Evaluation of the First Nations and Inuit Home and Community Care Program

1. Management Response

This Management Response and Action Plan has been developed to address recommendations resulting from the Evaluation of the First Nations and Inuit Home and Community Care Program (FNIHCC), which was finalized by the Evaluation, Performance Measurement, and Review Branch.

The First Nations and Inuit Health Branch (FNIHB) recognizes the findings highlighted by the evaluation regarding the relevance and performance of the program. Specifically:

• The demand for services is projected to increase and become more complex.
• The priorities of the Government and Indigenous communities are generally aligned with respect to the care provided under the program; however, existing policy and legislative gaps risk creating or maintaining disparities between Indigenous and non-Indigenous Canadians.
• Communities are supported in their training and capacity-building efforts, but there are gaps especially for personal care providers, and these disproportionately affect smaller and more remote communities.
• In general, evaluation participants believed First Nations and Inuit have access to services that in many cases is seen as superior to neighbouring non-Indigenous communities.
• The extent to which clients are provided with quality services and are having their needs met is viewed generally positively, but limited resources and communication issues were cited as barriers to meeting client need.
• The program coordinates and collaborates with other programs and services at both local and regional levels. In some communities, the First Nations and Inuit Home and Community Care Program, and the Assisted Living Program have been integrated from a service delivery perspective.

The evaluation provides four recommendations to improve the design and delivery of the program. All recommendations are accepted by the program and the attached Action Plan identifies specific activities to move towards meeting these recommendations. 

The Department will proceed with implementing a three-year staged response to co-develop and implement operational and policy improvements to the First Nations and Inuit Home and Community Care Program. An annual review of this Management Response and Action Plan will be conducted by the Departmental Evaluation Committee to monitor progress and activities.

The staged approach recognizes program complexities and provides time to engage First Nations and Inuit partners and others in a meaningful co-development process. This approach will also help ensure that any actions taken complement broader Government of Canada initiatives (e.g. New Fiscal Relationship, reduction in reporting burdens), initial thinking with the Assisted Living Program on the development of a continuing care strategy, the Government of Canada response to the Report of the Standing Committee on Indigenous and Northern Affairs entitled "The Challenges of Delivering Continuing Care in First Nation Communities", or changes to complementary initiatives and programs (e.g. Jordan's Principle, the Assisted Living Program, Child and Family Services, and infrastructure and housing programs).

2. Action Plan

Program Description

FNIHCC administers contribution agreements with First Nation and Inuit communities and territorial governments to fund the administration of home care by registered nurses and trained certified personal care workers in 455 First Nation and Inuit communities. This is to enable First Nations and Inuit individuals with disabilities, chronic or acute illnesses, and the elderly to receive the care they need in their homes and communities. Care is delivered primarily by home care registered nurses and trained certified personal care workers.

FNIHCC supports the delivery of a continuum of basic home care services. This suite of services is based on a case management approach that includes client assessment and reassessment, which can involve the client, family caregivers or service providers, and help determine a client's needs and the services required. Home care nursing includes direct service delivery, personal care services and support to family caregivers. The basic home care services also encompass home support (e.g., bathing and grooming, home management assistance, etc.), as well as in-home respite benefiting clients, families and caregivers. The program also entails access to medical equipment and supplies, management and supervision, data collection and record-keeping, as well as linkages and referral, as needed, to other health and social services. Depending on community needs, priorities, infrastructures and resources, the Program may also incorporate supportive services: rehabilitation and other therapies; adult day programs; meal programs; in home mental health; in home palliative care; and, specialized health promotion, wellness, and fitness services.

The program is guided by delivery principles, which emphasize respect for both traditional and contemporary approaches to healing and wellness; respect of community priorities; availability for those with assessed need; delivery of evidence-informed, integrated quality care; support for individuals, families and communities; and the pursuit of sustainable funding to provide continuous care.

