in the early 1990s through a major consultation process with the PTOs and Independent First Nations, Métis groups and organizations representing Aboriginal women and friendship centres. The 1994 Aboriginal Health Policy raised the profile of Aboriginal health issues and created a policy framework within which Ontario could begin to address Aboriginal health. This policy paved the way for Aboriginal involvement in local health planning and created an Aboriginal office within the Ministry of Health and Long Term Care to provide liaison and a portal into the provincial health system 22. An initiative related to the Aboriginal Health Policy, called the Aboriginal Healing and Wellness Strategy was developed during this same timeframe through a similar joint Aboriginal/provincial process. AHWS, launched in 1994, continues to invest significant funding into Aboriginal community wellness programs, healing lodges, Aboriginal health access centres, crisis intervention, counselling to address mental and emotional issues, health promotion, family shelters, pre and post natal care and substance abuse treatment centres. In 2008/09, the strategy provided direct services to more than 42,000 clients 23. Since the development of the Aboriginal Health Policy and AHWS a number of provincial program initiatives such as the Aboriginal Diabetes Strategy have emerged. First Nations participants on the HSIF Advisory Committee expressed the view that these broader pan Aboriginal initiatives might not necessarily address some of the unique issues and concerns of First Nations. First Nations in Ontario have called for the establishment of a First Nations/Ontario Health Accord to provide a table to address First Nations issues with regard to the management and administration of the LHINs, AHWS, the Aboriginal Health Policy and other emerging issues. 4. Trilateral First Nations Health Senior Officials Committee A Trilateral First Nations Health Senior Officials Committee (TFNHSOC), comprising First Nations, Federal and provincial government representatives, was launched on June 29, 2011 (See Appendix A, Terms of Reference and Schematic). Grand Council Treaty #3 does not currently participate in the Trilateral process however an invitation has been sent by the province inviting their participation. The mandate of the TFNHSOC is to act as a decision making table that addresses options, alternatives, and recommendations related to First Nations health priorities. At the inaugural meeting the Committee identified four clear priority areas for action: mental health and addictions, including prescription drug Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 9

abuse; diabetes prevention and management; public health and data management. It was also agreed that the work of FNIH ON HSIF advisory committee will be informed by the four priority areas identified by the committee (June, 2011 TFNHSOC Minutes, Appendix B, attached). In addition to these four areas which will inform the HSIF Integration Plan, additional priorities will also be considered as identified by the HSIF Advisory Committee. C. AHTF: LESSONS LEARNED Unlike HSIF, the Aboriginal Health Transition Fund (AHTF) consisted of three distinct funding envelopes: The Adaptation Envelope supported provincial and territorial governments in the adaptation of provincial and territorial health systems to better meet the unique needs of Aboriginal peoples, taking into account that Aboriginal peoples have different cultures; The Integration Envelope supported the integration of provincial/territorial health systems with the federally funded systems in place for First Nations communities and for the Inuit; and The Pan Canadian Envelope supported cross jurisdictional integration and adaptation initiatives for First Nations, Inuit and Métis peoples, provided capacity building funding to national Aboriginal organizations, and supported workshops, evaluation activities and the overall administration of the AHTF. In Ontario Region, AHTF funded 11 integration projects during the period 2006 2011.Integration referred to efforts to improve coordination and collaboration between the universal health system funded by provincial/territorial governments and the health services in First Nations and Inuit communities, funded by the federal government. The FNIH OR Evaluation of AHTF integration activities indicated that only one project achieved the extent of integration planned for this funding period, one achieved partial integration but fell short of its objectives, one project completed draft agreements, two completed business plans, two developed strategic plans plus two drafted partial strategic plans, one completed a needs assessment and community consultation, and the remaining project established an advisory committee. AHTF accomplishments, successes and recommendations emanating from the evaluation report were as follows. Some Key FNIH OR AHTF Accomplishments: Increased awareness among partners and affected parties of the concepts, challenges, barriers and enablers to adaptation and integration Increased collaboration and strengthened partnerships among federal/provincial governments and First Nations communities Increased awareness of the need for and benefit of tripartite involvement in health planning, program development, and service delivery Increased economies of scale AHTF projects have resulted in more services being available as well as the potential for more services to be funded in the future Improved relationships among partners While acknowledging the importance of unique conditions in communities, some basic approaches to engagement can achieve success across jurisdictions Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 10

