Non-Insured Health Benefits Program. Short-Term Crisis Intervention Mental Health Counselling. National Benefit Profile

Non-Insured Health Benefits Program Short-Term Crisis Intervention Mental Health Counselling National Benefit Profile Prepared for submission to the First Nations and Inuit Health Branch Assembly of First Nations Joint Review of the Non-Insured Health Benefits Program October 2015

Table of Contents 1. Introduction 1.1 Non-Insured Health Benefits Program Joint Review 1.2 STCIMHC Benefit Profile 1.3 History and scope of the benefit 2. STCIMHC Expenditures and Utilization 2.1 National expenditures 2.2 Regional expenditures and utilization 2.2.1 Atlantic 2.2.2 Quebec 2.2.3 Ontario 2.2.4 Manitoba 2.2.5 Saskatchewan 2.2.6 Alberta 2.2.7 Northern (Yukon) 3. STCIMHC Benefit Management 3.1 HQ and Regional roles 3.2 NIHB-IRS RHSP Mental Health Counselling Guidelines 3.3 Benefit delivery models 3.4 Administrative costs 3.5 Strengths and opportunities 4. STCIMHC Providers 4.1 Provider enrolment 4.2 Availability of providers 4.3 Provider rates 4.4 Strengths and opportunities 5. Client Awareness and Access 5.1 Awareness 5.2 Access points/pathways 5.3 Barriers 5.4 Strengths and opportunities 6. Summary of findings and opportunities Appendix 1 Regional NIHB Staff Questionnaire Appendix 2 Interim Program Directive Mental Health Services (1994) Appendix 3 Guide to Mental Health Counselling Services (2015) Appendix 4 Fee-for-Service Process Map Appendix 5 NIHB STCIMHC Contribution Agreement Schedule (template) 1

Section 1 Introduction 1.1 Non-Insured Health Benefits Program Joint Review In 2014, the Minister of Health agreed to undertake with the Assembly of First Nations a Joint Review of the Non-Insured Health Benefits (NIHB) Program. The overall objective of the review is to identify and implement actions that: Enhance client access to benefits; Identify and address gaps in benefits; Streamline service delivery to be more responsive to client needs; and, Increase Program efficiencies. Each NIHB benefit area will be examined separately, beginning with a review of the NIHB Short-Term Crisis Intervention Mental Health Counselling (STCIMHC) benefit. 1.2 STCIMHC Benefit Profile This STCIMHC benefit profile has been developed by NIHB to fulfill the requirement for administrative data analysis and regional profiles and provide a fulsome view of STCIMHC benefit management and delivery across the country (with the exception of BC, where the First Nations Health Authority now delivers NIHB benefits). In order to provide context for administrative data, additional descriptive information on benefit delivery is provided for each region, and FNIHB NIHB regional staff supporting STCIMHC benefit delivery have contributed their perspectives on benefit access and administration through the completion of a questionnaire distributed from NIHB national office (see Appendix 1). Information is organized into five sections: Section 2 Expenditures and Utilization STCIMHC is a regionally managed benefit, so administrative data was gathered from a number of sources. Expenditure data was extracted from Health Canada s national financial database and verified with regional staff. STCIMHC fee-for-service utilization and contribution agreement data was provided by regions. Section 3 Benefit Management Key aspects of benefit management are described, including national/regional responsibilities, new administrative guidelines, and benefit funding models. Estimated human resource costs associated with STCIMHC benefit administration are provided. Regional staff suggested a number of measures that could improve the efficiency of benefit management. 2

Section 4 STCIMHC Providers This section describes new guidelines for STCIMHC provider eligibility and enrolment, and presents regional information on provider rates and availability. Section 5 Client Awareness and Access Regional NIHB staff shared information on client awareness and access to STCIMHC services. While providing a national overview, this section also describes specific and varied approaches that Regions are using to increase client access (e.g. contracts with travelling providers, enhanced community funding). Access to services provided under contribution agreements is also discussed. Regional staff have identified promising approaches and opportunities to improve client access. Section 6 Summary of Findings and Opportunities A high level summary of key findings and opportunities for improvements to the STCIMHC benefit is presented. 1.3 History and scope of the benefit The NIHB Program formalized the addition of mental health counselling to the suite of available benefits in 1994 with the development of an interim program directive, Mental Health Services (see Appendix 2). This directive served as the policy framework for what became known as the Short-Term Crisis Intervention Mental Health Counselling (STCIMHC) benefit. Region-specific guidelines supplemented the policy framework and provided more detail on operational management of the benefit. In 2014, an internal audit of NIHB s STCIMHC, Vision and Medical Supplies and Equipment benefits recommended that that Program implement a nationally consistent provider enrolment process. Given that the NIHB Program and the Indian Residential Schools Resolution Health Support Program (IRS RHSP) both utilize mental health counselling providers, in 2015 the Programs jointly implemented a provider enrolment process and produced the Guide to Mental Health Counselling Services (see Appendix 3). The Guide outlines the specific terms and conditions, criteria, and policies under which the NIHB Program's STCIMHC benefit operates, and has replaced the 1994 directive in providing the current policy framework for the benefit. Information below compares key aspects of the two STCIMHC policy documents. Scope of the Benefit (1994/2015) 1994 Mental Health Services Directive 2015 Guide to Mental Health Counselling Purpose of the benefit To provide professional mental health treatment required on an early intervention, short-term basis, to address at-risk, crisis situations when such treatment is not available elsewhere, for example through provincially insured services, other MSB programs or other insured plans. To provide eligible clients with coverage for mental health counselling to address crisis situations when no other services or funding are available. To provide access to immediate psychological 3

