Canada’s most vulnerable Improving health care for First Nations, Inuit, and Métis seniors

Canada’s most vulnerable Improving health care for First Nations, Inuit, and Métis seniors
Canada’s most
Improving health care for First Nations,
Inuit, and Métis seniors
About the artist
The illustrations in this report are by Winnipeg artist Leah Fontaine,
who has a BA (Theatre Design), a BFA (with Honours), and an
MA (Native Studies). She connects her education with her Dakotah/
Anishinaabe/Métis heritage to create the iconography and world
view that are displayed in her work.
About the Health Council of Canada
Created by the 2003 First Ministers’ Accord on Health Care
Renewal, the Health Council of Canada is an independent
national agency that reports on the progress of health care
renewal. The Council provides a system-wide perspective on
health care reform in Canada, and disseminates information
on innovative practices across the country. The Councillors
are appointed by the participating provincial and territorial
governments and the Government of Canada.
To download reports and other Health Council of Canada
materials, visit
Dr. Jack Kitts (Chair)
Dr. Catherine Cook
Dr. Cy Frank
Dr. Dennis Kendel
Dr. Michael Moffatt
Mr. Murray Ramsden
Dr. Ingrid Sketris
Dr. Les Vertesi
Mr. Gerald White
Dr. Charles J. Wright
Mr. Bruce Cooper (ex-officio)
Canada’s most vulnerable
For the last three years, the Health Council of Canada
has been reporting on the health disparities between
First Nations, Inuit, and Métis populations a and
non‑Aboriginal Canadians, and on what can be done
to reduce these gaps.
In 2013, we set out to learn more about the health
challenges of older Aboriginal people, and the
ways in which Aboriginal communities, health care
providers, and governments are working to improve
health care services for First Nations, Inuit, and
Métis seniors. Little attention has been paid to the
health care needs of Aboriginal seniors in either
research or public policy, and this has created some
growing concerns.1,2,3,4
aSection 35 of Canada’s Constitution Act, 1982 recognizes three distinct
Aboriginal Peoples in Canada: First Nations (Indian), Inuit, and Métis.
Health Council of Canada
Table of contents
Section 1: Commentary by the Health Council of Canada
The pressing needs of First Nations, Inuit, and Métis seniors
11 Pressure points and politics
Changing landscapes and key approaches
Concluding comments
Section 2: Partnerships and progress
36Online education about elder care for community-based
health care providers
38One home care program for everyone, whether they live
on-reserve or off
Providing integrated services to elders on-reserve
Shared caregiving in the community
Improving care and reducing isolation for elders
46Building bridges between First Nations health care providers
and the mainstream health care system
Supporting Métis seniors and families
50Bringing chronic disease self-management to rural
and remote regions
52Adapting the Non-Insured Health Benefits program to meet
the needs of First Nations elders
54Community health aides help with nursing shortages and
cultural safety
Integrating culture into care
Youth caring for elders, and preventing elder abuse
Canada’s most vulnerable
Section 1
by the
Health Council
of Canada
Canada’s most vulnerable
The pressing needs of First Nations,
Inuit, and Métis seniors
First Nations, Inuit, and Métis seniors are among Canada’s
most vulnerable citizens. In comparison to the larger Canadian
population, a significantly larger proportion of Aboriginal seniors
live on low incomes and in poor health, with multiple chronic
conditions and disabilities.2-6 Many are in poorer physical and
mental health due to the disruption of their way of life caused
by colonization, particularly the intergenerational effects and
trauma of the residential school experience.5,7-10
The health needs of Aboriginal seniors are magnified by
determinants of health such as poverty, poor housing, racism,
language barriers, and cultural differences. First Nations,
Inuit, and Métis seniors are also more likely than younger
generations to live in rural and remote communities where the
majority of the population is Aboriginal, and where they can
be connected to their culture.8 Many First Nations seniors live
on-reserve. The result is that Aboriginal seniors have more
complex health needs but are often living in regions where
it is more challenging and expensive to provide care.2
In interviews conducted for this report, we heard that most
seniors need to travel to urban areas for anything beyond
the most basic care, with significant disruption to their lives
and at great cost to governments (which cover medical travel
for status First Nations and Inuit populations) or themselves
(non-status First Nations and Métis). In addition, because
many Aboriginal seniors don’t have the same level of care in
their communities as non-Aboriginal Canadians, their health
conditions can become more severe, increasing the amount
of care they need.2,10
These factors are often needlessly complicated by jurisdictional
disagreements about who is ultimately responsible for
providing health services to Aboriginal people.1,9,10 First Nations,
Inuit, and Métis seniors continue to face gaps in receiving
the health care and other supports they need because there
is little or no coordination and communication between
health care services provided by the federal government,
provincial/territorial governments, health authorities, and
Aboriginal communities.1,4,9,10
Interview respondents raised concerns that:
Nations seniors on-reserve are not receiving the home
care and continuing care support, including long-term care,
that they need to stay in their communities. Instead, many
seniors must leave their communities and live the rest of their
lives in institutions that are not culturally sensitive or safe,
often hundreds of miles or more from their communities
and families.
very small, isolated, and northern communities where
Inuit seniors live create a unique set of circumstances and
health care delivery challenges that affect seniors’ ability
to remain in their homes.
needs of the Métis population are not well understood
or addressed. Métis people were described as the “hidden”
Aboriginal group, which is reflected in significant gaps
in policy, programming, and services. Métis seniors lack
access to programs available to both First Nations and
Inuit populations, and the barriers they face are often
distinct from those experienced by First Nations and Inuit
populations. We heard that this needs to be recognized
as an issue.
Researchers and Aboriginal leaders are urging governments
to address these problems now, before a larger proportion
of the population reaches their senior years.1,3,10 Census
data show that the Aboriginal population is growing at a
rate almost double that of the overall Canadian population,
and an increasing number of seniors is part of this trend
(see An aging population, page 7).8,11
Health Council of Canada
About this report
To gather information for this report, the Health Council
conducted interviews with senior officials from provincial,
territorial, and federal governments and from First Nations,
Inuit, and Métis organizations. We also hosted regional
meetings across Canada to learn what is being done for
seniors in their communities and where problems still exist.
Many participants were health professionals and members
of First Nations, Inuit, or Métis communities; some were
seniors as well (see Methodology, page 64).
Although social, economic, and historical factors are
widely recognized as the primary cause of health disparities,
participants told us about system problems that are getting
in the way of good health care for seniors in their communities.
These are described in the section Pressure points and politics.
Use of terms
The specific designations of First Nations, Inuit, and Métis are
used whenever possible. When the discussions for this report
or supporting literature did not differentiate between First
Nations, Inuit, or Métis populations, the term Aboriginal is used.
The term community is used to refer either to a geographic
First Nations, Inuit, or Métis community or to a population,
depending on the context.
The term senior is used throughout this report unless a change
has been specifically requested. The term elder is used in
some communities to describe all seniors. In others, the term is
used specifically to identify an older person who is recognized
and respected in their community for their wisdom and cultural
knowledge, and in this case Elder is capitalized. Métis seniors
are called senators.
Many identified innovative practices that are breaking through
these barriers and improving the care of Aboriginal seniors.
We have synthesized key findings from these practices in the
section Changing landscapes and key approaches.
In the final section, Partnerships and progress, 12 innovative
programs are presented through a series of interviews
with health care providers and policy-makers. As their stories
demonstrate, change often begins with questioning the status
quo and reaching out to build new partnerships.
At the cross-country sessions, participants told us that hearing
from others who had resolved similar problems gave them
a sense of hope, possibility, and determination to discuss
new ideas back in their own communities. The Health Council
hopes this document will stimulate similar discussions about
the care of Aboriginal seniors across the country, and inspire
new directions from governments, communities, and health
care providers.
Canada’s most vulnerable
Different communities, common challenges
An aging population
Overall, First Nations, Inuit, and Métis seniors have poorer
health than non-Aboriginal seniors, with higher rates of
chronic diseases and other conditions.S1 As the number
of older Aboriginal people continues to grow, researchers
predict there will be greater challenges in providing health
care services.S1
The Aboriginal population is generally a demographically
younger population in comparison to the non-Aboriginal
population. However, the relative size of the senior
population is increasing.S1
In the 2006 census, nearly 5% of Aboriginal people were
aged 65 and older.S1 This is expected to increase to 6.5%
of the total Aboriginal population by 2017.S2
This percentage varies among the different populations.
By 2017, the First Nations senior population will reach
6% of all First Nations people, and the Inuit senior
population will reach 4% of all Inuit.S2 The Métis senior
population will experience the largest growth, to 8%
of the total Métis population.
Although age 65 is typically considered the start of senior
years, some organizations and health care providers offer
seniors’ services to Aboriginal people age 55 and older,
largely because statistics show an earlier onset of chronic
conditions and a lower life expectancy compared to
other Canadians.S3-S5
Despite differences among seniors in First Nations, Inuit, and
Métis communities, participants said they share many common
experiences that affect their health:
Inuit and First Nations participants from northern
communities said that in the last decades, their communities
have moved from a diet composed entirely of nutrient-dense
wild foods to one that is predominantly Western, which is
believed to be contributing to a higher incidence of disease.12
Many seniors cannot afford to buy healthy foods (especially
in the North, where food is extremely expensive) and struggle
simply to have enough to eat. This makes it difficult for
them to maintain the nutritious diets they need to manage
chronic conditions. In addition, the consumption of less
expensive and more readily available processed foods, which
are typically high in fat and sugar, often leads to obesity.
Traditional cultural foods, such as wild meat, fish, and berries,
are extremely important to the diet of seniors, providing both
nutritional value and cultural continuity. Some seniors rely
on family or other community members to supply them with
traditional foods, but these are less readily available than
they were in the past.
is a severe shortage of housing in many communities,
particularly in those that are remote or in the North, and what
is available is often in poor condition. Many First Nations,
Inuit, and Métis seniors live in overcrowded conditions,
which creates stress for all family members and, coupled
with poor nutrition, puts everyone at higher risk for diseases
such as tuberculosis. Poor housing conditions can also
make it difficult or impossible to receive home care services.
In addition, many seniors are not able to pay to adapt
their homes for medical equipment or to accommodate
disabilities, and have difficulty covering the costs of heating
their homes. Wood is the main source of fuel for many
Aboriginal seniors, which is not the case for the general
population.1 If the community is not able to provide support
(for example, by hauling and chopping a seasonal supply
of wood), many seniors are not able to stay in their homes.
Health Council of Canada
The lasting effects of colonization and residential
schools have been described as a form of posttraumatic stress disorder.
spoke a great deal about elder abuse, defined
as the financial, emotional, and physical neglect or abuse of
First Nations, Inuit, or Métis seniors. They said that financial
abuse is the most widespread. In small communities with
few economic opportunities, a senior who receives Old
Age Security may be the only family member with a reliable
income. Sharing is a core value and practice in many
Aboriginal cultures, and many seniors will share whatever
they have (housing, food, money) with family members,
even if it means that they will not be able to take care of their
own needs. Many communities are trying different strategies
to intervene if family members abuse this generosity.
Participants said this is challenging, as elder abuse is a
complex problem that is usually hidden. Seniors who do
experience abuse are often reluctant to talk about it or report
it to health providers or others. This makes it difficult to
intervene and help.
lasting effects of colonization and residential schools—
described as a form of post-traumatic stress disorder 13
for whole communities and cultures—have left many seniors
socially isolated. Families are less able to care for seniors
because they have their own challenges, including mental
health issues, addictions, poverty, and family violence.
A number of participants added that family members whose
own childhoods were dysfunctional are often reluctant to
care for their parents.
is an issue, particularly in Northern
communities. As one participant noted, “If your children
leave, who looks after you? Our young are getting educated
and not going back to the community. What you’re left with
then in the communities are the neediest—those on welfare,
and the elderly.”
significant proportion of First Nations, Inuit, and Métis
seniors may not have literacy skills in English or French.
Participants reported that seniors often do not fully
understand information about their health conditions.
They said that seniors may be reluctant to discuss their
needs with service providers or ask for help. In addition,
although all seniors are eligible for Old Age Security
pensions, many First Nations, Inuit, and Métis seniors have
not applied because they lack the documents (such as birth
certificates), or because of language and literacy barriers.
First Nations, Inuit, and Métis seniors suffer from
significant emotional and mental health concerns due to
the traumatic legacy of residential schools, grief associated
with aging (including the loss of their own independence,
as well as the loss of family members and friends), and the
desperate state of youth and families in their communities.
Several participants shared stories of seniors who were
struggling to cope with the suicides of their grandchildren.
We heard that mental health is not formally assessed or
treated, and culturally appropriate services are often difficult
to find. For example, a stigma associated with dementia
results in late diagnosis for some seniors.14
Participants stressed that despite these challenges, many
seniors are resilient and serve as primary caregivers
for grandchildren as well as cultural touchstones in their
communities. A growing number of innovative practices
demonstrate the importance of rebuilding what was stripped
away from Aboriginal people, such as knowledge of their
language and traditions, pride in their culture, and selfdetermination, in order to heal from the past.7 There are strong
links between these factors and health status.15 We heard
that communities are at different stages of healing, and that
seniors are an important part of these efforts because many
have retained knowledge of their language and cultural
traditions. Losing Elders and seniors to distant long-term
care facilities can be a cultural blow to entire communities.
Canada’s most vulnerable
The importance of culturally
safe care
Several Elders who attended our sessions shared their
residential school experiences with grace and courage,
helping participants to better understand the lasting physical,
emotional, and spiritual pain of many Aboriginal seniors and
why it is critical to provide culturally safe care.
Colonization and residential school experiences, along with
continuing experiences of racism in Canadian society, have
created a significant mistrust of mainstream institutions,
including the health care system. Participants said many seniors
delay seeing a health care professional about their symptoms
until they are seriously ill because they are afraid their diagnosis
will mean they will be sent away for care and never return.
And if care is not culturally safe, a senior may not return for
an appointment or continue a treatment plan.
Participants said that most health care providers have little
understanding of the historic experiences or the practical
realities of everyday life for First Nations, Inuit, and Métis seniors.
As a result, they make inaccurate assumptions about seniors’
ability to care for themselves, and their access to services
and resources. In addition, health systems often fail to provide
Aboriginal seniors with opportunities to communicate in their
own languages, participate in ceremonies, and eat traditional
foods. Participants stressed that these cultural supports are not
just “nice to have”; they are critically important to maintaining
the health and well-being of seniors.
The Health Council’s 2012 report, Empathy, dignity, and
respect: Creating cultural safety for Aboriginal people in urban
health care, further explains the importance of cultural safety
and provides examples of successful initiatives.
Canada’s most vulnerable
Pressure points
and politics
The health care of First Nations, Inuit, and Métis people
is complicated—and, many participants said, compromised—
by poor communication, disputes, and a lack of collaborative
problem-solving between governments or between government
departments and agencies. This creates overlaps, gaps in
service, and a lack of transparency, sending Aboriginal seniors
and their families through a jurisdictional maze, with detrimental
effects on their health and quality of life. Many of these
problems have been well documented.1,9,10,13,16
The roles and responsibilities for the health care of First Nations,
Inuit, and Métis seniors vary significantly across the country,
based on agreements between the federal government,
provincial/territorial governments, and individual Aboriginal
communities (see A complex environment for Aboriginal health,
page 20). We heard that the root of many of these problems
is confusion and disagreement about the role of the federal
government, and the degree of their responsibility for the health
of Aboriginal populations. The exclusion of First Nations people
from some provincial programs available to all other provincial
residents, on the grounds of their First Nations status, is also
contentious. In addition, Métis people do not have access
to federal programs available to both First Nations and Inuit,
or to provincial programming that meets Métis-specific needs.
The federal government directly funds some health and social
services through Aboriginal Affairs and Northern Development’s
Assisted Living Program and through Health Canada’s First
Nations and Inuit Health Branch.17,18 Beyond these limited
programs, the federal government assists provinces and
territories in funding health care for all their residents (including
First Nations and Inuit) by means of an annual transfer of funds
under the Canada Health Transfer, based on a per capita
calculation using population estimates that include First Nations
and Inuit residents.9 However, the provinces and territories
argue that this per capita calculation is based on outdated
population estimates and does not take into account the actual
cost of delivering health care services to remote communities
or to Aboriginal populations with complex care needs.9
What does this complex mix of jurisdictional arrangements
look like on the front lines of care? Participants identified key
pressure points that they believe are compromising the quality
of care, and quality of life, for Aboriginal seniors:
Too many seniors need to travel for care that could
be offered in their communities
Next to the determinants of health, the need to travel for most
health care services was identified by participants as one of
the most significant issues affecting the quality of life of seniors
and their families. There are minimal health care services
in many Aboriginal communities, particularly those that are
rural, remote, and in the North, with limited access to medical
technology, equipment, supplies, and medication.
Health Council of Canada
Medical travel is physically, emotionally, and often financially
challenging for Aboriginal seniors. Medical travel for preapproved appointments is covered by the federal government
for status First Nations and Inuit populations, but both the
application process and transportation logistics can be
complicated. Métis seniors, many of whom also live in remote
and rural areas with limited access to services, are not covered
for federally funded medical travel. Participants stressed that
a lack of affordable medical transportation can be a particular
barrier to seniors receiving timely and appropriate care.
With very high unemployment in some communities, many
families do not have their own vehicles and must rely on
other forms of transportation. In many remote communities,
the only way out is by air. Canadian winters wreak havoc
on travel schedules, particularly in the North, causing missed
appointments and delayed treatment.
Even if health care services exist in the community, there are
often constant problems with recruitment, retention, and training
of health professionals, leaving some communities with only
limited access to primary care. In addition, participants said
that a significant proportion of health care workers serving First
Nations, Inuit, and Métis communities do not have adequate
training or experience to meet the complex needs of seniors.
We heard a number of examples of telehealth and other
virtual or mobile health care programs (see Partnerships
and progress, page 35) that help bring health care to
communities. Participants said these technologies could,
and should, be used more widely, but acknowledged that
part of the challenge is that communities do not always
have adequate information and communications technology
and other infrastructure to reliably deliver these programs.
One participant shared the example of a provincial mobile
dialysis unit that could not provide care in one on-reserve
community because of a series of challenging living conditions
in the community, including a lack of health infrastructure.
As a result, people travel up to five hours each way for treatment
at a city hospital, and often need overnight accommodation.
