Table of Contents
Substance use issues continue to be a priority concern for First Nations people in Canada. The primary network in place to respond to First Nations substance use issues is the National Native Alcohol and Drug Abuse Program (NNADAP) and the National Youth Solvent Abuse Program (NYSAP). This network of on-reserve addiction services includes 58 centres and more than 550 NNADAP community-based prevention programs. In addition to NNADAP/NYSAP, First Nations people also access a wide range of substance use and mental health-related services from other sectors within the health care system both on- and off reserve, as well as other systems, including social services, child welfare, justice, housing, education, and employment. With the diverse systems in place to serve First Nations people, a challenge for communities, regions, and all levels of government is to coordinate a broad range of services and supports to ensure that First Nations have access to a comprehensive, client-centred continuum of care for substance use issues.
As a key activity under the National Anti-Drug Strategy, the Assembly of First Nations (AFN), the National Native Addiction Partnership Foundation (NNAPF), and the First Nations and Inuit Health Branch (FNIHB) of Health Canada oversaw a comprehensive, community-driven review of substance use-related services and supports for First Nations people in Canada. This review was guided by the First Nations Addictions Advisory Panel, and was informed by the First Nations and Inuit Mental Wellness Advisory Committee’s Strategic Action Plan for First Nations and Inuit Mental Wellness, which was developed in 2007 to provide national strategic advice on efforts related to First Nations and Inuit wellness. From 2007 to 2011, the review included a wide range of knowledge-gathering and consensus-building activities, including regional addiction needs assessments; a national forum; a series of research papers; regional workshops; and an Indigenous knowledge forum. These activities directly engaged community members, treatment centre workers, community-based addiction workers, health administrators, First Nations leadership, provincial service providers, researchers, and policy makers to develop and shape a renewed approach for community, regional, and national responses to substance use issues among First Nations people in Canada. Honouring Our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada was developed based on this process of engagement and feedback.
Honouring Our Strengths outlines a continuum of care in order to support strengthened community, regional, and national responses to substance use issues. This vision is intended to guide the delivery, design, and coordination of services at all levels of the program. This approach recognizes that a wide range of individuals, organizations, departments, and other partners are responsible for addressing the substance use-related needs of First Nations people in Canada. The focus of the framework is on addressing substance use issues, however it also considers the important roles mental health and well-being play in all aspects of care, including prevention, early identification, intervention, and follow-up. This document provides a summary of the guiding principles upon which the framework approach is based; the six elements of a continuum of care to respond to the needs of individuals, families, and communities; and six key supports to the continuum of care. For the full version of Honouring Our Strengths and other renewal-related documents, please visit the process website at: www.nnadaprenewal.ca (URL).
- Spirit-centred—A system-wide recognition that cultural practices and traditions are essential to the health and wellbeing of First Nations people. These practices and traditions are recognized as the outward expression of spirit; and that the revitalization of spirit is central to a strengthened system of care.
- Connected—Strong connections are the basis for holistic and integrated services and supports. These connections exist between Indigenous people, the land, and their culture, as well as relationships between various sectors and jurisdictions responsible for care delivery.
- Resiliency-focused—While trauma contributes substantially to both addictions and mental health; there is a need to recognize, support, and foster the natural strength and resilience of individuals, families, and communities. These strengths provide the foundation upon which healthy services, supports, and policies are built.
- Holistic Supports—Services and supports that consider all potential factors contributing to well-being (e.g., physical, spiritual, mental, cultural, emotional and social) over the lifespan, and ensure that these needs are addressed through a comprehensive, integrated continuum of care.
- Community-focused—Community is viewed as its own best resource with respect to the direction, design, and delivery of services. Adopting a community-focused lens will help to both ensure that diversity within and across communities is respected, and enhance overall system responsiveness to factors that make each community unique.
- Respectful—Respect for clients, family, and community should be demonstrated through consistent engagement, at all levels, in the planning and delivery of services. This engagement must also uphold an individual’s freedom of choice to access care when they are ready to do so, as well as seek to balance their needs and strengths with the needs of their families and communities.
- Balanced—Inclusion of both Indigenous and Western forms of evidence and approaches to all aspects of care (e.g., service delivery, administration, planning and evaluation) demonstrates respect and balance. It is also important to maintain awareness that each is informed by unique assumptions about health and well-being and a unique worldview.