and emotional care to individuals in significant distress in order to stabilize their condition, minimize potential trauma from an acute life event and, as appropriate, transition them to other mental health supports. Services provided Individual, conjoint (with a couple), family or group therapy sessions Individual, family or group counselling (couples can be considered as family ) Initial assessment; maximum number of sessions not specified (regionally applied maximum average from 10-15) Two sessions for initial assessment and up to 15 one hour sessions (with an additional 5 sessions available if necessary to transition to other services) Provider eligibility Mental health treatment must be provided or supervised by professional mental health therapists from the disciplines of psychology, psychiatric nursing or social work. Therapist(s) providing or supervising service must be registered/licensed with their professional college/association in the province in which the service is provided. Eligible mental health providers include psychologists and social workers with clinical counselling orientation or mental health counsellors with education and training comparable to psychologists or social workers. Mental health counselling providers must be registered with a legislated professional regulatory body and eligible for independent practice in the province/territory in which the service is being provided. Exclusions Psychiatric services Psychoanalysis Educational/vocational counselling Substance abuse counselling/therapy Life skills training Early intervention for infants with delayed development Psychiatric emergencies for person(s) at risk of harm to self or others; Non-crisis counselling; Services funded by another program or agency including Health Canada s IRS RHSP; Psychiatric and family physician services; Psychoanalysis; Psychoeducational assessments; Educational and vocational counselling; Substance abuse counselling/therapy; Life skills training; Early intervention programs for infants with delayed development; Assessment services for issues such as fetal alcohol spectrum disorder, learning disabilities and child custody; Expressive arts therapy; Hypnotherapy; Court-ordered assessment services to clients; 4

Services which are part of, or to be used for, legal actions; Sex therapy; and Incarcerated clients. From 1994 to the present, the scope of the STCIMHC benefit has remained largely consistent. Although psychiatric nursing is no longer listed as an eligible provider discipline, under current provider eligibility criteria psychiatric nurses can be enrolled if they belong to a legislated professional college. In order to ensure national and regional consistency of coverage, the 2015 Guide established benefit coverage and frequency guidelines (15 one hour sessions in a 20 week period; 5 additional sessions may be requested). The list of exclusions in the new guide provides more clarity in the application of benefit policy, and does not reflect any substantive changes to the original scope and intent of the benefit. 5

Millions Millions Section 2 STCIMHC Expenditures and Utilization 2.1 National STCIMHC Expenditures The figures in Table 1 below include all regions except Pacific (BC). Expenditures for Pacific Region have been removed to adjust for the impact on national NIHB expenditures when funding was transferred to the First Nations Health Authority in 2013/14. Table 2 shows the proportion of contribution agreement funding as a proportion of total STCIMHC expenditures. 16 Table 1 NIHB STCIMHC National Expenditures 2010/11 2014/15 15 $15.3 14 13 $13.6 12 11 10 $11.9 $11.4 $10.9 2010/11 2011/12 Table 2 STCIMHC Operational and Contribution Agreement Funding 2010/11 2014/15 16 14 12 10 8 6 4 2 0 30% 29% 28% 21% 24% 2010/11 2011/12 CA Operational 6

Discussion As shown in Table 1, national STCIMHC expenditures grew by more than 40% between 2010 and 2015. The largest year over year increase was between 2012/13 and 2013/14, when STCIMHC expenditure increased by 15%. Contribution agreement funding as a proportion of overall expenditure has increased steadily from 21% in 2010/11 to 30% in 2014/15. Further detail on regional expenditures is provided in the following section of this report. 2.2 Regional STCIMHC Expenditures and Utilization The following section presents available regional STCIMHC administrative data for fiscal years 2012/13, 2013/14 and 2014/15, including financial expenditures and fee-for-service client utilization. STCIMHC services in regions are delivered through 3 different funding models (described in more detail in Section 3, Benefit Management): Fee-for-service mental health providers bill NIHB for individual clients on a fee-for-service basis. NIHB Regional staff process all prior approvals and claims. Contracts regional office manages contracts with providers to travel to communities to provide STCIMHC services; providers are reimbursed on a per diem basis, with travel costs. This funding model is used primarily in Alberta. Contribution agreements funding for STCIMHC benefit is provided to First Nations community or organizations, and service delivery is managed by recipients. When considering the regional data profiles, it is important to note that a significant proportion of funding and services are delivered under contribution agreements in some regions, so the full extent of client utilization is not reflected in the fee-for-service data. Contribution agreement funding is shown as a proportion of regional expenditures, however corresponding client utilization data is not consistently available. A snapshot of STCIMHC contribution agreements in each region is provided for 2014/15. 7