Key FNIH OR AHTF Successes: Projects seemed to make the greatest progress when the following indicators were present: staff/contractors hired specifically for the project, human resources (having the right people in the right job), project effort that was based on community concerns (as determined through needs assessment and consultation), and focus on specific communities. All projects faced challenges; some were unique whereas other challenges were common across multiple projects. Common challenges included: inadequate preparation and authority of provincial representatives to make decisions; insufficient time to accomplish project objectives due to limited knowledge, time and resources; conflicting interests within service partnerships; funding delays and funding uncertainty; and travel challenges. Success has been consistently reported when all relevant stakeholders, including decision makers, are at the table; when processes are transparent; when dialogue is open and respectful; when diversity is valued and when sufficient time has been spent in planning activities. The speed at which plans are finalized is dependent upon many factors such as various levels of review required, including provinces/territories, organizations and Secretariat; time to develop and revise proposals; joint planning and consensus building. Sufficient capacity at the community levels is required. Development workshops were helpful for reaching out to Aboriginal communities and informing them about AHTF. Capacity building should focus on the organization, rather than individuals, so that staff turnover/attrition does not affect the increased competence that has been developed. A formalized structure can increase the success of forming sustainable partnerships. Formal agreements (MOUs, protocols, terms of reference, etc.) with identification of clear roles and responsibilities support the formation of effective partnerships and a structure for sustainability. Capacity funding was integral to advancing the work under AHTF, especially when it was used to hire a coordinator who could lead projects and liaise and/or build relationships with First Nations partners. Lessons learned included the need for increased time and resources, increased support in project planning and implementation from the funding agency, better planning, earlier hiring practices, and completion of research prior to project start up. Most projects made considerable progress towards integration objectives and understood the next steps that they needed to take. Recommendations from the FNIH ON Evaluation Report include: 1. Continue with support provided from AHTF office including promoting program logic models, etc. Add support/training/guidelines for environmental scan methods especially with regard to other stakeholder groups, create work plans with definitive milestones, etc., pre identify collaboration techniques and methods, community consultation methods, strategic planning, business plans, and follow up planning. 2. Assign provincial government representatives who have knowledge of the health subject (e.g., public health) and the ability to make decisions to correspond with project deadlines. 3. Provide training for provincial representatives to Aboriginal health projects to include training in the many cultures and living circumstances of First Nation peoples in Ontario. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 11

4. Provide resources for hiring staff or contractors who can lead the negotiation efforts so that it does not depend on those participants who are donating in kind time to lead the effort as well as provide all of the administrative support. 5. Allow sufficient time and resources for a) Negotiations when there are or may be conflicting vested interests b) Actual integration of services (as opposed to planning for integration) c) Collaboration training when there is no prior history of collaboration among players d) Consultations with communities on unfamiliar subjects e) Pre project environmental scans of potential stakeholders in the project. 6. Address the compatibility issues between the First Nations principles of Ownership, Control, Access and Possession (OCAP), and the use and integration of provincially held administrative databases. The OCAP principles are not always compatible with integration planning when integration with provincial databases is involved. Additional Comments: AHTF Lessons that Inform HSIF Based on lessons learned from AHTF, participants on the HSIF Advisory Committee commented that as HSIF moves forward it will be important not to lose sight of the many bilateral and trilateral relationships established by the PTOs/IFNs/First Nations with federal and provincial partners. Any work that moves forward through HSIF should be both informed by, and help to inform, such other PTO/IFN/First Nations processes related to health. In terms of HSIF project funding some Advisory Committee members expressed the view that in keeping with the original intent of the upstream investments, First Nations community submissions should have priority over non First Nations submissions. It is noted that the work of the Advisory Committee will be informed by the Terms of Reference as well as the HSIF Implementation Guide. There was also a suggestion that given the diversity of Ontario First Nations, regional approaches might not be applicable across Ontario and that HSIF should therefore be distributed equitably among the PTOs/Independent First Nations/other First Nations such that they would each be allocated a share of the HSIF funding to develop their own pilot project. However, it has been noted that HSIF is a national initiative funded by First Nations & Inuit Health Branch, and that based on the specific criteria in the HSIF Implementation Guide, the process for implementing HSIF in Ontario will involve soliciting, reviewing and recommending proposals. Below is a description of the overall goals, key objectives and principles of HSIF followed by the unique aspects of HSIF implementation to be undertaken in Ontario. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 12