Objectives and Outcomes

The specific objectives for FNIHCC are to:

• build the capacity within First Nations and Inuit communities to develop and deliver comprehensive, culturally sensitive, accessible and effective home care services at a pace acceptable to the community;
• assist First Nations and Inuit living with chronic and acute illness in maintaining optimum health, well-being and independence in their homes and communities;
• facilitate the effective use of home care resources through a structured, culturally defined and sensitive assessment process to determine service needs of clients and the development of a care plan;
• ensure that all clients with an assessed need for home care services have access to a comprehensive continuum of services within the community, where possible;
• assist clients and their families to participate in the development and implementation of the client's care plan to the fullest extent and to utilize available community support services where available and appropriate in the care of clients; and
• build the capacity in First Nations and Inuit to deliver home care services through training and evolving technology and information systems for monitoring care and services, and to develop measurable objectives and indicators.

The intended outcomes of FNIHCC are:

• improved access to home and community care services;
• increased effectiveness of services;
• improved coordinated and seamless responses to home and community care needs; and
• increased use of quality improvement, including patient safety processes, to respond to home and community needs.

Program Funding

Total expenditures under the Home and Community Care Program over the evaluation period were approximately $541 million. Program expenditures have increased by 15 percent since 2012-13 from $101.9 million to $116.7 by 2016-17. In 2016-17, service delivery represented 90 percent of annual expenditures for the program, followed by policy development and oversight that represented seven percent of expenditures and professional development representing three percent of annual expenditures. Most expenses are categorized as contributions, representing 93 percent of expenditures in 2016-17.

3.1 Continued Need

Among the Canadian population in general, personal care needs are becoming more complex, due in part to earlier release from hospitals, long-term care facilities focusing primarily on very high care need clients, comorbidity^{Footnote 2} of chronic disease, and increased desire to receive care in the home or community setting. Survey respondents for this evaluation corroborated this reality, reporting that demand for all FNIHCC services has increased significantly. This stands in contrast to data from FNIHB showing a decrease in actual funded hours and clients. However, demand is not measured by this data - only approved service delivery. The data therefore do not allow an analysis of level of service given relative to demand.

A perceived growing demand is occurring across Canada, but should be expected to disproportionately affect First Nations and Inuit. For example, compared to the non-Indigenous population, the prevalence of diabetes (20.7 percent compared to 6.2 percent), tuberculosis (25 times higher for First Nations, 154 times higher for Inuit), and other chronic conditions and communicable disease is far higher among First Nation and Inuit populations.^{Footnote 3}

Most respondents to the web-based survey referenced in Section 1 indicated that the demand for services across multiple activity types has increased, despite the decrease in the total number of service hours per client (see Section 3.4 for further discussion), including:

• Managing and coordinating care
• Home care nursing services
• In-home health care support services or in-home personal care
• Linking with other professionals and social services
• Access to specialized equipment, supplies and pharmaceuticals
• In-home services such as homemaking, house cleaning, meal preparation or companion/attendant support
• Client assessments
• Record keeping and data collection
• In-home respite care
• Need for admittance to long-term care facility
• Palliative care services

Notably, service providers who deliver/oversee both FNIHCC and Assisted Living services were more likely to report that demands for managing and coordinating care have increased (96 percent), compared to those who deliver/oversee FNIHCC services only (75 percent).

Additional pressures that impact First Nation and Inuit communities are the limited availability of local facilities, cultural considerations in caregiving, and increases in youth with care needs stemming from Jordan's Principle (specifically, the clearer accountabilities and requirements to respond/act in a timely manner in these cases adds strain to an already strained system).^{Footnote 4} The increase in demand is more pronounced where communities are more geographically isolated.