2.2.1 Atlantic Expenditures and Utilization Regional Expenditures CA funding $109,867 53% $71,780 38% $57,500 34% Fee-for-service $100,407 47% $120,618 62% $111,920 66% $210,274 $192,398 $169,420 Fee-for-Service Utilization Clients 147 156 166 Sessions Approved 1502 10.2 1394 8.9 1658 10.0 Paid 829.5 5.7 828.5 5.3 864* 5.2 Appeals <5** denied 0 0 *May not include all claims for this FY; claims can be submitted within one year of service **To protect client identity, values less than 5 cannot be reported 2014/15 Contribution Agreements Value # Clients Served $50,000 623* $7,500 Not available *Community mental health services are integrated; this number includes clients accessing all mental health services, and it is not possible to disaggregate individual STCIMHC clients. Discussion STCIMHC in Atlantic Region is delivered through fee-for-service billing and contribution agreements with First Nations. When a discrete community crisis event occurs (such as an unexpected or traumatic death) the community s health director may request a CA from NIHB for enhanced STCIMHC services. The decline in CA funding over the 3 fiscal years above is related to fluctuating demand for this type of funding support. One First Nation community in the region has a long-standing CA for mental health programming, including (but not limited to) STCIMHC. Other communities in the region have expressed interest in moving towards such a model of integrated community mental health services. Fee-for-service utilization in the Region has increased steadily from 2012/13 2014/15. The slight decline in operating expenditure in 2014/15 (while number of clients/paid sessions increased) may be related to providers charging lower rates in Newfoundland, where use of benefit by Qalipu clients is comparatively high. 8

2.2.2 Quebec Expenditures and Utilization Regional Expenditures CA funding $157,300 15% $159,800 16% $174,800 15% Fee-for-service $944,461 85% $834,008 84% $973,231 85% $1,101,761 $993,808 $1,148,031 Fee-for-Service Utilization Clients 966 1020 1102 Average# Sessions Approved 10705 11.1 11694 11.5 13338 12.1 Paid 6553 6.8 6725 6.6 7482* 6.8 Appeals 0 0 0 *May not include all claims for this FY; claims can be submitted within one year of service 2014/15 Contribution Agreements Value # Clients Served $46,800 45 $128,000 141 Discussion Quebec Region shows a steady increase in fee-for-service utilization across three fiscal years. The apparent decline in operating expenditure in 2013/14 is partly attributed to an artificial increase in the last quarter of the previous fiscal year, as the regional office processed a larger-than-usual volume of outstanding claims. Note that, for all regions, there is not always a precise correspondence of services to payments in any fiscal year, given that providers may submit invoices up to one year from date of service. The regional contribution agreements are viewed as effective models. Regional staff reported that services delivered by recipients are cost-efficient and effective in reaching vulnerable clients. 9

2.2.3 Ontario Expenditures and Utilization Regional Expenditures CA funding Nil 0% Nil 0% Nil 0% Fee-for-service $2,456,348 100% $2,753,723 100% $2,802,709 100% $2,456,348 $2,753,723 $2,802,709 Fee-For-Service Utilization Clients 2566 2745 2872 Sessions Approved 37,315 14.6 40,995 14.9 44,486 15.5 Paid 21,187 8.3 23,075 8.4 23,946* 8.3 <5 approved <5 approved <5 denied Appeals 7 denied <5 denied *May not include all claims for this FY; claims can be submitted within one year of service 2014/15 Contribution Agreements - N/A Discussion Ontario region has provided all STCIMHC benefits on a fee-for-service basis, managed by the regional office. Expenditures and utilization have risen steadily across three fiscal years. For 2015/16, a contribution agreement has been initiated with a First Nations organization to provide NIHB STCIMHC to 13 communities. Supplementing NIHB STCIMHC funding, communities in Ontario can request additional resources from FNIHB to assist them in a mental health crisis that has impacted a significant portion of their community. Such requests usually come from remote/isolated/semi-isolated communities. Funding is provided through a CA amendment to either the community directly or their Provincial Territorial Organization (PTO) to arrange for 1-2 counsellors to travel into the community and provide extra therapeutic support for a short term period (not more than 5 days). 10