- Shared Responsibility—Recognition of the individual, shared, and collective levels of responsibility to promote health and well-being among First Nations people. This begins with individuals managing their own health and extends to families, communities, service providers, and governments who have a shared responsibility to ensure services, supports, and systems are effective and accessible, both now and for future generations.
- Culturally Competent—Cultural competence requires that service providers, both on- and off-reserve, are aware of their own worldviews and attitudes towards cultural differences, and include both knowledge of, and openness to, the cultural realities and environments of the clients they serve.
- Culturally Safe—Cultural safety extends beyond cultural awareness and sensitivity within services and includes reflecting upon cultural, historical, and structural differences and power relationships within the care that is provided. It involves a process of ongoing self-reflection and organizational growth for service providers and the system as a whole to respond effectively to First Nations people.
Elements of Care
The elements of care described in Honouring Our Strengths reflect a continuum of care approach.This approach aims to support a strengthened, systems-wide response for First Nations people who are at risk of, or directly affected by substance use issues throughout the lifespan. This approach focuses on:
- Matching people affected by substance use issues to the kinds of services and supports they need at any point in their care journeys; and
- Co-ordination among partners and sectors to provide effective, client-centred services and supports.
The six elements of a continuum of care are intended to respond to the needs of individuals, families, and communities with a range of substance use issues. They are also designed to meet the needs of specific population groups (e.g., women, youth, and people with co-occurring mental health issues).
>> Element 1: Community Development, Prevention, and Health Promotion
Health and well-being must be pursued in the context of the community in which First Nations people live and remain connected throughout their lives. First Nations communities, with services and supports that are responsive to their needs and culture, are the primary means for promoting healthy connections between individuals, families, and communities. The key components of an effective approach to community development, prevention, and health promotion include:
- Community development efforts designed, directed, and implemented by community members and leadership, which promote the local control of services, and include a strong focus on community mental wellness;
- Prevention approaches for the general public or a population within a region or a community (such as youth, parents, pregnant women, or older adults) aimed at promoting healthy behaviours and preventing, reducing, or delaying substance use or abuse; and
- Health promotion activities which build on community and cultural knowledge. These efforts help people engage in safer and healthier lifestyles, create conditions that support such lifestyles, and restore healthy and supportive family dynamics.
>> Element 2: Early Identification, Brief Intervention, and Aftercare
Ongoing engagement and care for those who are either at risk of developing substance use issues or who have already accessed more intensive services is central to a system of care. Reducing and preventing potential issues requires that care providers, including health and social service providers, families, and other community members, are equipped with the skills and knowledge to identify, intervene, and support those in need of care. The key components of an effective approach to early identification, brief intervention, and aftercare include:
- Targeted prevention efforts for individuals at an increased risk (e.g., a youth with a confirmed or suspected mental health issue) or showing early signs of a substance use issue;
- Early identification and screening efforts in a wide range of settings in which individuals, both within and outside of communities, are equipped to identify and support those in need of care;
- Brief interventions/discussions between a substance user and someone they trust that contribute to goal setting and motivation to adopt healthier behaviours;
- Ongoing risk assessment and pre-treatment support to assess readiness for treatment and reduce potential risk factors related to substance use;
- Referral to care options based on an assessment of an individual’s holistic needs and strengths, along with ongoing case management and care; and
- Ongoing aftercare for those who have accessed treatment services and require life-long, holistic support from their communities and a range of service providers.
>> Element 3: Secondary Risk Reduction
People who are involved in risky substance use that may be putting themselves or others at risk, such as binge drinking or driving while intoxicated, require safe and nurturing environments and a range of services and supports. These services and supports actively engage people in a wide range of settings and help connect them with care responsive to their needs, priorities, and motivations to change. The key components of an effective approach to secondary risk reduction include:
- Community-based support through formal (e.g., drinking and driving reduction campaigns) and informal (e.g., community cultural gatherings) means to reduce risky behaviour and promote connection to family, community, and culture;
- Outreach efforts to engage substance users within and outside the community in order to assess needs, motivation to change, and link them with health, social, and cultural supports;
- Ongoing risk assessment and management to organize necessary services and supports to reduce risk factors and behaviours related to substance use; and
- A range of efforts (e.g., case management) that will ensure clients are connected with care options specific to their needs and supported throughout their healing journey.