We heard that the federal government has said that these
seniors must move permanently to the city because it has
exhausted its transportation budget for First Nations in that
community. The participant believes the federal government
is responsible for this situation because it has not provided
sufficient support to the community. There were many such
examples of a lack of mutual problem-solving by jurisdictions.
Poor communication and coordination between
governments, urban health care services, and on-reserve,
remote, or northern communities
Criticisms of poor communication and coordination applied
at all levels: between provincial ministries, health regions, and
health care services; between the different federal government
departments with responsibility for First Nations and Inuit
populations; and particularly between the federal government,
the provinces, and Aboriginal communities.
Aboriginal people, and particularly seniors, tend to move
back and forth between urban areas and their communities,
depending on their health needs.10,19
Canada’s most vulnerable
Participants in the Health Council’s consultations expressed
frustration that in the absence of coordinated services,
vulnerable seniors are expected to navigate complex health
care systems and government bureaucracies by themselves.
Many are struggling with chronic illness and disability, living
in poverty, and mistrustful of mainstream society. Unless there
is a case manager, Aboriginal patient navigator, translator,
other health care provider, or family member who actively
coordinates and oversees their care, seniors are fearful
and likely to experience problems when they travel for care.
Non-existent or weak links between services mean that
frail, vulnerable seniors end up without support and at risk
for neglect.10
In the absence of
coordinated services,
vulnerable seniors
are expected to
navigate complex health
care systems and
government bureaucracies
by themselves.
In particular, many participants spoke about the gaps in
care that happen when a senior is sent home from hospital.
They said that hospitals often send frail patients home to
their communities without checking if there are appropriate
support services or home accommodations in place, because
they historically have viewed Aboriginal communities as
“federal territory” and outside of their jurisdiction. This is a
well-recognized challenge that can be addressed with the
help of Aboriginal discharge planners who link hospitals and
communities.9 We heard a number of successful examples
of this role, but it is not yet widespread.
The lack of consistent medical records is also a significant
problem. Participants said that each health care provider or
institution involved in a senior’s care typically has a different
paper record. While this issue affects many Canadians, it
is a particular concern when First Nations and Inuit seniors
are moving back and forth between health care and
support services offered by the province or territory, federal
government, and their communities. Participants said that while
electronic record-keeping is now being used at many sites,
health systems and providers often use different electronic
systems that are difficult to integrate. This is a recognized
problem among health care services offered by the provinces
and territories, and it is further complicated by the fact that
on-reserve communities and federally run services also have
different systems, both paper-based and electronic. Key
information about a senior’s health does not get passed along
to all the people involved in his or her care.
Health Council of Canada
A number of participants stressed that communication
and coordination need to improve in ministries of health and
regional health authorities to ensure that Aboriginal communities
are involved in health planning and policy. They said that
provincial health reforms are often started without recognition
that they can place serious pressures on communities.1,20
Participants shared several examples of the consequences
of these provincial reforms. Many provinces are sending
patients home from the hospital at an earlier stage in their
recovery, with the expectation that home care programs will
provide more extensive support. This may save money in
hospital and provincial budgets but it inadvertently downloads
costs to First Nations communities, whose home care programs
are either run by the community (self-government) or (under)
funded by the federal government. This is a long-standing
problem.20 Participants also said that provincial privacy policies
or legislation that restrict the sharing of patient information are
slowing down and complicating the exchange of information.
Finally, InterRAI, a well-established health assessment
and planning tool,21,22 was recognized by many participants
as a valuable way to help providers across sectors and
jurisdictions organize care. However, there were many
concerns about communities losing control of the information,
and for this reason several participants had decided not to
use it. We heard that the First Nations and Inuit Health Branch–
Alberta region has successfully piloted the RAI-HC (Resident
Assessment Instrument for Home Care), consistent with the
First Nations principles of OCAP (ownership, control, access,
possession), and that a toolkit is now available nation-wide
for all First Nations.
Insufficient home and community care for seniors to live
out their lives in their communities
The majority of seniors want to live at home as long as their
health permits, and there is a growing trend in Canadian
society to support this as much as possible. For First Nations,
Inuit, and Métis seniors, this can be more of a challenge. The
pressures on communities can be enormous: as one example,
44% of First Nations adults over age 55 require one or more
home care services.23
Many seniors live in communities where only limited home
care and community services are available to help them
manage their health and stay in their homes. In addition,
in many rural, remote, and/or on-reserve communities, there
is a severe shortage of housing, and seniors have difficulty
getting access to the medical technology, equipment, supplies,
and medications that they need.
Sending patients home
from the hospital at an
earlier stage of recovery
may save money in
provincial budgets but it
inadvertently downloads
costs to First Nations
Canada’s most vulnerable
The federal government’s First Nations and Inuit Home and
Community Care program (FNIHCC) works with First Nations
and Inuit communities to develop home and community care
services that help people with chronic and acute illnesses
receive the care they need in their home or community. Services
may include nursing care, personal care such as bathing and
foot care, home support such as meal preparation, and caring
for someone while family members have a rest (respite).24
While many participants spoke favourably about the FNIHCC
program, they said that current funding is not sufficient to
provide seniors with the services they need. In addition, some
communities accessing the FNIHCC program find it difficult
to retain qualified nursing staff because some provinces pay
a higher wage scale, and because it can be difficult to recruit
nurses to rural and remote communities.
We heard that the lack of evening and weekend coverage by
FNIHCC for First Nations people on-reserve is a particularly
significant gap, and a glaring disparity in provinces where
such extended coverage is available to other residents.
Depending on provincial or regional health authority policies,
some on-reserve communities can access provincial services,
such as home care or respite care, to bridge the gaps. But
many cannot. For example, some provinces offer First Nations
seniors the same access to home care services as other
people in the province; some provide access only for services
not provided through FNIHCC, or have struck independent
agreements with communities; and others do not provide any
home care services at all, maintaining that on-reserve home
care is entirely the responsibility of the federal government.25
If services aren’t available in on-reserve First Nations
communities, and the province can’t or won’t provide additional
services on-reserve, seniors may need to leave the reserve
permanently in order to access provincial health care services.
One participant said that in his health region, on-reserve First
Nations people who move off-reserve to access either palliative
care or respite face a residency requirement of six months to a
year before they are eligible for these services, which effectively
prevents on-reserve seniors from accessing them.
In its 2011 report, the FNIHCC program indicates that it needs
to prepare for an increase in the number of First Nations and
Inuit who will need services, based on projected increases in
aging and acute and chronic illnesses, as well as government
attempts to reduce expenditures and contain costs.25 The
report notes that these trends will have an impact on the design
and delivery of health and social services, and that spending
may need to be reviewed because it has not changed
significantly over the past decade.25
Discussions about home and community care also identified
a growing focus on shared caregiving in communities. The
ability of a senior to stay safely at home is dependent on
more than the availability of a home care program. He or she
needs access to healthy food; safe, good-quality housing;
and support services such as transportation to appointments.
Many Aboriginal seniors also need someone to haul wood
and water, to chop wood for fuel, and to help maintain their
homes.1,26 An increasing number of communities are providing
a range of support services, often in partnership with provincial
services, that enable seniors to stay in their homes longer.
Health Council of Canada
Challenges preventing seniors
from staying in their homes
A 2004 study by the Government of Canada and First Nations
and Inuit organizations showed that:
seniors prefer care in their own homes, in their
own communities, and usually from family members.
have very limited ability to pay for services.
is an issue for many clients; it may be overcrowded,
in a poor physical state, or, in some cases, very isolated.
do a great deal of work and have a high potential
for burnout.
care, including respite, is needed on evenings
and weekends.
need to be designed to address the need for
higher levels of care, including long-term and short-term
care in facilities.
Palliative care
Many participants said the lack of culturally appropriate
and safe palliative care in communities is a significant gap.
There is no funding for palliative/end-of-life care through the
First Nations and Inuit Health Branch, and Health Canada’s
First Nations and Inuit Home and Community Care program
is unable to provide 24-hour support for palliative clients
and their families due to limited staffing and funds.
Some research with seniors to define culturally appropriate
end-of-life care yields a very different perspective from the
Western model. In some Aboriginal cultures, death is part of life,
housing can fill some of the gaps at lower levels
of care.
issues need to be addressed to meet the increased
demand and growing need for higher levels of care, taking
into account the size and location of the community, as well
as factors such as culture and language requirements.S17
A working group of representatives from First Nations and
Inuit communities, the Assembly of First Nations, Inuit Tapiriit
Kanatami, Indian and Northern Affairs Canada, and Health
Canada was established to review recommendations from the
2004 study and develop policy options.
They concluded that “jurisdictional disagreements around
who is responsible for the provision of continuing care has
resulted in a lack of responsiveness to the needs of First Nation
communities, significant gaps in services to these communities,
and a lack of long-term planning and development of services.
Any attempts to address these issues within the current policy
context have had limited success.” S15
and the care and comfort of heart and spirit take precedence
over medical procedures and protocols. The end of life
is an important time for families and communities to gather,
and for traditional practices.S15,S16
If palliative care is not available in communities, culturally safe
guidelines and environments need to be available for Aboriginal
seniors who die in health care facilities.S15,S16 We heard that
Lakehead University in Thunder Bay is currently developing a
model for culturally appropriate and safe palliative care services.
Canada’s most vulnerable
There is a lack of both funding and
understanding of Aboriginal communities’
needs for appropriate long-term care.
Not enough culturally safe long-term care
Many Aboriginal seniors lack family support and/or live in
communities that are too small, remote, or struggling to
provide adequate support to people with health challenges.
Participants said that small communities don’t receive enough
funding for full programs, as the amount of federal money that
they receive is based on factors that include the size of the
population.27 As a result, many Aboriginal seniors need assisted
living or long-term care at an earlier stage and younger age
than other Canadian seniors. Even those who are benefitting
from coordinated care in their communities may eventually
have health needs that are too great for the community and
their family to manage, and will need to consider a long-term
care facility.
Inuit seniors who need long-term care must leave their small
and remote communities for facilities available in larger towns.
Most are able to remain in Inuit territories, where the culture
and language are familiar and telehealth is used to connect
them with their families and communities.
This is less likely to be the case with First Nations seniors.
Less than 1% of First Nations on-reserve communities have
long-term care facilities,9 and the federal government has
restrictions on the approval of any new facilities on reserves.1,20
This means that most First Nations people requiring care
are placed in mainstream provincial facilities that are likely
to be a great distance from their own communities.9 Leaving
their homes for long-term care isolates First Nations people
from family, friends, and their communities. It also makes them
vulnerable to inappropriate care because of language barriers.
These factors can lead to depression and decreased quality
of life.1,9 Understandably, First Nations seniors do not want
to live out their days away from families, communities, and
cultural traditions.10
Participants said that cultural safety must be in the forefront
of all discussions about long-term care facilities. They stressed
that while First Nations communities are culturally safe for
seniors, most mainstream long-term facilities are not. They
shared stories of people from remote communities who were
sent to long-term care facilities in large cities far away from
their homes; they never saw their families again, and were
removed from all their cultural touchstones of traditional food,
ceremonies, and language. For some, being taken from
their homes and sent to an institution triggered memories
of residential school and caused them to relive the trauma.
Long‑term care facilities need to be culturally safe, with
respectful staff who offer traditional foods and medicines,
cultural activities, interpreters, and the ability to link by video
conference with remote families and communities.
Researchers have identified that the demand for long-term care
will grow rapidly over the next decades due to the increase
in the number of Aboriginal people who are aging, and the
disproportionately high rates of chronic disease, mental health
issues, brain injury (as a result of trauma or substance abuse),
and disability.1 Whether more long-term care homes should
be built in Aboriginal communities is an ongoing point of
discussion, complicated by the federal restriction on funding
any additional long-term care facilities on reserves.1 Although
Aboriginal Affairs and Northern Development’s Assisted Living/
Health Council of Canada
Adult Care program funds limited institutional support and
extended care for those requiring 24-hour medical or nursing
support, this funding is thinly spread.1 As a result, on-reserve
facilities are being pressured to provide higher levels of care
so that clients can remain in the community.13 We also heard
that some First Nations personal care homes must now meet
provincial regulations in order to be licensed, but they were
not built to those standards originally and there are no funds
to bring them up to code.13
In general, there is a lack of both funding and understanding of
Aboriginal communities’ needs for appropriate long-term care.1
Denials and delayed approvals for health benefits
and medical travel
The Non-Insured Health Benefits program (NIHB) is a federal
program for eligible First Nations and Inuit populations that
provides coverage for a specified range of medically necessary
drugs, dental care, vision care, medical supplies and equipment,
mental health crisis counselling, and medical transportation.28
The NIHB’s services, policies, and processes were a source
of frustration for many participants. It was described as
an underfunded and bureaucratic program with excessive
restrictions and rules that are hard to understand. These
same criticisms have been well documented elsewhere.29
NIHB officials told the Health Council that they are working
to make improvements, but based on what we heard across
the country, few of these changes appear to have reached
the front-line of care.
Delays in approvals for medicine, supplies, and medical
travel were a major point of contention. Participants said
delays in these services place seniors at risk for worsening
illness, admission or readmission to hospital, and reduced
quality of life.
Many participants also expressed concern about the number
of applications for NIHB benefits that are turned down, leaving
seniors—many of whom live in poverty—without any other
way to get the supplies or medications that they need. Some
turn to their province for help. People can also appeal the
decision through NIHB, which often results in coverage, but this
is an extra step that front-line staff say is an unnecessary delay
in care and extra work for staff. They are particularly frustrated
when coverage is refused simply because the form was not
completed properly. Front-line health care providers spoke
about the volume of paperwork; the levels of approval required;
the need for physicians’ signatures for most approvals, which
is particularly onerous in rural and remote areas with few
physicians; and the length of time it takes to process claims
and approve travel.
The NIHB requires approval of coverage in advance of all
medical travel or transportation, and must approve a nonmedical escort, such as a family member or translator, who
accompanies the patient. The approval process can take time
and, in some cases, significantly delays care. Escorts are not
always approved, leaving seniors vulnerable when they are
travelling for care. The medical travel process itself can also
leave seniors stranded. Adding to the complexity is that many
First Nations and Inuit seniors have only a limited understanding
of what is eligible for coverage or how to navigate the NIHB
system. Most need support from health care professionals who
are already stretched beyond capacity, particularly in the North
or in remote and rural areas.
Canada’s most vulnerable
The Health Council spoke with representatives from the NIHB
program, who are well aware of these concerns and working
to resolve them. One example is the work ongoing in the
Atlantic region (see page 52) as well as a new federal quality
improvement strategy for the First Nations and Inuit Health
Branch, including the NIHB.24,30
Some regions in Canada are taking different approaches to
managing the NIHB program. In BC, authority for health benefits
has recently been transferred to the new First Nations Health
Authority (FNHA). This will allow the FNHA to gradually redefine
the NIHB program to improve efficiency and effectiveness
and allocate money according to their own priorities.31 Out of
the four Inuit Land Claim regions, Nunatsiavut has chosen to
operate under a self-governing model and their NIHB program
is directly managed by the Nunatsiavut government.32 Frontline staff in Nunatsiavut told us this arrangement benefits
seniors because resources can be moved across departments
to meet needs in a way that is not possible when the federal
government is managing the program. In Nunavut and the
Inuvialuit Settlement Region, the NIHB is administered by the
respective territorial governments, and in Nunavik, the program
is the responsibility of the Nunavik Regional Board of Health
and Social Services.
We also heard that some regions and organizations, such
as the Council of Yukon First Nations, have NIHB navigators
in place to help seniors find their way through the program
and get support. They are also investigating whether the selfgoverning Yukon First Nations should take on administration
of the program.33
In BC, authority for
health benefits has recently
been transferred to the
new First Nations Health
Authority, allowing
them to allocate money
according to their own
Health Council of Canada
A complex environment
for Aboriginal healthb
Provinces provide hospitals, physicians, and public health
programs for all Canadians, including First Nations, Inuit, and
Métis populations, but generally do not operate direct health
services for First Nations on-reserve.
Territories deliver insured health services to all their citizens,
including First Nations, Inuit, and Métis populations. However,
the federal First Nations and Inuit Health Branch (FNIHB)
provides additional funding for home and community care,
as well as health promotion and disease prevention programs
to First Nations (including those that are self-governing) and
Inuit populations in the territories.
Health Canada funds primary care in 85 remote/isolated
First Nations communities. It also funds public health
nursing, health promotion/disease prevention programming,
environmental health services, and a First Nations and
Inuit Home and Community Care program in more than
600 communities.S5,S6
Health Canada also administers the National Insured Health
Benefits (NIHB) program, which provides eligible First Nations
and Inuit populations,c regardless of where they live, with
supplementary health benefits for certain medically required
services where these individuals do not have coverage from
other public or private programs. Items covered include
prescription drugs, medical supplies and equipment, dental
care, vision care, short-term mental health crisis counselling,
and medical transportation.S6 In BC, responsibility for
bUnless otherwise noted, information in this sidebar has been excerpted
from A complex environment for Aboriginal health, found in Health Canada’s
2012 First Nations and Inuit Health Branch Strategic Plan, A Shared Path
to Improved Health.
c The federal government does not provide programs for Métis people.
administering benefits has been transferred to the new
First Nations Health Authority.S7 In the Northwest Territories
and Nunavut, the program is delivered in partnership
with the territorial governments. In the Inuit region of
Nunatsiavut in Labrador, the NIHB is directly managed
by the Nunatsiavut government.S8
Aboriginal Affairs and Northern Development Canada
funds an Assisted Living Program that provides non-medical
social support services and an Income Assistance Program
for First Nations seniors on-reserve in all provinces and
the Yukon.S4,S9,S10
First Nations and Inuit communities have taken on various
levels of responsibility to direct, manage, and deliver a range
of federally funded health services.S11 Over the past two
decades, First Nations and Inuit communities have assumed an
increasingly prominent role in the design and delivery of a wide
range of community health services, through a series of transfer
arrangements and contribution agreements with the federal
government.S12 Delivery of health services can be administered
in a variety of ways, from direct delivery of services by the First
Nations and Inuit Health Branch through to transferred health
services or ultimately self-government, where communities
have full control and responsibility for all aspects of providing
government services.S11
It is well documented that when initiatives are developed, led,
and managed by First Nations and Inuit, there is the greatest
potential for success in improving health care for their people.S12
They have the flexibility to tailor care to meet community-specific
needs within the local social, cultural, and geographic context.S12
Canada’s most vulnerable
However, a number of participants in the Health Council
meetings said that when communities assume more
responsibility and control, they also need time and support
to build infrastructure, services, capacity, and partnerships,
and that often seniors’ needs exceed the communities’ ability
to provide care. There is an important role for governments
to play in improving community infrastructure, increasing
capacity, and helping communities sustain their services.S12
Taking on responsibility for community health care is
complicated for many communities. Participants noted that
it is not uncommon for a community to be located across
two or more regional health authorities, each with its own way
of doing business—which complicates trying to build better
links and access to services for their people. There are also
First Nations communities that cross not only regional health
authority boundaries but also provincial boundaries.