2.2.4 Manitoba Expenditures and Utilization Regional Expenditures CA funding $571,599 17% $681,600 20% $686,684 17% Fee-for-service $2,219,817 83% $2,834,738 80% $3,411,952 83% $2,791,416 $3,516,338 $4,098,636 Fee-For-Service Utilization Clients 2465 2507 2473 Sessions Approved 48789 19.8 50464 20.1 48303 19.5 Paid 11961 4.9 11618 4.6 9233* 3.7 Appeals 0 0 0 *May not include all claims for this FY; claims can be submitted within one year of service 2014/15 Contribution Agreements Value # Clients Served $284,600 500* $250,000 1479** $250,000 Unavailable *Does not include numbers who participate in group sessions **Includes group sessions; may not be distinct clients Discussion: Regional STCIMHC expenditures increased steadily over three years, with larger increases seen in operating expenditures. Increased operating expenditure in 2014/15 is attributed to a provider rate increase applied in that year, as well as an increased volume of outstanding claims processed. Manitoba reports the highest rate of average sessions approved, reflecting a regional administrative practice used when providers are travelling to communities. These providers seek prior approval for a standard maximum number of sessions, and subsequently bill for sessions actually used. 11

2.2.5 Saskatchewan Expenditures and Utilization Regional Expenditures CA funding $505,000 49% $553,124 56% $580,000 54% Fee-for-service $516,220 51% $436,207 44% $506,760 46% $1,021,220 $989,331 $1,086,760 Fee-For-Service Utilization Clients 1015 1120 1128 Sessions Approved 10048 9.9 8776 7.8 9504 7.9 Paid 5569.5 5.5 5264.5 4.7 5161* 4.2 Appeals 0 <5 denied 0 *May not include all claims for this FY; claims can be submitted within one year of service 2014/15 Contribution Agreements Value # Clients Served $150,000 6006* $180,000 Not available $150,000 Not available $100,000 Not available *Includes group sessions, community workshops and training; may not be distinct clients Discussion Saskatchewan region shows a fluctuation in operating expenditures over three years, partly attributable to claims processing across fiscal years (i.e. $20K of 2013/14 invoices paid in 2014/15). Although number of distinct fee-for-service clients has risen slightly over 3 years, number of paid sessions per client has declined slightly. Expenditures through contribution agreements have risen steadily during the same period, and increasing numbers of clients have access to STCIMHC benefits delivered by these recipient organizations. 12

2.2.6 Alberta Expenditures and Utilization Regional Expenditures CA funding $2,080,932 44% $2,397,699 49% $2,969,994 50% Fee-for-service $1,410,265 29% $1,437,503 28% $1,340,981 23% Contracts $1,277,612 27% $1,089,998 23% $1,677,694 27% $4,768,809 $4,925,200 $5,988,669 Fee-For-Service Utilization Clients 2231 2188 1917 Sessions Approved 15,300 6.9 14,009 6.4 12,708 6.6 Paid 12,713 5.7 13,031 6.0 10,772* 5.6 Appeals 0 0 0 *May not include all claims for this FY; claims can be submitted within one year of service 2014/15 Contribution Agreements Value # Clients Served $117,100 264 $316,478 515 $256,317 640 $725,200 1562 $197,200 655* $139,700 202* $163,400 Unavailable $161,000 292 $806,012 Unavailable *Incomplete; based on interim reports Discussion: STCIMHC expenditures in Alberta have increased steadily across three years. Fee-for-service appears to decline during this period, but the utilization data does not include services delivered through contracts with mental health providers. Alberta is unique in its relatively extensive use of this funding model. In 2014/15, 23 contracts were in place, representing $1.7 million (27%) of regional STCIMHC expenditure. 13

While client level data for contract services is currently unavailable, NIHB regional staff are working to improve utilization data and reporting for STCIMHC contract services. Funding through contribution agreements has increased by approximately $900,000 over three years. This reflects the increasing number of communities taking STCIMHC into their contribution agreements, as well as an increase in provider rates that was applied to fee-for-service providers in 2012, and contribution agreement holders in 2014/15. 2.2.7 Northern Region Expenditures and Utilization Regional Expenditures Yukon CA funding 0 0 0 0 -- -- Fee-for-service $4,130 100% $190 100% -- -- $4,130 $190 Nil Fee-For-Service Utilization Yukon Clients <5 Nil Nil Sessions Approved 30 15.0 -- -- -- -- Paid 25.75 12.9 -- -- -- -- 2014/14 Contribution Agreements N/A Discussion Of the three Northern regions (Northwest Territories, Nunavut, Yukon), NIHB STCIMHC is available in the Yukon only. Since the 1990s, mental health services have been delivered by the Government of the NWT (and now also Nunavut). In the Yukon, utilization of the NIHB STCIMHC benefit has historically been low. IRS RHSP services are well-utilized, and the Yukon Territorial Government provides access to mental health counselling. 14