>> Element 4: Active Treatment
Supporting people with alcohol and drug addictions and those close to them, requires that a range of client-centred, culturally competent approaches are available throughout the healing journey. These services and supports build on individual, family, and community strengths, consider the holistic needs of clients, and are offered in a range of settings, such as communities, treatment centres, and on the land. The key components of an effective approach to active treatment include:
- Early identification and intervention through effective screening, assessment, and referral to services appropriate to the client’s specific needs;
- Withdrawal management and stabilization services, when necessary, which help to support and stabilize clients withdrawing from drugs and alcohol;
- Ongoing case management where various health and social services are coordinated to meet the unique needs of a client;
- Treatment programs that are responsive to individual and community needs, which support individuals to stop or reduce substance use, improve their overall quality of life, and reconnect with family, community, and cultural supports; and
- Discharge planning and aftercare efforts that work with a client and their support networks to ensure access to a range of care options that build on the treatment experience and address key social determinant of health areas (e.g., housing, employment, education, living conditions, and social support).
>> Element 5: Specialized Treatment
People with highly complex service needs, including individuals with severe addiction and/or mental health or chronic health issues, require effective screening, assessment and referral; culturally competent services; and ongoing support and monitoring throughout a client’s healing journey. Those who access these care options, whether within or outside of the community, benefit from strong connections to their support networks, such as family and community. The key components of an effective approach to specialized treatment include:
- Coordination of care efforts, such as case management and multi-disciplinary teams that facilitate collaboration among treatment services, communities, and provincial and federal services in a manner that is culturally competent;
- Cultural competency among care providers that ensures they have knowledge of, and openness to, the cultural realities of the clients; and
- Community-level capacity and support to effectively screen, assess, refer, and provide ongoing care to clients with complex substance use issues. These efforts may draw upon a range of community services and supports, and require a high level of collaboration.
>> Element 6: Care Facilitation
An effective system of care requires coordination between a wide range of services and supports for individuals and families throughout the healing journey. This system of care provides collaborative and consistent communication, as well as planning and monitoring among various care options specific to a client’s holistic needs. It relies upon a range of individuals, including service providers, case managers, friends, or families to provide ongoing support to facilitate access to care. The key components of an effective approach to care facilitation include:
- Social and cultural supports, which provide a source of encouragement and care;
- Assessment and planning efforts based on an individual’s needs, strengths, values, and goals;
- Coordination efforts that work with a range of care options to ensure timely access to health and social services based on client needs;
- Collaboration and information sharing with clients, their families, and other community service providers;
- Advocacy on behalf of clients and their families in order to improve access to services; and
- Ongoing follow-up with a client that acknowledges what they have achieved, and connects them to the care options they need.
Supporting the Continuum of Care
The following are six key supports to the continuum of care.
>> Workforce Development
A qualified workforce with the appropriate skills and knowledge, supported by a healthy work environment, competitive wages and benefits, and opportunities for worker development, is the foundation to quality care for clients. Key components of an effective approach to workforce development include:
- Recruitment and training strategies that support the identification, retention, and training of culturally competent workers;
- Education, training, and certification to address the complex needs of individuals, families, and communities;
- Worker retention through a range of practices and policies to ensure healthy workers and work environments;
- Competitive wages and benefits; and
- Personal wellness supports for workers to reduce burnout and support retention.
>> Governance and Coordination of Systems
The development and maintenance of holistic community-based addictions services and supports are informed by First Nations culture, values, and tradition. These care options contribute to community health and well-being beginning with local control and often require collaboration between and among governing bodies and service providers. Key components that support strong governance and coordination of systems include:
- Community-driven addiction services that embody First Nations cultures, values, and traditions;
- Effective relationships and collaboration between various partners responsible for providing care to First Nations whose roles and responsibilities are clear; and
- Establishing and maintaining strong system-level partnerships and linkages among governing bodies, health, and social service providers that promote collaboration at the community, regional and national levels.
>> Addressing Mental Health Needs
Serving clients and communities with mental health and addiction needs requires a range of community and medical supports, which make use of both cultural and mainstream approaches to care. The foundation of this approach includes worker competence about mental health issues, capacity to meet specialized needs, and strong connections among care providers. Key components to effectively address mental health needs in an addictions system include:
- Strong referral and case management networks;
- Centres able to deal with co-occurring mental health and addiction issues;
- Community-based mental wellness supports that include a range of necessary care options (e.g., prevention, early identification, intervention, and follow-up);
- Culturally-based aftercare for clients and their families;
- Inclusion of Indigenous approaches to mental health within mainstream clinical services;
- Accessible medical assessments and medication support when necessary; and
- Multidisciplinary team approaches that are responsive to the needs of the community.