Some participants emphasized that although they value
the programs funded by Health Canada and Aboriginal Affairs
and Northern Development Canada, these are chronically
underfunded and there is little coordination between them.
The result is significant gaps in services, leaving many seniors
without the very basic kind of health care and supports
available to other Canadian seniors.S4,S10,S13
Many participants noted the landmark shift in British Columbia,
where authority for health care for First Nations in the province
has been transferred to a provincial First Nations Health
Authority. In the words of the chair of the First Nations Health
Council, “This strong partnership ensures that this is not a ‘dump
and run’ administrative arrangement—it’s an arrangement
that recognizes that BC First Nations are best positioned to
make decisions about the health and wellness of their people,
supported and funded by the Government of Canada.” S7 The
federal government has indicated that they see BC as a model
for other jurisdictions.S14
Health Council of Canada
Distinct perspectives
Participants said that First Nations sovereignty and treaties d
form a unique political context for health care delivery
to First Nations people and communities. Differences in how
First Nations and various levels of government interpret the
rights and responsibilities associated with health care delivery
have generated significant gaps in care and services for First
Nations people and communities.
Participants said that federal and provincial governments
should agree on and clarify their roles in health care for First
Nations people and establish policy that puts seniors first in
cases where it is not clear who has jurisdictional responsibility.
They said that a “first contact–first pay” principle should apply.
They also called for an increase in the number of flexible
agreements between First Nations and federal funders, such
as allowing tribal councils to maximize resources by pooling
funding from different federal initiatives.
Respondents said that Métis people comprise one-third of the
total Aboriginal population,S18 yet they tend to be the “hidden”
Aboriginal population, which is reflected in significant gaps
in policy, programming, and services. Participants said the
needs of Métis seniors are often neglected by governments.
They said that a large barrier to good health for Métis seniors
is a lack of access to provincial and federal programs offered
to First Nations and Inuit populations, particularly the NonInsured Health Benefits program, which provides coverage for
items such as prescription drugs and medical transportation.S19
The federal government does not fund or provide health care
services or health benefits specifically to Métis people,S19
and we heard that most provincial and territorial health-related
programming for Aboriginal populations tends to focus on First
Nations or Inuit.
d Along with Aboriginal rights, which are also held by Inuit and Métis peoples.
We heard that Métis seniors often live in rural, remote, or
northern communities (many of which are adjacent to First
Nations communities) and struggle with many of the same
disparities in health determinants and the same health care
challenges that First Nations and Inuit seniors do, but there are
no specific Métis programs and providers don’t understand
Métis issues. Costs such as medication and medical travel
are at their own expense unless they have access to support
services such as those run by the Métis Nation of Ontario
(see page 48). There is also little access to culturally appropriate
and safe services in urban areas; most Aboriginal health
centres have a focus on First Nations.
Participants wanted to see a Métis-specific focus in health
care planning at the provincial and regional levels to ensure
that Métis seniors are recognized and included.
The Health Council held sessions in three of the four Inuit
regions: Nunavut, the Inuvialuit Settlement Region in the
Northwest Territories, and Nunatsiavut in Labrador (the fourth
region is Nunavik in northern Quebec).
The Nunavut Territorial Government delivers health care to Inuit
in Nunavut. The Nunatsiavut Government was formed in 2005
and delivers some aspects of health care to Inuit in Nunatsiavut.
Inuvialuit in the Northwest Territories and Nunavik in Quebec
are working towards self-government; they currently share
management responsibilities with their respective territorial
or provincial government and the federal government.
While each Inuit region is different, they share similar
barriers in delivering health care in the very small, isolated
communities where seniors live. While most communities
have health centres and some have telehealth, there is very
little access to specialized services. Travel is required for
anything beyond the most basic health care services. We also
heard about a dangerous lack of emergency care in some
remote communities, including no 911 system, paramedics,
emergencies supplies, or ambulances.
Canada’s most vulnerable
Health care providers are very limited in the North. Nurses
may be on staff to provide services, but physicians only fly
in to most communities. Staff turnover is high. Specialists
may be flown in a few times a year, but typically there are
long waiting lists for their services and little or no follow-up
due to the lack of consistent health providers in communities.
Many remote communities in the North cannot use telehealth
because they don’t have the infrastructure needed for many
of these medical consultations.
Medical travel from small Inuit communities to southern cities
results in tremendous financial costs to the health care system
and diminished quality of life for seniors, their families, and
communities. In Nunavut alone, the costs of medical travel and
treatment provided in facilities outside of the territory consumes
one quarter of the $290 million Department of Health and Social
Services territorial operations and maintenance budget.S20
Participants expressed concerns about discharge planning
practices for seniors who must travel to access care in Ottawa
or other urban centres in the south, and how they often fall
through gaps between health care systems. They discussed
the burden on family members who must leave their families
and jobs when seniors need care.
Since most Inuit seniors are unilingual, they typically need
to be accompanied when they travel. Communication can
be a challenge, as medical interpretation requires a highly
specialized vocabulary and is more than just the ability
to speak English and Inuktitut. Participants also noted that
Inuit seniors often have low health literacy—they may not
understand their diagnosis, how to manage their health
conditions, or why or how to take medications that have
been prescribed.
The need to travel with escorts also puts seniors at risk for
financial abuse and neglect. In the words of one participant,
“they are required to be escorted, and they often have little say
in who does the escorting, or they choose someone who takes
advantage of them.” Participants shared stories of younger
relatives who accompanied the senior as an escort or translator,
only to disappear into town with the majority of the money
provided for their meals, accommodation, and other expenses.
The financial, emotional, and physical abuse and neglect
of seniors in the North is taking a toll. Participants told us
they have had confidential discussions with Inuit seniors over
the years on the topic, indicating that it is a pervasive problem
touching many families. Seniors Societies are emerging as a
way to raise awareness of abuse, encourage open discussions,
and develop strategies to deal with it.
It is important to put the health and health care delivery
challenges into a broader context. The rapid change from a
traditional society, in which Inuit lived on the land and moved
with the seasons to follow wildlife migrations, to a modern
industrialized society has affected all aspects of Inuit health
and well-being. A higher-than-average incidence of suicides,S21
tuberculosis,S22 and chronic health conditions can be attributed
to these changes and the social determinants of health,
including poverty, poor housing, food insecurity, and poor
nutrition.S22 Any attempts to improve the health of Inuit seniors
requires acknowledging and addressing these factors.S22
Participants discussed solutions to improve health care for Inuit
seniors, including a new model of care that:
a continuum of care for seniors in their communities;
sustainable service delivery;
structures in place to ensure accountability,
coordination across government departments, and
processes for ongoing feedback;
cultural safety through respect for seniors’ culture,
language, and way of life;
their language needs; and
traditional Inuit ways into health care delivery.
Finally, participants said that governments should ensure
that community-based providers have the infrastructure
and capacity to implement policies and strategies.
Canada’s most vulnerable
Changing landscapes
and key approaches
Although there are significant gaps and challenges in
the delivery of health care for Aboriginal seniors, innovative
changes are underway across the country.
We heard that federal, provincial, territorial, and regional
authorities are increasingly stepping up to recognize their role
in Aboriginal health and partnering with Aboriginal people
and communities in developing new policies for seniors. There
were many discussions about the groundbreaking transfer
of health care to the First Nations Health Authority in BC,
and the memorandums of understanding and other formal
agreements to improve health care that were recently forged
or are in development between various levels of government
and Aboriginal leadership. Many regional health authorities
are also working to ensure that Aboriginal people are equal
partners in health planning.
Participants at our sessions shared the positive changes that
are unfolding in their communities and programs. We have
highlighted 12 of these practices in the next section; further
examples are available on the Health Council’s Health Innovation
Portal ( Embedded in these
stories is a sense of the changing landscapes in Aboriginal
seniors’ health care that are taking shape across the country.
An analysis of these innovative practices and the common
themes identified in our interviews and cross-country
consultations indicates that some key approaches are being
used to improve the health of Aboriginal seniors. These
are listed on the following pages, along with examples from
selected practices that were brought to the Health Council’s
attention. A complete listing of practices discussed by
participants can be found on page 60.
Federal, provincial,
territorial, and regional
authorities are increasingly
stepping up to recognize
their role in Aboriginal
Health Council of Canada
The specific needs of Aboriginal seniors should be a focus
in provincial healthy aging strategies.
Participants also shared several examples of partnerships
that were built from the ground up:
All governments are looking at ways to better meet the
needs of their aging populations, and participants noted that
provincial “aging in place” strategies must include Aboriginal
seniors and be responsive to their unique cultural needs.
one example, Ontario’s recent Living Longer, Living
Well report, a core document informing the province’s
Seniors Strategy, states that Aboriginal people are
“deserving of specific recognition given their particularly
unique set of experiences, challenges and needs.”34
the regional level in Ontario, Mamaweswen, the
North Shore Tribal Council, uses provincial Aging
at Home funding to provide discharge planning for
both First Nations and Métis seniors in the region.
Well-structured partnerships and agreements can
eliminate unnecessary disparities between what is
available to Aboriginal seniors and what is available
to non-Aboriginal seniors.
The largest-scale example of this is in BC, where the selfgoverning First Nations Health Authority is forming partnerships
and agreements with regional health authorities to ensure
that First Nations people will have the same care as other
BC residents.
Practices in bold type are profiled on pages 35-59.
Additional information is available on the Health
Innovation Portal
Practices marked with an asterisk (*) can be found
on the Health Innovation Portal.
Bella Coola, BC, an agreement between the Nuxalk
Nation, Vancouver Coastal Health Authority, and the First
Nations and Inuit Home and Community Care program
ensures that everyone in the community—First Nation
or not, on-reserve or off—has access to the same health
care services.
Alberta, the Siksika Nation has a Memorandum of
Understanding with the province that allows them to form
partnerships with provincial services, giving their people
access to a wide range of health care services without
compromising their Nation’s Treaty Rights to Health.
We also heard that:
Primary Care Networks are working to provide
everyone with a home for primary care, and the province is
working with three Treaty areas and the federal government
to develop a community care model.
tripartite Memorandum of Understanding on First Nations
Health and Well-Being in Saskatchewan is paving the way
for improvements in seniors’ care; long-term care is one of
the priority areas.
Nova Scotia, a Tripartite Health Committee identified
disparities in access to home care for First Nations on-reserve
and made this a priority issue, which led to a comprehensive
continuing care strategy. One of the major findings was
that health authority staff need “clear and uncluttered
information about provincial programs” that they can share
with communities.16 The committee also underscored the
importance of close relationships among First Nations
community health staff, residents, regional health authorities,
and multi-jurisdictional partners so they can work together,
often on a case-by-case basis, to navigate “the high level
of complexity and persistent confusion” in the maze of federal
and provincial policies for program eligibility and to clear up
any misconceptions about access.16
Canada’s most vulnerable
Consulting with seniors about their needs and identifying
community-specific requirements are indispensable parts
of planning.
There is little data about the health of Aboriginal seniors
in general, the services available to them, and how these
compare to services offered to the non-Aboriginal population.
Participants from communities and governments that have
conducted seniors’ surveys and other consultations said they
were surprised by some of their findings, and had changed their
strategies accordingly. These findings varied by community,
but participants indicated that many seniors are suffering from
grief and depression because of the state of their families and
communities; that basic concerns are buying and paying for
wood to be split and brought into their homes and not having
adequate food; and that assisted living in their community
is a much-preferred option to long-term care in the community.
Some of the governments and communities that have
conducted surveys to determine seniors’ needs and/or
developed an inventory of services include:
Scotia; 13,16,25
Council of Yukon First Nations; 33
Sioux Lookout Meno Ya Win Health Centre in Ontario; 26
North Shore Tribal Council in Ontario.
In addition, we heard that the First Nations and Inuit Health
Branch–Atlantic region, in partnership with First Nations
leadership, developed a tool to review policies through the
eyes of First Nations seniors. As a result, they have simplified
some long-standing procedures for medical travel.
Communities pull together and share a common approach
to ensure that seniors have coordinated, comprehensive
health care and safe living environments, allowing them
to stay in their homes.
Shared caregiving means that families, health care providers,
and community services come together, often pooling their
resources, to meet seniors’ full range of needs, including
health care, home support and maintenance, and reducing
their social isolation. Participants told us that shared caregiving
reduces stress for everyone involved, particularly seniors and
their families, who are often unable to provide the support their
parent or grandparent requires.
We heard many examples of this approach:
Ballantyne Cree Nation in northeastern
Saskatchewan has been nationally recognized for
its shared caregiving approach.
Nation offers a full range of seniors’ services,
including an Elders Lodge (assisted living) and
a comprehensive home care program.
Shakotiia’takenhas Community Services
in Quebec provides an integrated service delivery program
including an Elders Day Program, Meals on Wheels, an
Elders Lodge, and home care.*
BC, shared caregiving through the Saanich First Nations
Adult Care Society has reduced hospital readmissions and
improved staff retention.*
self-governing Carcross/Tagish First Nation in the
Yukon hires unemployed youth to shovel snow and chop
wood for seniors, and tackles the sensitive problem
of elder abuse.
Health Council of Canada
Many Aboriginal seniors are isolated
and struggling due to multiple factors
in their lives and communities; they
need more intensive support than nonAboriginal seniors.
In some cases, government is a partner in shared care. In the
Northwest Territories, the Department of Health and Social
Services works with other territorial departments, particularly
the Northwest Territories Housing Corporation, to help seniors
remain in communities by ensuring that housing, socialization,
nutrition, hygiene, home care, and related health needs are
met. While these efforts are relatively new, the Health Council
heard that there is some evidence that they have reduced the
number of seniors who have needed to leave their communities
for care.
Dedicated Aboriginal health centres, case managers,
discharge planners, and patient navigators are available
as necessary supports to help seniors and their families
make their way through the complicated maze of health
care services across jurisdictions.
We heard many examples of the importance of a dedicated
person or health centre to help seniors navigate the health
care services and providers they need for their care, a process
that is complicated by receiving care on- and off-reserve
(for First Nations) and in- and out-of-province or territory.
Participants said that Aboriginal seniors need this support
more than non-Aboriginal seniors due to the challenging
determinants of health, greater burden of physical and mental
health conditions, and the devastating effects of residential
schools on family bonds and communities, which have left
many seniors isolated and struggling.
Many communities and programs, including the Saanich First
Nations Adult Care Society in BC and the North Shore Tribal
Council in Ontario, are working with regional hospitals to
improve communication related to hospital discharge, to ensure
that seniors have a range of support in place when they arrive
home, and to prevent hospital readmissions.
We also heard that:
General Hospital has a well-established
discharge planning system. It was critical to put this system
into place because of the vast distances in the North, and
to ensure that health information was transferred from the
hospital to the health directors in self-governing communities
that are responsible for organizing a patient’s care. The
discharge planner fulfills a community liaison role and is able
to manage communication in a culturally safe manner.*
Canada’s most vulnerable
Alberta Health Services, the Aboriginal care coordinator
role is based on the case management model. The care
coordinator follows patients through the health care system,
supporting coordinated care in the hospital and integrated
care between the hospital and the community.*
Discharge Planning Toolkit developed by the Federation
of Saskatchewan Indian Nations has been identified as a best
practice by provincial home care consultants.
Ottawa, the Tungasuvvingat Inuit Family Health Team
Medical Centre and the Inuit Family Resource and Health
Promotion Centre bring an integrated team of primary
health care to Inuit who travel to Ottawa for medical care.
Nation of Ontario community centres are important
cultural and service hubs that link Métis people to each
other as well as to health services and supports in
their area.
Community health staff who are not regulated health
professionals are recognized as playing a key support
role for Aboriginal seniors in remote communities.
We heard that community staff do not need to be regulated
health care providers:
Nunatsiavut, community health aides function as
the nurses’ “right hands” and as cultural bridges for
southern nurses who are working in remote communities.
Because they provide such extensive support, community
health aides allow communities to manage with fewer
nursing staff.
Inuvialuit Regional Corporation and the Beaufort-Delta
Health and Social Services Authority in the Northwest
Territories use community wellness coordinators in a flexible
role that addresses mental health and wellness, crisis
intervention, health promotion, helping seniors with social
and traditional activities, and health advocacy as necessary
to meet community-specific needs. This program hires
only temporary staff from the south to fill health and social
service positions, with the goal of training and mentoring
local people to move into the positions permanently.
professional development to health care
providers in remote communities is often challenging.
Saint Elizabeth offers a national online education program
in elder care that allows health care providers to learn new
information without the need to leave their communities.
Health Council of Canada
Increased use of telemedicine, videoconferencing, and
bringing care to the community reduces medical travel
and improves cultural safety.
While some participants said that technical issues currently
make it difficult for them to rely on telemedicine or other
mobile health care, most wanted it to be used more widely
to reduce the need for medical travel. This is a particular area
of emphasis in BC: participants from communities and the
First Nations Health Authority said there is an increasing push
to use portable equipment and travelling teams for prevention,
screening, and treatment for a range of conditions such as
diabetes, hearing and vision testing, podiatry, mammography,
and dental care. They said that Aboriginal seniors will come for
care if a program is in the community, because the environment
is culturally safe. Participants identified some leading practices:
Sekani (CS) Family Services in BC uses telemedicine
to improve access to primary health services and palliative
care, resulting in reduced travel and costs, improved access,
and better continuity of care. This practice is receiving
a great deal of attention in the province, particularly from
the First Nations Health Authority.*
mobile chronic disease management team (kinesiologist,
nurse, and pharmacist) out of Rocher-Percé, Quebec,
works with clients in their remote home communities for
an intensive three-month program, teaching about their
diseases, food and exercise choices, and medication
management. Participants are showing significant health
improvements. The program, a partnership with the
Government of Quebec and Pfizer, and based on an
internationally recognized chronic care model, is being
considered as a model by the First Nations and Inuit
Home and Community Care (FNIHCC) program.
collaborative practice model in Saskatchewan brought
together FNIHB, the Kidney Foundation (SK Branch),
the Regina Qu’Appelle Health Region’s chronic disease
program, and three First Nations communities to care for
chronic conditions on-reserve.*
Telemedicine, a First Nations–operated company that
serves communities in northwestern Ontario, is a nationally
recognized leader in telehealth. Recently, KO expanded
its in-home camera service to home care, including
palliative care.