Section 3 STCIMHC Benefit Management 3.1 HQ and Regional Roles The NIHB STCIMHC benefit is regionally managed, with HQ providing key support functions. HQ and Regional roles are described below in broad terms. HQ Role: Develop national benefit policy and administrative processes Develop and publish national communication material Responsible for national stakeholder and provider relations Coordinate national working groups Support regions on provider negotiations Responsible for benefit audit Manage level 3 appeals Regional Role: Manage benefit claims for clients not covered by a contribution agreement Responsible for the enrolment of mental health providers (including those used for IRS RHSP) Responsible for regional provider and stakeholder relations Responsible for regional communications material Review community proposals for crisis mental health support Negotiate and manage CA and contracts for mental health services Maintain regional mental health data Manage levels 1 and 2 appeals 3.2 NIHB-IRS RHSP Mental Health Counselling Guidelines In April 2015, NIHB and the Indian Residential Schools Resolution Health Support Program (IRS RHSP) jointly implemented a Guide to Mental Health Counselling Services which clarifies general and programspecific terms and conditions, criteria, and policies under which the NIHB Program's STCIMHC benefit and the Individual and Family Counselling component of the IRS RHSP operate. This Guide streamlines and aligns the administration of benefits and services provided under both programs. In particular: A joint provider enrolment process and agreement is now in place, with common criteria for providers enrolling to provide service under either (or both) Programs; Cultural competence has been introduced as an experience element for provider enrolment; 15

Standardized NIHB benefit coverage (number/frequency of sessions, and eligible services) is clearly outlined and applied in all regions; The prior approval process no longer requires the submission of a treatment plan; A national claims administration process is now in place, including new on-line forms for prior approval, appointment attendance confirmation, and claim submission; Guidelines have been introduced for the provision of mental health counselling through teleheath (where provider and client agree to this mode of service). The Guide is considered to be evergreen and will be reviewed and amended annually in partnership with stakeholders. 3.3 Benefit delivery models STCIMHC benefits are accessed in three ways: i. Fee-for-service ii. Contracts iii. Contribution agreements i. Fee-for-service Nationally, fee-for-service accounts for the majority of STCIMHC expenditures. Enrolled providers are independent mental health professionals who deliver services at their usual place of business or travel to First Nation communities, and bill NIHB for individual clients on a fee-for-service basis. In Ontario, Atlantic, Quebec and the Yukon, this model accounts for the large majority of services provided. In order to find an NIHB enrolled provider, clients or community health staff may contact the NIHB regional office for a list of enrolled providers in their area. Two (2) one-hour sessions for an initial assessment are allowed without prior approval. Following the initial assessment, mental health counselling providers must obtain prior approval from the NIHB regional office to continue the service. NIHB Regional staff process all fee-for-service prior approvals and claims. Please refer to the table below for regional turnaround times for processing STCIMHC prior approvals. Alberta Saskatchewan Manitoba Ontario Quebec Atlantic Yukon STCIMHC Prior Approval Turnaround Times* 5 business days** 2 business days 2 business days 2 business days 3 business days 3 business days 2 business days *Processing of prior approvals may take longer if required information is missing and follow-up with the provider is necessary ** Temporarily increased to 10 days due to technical system issues and staff capacity 16

Please refer to the STCIMHC process map (Appendix 4) for a more detailed description of the processes for provider enrolment, prior approval and claims submission, with minor regional differences noted. ii. Contracts In Alberta region, Health Canada enters into contracts with enrolled providers who have expressed a willingness to travel to communities to provide STCIMHC services. Health directors aid in the selection of suitable mental health counsellors, and serve as their community s point of the contact with the providers. Providers are reimbursed on a per diem basis, and travel costs are provided. Contracts stipulate a minimum number of days (per week or month) that the provider will deliver services in the communities, and additional time beyond contract parameters can be provided with prior approval. Providers are required to document services through signed Client Attendance Sheets, and submit these records for payment of claims. Clients typically work with their local health centre to schedule appointments. This model of service delivery reduces transportation that would otherwise be incurred by many individual clients, and promotes ongoing access to the benefit in these communities. Alberta region currently has 24 such contracts in place, and this funding model accounted for 27% of regional STCIMHC funding in 2014/15. iii. Contribution agreements Nationally, approximately 30% of STCIMHC expenditures are through contribution agreements for benefit delivery managed by First Nations community or organizations that contract or employ mental health professionals. Contribution agreements may be ongoing, or short-term in response to a specific community situation that increases the need for STCIMHC. Terms and conditions, objectives, activities and reporting requirements for STCIMHC delivery are aligned with HC policy on contribution agreements and administrative processes outlined in the Guide to Mental Health Counselling Services, and are outlined in Health Canada s compendium of program plans (see Appendix 5). 3.4 Administrative costs 2014/15 (estimated) Description Alberta $76,462 1 FTE @$74,462; $2K IT systems Saskatchewan $57,000 0.75 FTE (CR-5), 0.25 FTE (PM-4) Manitoba $87,500 1 FTE (CR-5), 0.5 FTE (PM-4) Ontario $94,500 1 FTE (CR-5), 0.5 FTE (CR-5) 0.25 (EC-2), Quebec $162,580 2 FTE (PS-4, CR-4) @$157,580, $5K IT systems Atlantic $40,931 0.75 FTE Yukon Nil National office $84,000 0.5 FTE (EC-6), 0.75 FTE (EC-4) 17