The rate of overall utilisation among the population is seven percent among all Canadians over 15, and this is similar in First Nations and Inuit communities. Additionally, the fact that seniors are the highest users of services, coupled with the growing population of seniors, will create increasing pressures. However, the segment of the First Nations population aged 45 years and older is expected to more than double by 2026 from approximately 63,000 in 2001 (21 percent of the population) to 159,000 in 2026 (31 percent of the population). The growth estimate of the older cohorts for Inuit is an expected growth rate of 4.9 percent, increasing from 17 to 22 percent over the same period.^{Footnote 5} This trend is similar among the general population in Canada with estimates of seniors representing between 23 percent and 25 percent of the population by 2036, compared to 14 percent in 2009.^{Footnote 6}

As a result, hospitals and long-term care facilities will continue to face increasing pressures to serve clients and patients with greater need, which may inadvertently result in lower prioritisation of those with less urgent needs, while also shortening hospital stays, and shifting the pressure to at-home care. While this shift may often be appropriate and even desired by clients and patients, it is important that administrators are able to accommodate increasing demands going forward. It is therefore essential to measure the current and prospective demand to be placed on administrators to accommodate needs, as current data do not capture what is needed; only what is provided.

With an expanding need to serve clients in their homes comes a growing need to ensure communities are able to deliver services and accommodate client needs in a culturally-consistent manner. Findings from the literature indicate that there is a continuing need for First Nations and Inuit communities to be able to define and receive health services. This goes beyond the need for cultural sensitivity and cultural competency (which are also critically important). Rather, it speaks to directly addressing the power relations between service users and service providers (addressing some Calls to Action from the Truth and Reconciliation Report).^{Footnote 7} Specifically, it indicates a need for increased funding of Indigenous health centres, recognizing the value of Indigenous healing practices and their use in the treatment of Indigenous patients in collaboration with Indigenous healers and Elders, to increase the number of Indigenous professionals working in health care, and to provide cultural competency training for all health care professionals.

3.2 Alignment Between the Priorities of Government and Indigenous Communities

First Nations and Inuit service administrators that participated in this evaluation viewed FNIHCC as aligned with their priorities, and as being culturally appropriate (e.g. Indigenous control over how client services operate). Representatives of Indigenous organizations at the national and regional levels participating in key informant interviews noted relatively high levels of perceived "ownership" of the program by communities. This sense of ownership has contributed to the perception of FNIHCC as being delivered in a culturally-consistent manner, as communities are responsible for hiring and training staff, and making them aware of cultural practices.

The vast majority of survey respondents (90 percent) indicated that services were delivered in a highly or somewhat culturally-responsive and appropriate manner. Notably, however, more non-Indigenous (57 percent) than Indigenous (46 percent) respondents agreed that services were highly culturally-responsive and appropriate.

The Government of Canada has agreed to implement the Truth and Reconciliation Report recommendations, including Call to Action [19], stated below:

However, most health care to First Nations and Inuit is provided and funded by the provincial/territorial systems, and is provided in off-reserve hospitals and clinics. The health services funded by the federal government are provided primarily on-reserve and are in the areas of health promotion, health education services, with some public health and environmental health services. The federal government also funds primary health care in remote and isolated First Nation communities, home and community care and health promotion and disease prevention programs to First Nations and Inuit in the territories.

There is no specific statutory authority for the provision of health care programs and services to First Nations and Inuit by the Government of Canada. The Constitution Act of 1867 does not explicitly include "health" as a legislative power assigned either to Parliament (in Section 91) nor to the provincial legislatures (in Section 92). Nonetheless, the Courts have confirmed that most aspects of the regulation of health care are within provincial jurisdiction. For example, provinces have extensive authority over public health as a local or private matter under s. 92(16) of the Constitution Act, 1867; over the regulation of medical professions as matters of property and civil rights under s. 92(13); and over hospitals under s. 92(7).

The specific health care programs and services provided or funded by FNIHB are approved annually by means of the Appropriations Act, which grants Parliamentary approval to the Minister for the budgets and objectives of FNIHB. Treasury Board provides authority for specific program activities. However, in the absence of any clear statutory authority, which describes and defines the mandate of the programs and services, FNIHB provides or funds health programs and services to First Nations and Inuit based on Health Canada's departmental mission and mandate statements and on policy in a manner intended to be consistent with the 1979 Indian Health Policy and as such, are subject to the discretion of the Government.