Nunatsiavut, a lifelike telemedicine robot allows southern
physicians to visit patients virtually in a remote community
health centre. Tele-oncology in the region has also been
identified as a promising practice for improving clinical
support, reducing travel for patients, and being cost- and
Acknowledging and integrating traditional culture
contributes to improving the quality of care, patient safety,
and quality of life for Aboriginal seniors.
While not all Aboriginal people follow traditional ways, culture
is particularly important to many seniors. A culturally safe
environment—one that honours their heritage and incorporates
their cultural traditions—is a crucial part of their care.
leading example of the value of integrating traditional
culture into the care of seniors is the Sioux Lookout Meno Ya
Win Health Centre in northwestern Ontario, which embeds a
Traditional Healing Medicines, Foods, and Supports program
in both its hospital and long-term care facility. Results
have included decreased medical errors and improved
patient satisfaction.*
Canada’s most vulnerable
Wikwemikong First Nation on Manitoulin Island in
Ontario provides seniors’ home care and a long-term facility
that follow teachings based on the medicine wheel and
holistic care.
cultural activities are integrated into all health
and social services programs under the Tlicho Community
Services Agency in the Northwest Territories, including
continuing care and independent living programs.
Saskatchewan, the Regina Qu’Appelle Health Region’s
home care program, nationally recognized as a leading
practice, features culturally safe services that are adaptable
according to clients’ needs and integrated with other
services to ensure clients do not fall through gaps.*
University in Thunder Bay is developing a model
for culturally appropriate and safe palliative care services that
will allow First Nations people to die in their communities.
A lack of culturally safe palliative care is a recognized gap,
and this work is of significant interest to participants.
Elizabeth’s First Nations Elder Care Course is an
example of how culture can be integrated into Western best
practices to support culturally safe care.
Reducing isolation through traditional and cultural
activities is part of good health care.
A number of participants said that seniors’ societies
and gatherings, particularly in the North, are an emerging and
important development. These social activities reduce isolation
and provide a low-key way to reach seniors with information
about health, wellness, aging, and elder abuse. They also
incorporate traditional activities and foods to keep seniors
connected to their cultures.
Many health care providers and organizations have
created community activities for seniors, either in person
or through technology:
Sioux Lookout Meno Ya Win Health Centre hosts regular
virtual gatherings using telemedicine technology and a bigscreen TV, accompanied by a traditional meal.
First Nations Adult Care Society and Peter
Ballantyne Cree Nation connect seniors with youth,
emphasizing the important role of First Nations Elders
and storytelling.
First Nation hosts regular gatherings for
all seniors in their region, First Nation and non-First Nation,
forging new friendships and community bonds.
Pond Inlet, Nunavut, the home and community care
program hosts a weekly Elders Tea aimed at reducing
isolation and reconnecting seniors with traditional foods
and activities, including going out on the land.*
Health Council of Canada
While the needs of all Canada’s seniors are important, the
health challenges of First Nations, Inuit, and Métis seniors are
more complex and in urgent need of attention. These seniors
are struggling with poor mental and physical health, the residual
effects of colonization and residential schools, and continuing
jurisdictional and organizational barriers that prevent them
from having access to the same level of health care as other
Canadian seniors.
The list of key themes outlined in the last section, along with
first-hand accounts of innovative practices profiled in Section 2
of this report, should provide health care providers, policymakers, and communities with ideas for improving the care
of Aboriginal seniors.
A number of overarching findings came from this work.
We heard that the best leaders—federal, provincial, territorial,
community, and Aboriginal—separate politics from service
delivery. They focus on building equal partnerships to resolve
problems and provide First Nations, Inuit, and Métis seniors
with access to the services they need.
We heard that case management is crucial at the front-line
of care. Whether the person’s role is case manager, patient
navigator, discharge planner, or community nurse, one
person needs to be the primary contact, with responsibility
for coordinating services and travel when seniors must leave
their communities for care. All governments should be offering
support and funding for these roles, as is the case in some
provinces and territories.
In addition, as governments and health care leaders address the
needs of Canada’s aging population, it is vital that they partner
with Aboriginal leadership to ensure that new policies do not
inadvertently cause problems for Aboriginal communities. It is
also important to develop healthy aging strategies that contain
a culturally appropriate and specific focus on the unique needs
of First Nations, Inuit, and Métis seniors.
Transferring the control of health care services from
governments to First Nations and Inuit communities has
great potential for improving the health of their people, but
participants stressed that this must be accompanied by the
necessary financial and program support as communities
develop the infrastructure and capacity to deliver these
services. Many participants, including those in provincial
governments, wanted more information about the federal
government’s future intentions regarding health care for First
Nations, Inuit, and Métis people.
In an August 2013 presentation to the Canadian Medical
Association, the federal Minister of Health said the government
will continue to look for creative ways of integrating First Nations
health care into the broader system, and that the creation of the
First Nations Health Authority in BC provides a model of how
First Nations can have a greater role in designing and delivering
health care while increasing integration with provincial health
systems. But participants in the Health Council consultations
asked for more clarity: Is the federal government’s role just
to transfer funds for health care services, or is it to be involved
in broader problem-solving, planning, and funding as well?
With significant inequities in health status and health outcomes
between Aboriginal and non-Aboriginal seniors, and a growing
population with unmet needs, governments must turn more
attention to the challenges faced by Aboriginal seniors and their
communities. The goal should be to improve care for seniors
through partnerships that focus on collaborative problemsolving, and to resolve confusion or disagreements about which
level of government is responsible for the improvements that
are needed. Some jurisdictions and communities have already
started this work, and we commend them for their efforts
and responsible approach. Others must now join them and
take up the mantle of leadership to address this critical health
policy challenge.
Canada’s most vulnerable
Eshkakogan., N., & Khalema, N.E. (2009). A contradictory image of need:
Long-term facilitative care for First Nations. In P. Armstrong et al. (Eds.),
A place to call home: Long-term care in Canada (pp. 66-78). Black Point,
NS: Fernwood Publishing.
Rosenberg, M.W., Wilson, K., Abonyi, S., Wiebe, A., Beach, K., & Lovelace,
R. (2009). Older Aboriginal peoples in Canada: Demographics, health
status and access to health care. Hamilton, ON: SEDAP Research Program.
Wilson, K., Rosenberg, M.W., Abonyi, S., & Lovelace, R. (2010). Aging
and health: An examination of differences between older Aboriginal and
non-Aboriginal people. Hamilton, ON: SEDAP Research Program.
Beatty, B., & Berdahl, L. (2011). Health care and Aboriginal seniors in urban
Canada: Helping a neglected class. The International Indigenous Policy
Journal, 2(1), 1-16.
Smylie, J. (2000). A guide for health professionals working with Aboriginal
peoples. Journal of Society of Obstetricians and Gynaecologists of Canada,
100, 1-15.
Reading, J. (2009). The crisis of chronic disease among Aboriginal peoples:
A challenge for public health, population and social policy. Victoria, BC:
Centre for Aboriginal Research, University of Victoria.
Aboriginal Healing Foundation. (2006). Volume III: Promising healing
practices in Aboriginal communities. Ottawa, ON: Aboriginal Healing
Turcotte, M., & Schellenberg, G. (2007). A portrait of seniors in Canada.
Ottawa, ON: Statistics Canada.
Special Senate Committee on Aging. (2009). Special Senate Committee
on Aging (Final report)–Canada’s aging population: Seizing the opportunity.
Ottawa, ON: Senate of Canada.
10. Beatty, B., & Weber-Beeds, A. (2012). Mitho-pimatisiwin for the elderly:
The strength of a shared caregiving approach in Aboriginal health. In
D. Newhouse et al. (Eds.), Well-being in the urban Aboriginal community
fostering Biimaadiziwin–a national research conference on urban Aboriginal
peoples (pp. 113-126). Toronto, ON: Thompson Educational Publishing.
11. Indian and Northern Affairs Canada (INAC). (2008). Aboriginal
demography– population, household and family projection 2001-2006.
Ottawa, ON: INAC.
12. Inuit Tapiriit Kanatami. (2013). Inuit-specific tuberculosis (TB) strategy.
Ottawa, ON: Inuit Tapiriit Kanatami.
13. Nova Scotia Aboriginal Home Care Steering Committee. (2010).
Aboriginal long-term care in Nova Scotia. Halifax, NS: Nova Scotia
Department of Health.
14. LaRose, L. (2010). Program supports First Nations people and their
families affected by dementia. Retrieved on October 23, 2013, from
15. Reading, C.L., & Wien, F. (2009). Health inequalities and social
determinants of Aboriginal peoples’ health. Prince George, BC: National
Collaborating Centre for Aboriginal Health.
16. Nova Scotia Department of Health and Wellness. (2012). Communications
strategy for provincial continuing care programs. Halifax, NS: Province of
Nova Scotia.
17. Aboriginal Affairs and Northern Development Canada. (2013). Assisted
living program. Retrieved on October 23, 2013, from
18. Health Canada. (2011). First Nations and Inuit Home and Community Care
2011 report. Ottawa, ON: Health Canada.
19. Tjepkema, M., Wilkins, R., Senecal, S., Guimond, E., & Penney, C. (2010).
Mortality of urban Aboriginal adults in Canada, 1991–2001. Chronic
Diseases in Canada, 31(1), 4-21.
20. Assembly of First Nations. (June 2005). First Nations Action Plan
on Continuing Care. Ottawa,ON: Assembly of First Nations.
21. Hirdes, J.P., Ljunggren, G., Morris, J.N., Frijters, D.H., Soveri, H.F., Gray, L.,
Björkgren, M., et al. (2008). Reliability of the interRAI suite of assessment
instruments: A 12-country study of an integrated health information system.
BMC Health Services Research, 8, 1-11.
22. Gray, L.C., Berg, K., Fries, B.E., Henrard, J-C., Hirdes, J.P., Steel, K., &
Morris, J.N. (2009). Sharing clinical information across care settings: the
birth of an integrated assessment system. BMC Health Services Research,
9(71), 1-10.
23. First Nations Information Governance Centre. (2011). First Nations regional
longitudinal health survey. RHS 2008/10 preliminary results, revised edition.
Ottawa, ON: First Nations Information Governance Centre.
24. Health Canada. (2011). Building quality healthcare–Final version. Ottawa,
ON: Health Canada.
25. Nova Scotia Aboriginal Home Care Steering Committee. (2010). Weaving
partnerships: A framework for Aboriginal home care in Nova Scotia, 20102011 resource guide. Halifax, NS: Nova Scotia Department of Health.
26. Woolner, F., Timpson.J., Mombourquette, L., & Wood, L. (2009). Elder care
environmental scan in Sioux Lookout zone First Nations. Sioux Lookout, ON:
Sioux Lookout Meno Ya Win Health Centre.
27. Health Canada. (2004). Transfer of health programs to First Nations and
Inuit communities. Handbook 1: An introduction to three approaches.
Ottawa, ON: Health Canada.
28. Health Canada. (2013). First Nations and Inuit Health: Non-Insured Health
Benefits for First Nations and Inuit. Retrieved on October 23, 2013, from
29. Saint Elizabeth First Nations, Inuit and Métis Program. (2012). Walk a mile
in my moccasins: Foundations for action in First Nations cancer control.
Markham, ON: Saint Elizabeth.
30. Health Canada, First Nations Inuit and Health Branch. (2012). Quality
improvement policy framework–Quality is everyone’s responsibility. Ottawa,
ON: Health Canada, First Nations and Inuit Health Branch.
Health Council of Canada
31. First Nations Health Council and First Nations Health Authority. (2013).
Transition update. Vancouver: First Nations Health Council and First
Nations Health Authority.
32. Nunatsiavut Government. (2009). Non-Insured Health Benefits (NIHB)
program. Retrieved on October 22, 2013, from
33. Council of Yukon First Nations. (2013). Yukon First Nations’ capacity
assessment. Whitehorse, YK: Council of Yukon First Nations.
34. Sinha, S.K. (2012). Living longer, living well. Toronto, ON: Ontario Ministry
of Health and Long-term Care.
35. Corvus Solutions. (2012). Cancer care and control in Inuit Nunangat. Wolfe
Island, ON: Corvus Solutions.
Sidebar references
S1. Rosenberg, M.W., Wilson, K., Abonyi, S., Wiebe, A., Beach, K., & Lovelace,
R. (2009). Older Aboriginal peoples in Canada: Demographics, health
status and access to health care. Hamilton, ON: SEDAP Research Program.
S2. Turcotte, M., & Schellenberg, G. (2007). A portrait of seniors in Canada.
Ottawa, ON: Statistics Canada.
S3. Eshkakogan, N., & Khalema, N.E. (2009). A contradictory image of need:
Long-term facilitative care for First Nations. In P. Armstrong et al. (Eds.),
A place to call home: Long-term care in Canada (pp. 66-78). Black Point,
NS: Fernwood Publishing.
S4. Special Senate Committee on Aging. (2009). Special Senate Committee
on Aging (Final report)–Canada’s aging population: Seizing the opportunity.
Ottawa, ON: Senate of Canada.
S5. Health Canada. (2011). First Nations and Inuit Home and Community Care
2011 report. Ottawa, ON: Health Canada.
S6. Health Canada. (2012). First Nations and Inuit Health strategic plan:
A shared path to improved health. Ottawa, ON: Health Canada.
S7. First Nations Health Council & First Nations Health Authority. (2013).
Transition update. Vancouver, BC: First Nations Health Council and First
Nations Health Authority.
S8. Nunatsiavut Government. (2009). Non-Insured Health Benefits (NHIB)
program. Retrieved on October 22, 2013, from
S9. Aboriginal Affairs and Northern Development Canada. (2013). Assisted
living program. Retrieved on October 23, 2013, from
S10. Johnston Research Inc. & Donna Cona. (2011, March 23). Indian and
Northern Affairs Canada Assisted Living Program national assessment:
Final report. Ottawa, ON: Johnston Research Inc. & Donna Cona.
S11. Health Canada. (2004). Transfer of health programs to First Nations and
Inuit communities. Handbook 1: An introduction to three approaches.
Ottawa, ON: Health Canada.
S12. Health Canada. (2011). Building quality health care–Final version. Ottawa,
ON: Health Canada.
S13. Beatty, B., & Berdahl, L. (2011). Health care and Aboriginal seniors in urban
Canada: Helping a neglected class. The International Indigenous Policy
Journal, 2(1), 1-16.
S14. Ambrose, R. (2013). Working together for real outcomes. Retrieved on
October 23, 2013, from
S15. Nova Scotia Aboriginal Home Care Steering Committee. (2010).
Aboriginal long-term care in Nova Scotia. Halifax, NS: Nova Scotia
Department of Health.
S16.Bourassa, C., Hampton, M., Baydala, A., Goodwill K., McKenna, B.,
McKay-McNabb, K., Saul, G., Clarke, V., et al. Completing the circle:
End-of-life care with Aboriginal families. Retrieved on October 23, 2013,
S17. Health Canada. (2007). Continuing care in First Nations and Inuit
communities: Evidence from the research. Ottawa, ON: Health Canada.
S18. Statistics Canada. (2013). Aboriginal peoples in Canada: First Nations
people, Métis and Inuit–National Household Survey 2011. Ottawa, ON:
Statistics Canada.
S19. Standing Senate Committee on Aboriginal Peoples. (June 2013). “The
people who own themselves”: Recognition of Métis identity in Canada.
Ottawa, ON: Senate of Canada.
S20.Health Canada. (2011). Canada Health Act: Annual report 2010-2011.
Ottawa, ON: Health Canada.
S21. Inuit Tapiriit Kanatami (ITK). (2012). Naniiliqpita. Retrieved October 13,
2013 from
S22.Inuit Tapiriit Kanatami. (2013). Inuit-specific tuberculosis (TB) strategy.
Ottawa, ON: Inuit Tapiriit Kanatami.
Canada’s most vulnerable
Section 2
and progress:
Innovative practices
as described by
the people involved
Health Council of Canada
Online education about elder care for
community-based health care providers
Saint Elizabeth’s “@YourSide Colleague” First Nations Elder
Care Course, Canada-wide
The need
In my previous role as a nurse supervisor for a First Nations
home and community care program, I saw that there were
major challenges in finding affordable, accessible, and
culturally appropriate health care provider training that meets
the needs and realities of First Nations people. Receiving
an education within the community was not often an option for
health care providers, and leaving the community for education
and training had several negative impacts on the health care
provider and the community—it affected the continuity of
care for their clients, increased the burden on the families
and community, and was a financial drain on already exhausted
community budgets. These problems were especially common
in remote communities.
We were cautious not to develop a pan-Aboriginal approach.
We wanted to make sure that people who take the course
understand that First Nations communities are very different
from one another. A key message spread throughout the
course is the need to understand that every community is
unique. Health care providers need to build relationships with
the communities to learn more about community-specific
cultural practices and protocols. They need to seek guidance
from a community champion to learn about the culture,
traditions, and practices within a community.
Being able to access culturally relevant health care training
and education that does not require travel is a fundamental
requirement in meeting First Nations realities.
Our program uses a unique model involving First Nations health
care providers, elders, and specialists in the development and
review phases of our courses. Our goal was to ensure that
we had comprehensive information to meet community needs
and to develop relationships of mutual trust and respect. We
started with a national survey of health care providers in order
to determine their needs for elder care information. After we
developed the course content, we put out a call for reviewers
from communities across the country—nearly 50 people
volunteered. In one example, a group of health care providers
gathered on three separate occasions to review and provide
their feedback. An elder was present at each gathering and
opened the day with a prayer as a customary tradition to
start off meetings in a good way. Feedback received from all
reviewers was then incorporated into the elder care course.
We also ran a webinar series on elder care that included
presentations by specialists and elders.
The new practice
Making a difference
The First Nations Elder Care Course is one of several online
professional development programs offered by Saint Elizabeth;
it is available at no cost to community-based health care
providers across Canada. The course provides evidence-based,
culturally sensitive education about First Nations history and
culture, as well as clinical information on health topics related
to elder care, such as falls, medication, nutrition, depression,
Alzheimer disease, elder abuse, and caring for yourself as
a health care provider.
The course was released in January 2013 and has received
an enthusiastic response, as indicated by new @YourSide
Colleague account creations, password resets, and multiple
phone calls requesting more information on the course.