Administrative costs reported above largely reflect human resources, with AB and QC also reporting some operational costs related to information systems. While full administrative costs would also include some fraction of Health Canada organizational resources and infrastructure (e.g. IT, office accommodations and supplies, etc.), it is not possible to disaggregate these type of shared service costs by benefit area. Similarly, NIHB regional managers oversee all benefit areas, and it is not possible to disaggregate their time or salary by benefit. When provided under contribution agreement, funding for STCIMHC typically allows for an administrative cost of approximately 10%. 3.5 Strengths and opportunities As noted in 3.1, the Program has recently taken steps to increase clarity and national consistency of benefit management through the publication of the joint NIHB-IRS RHSP Guide to Mental Health Counselling Services and a streamlined prior approval process. Additionally, regions provided the following suggestions for improving STCIMHC fee-for-service benefit administration: Streamline claims submission process (e.g. combine claim and appointment confirmation forms, on-line submission) Faster turnaround time for prior approvals and payments to service providers National database for provider enrolment, prior approvals and claims processing Promote community-based funding/service delivery models to increase efficiency of benefit administration and effectiveness of services 18

Section 4 STCIMHC Providers 4.1 Provider Enrolment A new mental health counselling provider enrolment process was jointly implemented by the NIHB and IRS RHS Programs in early 2015. The purpose of the enrolment process is to ensure that providers clearly understand the requirements of the IRS RHSP and NIHB Programs. Provider enrolment is renewed annually. Like other benefit areas, Health Canada does not provide services directly to clients, but rather reimburses health professionals for the provision of services according to Program guidelines. A professional wishing to be reimbursed for the provision of services must be enrolled as a provider with Health Canada. Requirements for health professionals practicing in Canada fall within provincial and territorial jurisdictions. Health Canada relies upon the oversight of provincially or territorially legislated professional regulatory bodies in order to ensure standards of practice in the provision of health services. Providers must be members in good standing with provincially or territorially recognized regulatory bodies. Eligible mental health providers include: Psychologists and Social Workers, with clinical counselling orientation; or Mental health counsellors with education and training comparable to psychologists or social workers. Any professional who meets these requirements can apply to enrol as a provider. In exceptional circumstances, other mental health counselling providers who do not meet these requirements may be accepted subject to the following conditions: There are no other mental health counselling providers enrolled with the NIHB Program in the vicinity and access to services is limited; or Where there is an emergency situation such that the health and safety of the client or other persons is at immediate risk. Provider enrolment forms and information are available on the Health Canada website. The enrolment process and providers lists are managed by Regional offices. Lists of enrolled providers are updated continuously, and are provided to clients and health providers upon request. 19

4.2 Availability of providers Previous and current numbers of STCIMHC/IRS mental health counselling providers are shown in the table below. AB SK MB ON QC ATL NR Previously registered* 260 89 118 305 210 140 26 Currently enrolled** 202 76 83 291 161 122 40 *Providers who had billed Health Canada one or more times in the period 2012-14, prior to implementation of new enrolment process **As of September 2015; enrolment ongoing The number of enrolled providers continues to increase in all regions. Most regions said that there was an adequate number of enrolled providers in their region overall. However ON, MB and SK regions said there were not enough providers enrolled, and all regions reported that access to providers is a challenge in some specific areas (i.e. rural, remote). 4.3 Provider Rates NIHB staff were asked to describe the process used to establish maximum STCIMHC fee-for-service provider rates in their regions, and provide the date of the last increase to provider rates. Process for establishing STCIMHC rates Last rate increase Atlantic Review of provincial rates. Maximum rate is consistent with New 2010 Brunswick (only province with a formal guide) Quebec Regional assessment of provincial rates, balanced with consideration 2012 of NIHB regional budget Ontario Based on a review of usual and customary rates requested by Unknown providers in the province Manitoba Regionally developed point system 2014 Saskatchewan Regionally developed point system 2008 Alberta Regional NIHB staff determined rates in consultation with provincial 2012 colleges (social workers and psychologists) Yukon Two rates based on training (social worker, psychologist) Unknown The maximum hourly rate paid to STCIMHC providers varies from $105 (QC, SK) to $160 (Yukon). The minimum, maximum, and most frequently paid rates are indicated in the tables below. When asked about STCIMHC rates compared to other provincial/territorial programs, 2 regions reported that the rates paid by NIHB were lower (MB, SK), 1 region reported that NIHB rates are higher (QC), and other regions did not know. 20

