Audit of the Assisted Living Program

Client needs used to inform funding allocations

The audit found that the current approach to funding allocation is not based on client needs.

The following sub-sections elaborate on the impact of the lack of data for each key funding allocation decision.

Determination of departmental funding allocation

As noted previously, the annual amount of assisted living funding allocated to the Department through the main estimates is based on the prior year budget plus an annual adjustment of approximately 2%. The audit observed that the program has identified a number of drivers that could increase the cost of eligible expenditures, including growth in on-reserve populations, increase of on-reserve life-expectancy, and steady increase to health and social support service provider costs. The audit also observed that over the past several years, there has been a consistent trend of budget shortfalls. Table 2 shows a breakdown of the funding shortfalls by fiscal year. From 2014-15 to 2021-22, there has been approximately $232M in total budget shortfall with an annual shortage of 23% over the period.

The noted funding shortfalls have been partially offset by approved program integrity budget requests, including $35M, $38.8M, and $35M contributions in fiscal years 2019-20, 2020-21, and 2021-22, respectively. However, analyses performed by the program indicated that there remains a gap and additional funding will be required to bridge the widening gap with provincial and Yukon comparability.

The audit observed that the program is exploring different approaches to funding due to the recognition that the Assisted Living Program may not be meeting demand for services, identified in the terms and conditions of the program, under the current model. However, the audit observed that current data on client and individual demand is not sufficient to effectively forecast expected demand, which could impact the accuracy of future funding forecast models assuming new data points are not introduced and/or collected.

Regional funding allocation

As noted previously, through an annual departmental strategic planning exercise, ESDPP HQ requires regions to prepare annual resource plans that forecast expenditures for the upcoming fiscal year. Resource plans are also updated during the budget’s fiscal year to inform additional program integrity requests, and to support ongoing program and departmental financial management discussions and decisions.

Resource plan methodologies vary across the examined regions and within the assisted living services components. As shown in the table below, forecasting models for in-home care, institutional care, and adult foster care for the in-scope regions follow different methodologies.

While funding allocated to each region was consistent with amounts requested in the forecasts, the audit observed that the regions in scope did not have sufficient client and individual demand data to inform their forecasting, which in turn impacts the accuracy of funding forecasted through their resource plans. As an example, the audit observed that forecast models used by in-scope regions to develop resource plans did not have data inputs accounting for increasing service demand (e.g. population growth, increase in life-expectancy) nor increasing costs of health and social support service provider.

Additionally, the historical data used to inform forecasts is based on actual costs expended which may not represent the complete view of client and individual demand. To recognize the need to consider the unmet demand of assisted living services, in fiscal year 2021-22 ESDPP HQ provided an updated methodology through a call letter to regions with a request to support a needs-based funding allocation. This methodology highlighted the importance of getting a sense of unmet needs based on past communications from communities or methods of comparison with comparable communities on or off reserve and including them in the estimated costs. As such, regions would require data on client and individual needs as well as data on other expected program cost drivers to accurately reflect full view of client and individual demand.

Furthermore, regional funding pressures may be identified via the FSR process and should additional funds be available, the program will provide the region with the requested funding. Regions prepare FSRs multiple times a year in order to identify additional funding needs of recipients. The audit observed that the in-scope regions had requested additional funding (i.e. top-ups), which are not guaranteed, 35 times from April 1, 2018 to March 31, 2022. For 2020-21 and 2021-22 top-up funding included some additional funding related to the ongoing engagement and the Supportive Care Initiative. It should be noted that in some instances the original amount requested may not be provided due to limitations in funding and regions make subsequent requests later in the year to fill the gap in funding.

The audit observed that in-scope regions used client data from invoices received for institutional care or directly from recipients related to a required need to inform funding pressures and requests for additional funds for single and block funding agreements as they relate to institutional care, adult foster care and in-home care, in the event actual expenditures surpass forecasted expenditures. Similar to the annual regional forecasting models, FSRs do not capture the full breadth of services that may be required, as data on unmet needs is not considered.

Recipient funding allocation

As noted previously, there are several funding approaches that may be used by the regions to deliver the Assisted Living Program to funding recipients including contribution, individual grant, and through the NFR 10-year Grant. The BMR describes the recipient allocation methodology for each funding approach.

Roles and responsibilities

Having clearly defined roles and responsibilities for performing outreach will help ensure that outreach program activities are completed, and that pertinent information is disseminated to First Nations communities. Furthermore, mechanisms to oversee the execution of outreach activities will help ensure that outreach is carried out consistently across the regions and that the program information shared with First Nations communities is accessible, complete, accurate, and sufficient.

As per the Program Control Framework, ESDPP HQ is responsible for providing leadership over the outreach activities. Furthermore, the Program Control Framework states that if deemed to be more effective, program officials may assign outreach functions to be performed at the regional level. ESDPP HQ is responsible for coordinating the development of outreach material and for disseminating the material to the regions. The regions are responsible for further disseminating this material to First Nations.

While some roles and responsibilities were defined in the Program Control Framework, the audit identified opportunities for improvement. For example, the audit did not identify a role and responsibility for establishing national guidance to help direct, guide, and set the frequency upon which outreach activities should be performed. There was also a lack of clarity on the conditions under which program officials would assign outreach functions to be performed at the regional level. Furthermore, an oversight responsibility to monitor the execution of outreach activities was not defined. Effective oversight will help ensure quality, accessibility and consistency of material disseminated to First Nations communities and will also ensure that the outreach activities are carried out appropriately.

Communication

The audit found that each in-scope region has developed outreach materials that communicate the components, eligibility requirements, eligible expenditures, reporting requirements, and National Program Guidelines of the Assisted Living Program. Moreover, the regions are readily available to First Nations to answer questions and provide information as needed.

While information on assisted living program services and eligibility has been developed (e.g., National Program Guidelines), formalized and consistent top-down procedures are not in place to ensure that the regions regularly and proactively communicate material to First Nations communities. This is necessary to guarantee that they are aware of the full extent of assisted living services and eligibility requirements. There are gaps in the consistency of approach to conducting outreach activities across regions due to lack of clear national guidance surrounding an overarching outreach mandate and unclear roles and responsibilities related to outreach and awareness activities. Consequently, First Nations may not receive the necessary information and support from the program to be fully aware of and benefit from the services and funding offered by the Assisted Living Program.

When updates are made to National Program Guidelines and Terms and Conditions, those changes are communicated from ESDPP HQ to regions and subsequently, from regions to First Nations. The audit noted that regions communicate those updates to First Nations via presentations and/or emails. However, since there is currently no process to ensure alignment between existing outreach material and any updates made at HQ, there is a risk that some information contained in outreach materials may not be relevant.