The shift of these health programs from Health Canada to ISC further complicates any clarity in jurisdictional responsibilities, which has been the subject of some reports of the Office of the Auditor General. There is a lack of ongoing coordination among federal and provincial jurisdictions, which has led to a lack of clarity regarding what services are to be provided, at what service levels, and what legislation applies. All levels of government have acknowledged that gaps created by jurisdictional conflicts contribute to the health disparities among Indigenous Peoples in Canada.

The establishment of long-term care facilities in communities was stated as a main priority by all participants, but currently the resources needed to achieve this priority are greater than the funding available.

3.3 Training and Capacity

The ratio of FNIHCC nurses to population remained relatively constant over recent years at about 1.2 to 1.3 full-time equivalent nurses per 1,000 people. All nursing services are provided by regulated and licensed staff. As of 2016-17, approximately four out of five personal care providers were certified. The number of personal care providers, as well as the proportion of those certified, continues to increase, as shown in Figure 1.

Description of Figure 1: Increase in both the total number of personal care providers and the proportion that are certified

Figure uses a column graph to show an increase in the proportion of personal care providers certified has increased from 74 to 80 percent from 2014 -15 to 2016-17, and a superimposed line to show an increase in the total number of personal care providers from approximately 1,080 to 1,180 over that time frame.

Dedicated funding envelopes for training are provided and prioritized (e.g. continuing education) at a regional level by the health directors, nurse managers and FNIHCC coordinators. Much of the training focuses on nurses, but much less so for personal care providers, who do not have a specific funding allocation for training. 

According to ISC's 2018-19 Departmental Plan, the Department intended to strengthen the support of health practitioners working in isolated contexts and also to improve the quality of care in these settings, and the Department is continuing its efforts in mandatory training, professional development, recruitment and retention, cultural safety, and accreditation.

Some of the specific activities targeted to small and remote communities highlighted in this evaluation included:

• Increasing access to nurse practitioners and interdisciplinary team models;
• Improving access to pharmacy services;
• Expanding access to physician supports in an on-call setting and first responders in communities;
• Strengthen regional capacities in nursing recruitment and retention; and
• Enhancing community capacity to deliver culturally appropriate palliative care services in the home setting.

These priorities stem from increased investments from Budget 2017 of an additional $184.6 million over five years.

A priority for training over the period covered by the evaluation has been on cultural safety and sensitivity, including topics such as intergenerational trauma, mental health, and health concepts from an Indigenous perspective.

3.4 Sufficiency of Amount of Services Provided

As shown in Table 1, funding overall has increased modestly; notably, the proportion devoted to policy development and oversight, and professional development has nearly doubled – see Figure 2.

When examining the proportion of expenditures devoted to Grants and Contributions, whether for the direct provision of services, or development, oversight and planning, the total amount has increased from $95.5 million to $108.1 million between 2012-13 and 2017-18. The proportion of expenditures spent internally on salary and operations and maintenance has increased from approximately $4.8 million to $8.6 million over this period.

Internal expenditures as a proportion of the total have increased very slightly from five to seven percent (Figure 3). Notably, however, this trend is not seen in regional data (see Appendix B), where the internal expenditures portion of regional funds is consistently around three percent. The increase in internal expenditures has largely been at Headquarters.

Over the past three years, funding for, and numbers of, FNIHCC delivery staff increased, while the number of service hours decreased. The total clients served per year remained the same between 2012 and 2017. This may be explained by the increasing demand being placed on FNIHCC staff to undertake coordinating and management of care roles, which leaves less time for direct service. A reduction in hours could also be partially due to new techniques and therapies or realising efficiencies. An increased cost of services may also result in service reductions where budgets become prohibitive. Figure 4 shows the percentage changes in this figure from 2012 to 2017.