Community representatives appreciate that the course provides
their staff with understanding and knowledge to provide a
safe environment along with respect and protocols in caring
for the elders. The goal in many communities is to keep elders
in their homes for as long as possible instead of moving them
to long-term care facilities.
It would take community home care staff several years to
obtain their Personal Support Worker certificates. They would
leave their families, communities, and positions for weeks
at a time. If there were a crisis or a death in a community
they would return home, losing out on training and delaying
their education. In addition, many times nurses come to
communities without a proper understanding of the importance
of culture and protocol and of building relationships within
the community.
Canada’s most vulnerable
The online training means that health care providers don’t
have to leave their communities to develop the knowledge and
skills they need to care for elders. Health care providers are
sometimes intimidated by online training, but most of them know
how to use Facebook and once they realize it’s just as easy,
they are very enthusiastic.
An elder care webinar series was delivered to promote the
newly released Elder Care Course and provide additional
education on the topics within the course. Three months after
the webinar series was completed, we sent out a knowledgeto-practice survey to help us determine what participants
had learned from the webinar and course, and the impact on
client care. The results were very positive: respondents told
us that the course stimulated more discussion and program
planning for elders in their communities, stimulated a change
in the course curriculum in a school of nursing, and reinforced
to health care providers that it is important to take a holistic
approach to care.
What changed
knowledge utilization and uptake
care providers in the community no longer need
to travel for elder care training
from outside who are going into communities
can learn about First Nations culture and how to build
good relationships with elders and communities
Key components
national survey of community health care providers
identified learning needs
guided cultural content throughout the
development of the course
advanced practice consultant in gerontology
provided clinical content
reviewers ensured that content was
relevant to their unique practice needs
Information provided by Marney Vermette, Engagement Liaison,
Saint Elizabeth First Nations, Inuit, and Métis Program.
Health Council of Canada
One home care program for everyone,
whether they live on-reserve or off
Bella Coola, British Columbia
The need
Bella Coola is a geographically remote community with limited
resources, situated on the central coast of British Columbia.
I was the federal health nurse there for years, until I went back
to university. When I returned, there was a vacant RN position in
the Nuxalk home care program: two community health workers
had been working to provide home support services, and
they had been working without supervision. Their dedication
and commitment was tremendous—they kept the program
operating in the absence of a nurse. I was hired by the province
to set up home care in the region.
I saw that people on-reserve weren’t getting services. The
community was economically depressed. Younger people
had left to find jobs, and they left behind an aging population.
There was no structured home and community care program,
and no integrated service delivery model between the services
offered on-reserve and those offered by the province. We
had five long-term care beds in a small community hospital,
and no assisted living.
Complicating the situation were factors such as budget
constraints, nursing shortages, and a lack of clarity around
staff roles and responsibilities. And everyone had a different
opinion about what a home and community care program
should look like.
The new practice
We now have a fully integrated home and community care
program situated in a new health centre on-reserve that is used
by everyone in the community. We provide services 365 days
a year to all community residents, both First Nations and nonFirst Nations, on-reserve and off-reserve.
We started with a shared vision to give people equal access
to care and the option to remain at home as long as possible—
not just in their community but in their own homes. We needed
an integrated care program to support this vision and we
wanted to build capacity for culturally sensitive care.
We started the planning by going to the Chief and Council of
Nuxalk Nation and saying, “Why don’t we work together and
set up a program for everyone?” Always talk to the Chief
and Council; they have to be behind you and working with you.
Because they knew me, there was trust and they agreed.
We went out on the road talking to the community, conducting
a community needs assessment, and meeting with the Nuxalk
Nation Health Director, with Elders, and with the RCMP.
We had a meeting between the Chief and Council, the United
Church Health Services (an affiliate of Vancouver Coastal
Health), Vancouver Coastal Health, and Health Canada’s
First Nations and Inuit Home and Community Care program
(FNIHCC), which offers home care on-reserve.
We got federal and provincial funding and made just one
home care program where there had been two (the province’s
program and the federal FNIHCC program). We made
an agreement that the Nuxalk Nation would deliver services
on-reserve, and they would send funding to our program.
We had full community support. In 2007, we slowly began
to integrate all programs based on what the clients needed,
not based on whether they lived on- or off-reserve.
Everyone in the Bella Coola area uses the on-reserve health
centre, whether or not they are First Nations and whether
they live on- or off-reserve. Clinic programs include foot care,
wound care, blood pressure monitoring, diabetes education,
and a bath program, which can be done as part of the adult
day program. We use the interRAI home care assessment,
make home support visits, and develop a care plan based on
the assessment. We also offer an interdisciplinary palliative
care program. We manage palliative clients by being kind,
gentle, and respectful of their wishes, by knowing them and
their environments, and by providing constant support.
The program is like a hub that offers primary health care,
telehealth, pharmacy, mental health and addictions programs,
public health services, social services, and an administrative
office to support patient travel. We are connected to all of
these services and we meet with doctors weekly to review
our clients’ concerns. We are also connected to specialists
outside the community. For example, for wound care, we have
Pixalere, a complete wound care management system. We use
telehealth so we are connected virtually to highly skilled teams.
We are also connected to BC’s health information network and
medication database, Medinet.
Canada’s most vulnerable
We work together—federal, provincial, and band-employed
workers—in interdisciplinary teams with clear roles and
responsibilities. There is no new money; we pooled our funding
streams to work around budget constraints. By coming together,
we expanded our capacity and flexibility. For instance, there
is a four-hour cap on the number of hours of home support we
can provide to a client in a day. But if a couple of more hours
a day means that the client can stay in the community and
in their home, then we provide more hours. We did this for one
woman and she was able to die at home. It’s good quality care,
and it’s cost effective for the system.
In addition, working towards and then passing the Accreditation
Canada program was a huge benefit because it helped us
focus on where to make improvements.
Making a difference
Before we integrated, the people on-reserve didn’t have access
to most of these programs. Now they do.
There is no doubt that we are making a difference to the quality
of care. Some benefits include fewer emergency room visits and
hospital admissions, and a decrease in the number of alternate
level of care (ALC) clients at Bella Coola General Hospital.
We’ve transitioned some people who had lived in the hospital
for more than a year back into their homes. Patient travel has
been reduced. And due to improved foot care, no one has had
an amputation in years—that’s really significant.
Seniors are remaining active at home, and they are happier
and healthier. They receive culturally competent care. We
try to hire local people; they go off to do further training and
education and then return. Health providers are also satisfied—
we don’t have a high staff turnover.
Other communities are interested in developing the same type
of integrated program. We tell them your standards of care are
going to be the same—how you do your lower limb assessment,
how you clean your tools, how you chart—but how you deliver
the care might be a little different because of the culture in your
community. And you have to know the community. I’m not of
Nuxalk ancestry, but, you know, it just works.
Information provided by Glenda Phillips, Manager, Home & Community
Support, Bella Coola General Hospital.
What changed
programs—the federal on-reserve home care
program and the provincial program—were replaced
by one integrated program in the community
living on-reserve have access to the same
services as people off-reserve
of care and access to care have improved
shortages were eliminated, and there is clarity
around roles, responsibilities, and scope of practice
Key components
person identified a gap and was a champion
for change
Chief and Council were consulted first—
their support was crucial
federal government, province, regional health
authority, and band were willing to explore a different
are hired from within the community
and developed
shared-care approach means the whole community
is working together
Accreditation Canada program helps to drive
quality improvement
use of technology and assessment tools improves
client care
Health Council of Canada
Providing integrated services
to elders on-reserve
Siksika Nation, Alberta
The need
The health needs of elders are many, and so are the challenges
of delivering care to them. A lack of federal investment has
meant a lack of service in the communities. Aging elders
are suffering from a number of health conditions—including
diabetes, cancer, mental health issues, and addictions—
that require a range of primary health care, acute care, and
longer-term services and supports.
All levels of housing are needed, but in particular long-term
care facilities, which are lacking in First Nations communities.
Currently, when an elder can no longer be cared for in the
community, they must be assessed for long-term care by an RN
in a hospital. After the assessment has been completed, they
are placed on a waiting list. Placement may take months, and
the first available bed may be many miles from the community.
This leads to isolation and loss of culture.
Beyond health care services, there are the social determinants
of health—poverty, housing, food insecurity, and the general
challenges associated with living in isolated areas with poor
infrastructure. These conditions get in the way of providing
good care.
The new practice
Siksika Health Services is a non-profit, incorporated entity of the
Siksika Nation. With the lack of federal investment, we have had
to find alternative ways to build capacity. To improve access
to services, we entered into a Memorandum of Understanding
(MOU), originally with the Calgary Health Region and then with
the Province of Alberta (after amalgamation of the regional
health authorities). The MOU delineates mutual responsibilities
and accountabilities regarding the provision of health care
services without disturbing Siksika Treaty Rights to Health. We
also built partnerships with a range of organizations.
We are an accredited First Nations health organization offering
a broad range of health care services and programs on-reserve,
including a dedicated elders services area with an Elders
Lodge (assisted living) and home care program. It is truly
a great achievement to continue to retain accreditation status
on a national basis, as it indicates to us that we are providing
quality health care to our communities.
Our services include home visits for elders who are frail
or recently discharged from hospital; meal delivery and
homemaking; medication delivery; medical transportation and
escorts for medical appointments outside of the community;
case management; occupational therapy; assessments for
mobility equipment needs and home assessments for home
modifications; assistance with bathing at our health centre;
basic and advanced foot care for elders; and palliative/endof‑life care.
Elders also receive primary health care, chronic disease
prevention, and management of mental health issues,
including traditional counselling, addictions programs,
and social work/case management—all delivered through
a team-based approach.
To address the gap in long-term care and support continuing
care, we work closely with the local hospital by participating
in weekly discharge planning rounds via telehealth and
by attending case conferences to assist the elders and their
families. To provide palliative care, we partnered with the
Calgary Rural Primary Care Network.
We also partner with radiologists to provide ultrasound
services on-reserve. We work closely with Aboriginal Affairs
and Northern Development Canada to provide assisted-living
services, and we also work closely with the Non-Insured
Health Benefit program and the federal First Nations and Inuit
Home and Community Care program.
Siksika Health Services has invested in information technology
and formed partnerships that allow us to connect to Alberta’s
SuperNet so that health providers have better and faster access
to telehealth, medical records, digital X-rays, and more. Siksika
Health Services also uses electronic clinical information systems
for medical records and for the community health immunization
program. Netcare is also provided to physicians and for nursing.
Canada’s most vulnerable
Making a difference
Dramatic improvements are made when First Nations reach
agreements with the federal and provincial governments and
develop partnerships for new health care service delivery
models. We’ve been very successful in improving access to
home care and a continuum of integrated care for First Nations
seniors in our Treaty area (Treaty 7). We are seeing evidence
of this success. Outcomes include helping elders regain their
independence following illness or surgery and preventing
further disability. Elders are being supported upon discharge
from the hospital and are remaining comfortably and safely
in their homes for longer.
We have some ongoing challenges. There is limited funding
to recruit and retain licensed professionals to work in home
care and in the Siksika Elders Lodge, as well as to provide
extended hours of care. Wages are lower for our home care
registered nurses and licensed practical nurses compared
with nurses who work for Alberta Health Services (AHS). And
improvements still need to be made to provide access to longterm care in First Nations communities so elders are not forced
to move to far-away communities. Also, as AHS hospitals
continue to decrease length of stay and rely on home care to
provide care after hospital discharge, we are stretched because
Siksika Home Care does not receive additional funding.
At a higher policy level, a major overhaul is required for First
Nations to truly realize prosperous health and positive change
for future generations. The federal First Nations and Inuit Health
Branch is mainly concerned with delivering programs in the
short term, rather than taking a long-term, strategic approach.
This results in increased health needs and costs. A stronger
focus on investing in First Nations health and developing our
capacity is required.
We are hopeful that some changes are underway. Three treaty
areas are working with the federal and provincial governments
to develop a community care model through a Health Services
Integration Fund project, which is expected to be complete
by 2015.
Information provided by Tyler White, Chief Executive Officer, Siksika
Health Services, and Cheryl Sorenson, Team Leader, Siksika Home
Care/Siksika Elders Lodge.
What changed
access to a range of housing options,
including home and continuing care—allowing elders
to remain safely in their own communities
access to a full range of health
care services—allowing elders to regain their
independence following illness or surgery and
preventing further disability
palliative/end-of-life care
discharge planning, ensuring coordinated
care and good communication between the hospital
and the community
Key components
and partnerships with governments, regional
health services, and other organizations
leadership among Siksika First Nations and
Siksika Nation Health Services
the accreditation process and maintaining
our accreditation status
technology, which in turn supports the
recruitment of health professionals and the continuity
of care
Health Council of Canada
Shared caregiving in the community
Peter Ballantyne Cree Nation, Saskatchewan
The need
The Peter Ballantyne Cree Nation (PBCN) consists of over
8,500 Woodland Cree members residing in eight largely
isolated communities in northeastern Saskatchewan. Elder
care is a growing priority for PBCN, as increasing numbers
of seniors require higher levels of specialized health care
that is offered primarily in urban centres. Managing chronic
medical issues, especially in seniors over 70 years of age, is
a real concern because of the lack of community-based longterm care facilities, palliative care, respite care, and after-hour
care services.
This serious situation is complicated by jurisdictional
disagreements over authority and financial resourcing, and
by the fragmentation and lack of coordination provided by
the federal government, the provincial government, and the
regional health authority when it comes to providing services
both on- and off-reserve. Elders travelling between their
home communities and urban areas are especially vulnerable
because there are no service links or communication between
northern and southern services. Increasingly, PBCN Health
Services is being strained to capacity and is continuously
struggling to find innovative means to help the elderly.
The new practice
Many years ago, PBCN Health developed an organized and
more structured home and community care program based
on the needs identified by elders and their families. While
this provided an excellent foundation for improved, culturally
responsive services, it also became evident that we needed
more networks and resources to support the diverse needs
of the elderly.
We developed a Home and Community Care Service
and Delivery Plan that helped identify short- and long-term
strategies to enhance the federal First Nations and Inuit
Home and Community Care (FNIHCC) program. Community
resources were pooled for some services, and plans for
serving the elderly were coordinated using all community
services; a proper strategic plan for eldercare was a necessary
next step. Improving access to primary health care was the
critical factor for all PBCN health centres in the communities.
When an elder cannot come to the clinic, the home care
staff either provides transportation or offers at-home nursing
and home help; when needed, a doctor provides bedside
care. When an elder needs to leave his or her community
for care in the south, PBCN Health helps the caregivers,
the family, and the patient bridge the north-south divide by
assisting the elder’s transition into the urban health care
setting. PBCN Health has home care nurse assessors who
advocate for, and work with, the elderly and their families to
arrange long-term care or hospital care in conjunction with the
home care director located in Prince Albert, which is the main
urban setting for PBCN. Networking between the community
health care providers and the urban (provincial) health care
providers is fundamental to providing consistent, coordinated
care. It is crucial for PBCN Health to help coordinate medical
health information on behalf of the elderly so that the patient’s
most up-to-date information is shared with the urban
health providers.
PBCN Health continues to ensure that trained, Cree-speaking,
local home care aides and elder coordinators are available
to help the elderly navigate the medical system and provide
translation, transportation, and other support services.
Other focus areas include working with local agencies to help
elders stay at home for as long as possible. For example, in the
winter, wood and assistance with propane costs are provided
to the elderly. An elder worker helps to provide transportation
and organizes traditional and social activities like grocery
shopping and blueberry picking.
Working together at the community level and coordinating
the community and urban health providers are the crux of the
shared caregiving approach.
Canada’s most vulnerable
Making a difference
From 2008 to 2010, PBCN Health did a small study on its PBCN
elder care programs and services to explore how they could
better facilitate the respect and dignity of the elderly during
chronic and/or end-of-life care in the communities.
Results showed that the shared caregiving model helped the
FNIHCC program to enhance its local services to the elderly,
largely by good local planning and implementation, and by
better coordinating services with urban hospitals and long-term
care facilities. More elderly people in their late 80s are able to
stay at home rather than being forced into urban facilities. The
multi-level programs, including home care, offered in the PBCN
health centres have helped promote independence in the elderly
and allow them to remain at home for as long as possible.
Although some elders have had to leave the community for
long-term care or hospital care, PBCN health providers ensure
that they don’t fall through the cracks by linking community and
urban health care services through coordination and advocacy.
It’s noteworthy that the primary health model that PBCN
promotes through the shared caregiving approach is aligned
with health reforms occurring across Canada—reforms that
go beyond the medical model and take into account other
social and economic factors affecting health.
Research shows not only that working together can address
complex jurisdictional issues, but also that broader policy
and jurisdictional issues affecting local health services and
infrastructure must be addressed at higher political and
policy levels. The need to build long-term care facilities in the
communities is a prime example, as is the need to coordinate
services with the urban health care and long-term care
providers. Furthermore, there has never been an Aboriginal
elder care strategy at either the provincial or national level,
but such a strategy is crucial for better organization, efficiency,
and coordination of efforts.
Information provided by Arnette Weber-Beeds, Executive Director,
Peter Ballantyne Health Services, and Bonita Beatty, Assistant
Professor, Department of Native Studies and Co-Director, Graduate
Studies, International Centre for Northern Governance and
Development, University of Saskatchewan.
What changed
quality of care for elders, including culturally
safe care
coordination across jurisdictions and health
care providers
use of resources through collective efforts
supports for families
Key components
vision and focus on improving care of the elderly
stable, structured, and well-supported home and
community care program
services, which made a big difference
with elders and their families to understand
their needs
safe programming and activities
and collaboration among agencies
Health Council of Canada
Improving care and reducing
isolation for elders
KO Telemedicine in northwestern Ontario
The need
Our catchment area includes communities in northwestern
Ontario that are geographically isolated. They are culturally
distinct and have less access to health care services and
lower health status compared to the rest of Ontario. Most are
fly-in communities without road access, which makes it more
challenging and expensive to travel for health care. Some
communities are so remote that sometimes clients cannot
even travel to nursing stations to access telemedicine.
There is also the issue of the isolation of elders from
community events as well as from their families. Many family
members, such as adult children or siblings, move away from
the community. It is very expensive for elders to travel, even
if they are physically able to do so. Elders become lonely, and
some are without caregivers to support them. If elders have
difficulty leaving their homes they might not have access to
care or to information about health and wellness topics, or
even know which health care services are available. They need
access to a full continuum of care, the opportunities to ask
questions about any topic, and to be connected to their families
and communities.
