Non-Insured Health Benefits Program Short-Term Crisis ... · Individual, conjoint (with a couple),...

Non-Insured Health Benefits Program

Short-Term Crisis Intervention Mental Health Counselling

National Benefit Profile

Document for Discussion

Produced by the First Nations and Inuit Health Branch

Approved by the First Nations and Inuit Health Branch – Assembly of First Nations

Non-Insured Health Benefits Joint Review Steering Committee

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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


5. Client Awareness and Access

5.1 Awareness

5.2 Access points/pathways

5.3 Barriers


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)

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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.

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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

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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

Initial assessment; maximum number of sessions not specified (regionally applied maximum average from 10-15)

Individual, family or group counselling (couples can be considered as ‘family’)

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;

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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.

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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.

Table 1

NIHB STCIMHC National Expenditures 2010/11 – 2014/15

Table 2

STCIMHC Operational and Contribution Agreement Funding 2010/11 – 2014/15

$10.9

$11.4

$11.9

$13.6

$15.3

10

11

12

13

14

15

16

2010/11 2011/12 2012/13 2013/14 2014/15

Mill

ion

s

0

2

4

6

8

10

12

14

16

2010/11 2011/12 2012/13 2013/14 2014/15

21% 24% 28%

29%

30%

Mill

ion

s

CA

Operational

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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.

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2.2.1 Atlantic Expenditures and Utilization

Regional Expenditures

2012/13 2013/14 2014/15

CA funding $109,867 53% $71,780 38% $57,500 34%

Fee-for-service $100,407 47% $120,618 62% $111,920 66%

Total $210,274 $192,398 $169,420

Fee-for-Service Utilization

2012/13 2013/14 2014/15

Clients 147 156 166

Sessions Total

Average # per client

Total Average # per client


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.

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2.2.2 Quebec Expenditures and Utilization


2012/13 2013/14 2014/15

CA funding $157,300 15% $159,800 16% $174,800 15%

Fee-for-service $944,461 85% $834,008 84% $973,231 85%

Total $1,101,761 $993,808 $1,148,031

Fee-for-Service Utilization

2012/13 2013/14 2014/15

Clients 966 1020 1102

Sessions Total



Total Average# per client

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



$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.

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2.2.3 Ontario Expenditures and Utilization


2012/13 2013/14 2014/15

CA funding Nil 0% Nil 0% Nil 0%

Fee-for-service $2,456,348 100% $2,753,723 100% $2,802,709 100%

Total $2,456,348 $2,753,723 $2,802,709

Fee-For-Service Utilization

2012/13 2013/14 2014/15

Clients 2566 2745 2872

Sessions Total Average # per client



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

Appeals <5 approved

7 denied <5 approved

<5 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).

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2.2.4 Manitoba Expenditures and Utilization


2012/13 2013/14 2014/15

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%

Total $2,791,416 $3,516,338 $4,098,636


2012/13 2013/14 2014/15

Clients 2465 2507 2473

Sessions Total




Approved 48789 19.8 50464 20.1 48303 19.5

Paid 11961 4.9 11618 4.6 9233* 3.7



*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 per client, reflecting a regional

administrative practice used when providers are travelling to communities. These providers seek prior

approval for a standard maximum number of sessions per client, and subsequently bill for sessions

actually used.


$284,600 500*

$250,000 1479**

$250,000 Unavailable

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2.2.5 Saskatchewan Expenditures and Utilization


2012/13 2013/14 2014/15

CA funding $505,000 49% $553,124 56% $580,000 54%

Fee-for-service $516,220 51% $436,207 44% $506,760 46%

Total $1,021,220 $989,331 $1,086,760


2012/13 2013/14 2014/15

Clients 1015 1120 1128

Sessions Total




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



$150,000 6006*

$180,000 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.

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2.2.6 Alberta Expenditures and Utilization


2012/13 2013/14 2014/15

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%

Total $4,768,809 $4,925,200 $5,988,669


2012/13 2013/14 2014/15

Clients 2231 2188 1917

Sessions Total




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




$117,100 264

$316,478 515

$256,317 640

$725,200 1562

$197,200 655*

$139,700 202*


$161,000 292


*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.

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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

2012/13 2013/14 2014/15

CA funding 0 0 0 0 -- --

Fee-for-service $4,130 100% $190 100% -- --

Total $4,130 $190 Nil

Fee-For-Service Utilization – Yukon

2012/13 2013/14 2014/15

Clients <5 Nil Nil

Sessions Total Average # per client



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.

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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 program-

specific 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;

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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.

STCIMHC Prior Approval Turnaround Times*

Alberta 5 business days**

Saskatchewan 2 business days

Manitoba 2 business days

Ontario 2 business days

Quebec 3 business days

Atlantic 3 business days

Yukon 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

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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 Total (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)

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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%.


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

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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.

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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 Brunswick (only province with a formal guide)

2010

Quebec Regional assessment of provincial rates, balanced with consideration of NIHB regional budget

2012

Ontario

Based on a review of usual and customary rates requested by providers in the province

Unknown

Manitoba Regionally developed point system

2014

Saskatchewan Regionally developed point system

2008

Alberta Regional NIHB staff determined rates in consultation with provincial colleges (social workers and psychologists)

2012

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.

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NIHB Provider Rates

Psychologists Hourly Rates Social Workers Hourly Rates

*Average


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

Province NIHB

Min. Frequent Max.

Newfoundland $90 $125 $150

Prince Edward Island

$90 $125 $150

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

Province NIHB

Min. Frequent Max.

Newfoundland $85 $125 $150

Prince Edward Island

$85 $125 $150

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

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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

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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

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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)


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

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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

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