Description of Figure 2: Total spending has increased modestly from 2012-13 to 2016-17, most notably in development, oversight and planning

Figure uses a stacked column graph to show the total expenditures increasing from close to 100 million dollars in 2012-13 to close to 110 million in 2016-17, with the proportion of these expenditures represented by service delivery decreasing gradually from 94 to 90 percent, and the proportion represented by development, oversight and planning increasing gradually from 6 to 10 percent over this timeframe.

G&C: Grants and Contributions

Description of Figure 3: Internal expenditures as a proportion of total expenditures have increased modestly over time

Figure uses a stacked column graph to show total expenditures increasing from close to 100 million dollars in 2012-13 to close to 110 million in 2016-17, with the proportion of these expenditures represented by internal expenditures increasing slightly from 5 to 7 percent, and the proportion represented by grants and contributions decreasing slightly from 95 to 93 percent over this timeframe.

Source: Administrative Data provided by FNIHB
* Includes all expenditures
**Excludes northern region

Description of Figure 4: Care providers, nurses and total expenditures have increased with a simultaneous decrease in total and average service hours between 2012 and 2017

Figure uses a column graph to compare changes, with a 9 percent increase in the number of personal care providers, an 8 percent increase in the number of full-time equivalent nurses per 1000 people, an 8 percent increase in total expenditures, a 0 percent change in the total number of clients a 4 percent decrease in the total service hours, and a 5 percent decrease in the average number of service hours.

In terms of general access, it was felt by the great majority of health directors and FNIHCC staff interviewed and surveyed that the amount of services was the same as or greater than neighbouring non-Indigenous communities for home care nursing, in-home health care support or in-home personal care services, and especially for in-home services such as homemaking, house cleaning, meal preparation or companion/attendant support.

It is worth noting, however, that most of the respondents to this survey were those tasked with administering the provision of these services, and there is no adequate data to support or refute this view. In essence, a measure of provincial or other community comparability says nothing of adequacy itself, because neighbouring communities may not be adequately providing access. If the goal is 'adequate' access, it would be necessary to better assess the level of need relative to what is provided, regardless of how that compares to non-Indigenous communities.

Key issues raised by intereviewees about access to services included:

• Variability between provinces, where multi-jurisdictional issues can complicate access and make it difficult for clients to navigate the various services and supports;
• In some regions, poor communication with the province results in challenges regarding discharge plans from a provincial care institution;
• Access to the program is generally available, but the resources available and services and supports provided are not necessarily meeting the needs of clients;
• Lack of 24/7 supports and services;
• Lack of access to specialists, particularly in smaller and more remote communities, for rehabilitation, occupational therapy, etc.; and
• Lack of economies of scale^{Footnote 8} in smaller communities with higher costs.

Interviewees indicated that where there are funding shortfalls, it results in various gaps, such as coverage for children (however, this is largely recently being addressed by programs affiliated with Jordan's Principle), mental health, opioid addiction, medications, wound care, foot care, diabetic care, and may result in caregiver fatigue. Smaller and remote communities may face additional challenges accessing training; for example, connectivity issues restricting online training, challenges in bringing trainers into communities, and difficulty backfilling a position if an employee leaves the community to attend training. 

3.5 Meeting Needs and Quality of Services

Overall, in the survey, respondents reported higher quality of services, and lower wait times, than similar programs in non-Indigenous communities. The quality of services was primarily attributed to the quality and dedication of service delivery personnel, and it was felt that quality was further supported when services are accredited.^{Footnote 9} Administrative data derived from the Community-Based Reporting Template that indicated approximately 25 percent of communities in 2015-16 had an accredited Home and Community Care program. 

Representatives from Indigenous organizations noted that the smaller and more remote communities can be at a disadvantage regarding quality of services offered in part due to the challenges encountered in recruiting and retaining the required staff able to deliver quality services. Some indications of the quality of services highlighted by interviewees included perceived low rates of readmission to a hospital within 30 days of discharge and low rates of clients requiring hospitalization services since their last FNIHCC assessment, although there is no data to support or refute these perceptions.