The new practice
KO Telemedicine is a First Nations-operated, not-for-profit
organization affiliated with the Ontario Telemedicine Network
(OTN). It serves 26 communities in the Sioux Lookout Zone
of northwestern Ontario. It has won awards for its work, and
has been recognized as a best Aboriginal practice in the
country and in the world.
In our region, physicians and other health professionals visit
communities if the weather permits, but it’s very costly and timeconsuming. Telemedicine—the use of information technology
to link health care providers and patients onscreen—improves
access to a range of health care services and professionals.
It is especially valuable for follow-up care.
KO Telemedicine is as much about the people as the
technology. In our region, community telemedicine coordinators
are the cornerstone of our service. Supported by off-site health
providers, they are the eyes and ears of what’s happening
in the community. Their roles are flexible and they are a great
resource in so many ways. They often help with a range of
tasks including translation, providing appointment reminders
to clients, and technical assistance.
A lot of telemedicine is done at designated telemedicine sites
such as nursing stations and health centres, but it can also
be done in a person’s home with a hand-held camera. We
recently expanded this in-home service to include home care.
A community telemedicine coordinator will take a camera
into a client’s home and move it around according to a health
care provider’s direction. This allows the health care provider
to assess the safety of the environment and/or to see the
patient up close. Assessments are done not only by doctors
and nurses, but also by physiotherapists and occupational
therapists who assess the need for assistive devices such
as handrails, leg braces, walkers, and wheelchairs. A virtual
social worker might also be involved to help explain things
or to talk about the mental and emotional impact of a condition.
In-home cameras also allow us to link service providers
together. For example, a home care nurse can be in the home
virtually to support a personal care worker when he or she is
doing a dressing change, or to provide advice on how to turn
a patient. In-home cameras are being used for palliative care
as well.
KO Telemedicine also plays a huge role in reducing the
isolation of elders. We hold monthly Elders’ Gatherings, where
elders can visit virtually with family and elders who live in other
communities. A medical van picks up the elders and brings
them to different telemedicine locations. There, they meet
onscreen with each other, family, and friends, and hear about
educational health and wellness topics. It is a highly anticipated,
social way of connecting with loved ones.
Canada’s most vulnerable
Making a difference
In general, elders have been accepting of telemedicine.
Elders have told us there was a prophecy long ago that this
type of technology would come. Telemedicine makes sense
to them; they don’t like to leave home, and travel is physically
more challenging.
Telemedicine can make a huge difference in health care.
KO Telemedicine heard from a family that wished it had known
about our in-home service. An elder with diabetes and foot
trouble refused to go to the nursing station because he believed
they would tell him that he needed to leave the community for
care. Finally, he became seriously ill and needed to have his
toes amputated. He had to be medevaced out to a city hospital.
The daughter stayed by his side, but the treatment took three
weeks and she ended up losing her job. When they returned,
they learned about the in-home service through the home
care program, which could have provided wound care earlier
on, and could have possibly prevented the escalation of his
condition. There is more work to be done in terms of making
people aware.
Telemedicine is not perfect—for example, the technology,
the Internet, and the weather can sometimes make things
unpredictable, but overall KO Telemedicine has had great
success. Without question, telemedicine in general, and the
in-home service specifically, has improved access to an
integrated continuum of quality health care that’s helping elders
to stay in their homes longer. It also reduces costs. Overall,
telemedicine reduces isolation, which improves health and
well-being. In addition, providers and clients are very satisfied.
Information provided by Heather Coulson, Project Development
Coordinator, KO Telemedicine.
What changed
need to leave the community for care
health outcomes
provider, family, and patient confidence
and satisfaction
Key components
community telemedicine coordinators
and a strong, supportive community team
care providers who realize the importance of
telemedicine for elder care and who are willing to use
the technology
and partnerships to enable the growth and
development of services
Health Council of Canada
Building bridges between First Nations health care
providers and the mainstream health care system
Mamaweswen, the North Shore Tribal Council, Ontario
The need
There was disconnect and a real gap in the communication
flow when seniors were being discharged home from the
hospital back to their First Nations community. No referrals were
being made to community services to ensure follow-up care.
Clients would return home after the hospital stay but community
support services were not aware of the hospitalization or
the need for follow-up care and assessment, homemaking
services, assistive devices, and general support that would
enable the clients to live independently.
The new practice
A partnership was formed between the North Shore Tribal
Council (NSTC), the Indian Friendship Centre, and the Métis
Nation of Ontario in Sault Ste. Marie to provide collaborative,
integrated care and a client-centred case management
approach to the senior population. We now have two First
Nations system navigators/discharge planning nurses in place
as part of the discharge teams at the hospitals in our region.
When seniors are admitted to the hospital, they are encouraged
to identify as a First Nations, Aboriginal, or Métis senior—then
they are referred to the service. If a client accepts our nurses’
involvement, we have access to the chart and become part
of their discharge team. The nurse works in collaboration with
hospital staff, the Community Care Access Centre, the client
and family, and the NSTC communities to assist in the client’s
transition back home. Some of the discharge planning nurses’
roles include visiting clients at the bedside to assess needs;
attending rounds and being a part of developing discharge
plans; keeping clients and families informed about discharge
information; helping clients to understand their conditions and
how the discharge plan will help; advising the First Nations
community support services of discharge dates and ensuring
that services will be in place; and providing follow-up home
visits to ensure that appointments with health care providers
are in place and kept.
We were able to do this program because of provincial funding.
The Tribal Council already has a comprehensive primary care
program as well as a Community Support Services program for
elders; this was a much-needed enhancement to our services.
We submitted a proposal to our Local Health Integration
Network (LHIN) under the province’s Aging at Home Strategy.
A requirement of applying for the provincial funding was
to partner with other organizations. The NSTC invited both
the Indian Friendship Centre and the Métis Nation in Sault
Ste. Marie to be part of the provincial proposal.
We have established a very good working relationship with our
LHIN and we meet regularly. When our LHIN initially started,
they met with our Chief and Council and discussed programs
and funding that we could access through LHINs. Our Chiefs
approved working together with the LHIN, and said they would
address the fiduciary responsibilities of the federal government
at a different level. The politics were separated from the service
delivery in order to work together to bring these services to
our seniors.
Making a difference
Now when we have individuals in the hospital, we know who
they are and when they are going home, and we are able
to put services in place for their continued care at home.
This program has also enabled us to look at what additional
off-reserve services are available to wrap around their care,
if required.
I think it was a real education for the hospital as well as the
Community Care Access Centre to realize the level of services
provided in our communities. We offer homemaking services,
therapy services, and nurse practitioners, including a specialized
geriatric nurse practitioner who can do assessments. We also
provide linkages to mental health programs and to traditional
health programs in the communities. Having us come in and be
a part of discharge planning has helped break down barriers.
Canada’s most vulnerable
Our next steps are to track whether these efforts are reducing
hospital readmissions. Also, we want our discharge planning
services to be truly integrated within the health care system
as part of the hospital admission and discharge process. Right
now it’s based on front-line workers’ relationships; if those
change, which happens because of staff turnover, then we’re
back to re-establishing those linkages with a new person.
It has also been difficult for one of our partner hospitals to feel
comfortable with their staff asking questions about Aboriginal
descent in order to identify people who need our services. It
is also difficult for our seniors who go to the hospital and are
asked that question for the first time. Their worry is that they
will have to wait longer or that they’ll receive substandard care
if they say they’re First Nations. There is still a perception of
racism. We brought in a cultural worker to do training on cultural
safety, and we’re working with the hospitals around language—
suggesting they say, for example, “If you are of Aboriginal
ancestry, you would be eligible for this discharge planning
service: would you like to receive it?” rather than “Are you an
Aboriginal person?”
As part of our broader services for seniors, we are also looking
at housing options in our communities. Our leadership had
looked at the projected population and health issues and
thought that a long-term care facility for First Nations was the
answer. We commissioned a study and community consultation,
and we came back with a new vision because the elders were
saying, “Because of the residential school experience, we don’t
want to be institutionalized again. We want to stay home and
we want to live in our own homes and in our own communities.”
So instead, we’ve submitted a proposal for provincial funding
for assisted living for high-risk seniors. The services would
wrap around the individual’s assessed needs, and there would
be various levels of care in order to keep these seniors at
home longer.
Information provided by Edith Mercieca, Community Support Services
Manager, Mamaweswen, the North Shore Tribal Council.
What changed
quality of care for seniors—a smooth return
home with services in place
misperceptions (by hospitals, CCAC, and
First Nations and Métis clients) about services that are
available on- and off-reserve
understanding, communication, and trust
between hospital and communities
Key components
delivery kept separate from politics
built between on-reserve and urban
service providers in order to provide hospital
discharge services to First Nations and Métis seniors
within the catchment area
Health Council of Canada
Supporting Métis seniors and families
Métis Nation of Ontario community centres
The need
One third of all Aboriginal people in Canada are Métis. The
Métis population is also one of the fastest growing populations
in Canada, having doubled in the past 10 years or so. It is also
an older population compared to other Aboriginal groups.
From our research, we know that many of our seniors are
experiencing significantly higher rates of chronic disease and
other complex conditions compared to non-Métis Ontarians.
Métis people also fall under a different legislative and regulatory
structure than do other Aboriginal groups, and do not have
access to programming supports such as the Non-Insured
Health Benefits program. Many also live in more remote and
rural areas.
These kinds of factors can sometimes prevent Métis seniors
from receiving the proper health care and treatment they need.
Many have limited incomes. Things like transportation to see
doctors and specialists, as well as having the money to fill
expensive prescriptions, can become a problem. Specialist care
can also be an issue; for example, it can be difficult to obtain
foot care for Métis people with diabetes. These kinds of services
are often out of the reach of many Métis seniors because of
social, geographical, and other barriers. This is especially true
for those living in more rural and remote communities. Last but
not least, access to culturally safe care is extremely important
for our older Métis community members and, in fact, for the
Métis community more generally.
The practice
It is for all these reasons and more that our Métis Nation of
Ontario (MNO) community centres were developed. Situated
in 18 historical Métis communities distributed across the
province, MNO community centres serve as important cultural
and service hubs that link our Métis citizens to each other,
as well as to health services and supports in their local areas.
The MNO community centres are especially important in
providing our Métis seniors with the kinds of social and cultural
supports they need, and with assistance in accessing medical
services. Some of our centres also offer specialist services
such as foot care clinics for seniors and other Métis people
suffering from diabetes. MNO community centre workers also
do a lot of outreach to Métis seniors and other citizens in need
of assistance, visiting their homes on a regular basis to help
with things like meal preparation, house maintenance, and other
tasks of daily living. As well, in some centres, we are now able
to provide transportation services to help Métis seniors travel to
their medical appointments. Most importantly, the MNO centres
are based on a holistic, family-centred model of care for our
senior citizens that has deep roots in our community-minded
Métis culture and way of life. They provide much-needed
and very tangible support to Métis senior citizens who are at
heightened risk of falling through the cracks in our complex
health care system.
Making a difference
For the many Métis seniors and other community members
who are suffering from significantly higher rates of chronic
diseases and conditions, MNO community centres provide a
place where they meet with other Métis community members,
receive appropriate support and care, and get help in
linking to essential services and programs in the broader
community. The centres also provide a haven for culturally
safe community care.
The MNO service model is unique in the province in both its
scope and conceptualization, and has been hailed as a best
practice. MNO’s programs and services receive provincial
support through a number of ministries, including the Ministry
of Health and Long-Term Care’s Community Support Services
Program, the Ministry of Aboriginal Affairs, and the Ministry
of Children and Youth Services, among others. Programs and
services are also supported by the MNO’s large volunteer
base, which includes the Métis Provincial Councils, the Youth
Council, and Métis Senators. Together, the centres provide
critical support for Métis seniors, particularly those in more rural
and remote areas who might not otherwise be able to benefit
from essential health services and programs because of social,
cultural, and geographical barriers.
Canada’s most vulnerable
As the MNO continues to build its community centre
programming, we are looking to strengthen our local care
networks for Métis seniors and other citizens, as well as
MNO prevention and health promotion programming and
services. From our research we know that chronic disease
and complex conditions are particular issues for our senior
community members, and this will be an important focus
area for us as we move forward, as will knowledge translation
more generally. We are now providing specific training to our
Community Support Services on chronic disease, for example,
and are exploring ways to enhance our outreach and in-home
supports to enable seniors to live independently and stay
in their homes longer.
What changed
health and well-being for Métis seniors
access to culturally appropriate and safe
care for seniors, both in their communities and
in their homes
Métis community support in the form of
cultural programming and activities offered through
the centres
the cultural and social isolation and
loneliness that so many seniors experience
awareness of Ontario Métis culture and
people, and their unique history, needs, and aspirations
Key components
seniors and other clients are involved in the
development and delivery of programs and services
to ensure that their health and broader well-being
needs are met
appropriate and safe care
leadership combined with the ability
to build effective teams
training for all staff and volunteers involved
in care and service delivery
a “determinants of health” and holistic
approach to developing and delivering programs and
services that are grounded in Métis community
and culture, and built around identified client needs
out to Métis seniors who, because of
significant cultural, social, and geographical barriers,
may not otherwise have access to the care and
supports they need to live healthy, independent lives
Information was provided by Wenda Watteyne, Director of Healing
and Wellness, and Dr. Storm J. Russell, Senior Policy and Research
Analyst, Métis Nation of Ontario.
Health Council of Canada
Bringing chronic disease self-management
to rural and remote regions
Rocher-Percé, Quebec
The need
Our population is estimated at around 17,000 people who
are scattered along the coastline and throughout the vast
territory of Rocher-Percé. Approximately 60% of our clients are
seniors. Chronic diseases are a significant problem, with risk
factors such as obesity, hypertension, high cholesterol levels,
a sedentary lifestyle, alcohol abuse, and smoking.
Accessing treatment is also a problem, especially for people
with cardiovascular disease, pulmonary disease, diabetes,
and renal disease. We have a small team at the health centre
(centre de santé et des services sociaux du Rocher-Percé)
with limited capacity and resources—specialized resources
are far away. Clients travel to Montreal and Quebec City. Even
Rimouski, which is the closest place, is a five-hour drive away.
Our clients were overloading the hospital emergency room,
which is a very costly experience. And we know from our clients
and the hospital directors that programs were not operating
efficiently. For example, there were separate clinics to treat each
chronic disease. Not only was it an ineffective approach for the
clients because they had multiple chronic diseases, it was also
an inefficient use of staff resources. In most cases there would
be two or three different nurses working on the same client, but
they weren’t communicating among themselves. So, the nurse
looking after someone with diabetes didn’t know that her client
was also being followed by another nurse for another condition.
Sometimes the client became mixed up with appointments and
with care regimens.
The new practice
It started with a Pfizer company representative who met with
our director and told us that Pfizer had a funding program
in partnership with the Government of Quebec for new and
innovative chronic disease programs. He suggested that
we put in a proposal. So we developed a program not only
to treat our clientele, but also to transform an outdated,
“siloed,” and reactive service delivery model. We based
it on the internationally recognized Chronic Care Model
We focused on bringing services closer to clients in their
communities through a partnership and team-based model.
We are teaching our clients to understand their health
and to take responsibility and control (with our help to get
them started).
We created a three-month intensive program that takes a holistic
look at the client. Rather than having different treatment plans
for each chronic condition, our interdisciplinary team (dietitian,
registered nurse, and kinesiologist) develops a treatment plan
together to effectively address all of the client’s conditions.
The team receives a referral from the doctor, and then there is
follow-up communication about every third week when the team
reports on information, such as blood pressure and diabetes
status, and makes medication adjustments.
The program includes a focus on a healthy lifestyle (exercise,
good nutrition) and we educate our clients (in groups) so they
better understand their health situation. The program involves
seeing our clients twice a week at a clinic or at a local gym
in their community—so it’s like a mobile clinic. After the three
months, we remain available to our clients but we see them
less often so that we can start up a new group.
It’s a first for a rural and remote region to have this kind
of program. This kind of intensive follow-up is typically only
available in specialized health centres, which are far away
and difficult for our clients to access.
Let me give you an example of just how intensive the program
is. We don’t only teach clients what to do; we make them do
it in front of us so that we see everything that touches their
healthy lifestyle—the exercise, the nutrition, and the medication
management. Also we teach them about their disease—for
example, how diabetes works in the body and what it does to
the different organs. Clients come with a list of their daily eating
habits and they bring in their food products so we can read
the labels together. We’re trying to make them proactive in their
treatment so they understand why a particular food is, or isn’t,
a good choice. The dietitian talks about what they should and
shouldn’t eat, and we give them written information to take
away. At the end of our three-month intensive follow-up, the
dietitian travels with the client to the grocery store to discuss
any questions about food products.
Canada’s most vulnerable
Making a difference
Since we see clients twice a week for three months, it’s long
enough for them to include this new healthy lifestyle into their
everyday life, and it’s having an impact on their health. For
example, a 66-year-old man who had a very low heart ejection
fraction (a measure of heart function) was supposed to have
an operation to implant a pacemaker and defibrillator, but he
heard about our program and was interested in trying it first.
During his three months with our program, his ejection fraction
went from 13% to 48%, which is close to normal. He continues
to be in good health and has not had an operation to date.
What changed
access to care
health outcomes for clients
efficiency and effectiveness of care delivery
ability to manage multiple chronic conditions
satisfaction among health care providers
In another case, a man who visited the emergency room
approximately twice a week was referred to us. It’s been about
a year and he hasn’t been to the emergency room since he’s
been under the care of our team.
Key components
We’ve also seen reduced use of medication, reduced levels
of hypertension, reduced cholesterol levels, better-controlled
diabetes, weight loss, and a change of lifestyle, including
less smoking.
Physicians view the program positively because they no longer
need to see their patients every month. They may see them
every three months if they’re really sick, otherwise once a year.
The program also makes very good use of resources. Initially,
it was funded only for two years (ending in January 2013),
but we continue to operate because the health centre liked
our results and decided to integrate all of the different chronic
disease programs into one. As a result, we were able to
reallocate money. We’re also able spend more time with clients
because we don’t have separate staff for each program.
There’s a lot of interest in our program. The Government
of Quebec is interested in spreading it across the province.
And the Government of Canada, specifically the First Nations
and Inuit Home and Community Care program, is also
interested because they believe it is applicable to rural and
remote First Nations and Inuit communities.