D. ONTARIO REGION HSIF: KEY OBJECTIVES AND PRIORITIES Health Services Integration Fund Overview HSIF documentation describes the Health Services Integration Fund as the successor program to the Aboriginal Health Transition Fund under the federal upstream investments. HSIF is not a renewal or rollover of activities under AHTF, which ended in March 2011. In terms of the continuum of integration 24 HSIF is described as being at a new level, beyond coordination at either the program or intergovernmental levels. The overall goal of HSIF is to enable sustained system change by achieving a level of integration through enhanced policy and planning at senior management and political levels. HSIF Objectives and Principles The key objectives of HSIF are to: Improve the integration of federal and provincially/territorially funded health services; Build multi party partnerships to advance the integration of health services that are better suited to the health needs of First Nations, Inuit and Métis peoples; Improve access to health services; Improve the participation of First Nations, Inuit and Métis peoples in the design, delivery and evaluation of health programs and services; and Allow for a broader engagement of partners, regions and provinces/territories that is more likely to lead to significant and lasting improvement in the integration of health system. HSIF is guided by the following principles: Many partners have a legitimate role in improving First Nations, Inuit and Métis health and in achieving worthwhile health services integration; Through coordinated efforts of partners, the integration of health services can offer a better fit between client health needs and the health services made available, including more culturally relevant services; Collaboration and agreement among partners is key in establishing priorities for health services integration and the approaches to achieve this objective; There is no one size fits all model of integration a flexible approach is vital given the different contexts, capacities and priorities of the regions within which the work will progress; and New and adapted approaches that build on AHTF achievements, rather than simply sustaining existing projects, will most effectively advance integration. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 13

HSIF Implementation in Ontario Region In provinces where high level tripartite discussions are currently underway, HSIF will support and help move forward broader level integration of health services 25. As referenced above from the HSIF Implementation Guide, HSIF implementation in Ontario will support broader level integration initiatives. HSIF projects in Ontario will be solicited, reviewed, recommended for approval by the Ontario HSIF Advisory Committee with participation from First Nations, provincial and federal governments. The Committee will monitor project implementation. As indicated in the Implementation Guide (page 8), Health Canada will provide oversight of HSIF project funding and financial and activity reporting. HSIF projects will be recommended by the Advisory Committee in keeping with the above noted goals, objectives and principles of HSIF and informed by the four priorities set by the Trilateral First Nations Health Senior Officials Committee as well as other priorities identified by the HSIF Advisory Committee. The focus of HSIF projects will be guided by the direction and evidence based priorities set out by the First Nations. In order to plan and prepare for HSIF implementation in Ontario a Terms of Reference for the Advisory Committee has been completed (see attached) to accompany this Integration Plan. The Ontario HSIF Advisory Committee is prepared to recommend further integration activity within the parameters of First Nations priorities for integration and the key objectives of HSIF. Partner engagement, communications and reporting, proposal solicitation and review, sustainability and evaluation are outlined below along with a critical path for HSIF implementation in Ontario. The current initial planning phase will set the groundwork for a call for multi year proposals in 2011 12 with project activity wrapping up in 2014 15. A total of $7.4 M in HSIF funding will be allocated in Ontario region to advance the integration of services. HSIF in Ontario: Priority Areas HSIF activities in Ontario will focus on evidence informed trilateral priorities such as those identified by the TFNHSOC as well as other additional priorities identified. The following are the four priorities identified by TFNHSOC. 1. Mental Health and Addictions HSIF Advisory Committee participants identified issues requiring immediate attention within the arena of mental health and addictions. They cited the current epidemic of prescription drug abuse, as well as suicide, depression, the need for mental health/addictions services including detox programs, after care and the need for education and training of service providers (particularly in prescription drug abuse). Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 14