Service providers and health directors are typically familiar with the Quality Resource Kit;^{Footnote 10} however, only about 20 percent of service providers and program administrators use it frequently.

Smaller and more remote communities have challenges with adequate services in part due to the funding constraints and recruitment/retention issues of qualified personnel.

According to survey respondents, the main gaps in meeting communities' needs for Home and Community Care services consisted of the following:

• Lack of resources causing gaps in services or limiting service delivery, including staff shortages (including nurses, personal care providers and other human resources). Respondents touched on issues of access, lack of training, hiring, turnover and retention, especially in the case of remote communities. Some respondents also explained that having minimal staff means people have to cumulate different roles, which can hinder efficient delivery. Most comments pertaining to underfunding also related to staffing needs. Respondents referred to demographic shifts and new/higher demand (e.g., increased complexity of cases, increased co-morbidity, more mental health cases, addiction, etc.) as increasingly challenging to address with limited resources. 
• The second most commonly identified gaps related to communication and coordination with other stakeholders, including gaps in communication with physicians, local hospitals and regional health authorities, namely regarding discharge planning and access to physicians. A few respondents mentioned challenges in communicating with families and clients themselves (e.g., gaps in support and challenges in compliance, language barrier).
• Respondents also noted gaps in terms of specific services, namely respite and palliative care, allied health services, wound care/clinical home care and mental health services. Some mentioned gaps in access to supplies (e.g., intravenous, medication). Respondents also noted that delivering services during business hours was restrictive, especially with regards to palliative care.

Funding for direct service provision has been increasing year over year at a rate approximately double the annual rate of inflation (Figure 5), and this growth rate is generally consistent with the growth rate of health care spending in Canada.^{Footnote 11} However, it is important to note that this is within the context of increasing complexity of needs, a competitive environment to recruit and retain health care workers, overall increasing health care and infrastructure costs, and demand for FNIHCC services that is widely expected to increase dramatically. 

Description of Figure 5: Rate of annual funding increases for FNIHCC exceeds the national inflation rate

Figure plots two lines showing percent change over one year in each of the four years from 2012-13 to 2015-16. The line representing FNIHCC funding moves from 1, to 2.8, to 2.5, to 2.9 percent. The line representing the national inflation moves from 1, to 2, to 1.1, to 1.4 over the same time period.

The vast majority of survey respondents felt that clients are having their needs generally or mostly met. However, there is a need to systematically assess the current demand and project it over the coming decade to better anticipate current and future needs.

Overall, however, this program was credited by interviewees as enabling clients to stay in their homes and communities more often and for longer than would have been possible without it, and ultimately as strengthening the quality of life of clients.

Another key contribution to improving the quality of life of clients was the assistance that is provided by FNIHCC staff in helping them and their families navigate various aspects of the health care system. This was highlighted as particularly important and necessary for many clients and families given the complex systems and challenges in understanding the interplay between the services received in the community and those provided by other institutions and organizations under provincial health systems.

According to the respondents, factors detracting from clients' needs being fully met include:

3.6 Coordination and Integration

FNIHCC is tied closely to other health and social programs. Health directors and direct service delivery staff reported the level of collaboration and coordination across programs,^{Footnote 16} see Figure 6:

Description of Figure 6: A significant majority of respondents viewed FNIHCC as collaborative with other health and social programs

Figure uses a bar graph to plot the proportion of interviewees seeing much or some, little, or no collaboration between 5 program areas. From much some, to little, to no collaboration, the graphic shows 53, 22 and 25 percent, respectively for Jordan’s Principle; 60, 18, and 22 percent, respectively for Assisted Living; 68, 19, and 13, respectively for Non-Insured Health Benefits; 70, 22 and 8, respectively for Provincial/Territorial or Regional Health Services; and 86, 9 and 5, respectively for Clinical and Client Care.