NIHB Provider Rates Psychologists Hourly Rates Province NIHB Min. Frequent Max. Newfoundland $90 $125 $150 Prince Edward $90 $125 $150 Island Nova Scotia $90 $125 $150 New Brunswick $90 $125 $150 Quebec $55 $90 $105 Ontario $100 $140 $140 Manitoba $80 $110 $120 Saskatchewan $47 $88* $105 Alberta Nil $130 $130 North (Yukon) Nil Nil $160 Social Workers Hourly Rates Province NIHB Min. Frequent Max. Newfoundland $85 $125 $150 Prince Edward $85 $125 $150 Island Nova Scotia $85 $125 $150 New Brunswick $85 $125 $150 Quebec $55 $90 $105 Ontario $55 $120 $120 Manitoba $70 $80 $120 Saskatchewan $47 $76*/85 $105 Alberta Nil $100 $130 North (Yukon) Nil $125 $125 *Average 4.4 Strengths and opportunities The establishment of a national joint NIHB-IRS RHSP provider enrolment process, with clear eligibility criteria, establishes a consistent standard for provider qualifications. The provider enrolment criteria and process are important measures to ensure quality of services and appropriate oversight of providers by professional regulatory bodies. One region suggested that the new prior approval process for fee-for-service delivery, which eliminates the requirement for providers to submit client treatment plans, is an administrative improvement that may increase the number of providers who want to work with the Program. Regional staff identified a number of measures that could increase the number of enrolled STCIMHC providers, and address concerns commonly raised by providers. The following opportunities to increase provider enrolment or access were suggested by two or more regions: Increase provider rates Enhance efforts to increase the number of providers travelling to rural, remote or under-served communities Streamline claims administration 21

Section 5 Client awareness and access 5.1 Awareness Most regions report that while some NIHB clients are aware of the availability of the STCIMHC benefit, awareness in some areas is low. This was particularly noted in Saskatchewan. The availability of other community or provincial/territorial mental health services may influence awareness of the STCIMHC benefit, as clients and communities who have access to these services are not seeking information on similar benefits provided through NIHB. Atlantic region also noted that clients with lower levels of health literacy are less likely to know about the benefit, although their needs may be the highest. Information about the benefit is communicated by regional offices through the following means (in two or more regions): Information on the Health Canada website Client calls to NIHB office Community visits and meetings with health staff Brochures and information sheets distributed at health centres, events Meetings and communication with regional FN health stakeholders Through health providers and health/social service organizations 5.2 Access points/pathways Clients access regionally administered (i.e. fee-for-service) STCIMHC in one of the following ways: Clients call the NIHB regional office directly to request names of eligible providers in their area Clients are referred directly to eligible STCIMHC providers in their area by other health care providers or community program staff Clients access the provider of their choice (who may be enrolled, or can enrol if eligible) Some regions enhance access to STCIMHC by bringing service providers to communities. In AB, MB, SK, QC and the Yukon, mental health providers travel to rural and remote communities to provide STCIMHC services. Clients can make appointments directly with the provider, or through the health centre. These arrangements may be time limited to provide services to a cluster of clients, or in response to a specific community crisis situation. In-community service arrangements may also be ongoing in response to higher community need. Some clients are referred to STCIMHC providers through mental health intake centres (SK) or discharge services (MB) from hospitals. AB, ATL, QC regions also described the links between STCIMHC and IRS RHSP, including referrals between the Programs. In AB, SK, and MB Regions, a significant proportion of clients access STCIMHC benefits provided by First Nations communities or organizations through contribution agreement funding. Regions noted that when STCIMHC services are provided under contribution agreements, clients may access services in a 22