They also noted the significant gaps in services both within the provincial and federal streams. They stated that mental health should include a focus on First Nations cultural identity and an understanding as First Nations people. Recent efforts by First Nations in Ontario have identified strategic approaches that could be undertaken immediately to curtail and address prescription drug abuse in First Nations communities. This has been flagged as a key priority of the Trilateral First Nations Health Senior Officials Committee. As work progresses in this area, HSIF integration projects could play a key role. Ontario s new Comprehensive Mental Health and Addictions Strategy 26 has a First Nations, Inuit and Métis component and there is opportunity for First Nations to participate in an advisory council to help shape implementation. This strategy aims to create more coordinated, client centred mental health and addictions services through early identification of mental health needs, the provision of coordinated, high quality programs and services closer to home, targeted education focusing on risk reduction, children s mental health and enhancing first responders services. It also aims to improve access to information about services, expand service delivery into local schools and community centres and improve transitions between youth, adult and seniors services and between the justice and health systems. HSIF Advisory Committee participants stated that Ontario First Nations require processes to ensure coordination of mental health and addictions services so that First Nations are able to access them. As the provincial strategy moves forward, HSIF activity could help to ensure First Nations service access and needs are addressed through identified mental health service agencies, and that First Nations expertise is tapped in order to inform the provincial strategy. Discussion will be required to clarify what integration of mental health and addictions services would look like to the client and how best to re profile First Nations community mental health workers (trained in alcohol addictions) to equip them to deal with prescription drug abuse. Work done thus far by First Nations with regard to prescription drug abuse has also revealed potential activity that could be undertaken or tested immediately for little or no additional cost. Case scenarios could be developed to identify policy and legislative barriers, or existing trilateral pilot projects could be reviewed and examined in terms of the challenges and barriers they face, such as drug formulary policies etc. HSIF Advisory Committee participants gave examples such as the case of a youth who needs mental health services and can only access them once admitted to hospital, but does not need to be hospitalized. They also suggested that policy work is needed now to set out how Jordan s Principle would be implemented in Ontario. 2. Diabetes Treatment and Prevention Ontario s Aboriginal Diabetes Strategy 27 noted the importance of coordination of diabetes initiatives in Ontario. The goal of this Strategy is to improve integration, collaboration and partnerships in Aboriginal diabetes policy, programs and services to enhance Ontario s capacity to deliver comprehensive, quality programs and services for Aboriginal people and communities. It noted gaps such as lack of a consistent Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 15

case management approach among local health care professionals serving Aboriginal people with diabetes, lack of seamless services and coordinated local strategies to help clients, duplication of health promotion services and resources, lack of planning for systematic diabetes screening, lack of coordination between federally funded and provincially funded initiatives and lack of coordination between Aboriginal and mainstream provincially funded programs. To remedy these issues the provincial strategy recommended: Consistent messaging on all aspects of diabetes prevention, care and treatment, targeted to Aboriginal communities and service providers, as well as mainstream health care providers; Increased communication and cooperation among the federal and provincial governments, funding agencies, researchers, and Aboriginal organizations and communities around common goals of diabetes prevention and management and opportunities to coordinate public policy on Aboriginal diabetes; Reduced gaps and avoiding duplication in diabetes programs and services, and coordination with other diabetes initiatives including the Canadian Diabetes Strategy and federal Aboriginal Diabetes Initiative; and Promotion of the Ontario Aboriginal Diabetes Strategy to First Nations leaders, prevention and education workers, treatment/care providers, researchers, and other individuals and organizations with an interest in Aboriginal diabetes and that ongoing communication among community and regional service providers be encouraged, to maximize collaboration and avoid duplication. HSIF Advisory Committee participants commented that efforts to address diabetes through HSIF could focus on integration activity that achieves measurable results such as increases in self management and reduction of negative outcomes such as amputations. They identified the need for education of provincial health care workers and agencies such as community care access centres to ensure they have been directed to serve First Nations on reserve, and mechanisms such as MOUs that can support access to such services. Overarching policy development could address this issue and the one window notion of some provincial agencies, where it is assumed that First Nations come under federal jurisdiction and therefore do not receive provincial services. 3. Public Health The perception of HSIF Advisory Committee participants is that the First Nations Public Health Project served to strengthen relationships within the jurisdictions. A clear message was that all partners need to come forward with a demonstrated commitment to participate in the process in order for the process to succeed. Some First Nations or PTOs/IFNs might have been developing relationships with public health units or with LHINs on their own but the First Nations Public Health Project did not capture this information in a measurable way. Advisory Committee participants also commented that due to First Nations diversity in terms of geographical location and the variations in their level of services provided, it is unrealistic to attempt to Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 16

develop one public health approach that would work for all Ontario First Nations, some of whom may be ready to develop their own public health unit, whereas other First Nations may only be offering rudimentary health services and have no linkages to public health. Participants noted that not all of the AHTF projects had established communications links with their PTOs/IFNs, and that regular updates could enhance information sharing and advocacy. 4. Data Management Concerns There is a notable lack of data availability related to First Nations health. There are multiple causes for this including lack of public health legislation to authorize the collection of reportable disease information, lack of First Nations identifiers in provincial databases and the lack of First Nations specific geo codes. Also, service delivery such as immunization is split between federal and provincial providers resulting in fragmented information and services. Furthermore, there are issues relating to the need for strengthening First Nations capacity. Tripartite processes are therefore needed to ensure effective information is at the disposal of the three partners to move towards improved health outcomes for First Nations people. Additional Priorities In addition to the four priorities identified by TFNHSOC, the HSIF Advisory Committee will also identify additional evidence informed Ontario First Nations priorities during the committee s work planning activities. E. PARTNER ENGAGEMENT Participants from the Ontario Ministry of Health and Long Term Care, Ontario First Nations, and First Nations and Inuit Health Ontario Region, have been involved in the development of this Integration Plan through a series of participant interviews and discussions. At a meeting on September 9, 2011 the HSIF Terms of Reference were approved and discussions and planning occurred to ensure that the Integration Plan and the Terms of Reference would be finalized for submission to Health Canada for funding approval. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 17