Information was provided by Tim Sutton, a kinesiologist and clinical
team leader in chronic disease management at the Rocher-Percé health
centre (Centre de santé et de services sociaux du Rocher-Percé).
Pfizer, the Government of Quebec,
and local gyms
team-based care
best-practice model that empowers clients
to manage their chronic diseases
follow-up with clients
Health Council of Canada
Adapting the Non-Insured Health Benefits
program to meet the needs of First Nations elders
First Nations and Inuit Health Branch, Health Canada-Atlantic region
The need
Elders have expressed a number of ongoing issues about
programs and services of the First Nations and Inuit Health
Branch (FNIHB)–Atlantic region. As part of a new Strategic
Action Plan for Atlantic First Nations Elder Care, the FNIHB–
Atlantic region is working to improve existing programs
and services.
FNIHB–Atlantic has a co-management (i.e. shared decisionmaking) committee with the Atlantic First Nations Chiefs, called
the Mi’kmaq Maliseet Atlantic Health Board. In 2007, the health
board established priorities that included elder care. The focus
of the strategic plan includes identifying and supporting local
options to keep First Nations elders in the community for as
long as possible, as well as addressing cultural competency,
quality of care, and access to family for those who are admitted
to long-term care facilities off-reserve.
The new practice
A first priority was to look at the Non-Insured Health Benefits
(NIHB) program. Policies and requirements associated with
the program are established mainly at the national level and
cannot be easily changed. The program was reviewed from
the perspective of whether the region had any flexibility to
make changes for the benefit of elders’ health and well-being.
A “policy lens” tool was created called the Elder Care
Assessment Tool. The process began with identifying what
aspects of the program are within the region’s discretion
to design or modify. Based on elders’ issues with the NIHB
program, and what they need for their health and wellbeing, areas for improvement were identified and considered
against potential options the region may have to make
In a pilot test, the policy tool was applied to the medical
transportation component of the NIHB program. One of
several issues that elders had identified was the requirement
for pre-approval to cover the travel costs of “non-medical”
escorts—usually a family member or friend—to travel with them
to appointments. Prior to the review, all First Nations people
required pre-approval for every single appointment. For elders
with complex health needs and multiple doctors, or whose first
language is not English, this could mean a lot of paperwork.
As a result of applying the elder care assessment tool, it was
learned that while a regional branch of FNIHB could not remove
the pre-approval requirement, there was some flexibility to
change the procedure for people with chronic health problems
or translation needs. Now, they only need to seek pre-approval
once a year to have a non-medical escort accompany them to
all their appointments. Also, there was a change to the request
form so that it was clearer, with easy-to-answer questions,
enabling staff to quickly determine whether someone is eligible.
Another area that was explored for improvements was elders’
access to prescribed medications. Some medications are
covered automatically, but others need to be approved
for coverage by the NIHB Drug Exception Centre in Ottawa.
The pharmacist needs to call to initiate the review, and
then the Drug Exception Centre will send paperwork to the
health professional who prescribed the medication. Sometimes
there is a breakdown in the process—for example, pharmacists
don’t call the Drug Exception Centre to ask for a review, or
prescribers don’t fill out the paperwork. The result is that the
elder is denied coverage for the medication, and they must
pay for it themselves or have their band pay with money from
another program.
FNIHB–Atlantic looked at the medications that were rejected
for payment to identify the top medications being requested,
and learned that most were approved once they were reviewed
at the Drug Exception Centre. In those instances where
the pharmacist didn’t call, the regional pharmacist in the
FNIHB office contacted the pharmacies and reminded them
about the process. The regional pharmacist also sent the
results of this work to a pharmacy working group at NIHB
headquarters in Ottawa, to support policy change for commonly
requested medications. The regional pharmacist also created
formularies that identified appropriate substitutions for common
medications, so that if someone is prescribed a drug that
requires a call to the Drug Exception Centre, pharmacists can
choose an alternate that is automatically covered by NIHB.
Canada’s most vulnerable
Making a difference
Once it became evident that the Elder Care Assessment Tool
had the potential to make a real difference in the lives of First
Nations elders, the regional office became very enthusiastic and
motivated to promote the success. It was because of this tool
that was possible to identify that FNIHB–Atlantic did in fact have
flexibility to adjust the procedure for medical transportation, and
to think creatively about what else could be done to increase
flexibility while at the same time adhering to national policies.
A lot of work remains, and the Elder Care Assessment Tool
is still in its infancy, but already FNIH–Atlantic staff and the
First Nations partners are developing a strong sense of shared
commitment to and responsibility for elders’ health.
There are still aspects of programs that cannot be changed
easily like national policies and requirements, but conversations
with First Nations partners are slowly evolving for the better.
More time is now spent in discussions with the health board
and other First Nations partners on what FNIHB–Atlantic
can change, and on finding creative ways to be more flexible
for the benefit of elders’ health and well-being.
As a result of this policy tool and other evaluation and
quality improvement initiatives taking place within FNIHB
nationally, changes to the way the FNIHB–Atlantic region
works and changes to policies and programs are beginning
to be implemented.
Following the successful pilot test of the Elder Care Assessment
Tool, the regional office has committed to completing at least
one program review per year. A review of the Aboriginal Diabetes
Initiative is underway and is expected to be completed this year.
The joint working group of the regional office and First Nations
leadership that created the Strategic Action Plan for Atlantic First
Nations Elder Care will determine which program should be
up next.
Information provided by Louise Cholock, Director of the NIHB Program,
First Nations and Inuit Health, Health Canada-Atlantic region.
What changed
process and paperwork for
non-medical escorts
medications declined for coverage
Key components
and joint working group with First Nations
Elder Care Assessment Tool used to review
policies and procedures
for regional office to make changes
to procedures while still working within overall
national policies
Health Council of Canada
Community health aides help with
nursing shortages and cultural safety
The need
We were having difficulty recruiting and retaining nurses.
We were also concerned about the continuity of care for the
residents of Nunatsiavut, especially the seniors receiving
services through the Home and Community Care program.
The new practice
The Community Health Aide model borrows from Labrador in
the past and from Alaska in the present, where community
health aides deliver primary health care in remote communities.
A new position was created out of necessity, allowing
Nunatsiavut to deliver culturally safe, cost-effective care. Where
there were two nurses, we now have one nurse and one aide,
a skill mix that provides continuity of care.
When the Grenfell Mission first came to Labrador, the doctors
and nurses hired local women “aides” to assist in all areas of
care. The tradition continued and, in 1996, when the Labrador
Inuit Association assumed responsibility for nursing in what
is now Nunatsiavut, the community health aides came over
as well.
The community health aide has an expanded role in both public
health and home and community care. The aides are from the
community and bring the language and cultural knowledge that
is essential for safe practice.
In the Home and Community Care program, the community
health aides function as the nurses’ “right hands” because they
fill so many roles, such as being supporters, cultural advisors,
and planners. They manage the home support workers, go
with the nurse to client visits as needed, order equipment and
supplies, schedule appointments, sterilize equipment, complete
month-end reports, and anything else that doesn’t require
a nurse to do. The nurse is then able to concentrate on direct
client care. The aides also do independent home visiting to
support the programs, both when a nurse is in town and when
the position is vacant.
Just as important, the aides are the cultural advisors to
new nurses. They are so trusted in the community that
any new nurse is immediately accepted if accompanied by
the aide. The aides know everything about the people in the
community, including where to find them on any particular
day to ensure they come to appointments. Sometimes a new
nurse will come in and want to set up a clinic on a certain
day, and the community health aide will be the one to tell her
it’s the wrong week because it’s duck-hunting season, or that
there is a community event going on at that time. You can’t
underestimate the value of this relationship.
We have had periods without a nurse in a community, and
the community health aide has been our eyes and ears. She
would call and say, “This person is deteriorating. This person
needs to be reassessed. You need to send a nurse in.” And
then when the nurse went in, her work was much more focused
because everything had been pre-planned by the aide. The
appointments had been made. Everything was set up.
From an elder care perspective, the aides can spend more time
with elders than the nurses do; also, they have those personal
connections and speak the language. Often elders are alone
in their communities because their families have moved away.
Community health aides are advocates for elders and they’ll
support them with a range of issues including elder abuse,
which is a big problem, especially financial abuse. We have also
given the community health aides tours of the regional health
and long-term care centres in Happy Valley-Goose Bay so that
they can describe them to elders and their families and help
them become comfortable with the transition.
Canada’s most vulnerable
Making a difference
There is no question about value. We have a challenge
recruiting and retaining nurses, and this aide position has
allowed us to manage with fewer nurses. For example, in our
largest community, instead of having three nurses and one
aide, we have two nurses and two aides. We’ve even been
able to maintain programming in a community with no nurse.
And the community health aides are a very stable workforce.
They live in the community, are committed to the community,
and they love their jobs, so there is no turnover. If someone ever
does leave, there are people waiting for these jobs.
It’s hard to quantify or even to put into words the value they
bring—essentially, we would not be able to deliver care
without them and clients would not be as willing to receive
care. What has enabled the success of the community health
aide role is the fact that we are self-governing, so we can
be flexible and innovative and develop roles that meet our
communities’ needs.
This model would work well in other communities. It’s hard to
understand why it hasn’t spread to other parts of the country,
particularly since it’s also well known in Alaska. I think there’s
almost a strange fear that by allowing this kind of practice we’re
encouraging people to be community health aides instead of
going into the health professions, but that’s not what it’s about
at all. There is an incredibly valuable role for these people at
the community level that no one else can fill like they do, and
it just enhances service delivery.
Information provided by Tina Buckle, Community Health Nursing
Coordinator, and Gail Turner, Director of Health Services, Nunatsiavut
Department of Health and Social Development.
What changed
well-being of elders, including the ability
to remain in their homes in their communities
recruitment and retention in the Home and
Community Care program
ability to deliver the home and community care
and public health programs and services needed by
the communities
Key components
the community health aide role, training
aides as necessary, being innovative with their roles,
and reducing nursing positions for optimal service
delivery—enabled by self-governance and a nonunionized environment
on what was already working well
in public health
Inuit people from the community who have
a vested interest in the health and well-being of others
in their community
Health Council of Canada
Integrating culture into care
Continuing Care and Independent Living Program,
Tlicho Community Service Agency, Northwest Territories
The need
Culture is a critical part of the effectiveness of all health
and social service programs. As part of the transition
to self‑government in 2005, a Tlicho Cosmology Project was
developed to help initiate discussion about what culture
means for the Tlicho people and to apply this knowledge
to modern organizations and programs.
Culture includes stories, legends, rituals, celebrations and
practices, taboos, songs, drum dances, child-rearing practices,
hunting practices, roles and responsibilities, expectations
of leaders, forms of punishment, teaching methods, and how
to relate to outsiders—every aspect of how to live one’s life.
Cosmology was successfully integrated into a variety of
program areas and there was interest in trialing it within the
Home and Continuing Care program to enhance its cultural
component. There was also a need for new staff roles and
training to put cosmology into practice and to expand staff
skills and enhance programming.
The new practice
Continuing Care and Independent Living is a program of
the Tlicho Community Services Agency (TCSA), which provides
the management, administration, and delivery of three program
areas—education, health care, and social services—in the four
Tlicho communities.
The TCSA is the only authority that combines the functions
of a health authority and an education council in the Northwest
Territories. So, you can see that we take a holistic approach
to the delivery of our programs.
The Continuing Care and Independent Living program
includes the following services: continuing care, home care,
a day program and a recreational activity program for elders,
independent assisted living, medical social work, adult foster
homes, and Meals on Wheels. A new position called Manager
of Continuing Care and Independent Living was created, and
I was hired to fill this role. I am a social worker by training
and I am Tlicho, from the community. The new role integrates
social work, clinical practice, and a cultural component into
a medical model of care. I work with coordinators in all of the
program areas to apply cosmology to the programming.
Here are some examples of our work: We did some
fundraising through a partnership with the territorial government,
the community government, the Friendship Centre, and a
local gas station for an elders’ five-day spiritual gathering that
required traditional food. We bought fish, muskrats, and
beavertail. We hired a young adult and provided him with $200
to buy ammunition to hunt a caribou. He brought it back
for the elders to inspect, clean, and cook, and to teach
other community members about traditional food preparation
and about the ceremonies associated with feasts. Traditional
food is very important to elders—not only because the food
is of high quality, high in protein, and really fresh, tender,
and healthy, but also because of the cooking and cleaning
activities that are required.
The TCSA worked with Health Canada to develop and approve
a Traditional Food and Diet Policy that basically says that
elders have the expertise to determine when an animal is safe
to eat. It was quite an effort to get Health Canada on board.
We also established the position of Elder’s Day Coordinator
to oversee elders spending time on the land and in traditional
activities such as snaring rabbits, berry picking, and caribou
hunting. The coordinator also arranges to bring youth and
elders together for games and drumming. The elders really
participate by clapping and moving their feet—it’s very
enjoyable for them and keeps them moving and busy.
Another key area has been the hiring and training of local
Tlicho staff. All staff in long-term care and the Continuing Care
and Independent Living program are Tlicho, which means
elders can communicate with staff. We provide additional
training that allows personal support workers to give injections.
They become residential care aide workers. They’ve been
tremendously valuable as a back-up to the nurses because we
don’t have a 24-hour nursing service—it’s allowed elders
to remain in their community. Without this new staff role, one
gentleman who was receiving palliative care would have had
to go to a long-term care facility outside of the community.
Last year we started an eight-month program to train students
as personal support workers in the community. A trainer from
one of the colleges came to the community, and she’s living
right here in the school. The program is supported by the
Tlicho government. Hiring local people has positive impacts
on staff retention.
Canada’s most vulnerable
The Tlicho government strongly believes in increasing the
knowledge and skills of front-line staff in all health, social,
and education program areas so that all services will improve
health. So the government funds the Tlicho Community Action
Research Team (CART, This
is a collaborative project with university-based researchers who
conduct “research-to-action” projects to find solutions to health
problems and then translate this information into teaching
materials for providers. The materials integrate the Tlicho values
and beliefs. For example, we have a problem with diabetes
in the community and CART developed an Aboriginal Diabetes
Initiative. It’s based on a First Nations-owned program in
Quebec, and we are now training staff on this program.
Making a difference
We held a community consultation to receive feedback on
these initiatives, and the results were very positive. Elders enjoy
the community activities; they keep them healthy, happy, and
more independent. Hiring and training local people has had
very positive impacts on staff retention. Our capacity to fill gaps
in care has improved, and our waiting list for long-term care
has shortened to only one or two people because we are able
to keep people in their homes longer. The cultural component
is now embedded in our programs and services.
We are always trying out new ideas, and two important
changes are fast approaching. First, our old Seniors Home is
being replaced by a larger facility. The second change will take
longer, but it will be very important to how we deliver long-term
care. The Tlicho government has notified the Government of
the NWT (GNWT) and the federal Minister of Aboriginal Affairs
that it wants to negotiate changes to the Intergovernmental
Services Agreement (ISA), which lays out the arrangements by
which the TCSA delivers GNWT education, health, and social
programs in our communities.
Information was provided by Nora Wedzin, Manager of Continuing
Care and Independent Living, Tlicho Community Service Agency.
What changed
are able to remain in their communities and
in their homes longer
in care are filled and long-term care wait times
have been reduced
are participating in traditional activities, which
benefits their well-being
Key components
allows for flexible development
of programs to meet community needs
First Nations leadership provides guidance
Cosmology Project provides a holistic framework
that guides the development of programs and services
collaborative CART project brings best practice
research and programs into the community and then
integrates them with the traditions and values of the
Tlicho people
from leadership to train personal support
workers to provide injections
and training local staff to improve retention
Health Council of Canada
Youth caring for elders,
and preventing elder abuse
Carcross/Tagish First Nation Health and Wellness Department, Yukon
The need
Our major concern was the need to build family and community
capacity to care for elders, in order to more effectively meet
elders’ needs and relieve some of the workload burden on the
home care program. Families just weren’t stepping up to take
care of elders. There were also concerns about elder abuse.
We also needed to improve collaboration between the home
care program and families, and among the different types
of workers in the home care program.
We wanted to address these needs in keeping with the
philosophy of the Carcross/Tagish First Nation government,
which is to value and care for seniors by drawing on community
assets and traditional ways of being.
The new practice
We’ve taken a few different approaches to bring elders’
needs to the forefront, and we’ve come up with “out of the
box” solutions. Self-government has meant that we have
the flexibility to meet our community’s needs in the way we
think will work best.
About two years ago, we implemented a Transitional
Employment Program for youth in order to break the generational
cycle of dependence on social assistance. The program
was based on a model in the United States called ROCA
( It is an evidence-based model that seeks
out and helps the most difficult and challenging youth who
are unable or unwilling to work or go to school. Because of our
need to build capacity in caring for elders, we decided to put
elders’ needs first when identifying work opportunities
for youth.
Youth are assigned to an outreach worker and together they
develop a case plan to identify goals and aspirations for
education and experience. Some examples of the work that
youth do for elders include collecting, cutting, and stacking
wood to heat their homes; making sure that snow is removed
from their driveways; maintaining their yards; checking
their houses for safety issues and doing repairs; putting up
handrails; and helping elders with tanning hides.
In exchange, the youth are paid well ($15 an hour) and receive
a job reference to help them get on track. They’ve learned
that they have to show up to work on time and that they cannot
show up drunk or hung over. And they’ve learned that it’s
not called “social assistance” but “temporary assistance”—
it’s not a way of life but it is there to help people who are
temporarily in difficult situations.
We also knew that elders were suffering abuse at the hands
of their family members—primarily financial abuse by an
adult child or grandchild. They were spending their temporary
financial assistance on alcohol and drugs, then staying
with their grandparent(s) and expecting them to feed and
shelter them.
We use a couple of different strategies. We contact family
members to let them know what we are seeing and if
necessary we speak to the perpetrators directly. We’re not
going to just sweep things under the carpet and pretend
they’re not happening. It’s not going to be tolerated and we’ll
bring it to the forefront if we have to.
In more extreme situations, if the abuse doesn’t stop, rather than
giving the family member their temporary financial assistance
cheque (which comes from the First Nation government), the
elder is provided with money for the family member’s room and
board. We put the rest of the cheque into the form of a purchase
order (PO) at the store to ensure that the money is spent on
food. If necessary, we even take it a step further and divide the
purchase order in half, so that only half of the PO is spent in
the first two weeks of the month and then the other half in the
last two weeks. Otherwise, if all of the food was purchased at
once, the family member could sell the food for cash. We will
put the PO in an outreach worker’s name if we suspect the client
is selling the PO and will also visit the elder to see what kind of
food they need for the household. It seems fairly drastic, and
we only do this when absolutely necessary, but we’ve managed
to cover all possibilities to protect the elders and ensure that
they have food and that their housing needs are covered.