variety of ways, as recipients adapt service delivery to meet the needs of their communities and clientele. Clients may contact the community health service and be referred to counsellors working on a fee-for-service basis. In other cases, mental health providers are hired on salary or contract, and provide STCIMHC services in one or several communities. In Québec, approximately ten percent of STCIMHC funding is accounted for by a contribution agreement with a social services agency in a large, urban First Nation community. The organization provides integrated case management services, of which crisis mental health counselling is one component. Some regions have mechanisms to increase client access to STCIMHC during periods of acute community need for the benefit. In ATL Region, when a discrete community crisis event occurs, the Health Director may request a CA amendment from NIHB to provide enhanced STCIMHC services and supports in the community for a period of time. In Ontario, communities can request additional resources from FNIHB to assist them in a mental health crisis that has impacted a significant portion of their community. Such requests usually come from remote/isolated/semi-isolated communities. Funding is provided through a CA amendment to either the community directly or their PTO, to arrange for 1-2 counsellors to travel into the community and provide extra therapeutic support for a short term period (not more than 5 days). Regions also commented on access to other mental health services for clients who require longer-term or additional mental health supports other than what the NIHB Program can provide under STCIMHC. In ATL and QC Regions, eligible clients use IRS RHSP services for longer-term mental health counselling. In the Yukon, the majority of all mental health counselling for First Nations clients is provided through IRS RHSP. Other FNIHB mental wellness programs available in First Nations communities include the National Aboriginal Youth Suicide Prevention Strategy, Brighter Futures/Building Health Communities, and the National Native Alcohol and Drug Abuse Program (NNADAP). QC and SK regions noted that there is some coordination between NNADAP and NIHB STCIMHC, with clients being referred between programs as appropriate to their needs. ATL region noted that some communities use other FNIHB funding to employ community-based mental health professionals that provide counselling services including, but not limited to, STCIMHC. In Ontario, some First Nations organizations provide mental health counselling through contribution agreement funding provided outside of the NIHB program. These arrangements represent alternative delivery models whereby First Nations organizations are able to leverage various sources of funding to maximise mental health programming specific to their needs. Regions also indicated that there are gaps or inconsistency in provincial/territorial mental health and crisis intervention services available to First Nations. 5.3 Barriers Regional staff identified numerous barriers that clients may experience in accessing STCIMHC services. These barriers were identified by two or more regions: Lack of awareness of the benefit or how to access it Lack of First Nation or culturally competent service providers Stigma surrounding mental health issues 23

Concerns about confidentiality when accessing providers in community Limited access to providers in rural/remote areas Lack of transportation to access services outside the community Discomfort/lack of trust to engage in counselling Other health issues (e.g. chronic disease, addictions) Social determinants of health (poverty, social isolation, low health literacy, disempowerment, racism) 5.4 Strengths and opportunities Regions identified a number of measures or promising approaches to increase client access to STCIMHC: In-community service provision (travelling providers) Counselling through telehealth STCIMHC provided through contribution agreements Numerous opportunities to improve client awareness and access to the STCIMHC were identified by regional STCIMHC staff. Additional opportunities are extrapolated, based on the barriers described above. Increase client-level awareness of benefit parameters and process Increase access and referrals through front-line health services, other mental health programs Produce client-focused brochures and information to promote awareness and access Share information through a variety of media (e.g. radio, social media) Provide more STCIMHC services in communities (i.e. through community-based service, or travelling providers) Continue to facilitate access through telehealth Increase number of First Nations and culturally competent service providers Finally, Regions provided various suggestions for models or approaches to enhance integration of STCIMHC with other mental health services: Strengthen collaboration and information sharing (internally, and within communities) between NIHB STCIMHC and community-based mental wellness programs Provide information to STCIMHC therapists and clients regarding all mental wellness programs available to clients Development of protocols at the local/regional level between communities, hospitals and clinics to promote integration of services and collaborative care Community based service provided through contribution agreement supports integration with other health and community services 24

Section 6 - Summary of findings and opportunities In 2014/15, the NIHB Program spent $15.3 million on STCIMHC benefits. Benefit expenditures have risen steadily across five years, increasing by 40% since 2010/11. The proportion of annual STCIMHC expenditures through contribution agreements also increased every year during this period. The number of clients accessing STCIMHC through fee-for-service has increased steadily across three fiscal years in 4 regions (ATL, QC, ON, SK). In 2 regions, while the number of fee-for-service clients declined slightly during this period, STCIMHC funding through contribution agreements increased. This suggests a trend that is consistent with national expenditure data: more clients are accessing STCIMHC provided through contribution agreements with First Nations communities and organizations. Regions reported that awareness of the STCIMHC benefit is low in some areas. Availability of other mental health services may impact awareness of the STCIMHC benefit, as clients with access to other options have less need to seek this type of service through NIHB. The NIHB Program continues to take steps to improve management of the benefit, notably with the development of the new Guide to Mental Health Counselling Services that clearly outlines STCIMHC policies and coverage. The Guide also presents new guidelines for the provision of mental health counselling through teleheath, so providers and clients are aware of this option for service delivery. As well, a national claims administration process is now in place, including new on-line forms for prior approval and claims submission. A nationally consistent provider enrolment process and agreement form has been introduced, with common criteria for providers to work with the NIHB or IRS RHS Programs. Feedback from NIHB regional staff involved with STCIMHC administration suggested a number of areas for improvement in benefit management, provider relations, and client access: Continue efforts to streamline claims administration Implement a national database for provider enrolment and claims administration Revise regional provider rates and make adjustments to ensure P/T comparability Identify and implement a client-focused communications strategy to increase awareness of the benefit, and provide region-specific information on how to access counselling Increase the number of providers travelling to under-served areas Promote the use of tele-health as an option to increase access for clients in under-served areas Collaborate with partners and professional associations to promote cultural competency among STCIMHC providers Consistent with the Mental Wellness Continuum Framework, strengthen integration at the local and regional level between STCIMHC, IRS RHSP and other community-based or P/T mental health services Enhance support for First Nations community-based benefit management and service delivery 25