F. COMMUNICATION, REPORTING AND DISSEMINATION Communications Plan The communications plan or strategy for Ontario HSIF will flow from the HSIF Ontario Region Logic Model to be developed by the HSIF advisory committee once it is established. The Plan will include the following objectives: Key messages developed jointly through a collaborative process; Plan Dissemination mechanism; Acknowledge that while key messages will be developed jointly, the privacy of the partners internal communications will be respected Provide clear initial communications on what HSIF is, how it is different from AHTF, why we are doing this and what we are trying to achieve Cover key points such as: who are the partners, how is integration being defined, what is HSIF realistically expected to achieve and how is it being communicated Identify what the common messaging will be to describe the progress being made by HSIF projects Outline how common messaging regarding HSIF progress, challenges, risks and next steps will be determined and agreed to at the Advisory Committee table List how various internal First Nations, provincial and federal communications plans and mechanisms will be activated and provided with common messaging regarding HSIF progress Decide who the target audiences will be for providing reports and updates on HSIF progress Develop tools and timetables for ensuring that everyone who needs to be informed is informed in a timely manner Determine how communications results will be measured through the evaluation plan HSIF Advisory Committee participants indicated that First Nations, PTOs/IFNs, the Chiefs of Ontario office and provincial and federal partners all have their own internal communications plans or processes that should be acknowledged and utilized to inform leaders/decision makers and broader public audiences for accountability and information sharing. Common messaging will also be tailored by each of the partners. Given previous experiences with AHTF, partners may need to see specific deliverables spelled out in communications pieces. It is also noted that costing for First Nations and PTOs/IFNs will be a factor in executing a communications plan for HSIF. In terms of methods for sharing information, participants suggested a brief newsletter; Q & A sheets, email updates and/or a website access point. They suggested that if feasible, a forum could be explored. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 18

Reporting and Disseminating Information In terms of reporting, HSIF Advisory Committee participants advocated for annual project reporting in relation to the goals and performance measures to establish accountability in terms of the funding and intent of project activity and outcomes. Annual project updates would provide publicly documented updates to ensure transparency. Regular updates on HSIF activities will be provided by the Advisory Committee to the Trilateral First Nations Health Senior Officials Committee, to update the Trilateral table and so that policy discussions occurring at the senior trilateral level will inform any further HSIF project work. As indicated in the Implementation Guide (Page 8), Health Canada will provide oversight of HSIF project funding and financial and activity reports. It is noted that projects will be bound by the contribution agreement based audit and reporting requirements which include evaluation reports and year end and mid term reports to FNIH OR. It was suggested that a wide variety of reporting mechanisms be used. For example, for some First Nations fax may be preferred over email. In terms of disseminating information it was noted that in addition to disseminating information to PTOs/IFNs it should also go to individual First Nations. At the Advisory Committee table a list of stakeholders and communities could be identified for purposes of disseminating information. Participants interviewed for this document suggested that there should be open dialogue as proposals move through their three year process, to identify their challenges and any assistance they require. It was also suggested that through the Advisory Committee there could be an opportunity for networking among successful proposal applicants. As noted in the Communications Plan a centrally located website or a secured portal could provide further opportunity for projects to inform and share insights with each other regarding their progress. Participants suggested that through HSIF a streamlined reporting system should be created, suggesting the need for integrated project reporting through consistent methods and mechanisms across ministries and departments. G. SOLICITING, DEVELOPMENT AND REVIEW OF PROJECT PROPOSALS As stated on page 10 of the HSIF Implementation Guide, the HSIF Advisory Committee is responsible for developing the process for requesting project proposals. The Committee is also responsible for issuing the request for proposals, reviewing and selecting project proposals which the Committee will submit to Health Canada for approval. Ontario Health Services Integration Fund: Integration Plan September 29, 2011 Page 19