>> Performance Measurement and Research
Ensuring an effective system of care requires culturally-relevant research and ongoing tracking of program results, including not only data on individual substance use but also all factors which contribute to wellness for First Nations. This approach combines opportunities to share knowledge and support addictions programs to better meet the needs of clients and communities. Key components of a strong approach to performance measurement and research include:
- Population health information consisting of both outcome and socio-economic measures to inform planning and programming;
- Integrated performance measurement that includes tracking and reporting of activity data (e.g., rates of use, results data, and client outcomes);
- A research strategy or plan for client and community wellness that recognizes cultural knowledge and values;
- Identification and resolution of and resolving research and information gaps in the evidence base; and
- Knowledge exchange activities on research findings, policies, and practices to strengthen service and support at community, regional, and national levels.
>> Pharmacological Approaches
Training, support, and information-sharing are central to ensuring a safe and appropriate approach to medication in support of addiction recovery in First Nations communities. This approach places an emphasis on collaboration between a range of individuals, including clients, medical service providers addiction workers, and cultural supports to ensure that clients get the care they need. Key components for the correct use of pharmacotherapy include:
- Medical assessments of a client with a substance use issue by a primary care provider;
- Ongoing follow-up and monitoring through assessments by a health care provider to monitor symptoms and side-effects;
- Community-based services that help with the coordination of care for clients on medication which may include traditional and complementary medicine; and
- Multidisciplinary team approaches to care that help address the complex needs of clients on medications.
National standards for treatment centres and community-based health services that reflect First Nations culture are essential to promoting quality services, and ensuring the safety of both clients and addiction workers. This approach helps to meet and maintain standards of care, which encourage continuous quality improvement of addictions services. Key components for a strong accreditation approach include:
- Assessing organizational readiness and the risks and benefits of accreditation, and reaching consensus on an organization’s readiness for accreditation;
- Choosing an accreditation body/organization suited to both the organization’s needs and Health Canada’s policies related to accreditation;
- Conducting a self-assessment on policies, practices, and evidence that will support organizational accreditation based on a set of standards;
- Gathering information to support ratings based on the accreditation standards;
- Setting up a peer review after the self-assessment has been sent to the accreditation body;
- Receiving a report and recommendations from the accreditation body; and
- Ensuring follow-up and continuous improvement by implementing recommendations made and following up with the accreditation body.
Honouring Our Strengths outlines a vision for a comprehensive continuum of services and supports to guide community, regional, and national responses to substance use issues among First Nations people in Canada. This vision recognizes that a strengthened system of care is the shared responsibility of various jurisdictions (community, province, federal), as well as a wide range of care providers including family and community members, community service providers, primary care and other medical staff, and off-reserve service providers. Within this vision, the emphasis is on ensuring that people, families, and communities have access to a range of effective, culturally-relevant care options at any point in their healing journey. Realization of this vision will require ongoing commitment, collaboration, and sustained partnerships. Commitment and collaboration will, in turn, depend upon effective leadership throughout the system.
The NNADAP Renewal Leadership Team was formed in 2010 to exercise leadership in guiding the implementation of Honouring Our Strengths. The Leadership Team, with support from AFN, NNAPF, and Health Canada, will work with various networks and partners toward strengthening the system of care for First Nations people. However, solutions for renewal must also come from First Nations people, who own the vision of the framework and must guide its implementation in order to ensure the system remains responsive to their needs. Implementation of this framework will involve developing tools and guides to support partners at all levels. It will involve ongoing communication through established networks (e.g., AFN First Nations Health Technicians Network; NNAPF regional networks; Regional Addiction Partnership Committees; the Youth Solvent Abuse Committee; and Health Canada First Nations and Inuit Health regional offices). It will also require identification of opportunities to positively influence change, optimize the use of existing resources, and identify new funding opportunities. While Honouring Our Strengths provides a comprehensive vision for the renewal of First Nations substance use-related services, it is recognized that the framework must be viewed as a living document, which can be adapted or revised based on the evolving Indigenous and mainstream evidence base, as well as the changing needs and realities of First Nations people. Over time, this will require integrating programs for tobacco abuse, problem gambling, and other addictive behaviours. It will also involve efforts to create a fully integrated mental wellness continuum of services and supports.
The opportunities that exist to strengthen the system of care are great. Many First Nations cultural teachings indicate that the Creator gave everyone tomorrow to make a difference, and with this promise of tomorrow comes responsibility. Everyone involved in this framework must manage the responsibility of “tomorrow” so that collectively, we can pursue our vision for change.
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