Respondents to the survey were also asked what coordination mechanisms they currently use with each of the other programs/initiatives, and how they could be improved. A summary of these are presented in Table 2. Overall, there are some common mechanisms; however, it should be noted that some of the suggested improvements are specific to each initiative. 

The 2013 evaluation of FNIHCC reported that in communities where both FNIHCC and Assisted Living were formally integrated, delivery efficiency increased due to improved coordination, improved assessments and case management, and more targeted funding to address needs and staff training. Almost unanimously, First Nations administrators and ISC staff reported that most clients receiving services from one program also receive services from the other. Integration of FNIHCC and Assisted Living at the community level also resulted in more appropriate hours of service provided and increased responsiveness to client needs.

In some instances, the FNIHCC and the Assisted Living programs are administered or delivered jointly by the same staff in the community. As shown in Table 3, six of the 21 services provided between the two programs overlap.

Survey and interview participants suggested that the aging population has been a significant change impacting their caseloads. FNIHCC staff report that because FNIHCC helps the aging population be more independent and remain in their homes longer, this increases the need for non-medical Assisted Living services, such as meal preparation, cleaning, and transportation.

In cases where the programs were administered separately, there was regular communication between Assisted Living and FNIHCC in-home workers and their respective band administrators to ensure individuals were recommended for assessments if they were observed to need services that one program or the other was not able to provide.

The degree of integration of Assisted Living and FNIHCC varied by community. According to the survey, respondents from Ontario (39 percent) and Manitoba (54 percent) were the least likely to report some or much collaboration between FNIHCC and Assisted Living compared to other regions (Atlantic – 100 percent; Quebec – 93 percent, and Alberta – 69 percent). Some communities pooled the funding from both programs in order to provide the continuum of services a given client may need. In those cases, First Nations reported services separately under one program or the other, as accurately as possible, but with a largely arbitrary distinction. In other communities where there was a strong separation between the two programs, staff salaries were paid from each program separately, and the band had two separate software programs to manage the accounting. 

Regardless of individual approaches to delivering the two programs, it is clear that either Assisted Living funding should broaden its eligible activities, or that the funding formula should be more flexible to account for unique circumstances in each community. Overall, there is a desire for a centralized, streamlined, or formally integrated approach of the two programs. Conversely, other respondents reported that if the programs remain separate, the distinction between the two should be made even clearer. All communities desired the flexibility required to deliver seamless responses to personal care needs.

Survey respondents reported that coordination between FNIHCC and all other programs should be improved, primarily through increased communication across all parties.

Evaluation Core Issues and Evaluation Questions

Research Methods:

Document and File Review - An extensive list of documents was prepared, and each was reviewed. There were approximately 85 key documents and websites that provided information for the evaluation. 

Administrative Data Review - The program manages two databases where information regarding service delivery and resources are tracked: The Electronic Service Delivery Reporting Template contains client and provider information. Data is inputted at the individual-record level and then automatically aggregated during the upload process by sex and nine age categories; and The Electronic Human Resources Tracking Tool, contains information on full-time equivalents providing client services by source of funding and by application. The data available from these were reviewed for the evaluation along with financial data made available from Health Canada's Chief Financial Officer Branch regarding program funding and expenditures. 

Key Informant Interviews - The purpose of the key informant interviews was to collect in-depth qualitative information on the FNIHCC evaluation issues and specifically to address gaps or clarify evidence from other methods. The information collected included opinions, descriptions, interpretations, and examples. Interviews were conducted with 55 representatives, including FNIHCC personnel at Headquarters and the regions, representatives from Indigenous communities delivering FNIHCC, national and regional Indigenous organizations, territorial and provincial representatives, and home care researchers and associations.

Web-based Survey – an online survey of Indigenous communities delivering FNIHCC was undertaken. Respondents were primarily health directors and/or Home and Community Care coordinators and nurses. There were 131 respondents to the survey, representing a 31 percent response rate.