We’ve also strengthened the Outreach Program to enhance
elders’ ability to live well in their homes as long as possible.
The staff work collaboratively with families to help them better
Canada’s most vulnerable
understand and fulfill their responsibilities to their elders. They
also go out to visit with elders in their homes to hear about
their concerns and needs. We purchased a couple of vehicles
to take elders to their medical appointments, and outreach
workers go along as advocates and make sure the information
is being understood correctly.
What changed
are better taken care of, with food and housing
needs looked after
In the last year, we also started organizing a weekly tea that
brings together elders and non-indigenous seniors in the
Carcross community. It’s been a tremendous experience;
people who’ve been neighbours for years but have never
socialized are now becoming friends. Traditional activities
such as berry picking are also being organized.
We also have interagency meetings once a month where our
Health and Wellness Department meets with other agencies
to make sure we collaborate better. We’ve also built the capacity
of home care workers with training activities, and we pay staff
well in order to support retention.
Key components
Making a difference
The Transitional Employment Program has made a big
difference in helping elders remain in their homes. They have
wood to heat their homes and their homes are safer. The elders
are also happier and less frustrated because they can get
out in winter, now that their driveways are cleared sooner. The
youth are making progress in terms of becoming responsible,
and they are able to apply for jobs outside of the First Nations
community because they have a job reference.
Although it is relatively new, the PO strategy appears to be
working. The outreach workers see that there is food in the
homes and the elders are happier.
Overall, we’ve been able to encourage more responsibility
(especially on the part of families) for elders and their care.
Family members appreciate the shared responsibility and feel
less stress because they are relieved to know there is a team of
people involved in the well-being of their elders. This gives them
the motivation to be involved because it’s not so overwhelming.
Information provided by Nina Bolton, Director, and Roberta Shepherd,
Outreach Program Manager, Carcross/Tagish First Nation Health and
Wellness Department.
feel happier and less isolated, with family
support and new friendships
is working as a team to support elders—
families, outreach workers, home care workers, mental
health workers, and other community agencies
and great support from the First
Nations government for the elders and for the outreach
and home care workers
is in agreement that elders’ needs are
a priority
and lots of communication
Health Council of Canada
List of practices discussed by participants
This list provides the majority of practices discussed at the Health Council’s
sessions and during the key informant interviews with senior government
officials and First Nations, Inuit, and Métis organizations. Wherever possible,
we have provided links to websites.
In Bella Coola there is one home care program for everyone, whether they
live on- or off-reserve, to ensure equal access to care. British Columbia.
In the Bella Bella region, seniors in remote communities have access to a
range of integrated services through travelling teams, portable technology,
and telehealth. British Columbia.
Online education for community-based health care providers means they
can receive culturally appropriate elder care training without leaving their
communities – Saint Elizabeth @YourSide Colleague First Nation Elder Care
Course. National.
The Saanich First Nations’ Adult Care Society addresses gaps in care for
elders and disabled people in First Nations communities on Vancouver
Island. British Columbia.
The federal First Nations and Inuit Home and Community Care program
seeded innovative initiatives and helps seniors remain in their communities.
The British Columbia Association of Aboriginal Friendship Centres provides
important urban services for Aboriginal seniors and others. British Columbia.
The Aboriginal Affairs and Northern Development Canada Assisted Living
program helps meet the health care needs of older Aboriginal people.
The government of British Columbia partnered with the United Way to
improve non-medical home support services to First Nations communities.
British Columbia.
Inuit Tapiriit Kanatami, the national Inuit organization in Canada, addresses
issues of concern regarding the health and well-being of elders. National.
The Aboriginal Health Team project at Interior Health supports integrated
care, navigators, and community development. British Columbia.
The National Association of Aboriginal Friendship Centres held a
Fostering Biimaadiziwin (“the good life”) National Research Conference
on Urban Aboriginal Peoples that focused on elder care, providing a
knowledge exchange that will improve Aboriginal seniors’ health. National.
The Home and Community Health Program run by the North Peace Tribal
Council provides home and community health care on-reserve to prevent
clients from falling through gaps. British Columbia.
The First Nations ReAct tool was developed in partnership between home
care and mental health services. It supports the recognition and awareness
of elder abuse. British Columbia, Saskatchewan.
Q’wemtsin Health Society developed a home and community care
program to help seniors maintain their independence. British Columbia.
Métis Nation BC works in partnership with other organizations to meet
the needs of elders. British Columbia.
New Horizons for Seniors is a proposal-driven program in which projects
are led or inspired by seniors. This initiative helps develop communitybased programs and incorporates traditional activities. National.
The Canadian Home Care Association produced a document on promising
practices in Aboriginal home care and works with the First Nations and Inuit
Home and Community Care program (FNIHCC) to improve home care.
HelpAge Canada is the country’s only organization dedicated exclusively
to helping older people in Canada and the developing world. It has played
a key role in helping to develop seniors societies in the North. National.
British Columbia
The First Nations Health Authority (FNHA) is moving forward with
transformative change with a focus on wellness and through partnerships
with the federal and provincial governments and regional health authorities.
British Columbia.
Carrier Sekani Family Services uses telehealth to enhance access to primary
care and continuity of care in remote First Nations communities in northcentral British Columbia.
Providing integrated services to elders on-reserve, Siksika Health Services
allows seniors to remain comfortably and safely in their homes for longer.
The Royal Alexandra Hospital’s Aboriginal care coordinators and case
management approach improve coordinated care in a hospital environment
for First Nations and Métis people – Alberta Health Services. Alberta.
Alexander First Nation built a facility for seniors, and through a memorandum
of understanding with Capital Health provides beds for seniors who are not
part of the community. Alberta.
Canada’s most vulnerable
The Aboriginal Diabetes Wellness program at the Royal
Alexandra Hospital improves care for seniors and others. Alberta.
The Alberta Region of Health Canada’s First Nations and Inuit Health Branch
successfully piloted InterRAI in six communities according to the principles
of ownership, control, access, and possession (OCAP), and a toolkit is now
available nationwide for all First Nations. Alberta.
The Métis Elder Abuse Awareness Program raises awareness about elder
abuse and about who the Métis people are. Alberta. http://metiselder.
Shared caregiving in the community improves care for the elderly,
reduces the burden on families, and improves the coordination of
culturally safe care – Peter Ballantyne Cree Nation. Saskatchewan.
The Aboriginal Home Care Program in the Regina Qu’Appelle Health
Region is improving culturally safe home care services for First Nations
and Métis people. Saskatchewan.
The Saskatchewan First Nations Aboriginal Diabetes Initiative Action
Plan reduces the incidence and effects of type 2 diabetes in First Nations
people – First Nations and Inuit Health Branch, Saskatchewan region.
The Collaborative Practice Model pilot program supported chronic disease
prevention and management through collaboration among the First
Nations and Inuit Health Branch (SK Region), the Kidney Foundation of
Canada (Saskatchewan), the Regina Qu’Appelle Health Region, and three
First Nations communities (Cowessess First Nation, Gordon First Nation,
and Muskowekwan First Nation). Saskatchewan.
The Discharge Planning Toolkit of the Federation of Saskatchewan
Indian Nations supports continuity in care from hospital to community.
The Standing Buffalo long-term care facility in Fort Qu’appelle provides
long‑term care on-reserve for First Nations elders. Saskatchewan.
The Lac La Ronge Indian Band has elder care facilities, including long-term
care, in three of their communities on-reserve. Saskatchewan.
White Bear First Nations has a multi-use elder care facility including home
and community care on-reserve, and an elder facility adapted to enable
children’s programming. Saskatchewan.
Onion Lake Cree Nation has an elder care facility, home and community
care, and traditional and community supports on-reserve. Saskatchewan.
Battlefords Tribal Council Indian Health Services coordinates health services
between First Nations and the local health region. It also provides chronic
disease management, home support, and health and social programs.
The Meadow Lake Tribal Council Health and Social Development Authority
includes an Elders Advisory Council and provides home and community
care, traditional supports, and community supports in a remote northern
region. Saskatchewan.
Saskatoon Health Region’s Aboriginal Health Strategy 2010–2015 addresses
the needs of the elderly. Saskatchewan. http://www.saskatoonhealthregion.
The Prince Albert Grand Council Health and Social Development Office
works in partnership with the Prince Albert Parkland Health District on elder
care including home care. Saskatchewan.
The Manitoba Métis Federation is recognized for its programs, services,
and reports that improve the health and well-being of Métis people,
particularly its research on aging in place. Manitoba.
The Southeast Personal Care Home supports culturally safe care and
connections with family and community. Manitoba.
The Aboriginal Senior Resources Centre provides advocacy and support
with housing, assisted living, home care, long-term care, and elder abuse.
Fisher River Cree Nation and the Manitoba First Nations Personal
Care Home Networking Group involves collaboration across governments
and communities to improve culturally safe long-term care, including the
development of culturally appropriate licensing standards for six personal care
homes in First Nations communities. Manitoba.
Aboriginal home support workers in the Southern Region Health Authority
provide culturally safe care and advocacy for clients and support for health
providers. Manitoba.
Peguis First Nation’s Health Centre supports a home care program and
delivers senior care through an interdisciplinary team approach; Peguis First
Nation also participates in the Lakehead University palliative care project.
The Keewatin Tribal Council Health Department provides a comprehensive
home and community care program to support seniors and their families.
Health Council of Canada
Central Canada
Tungasuvvingat Inuit Family Health Team Medical Centre and Family
Resource and Health Promotion Centre bring an integrated primary health
care team to Inuit who are living in Ottawa to access medical care. Ontario.
Ottawa Health Services Network Inc. is a not-for-profit organization that
coordinates specialist and tertiary health care for residents of the Baffin
region while respecting the Inuit vision of wellness. Ontario, Nunavut.
The Tyendiaga Home and Community Care Program and the Community
Wellbeing Centre run by the Mohawks of the Bay of Quinte supports
integrated care, a single point of access, a continuum of home care, and links
between hospital and communities to support discharge planning. Ontario.
Lakehead University is developing a model for culturally appropriate and
safe palliative care services, allowing First Nations people to die in their
communities. Ontario.
Kahnawake Home and Community Care Services provides a continuum
of integrated care in communities for First Nations seniors and others and
ensures elders’ needs are met through an efficient care delivery model.
Building bridges between First Nation health care providers and
the mainstream health care system improves quality of care and
trust – Mamaweswen, the North Shore Tribal Council. Ontario.
Métis Nation of Ontario Community Centres serve as cultural and service
hubs that link Métis citizens to each other and to services and supports in
their local areas. Ontario.
Telehealth improves care, reduces isolation for Elders, and allows seniors
to remain in their communities – Keewaytinook Okimakanak Telemedicine.
Supporting Aboriginal Seniors at Home (SASH) provides culturally safe
care to address health disparities between Aboriginal and non-Aboriginal
seniors – Southwest Ontario Aboriginal Health Access Centre. Ontario.
The Traditional Healing, Medicines, Foods and Supports program and Aging
at Home Elder Care Continuum improve the health and well-being of seniors
in remote and isolated communities – Sioux Lookout Meno Ya Win Health
Centre. Ontario.
Bringing chronic disease self-management to rural and remote regions
through an interprofessional team improves access to care, improves health
outcomes, and reduces cost – Rocher-Percé. Quebec.
The Kanesatake Home and Community Care Program delivers programming
to improve quality of life and help seniors remain in their communities.
Alzheimer Society London & Middlesex and the Oneida Nation of the Thames
developed the First Link First Nations Program, which provides culturally
safe information and support to people with dementia and their families and
caregivers. Ontario.
Atlantic region
Wikwemikong Health Centre on Manitoulin Island works in partnership with
the Noojmowin Teg Health Centre and the Victoria Order of Nurses to provide
seniors’ home care and a long-term care facility that incorporates traditional
teaching. Ontario.
Geriatric telemedicine at St. Joseph’s hospital in northwestern Ontario is
a nurse-led program that provides assessment and support to clients and
their families, including health promotion for chronic disease and cognitive
decline and discharge support for those living in remote communities.
Oneida Nation of the Thames home and community care, long-term care,
and aging-at-home programs offer a full range of programming and reduce
the isolation of seniors by promoting social interaction and activities. Ontario.
The Chiefs of Ontario Home and Community Care Liaison Officer works with
a representative of Health Canada to support home and community care
programs throughout Ontario. Ontario.
Akwesasne Health provides home care, home support, and long-term care
to improve quality of life and help seniors stay in their communities. Ontario.
An Atlantic First Nations Elder Care Assessment Tool helps programs
better meet the needs of Atlantic First Nations Elders, based on Elders’
perspectives – First Nations and Inuit Health Branch, Atlantic region.
The Strategic Plan for Atlantic First Nations Elder Care outlines directions
in policy development, advocacy, program and service design and delivery,
healthy aging, and aging in place. Atlantic region.
The Nova Scotia Aboriginal Home Care Steering Committee completed
detailed analyses and reports on home care, long-term care, and discharge
planning. They recently launched a communications strategy to improve
provincial continuing care programs. Nova Scotia.
The Nova Scotia Aboriginal Continuing Care Policy Forum is an ongoing,
effective mechanism that addresses multi-jurisdictional continuing care issues.
Nova Scotia.
Aboriginal patient navigators at the tertiary care centre in St. John’s
support system navigation and coordination for First Nations and
Inuit. Atlantic region.
Canada’s most vulnerable
Inuit regions
The Pond Inlet Elder Education and Awareness Program addresses the
isolation, health knowledge levels, and self-management skills of Inuit Elders
in a rural and remote community. Nunavut.
The Nunavut Senior’s Society is in development with the support of HelpAge
Canada. The society will address elder abuse and reduce isolation. Nunavut.
The Home and Community Care Program delivers culturally safe care and
supports discharge planning to all communities with assistance from Elders,
interpreters, doctors, nurses, and other professionals, which is supporting
reduced hospitalizations. Nunavut.
Caregiver consultations helped to shape a new territorial policy that
provides financial compensation to informal caregivers. Nunavut.
The Nunavik Regional Board of Health and Social Services participated
in a global elder abuse awareness campaign. Nunavik. http://www.rrsss17.
Community health aides help with nursing shortages and cultural
safety, thereby improving the well-being of seniors and allowing them to
remain in their homes. Nunatsiavut.
Patient liaisons in Labrador work closely with the Non-Insured Health Benefits
program to support Innu and Inuit in Happy Valley-Goose Bay, Labrador.
Robotic telemedicine using a lifelike robot named Rosie improves access
to care in remote communities. Nunatsiavut.
A continuing care and independent living program embeds culture
into a continuum of care for the elderly – Tlicho Community Service
Agency. Northwest Territories.
Home care and health care services support integrated care and help seniors
remain in their communities. Northwest Territories.
The NWT Seniors’ Society provides a range of support for seniors to reduce
isolation and increase awareness of elder abuse. Northwest Territories.
The Aklavik Health Centre is a bright new centre that provides not only
health care but a welcoming space for elders to meet. Northwest Territories.
* Practices from Nunavut are found in the section on Inuit regions.
The William Firth Health Centre in Tetlit Zheh (Fort McPherson)
includes a home care nurse, activity worker, and home support worker
for the community. Northwest Territories.
A partnership between the Inuvialuit Regional Corporation and the BeaufortDelta Health Authority is supporting a number of innovative initiatives
including development of a new position, called community wellness
coordinators, who are health professionals with broad health and wellness
roles in communities. Northwest Territories.
Stanton Territorial Hospital includes an extended care unit in the hospital, with
a holistic and interdisciplinary team approach and an Aboriginal wellness
program. Northwest Territories.
Territorial/Integrated Services of the Northwest Territories Department of
Health and Social Services oversees home care and long-term care services
in the territory. Northwest Territories.
Youth caring for Elders and preventing elder abuse improves employment for
youth and brings the community together to care for Elders – Carcross/Tagish
First Nation’s Health and Wellness Department. Yukon.
Community liaison discharge planning addresses the complex needs of
First Nations, Inuit, and Métis patients who are discharged from hospital
to rural and remote communities – Whitehorse General Hospital. Yukon.
The First Nation of Na-Cho Nyak Dun Health and Social Services Department
includes a focus on elder care, such as a wood/fuel program. Yukon.
The Council of Yukon First Nations conducted community health assessments
and an environmental scan to support improved service delivery and health
outcomes. Yukon.
Health Council of Canada
In the spring of 2013, the Health Council of Canada held
meetings in Vancouver, Winnipeg, Ottawa, Iqaluit, Inuvik,
and Happy Valley-Goose Bay to discuss the health care of
First Nations, Inuit, and Métis seniors. The meetings brought
together health care providers and managers from across
Canada to discuss the unique health needs and care delivery
challenges; to learn how programs, practices, or policies
were helping to address these needs and challenges; and
to identify key learnings from these successes. The Health
Council also commissioned interviews with senior provincial
and territorial government staff as well as regional First
Nations, Inuit, and Métis organizations across the country.
The Health Council gratefully acknowledges the generous time
and support of all participants, organizations, and Elders who
participated in the interviews and meetings and who openly
shared their knowledge, experience, and recommendations.
Participants for the interviews and the meetings were selected
through a scoping process and literature review. Themes
discussed throughout this report were shared by participants
in the meetings and interviews. The report draws on these
The Council would also like to thank AMR Planning &
Consulting for their contributions to the scoping, planning,
facilitation, and analysis of the meetings; Johnston Research
Inc., for conducting and synthesizing interviews; and Inuit
Tapiriit Kanatami for their vital role in planning for the Iqaluit,
Inuvik, and Happy Valley-Goose Bay meetings.
The Health Council of Canada would like to
acknowledge funding support from Health Canada.
The views expressed here do not necessarily
represent the views of Health Canada.
Recommended citation format:
Health Council of Canada. (2013). Canada’s most
vulnerable: Improving health care for First Nations,
Inuit, and Métis seniors. Toronto, ON: Health Council
of Canada.
ISBN 978-1-926961-90-3 PDF
ISBN 978-1-926961-89-7 Print
Contents of this publication may be reproduced
in whole or in part provided the intended
use is for non-commercial purposes and
full acknowledgement is given to the Health
Council of Canada. For permission, contact
[email protected]
© (2013) Health Council of Canada
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