National Native Alcohol and Drug Abuse Program (NNADAP) Review
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Purpose of this Document
The purpose of this document is to highlight the major findings
and conclusions of the NNADAP Review. It can be considered an Executive
Summary of all elements of the Review. Readers are encouraged to
familiarize themselves with the NNADAP Review, Literature Review,
Financial Review, Terms of Reference and the Worker Questionaire
Frequency Report.
While there are many challenges which have been identified as
a result of this Review, the Review also identified a number of
models currently in operation that have been successful in dealing
with various aspects of management of the program. Many of these
models can be found in the NNADAP Review.
The Steering Committee hopes that you will validate the findings
of this report, and support and work to implement the conclusions.
Discussions will need to occur within each MSB Region on the findings
and conclusions. Priorities and regionally specific action plans
will need to be agreed upon by all stakeholders and implemented.
Findings and Conclusions
1. Introduction
The key elements of a successful review were openness, the
sharing of information and input by First Nations and the Inuit.
A review of the NNADAP program was undertaken in order to ensure
that the needs and challenges of today's clients were being met
in a timely and comprehensive fashion. Under the direction of a
National Steering Committee the NNADAP program was reviewed by
team of outside consultants. The NNADAP Review Steering Committee
was composed of the following individuals:
Deanna Greyeyes
Co-chair, former
Executive Director of the Society of
Aboriginal Addictions Recovery and appointed by a SOARR
Paul Glover
Co-chair, Director
General of the First Nations and
Inuit Health Programs Directorate,
Health Canada
Lindsay Kaye
Member, former Member of the
Chiefs Committee of Health
appointed by the Assembly of First Nations
(AFN)
Elsie Casaway
Member, Senior Policy Analyst for
the Health Secretariat of the AFN
Paul Kyba
Member, Associate Director of Medical Services
Branch, British Columbia
representing Health Canada
Ronald Linklater
Member, former NNADAP Regional
Consultant, MSB Manitoba Region
Health Canada and currently with the
Addictions Foundation of Manitoba
2. Methodology
Through a competitive process a contract to Richard Jock and Associates
was awarded via the Aboriginal Procurement Policy of the Government
of Canada. The Review was conducted in the following manner:
Approximately 50 interviews of key informants were conducted to
determine major issues.
A series of 5 written questionnaires (NNADAP Workers, leadership,
health workers, social services workers and treatment centers)
were mailed to all First Nations communities and NNADAP treatment
centers. The overall response rate was 37 percent.
Field visits were carried out to 37 First Nations communities
across the country.
Ten focus groups were held in each MSB Region plus the N.W.T.
Field visits to seven NNADAP treatment centers were conducted.
One in every MSB region.
The results of the Review form the basis of this discussion paper
which is intended to indicate areas to focus future activities
upon.
3. NNADAP Mandate
The original mandate of the NNADAP program should continue.
The mandate that defined the NNADAP program was "to support First
Nations and Inuit people and their communities establishing operating
programs aimed at arresting and offsetting high levels of alcohol,
other drugs, and substance abuse among the target population living
on reserve". Since the establishment of the program in 1987 significant
change has occurred particularly in the nature of addictions and
substances involved. The program has evolved somewhat but is faced
with a bewildering array of new challenges. The original assumption,
which remains valid to this day, is a belief that effective community
programs will, in time, decrease the need for inpatient treatment
services. The Steering Committee agreed that the original mandate
of the NNADAP program should continue as there was a continuing
need for extensive programming in this area.
4. Findings
There is recognition that various forms of addiction including
alcohol, illegal drugs, prescription drugs, bingo and gambling
remains a serious problem at the community level.
Surveys indicate that alcohol and drug abuse continues to be one
of the major health concerns among First Nations. It was encouraging
to find that the program has significant support with First Nations
and their leaders across the country.
It is clear that there is a large existing workforce that has
great devotion to the program. It is also clear that First Nations
have a sense of ownership as the programs provide culturally sensitive
solutions that are not offered or available from other sources.
However it is now evident that the benefits and attributes of a
series of treatment centres and prevention programs working as
a network have not been realized with this program. It is important
to have a series of complementary treatment and prevention capacities
that ensure that the interests of all potential clients are met.
This can only occur if joint planning and cooperation occurs.
Community Based Programs
There is a high level of importance assigned to NNADAP by
the leadership.
There is generally a high level of commitment and dedication
by the NNADAP workers both to the field of addictions and to
the community
The community-based program of NNADAP is one of the largest funded
by Medical Services and features approximately 729 funded positions
across Canada making the breadth of the program one of the most
comprehensive offered by Health Canada. A total of 24.9 million
dollars is spent annually in contribution agreements and this amount
is supplemented by funding provided by transfer agreements. The
total funding for this prevention activity is therefore nearly
30 million dollars annually.
The Review highlights a number of successes achieved by the NNADAP
program. These range from spectacular community wide impacts to individual
success stories relayed anecdotally to the review team across the
country. By any measure the successes achieved are priceless.
It is very clear that there exists a lack of program integration
with treatment centers and other community based health programs
and this may have resulted from a number of different factors.
Most obvious is the lack of a well defined national or regional
strategy for dealing with the problems posed by addictions. In
many areas this was interpreted to be the result of a lack of program
direction. Other sources cited the lack of information to make
program decisions as the salient factor. Regardless of cause, it
is clear that the lack of a defined strategy has had a number of
negative impacts.
The most obvious of these is the subsequent high turnover of staff
that has resulted from the isolation of workers, in itself a result
of inconsistent access to training, particularly in remote areas.
Another major factor cited was the perception that funding has
been severely limited in the past number of years. This has resulted
in competent trained staff being recruited by other Aboriginal
employers. Many perceive that the NNADAP program serves simply
as a training ground or stepping stone for other opportunities.
Evidence exists to support this contention.
Treatment Centers
Addictions patterns and challenges have changed and NNADAP
must respond to these changes.
Medical Services Branch currently funds 50 NNADAP treatment centers
in a variety of locations across Canada. A total of 695 treatment
beds are operated in the centers and funding for them totals $23.8
million in contribution agreements. Additional funding is available
for the three transferred centers.
The review team found that most NNADAP centers operate on an extremely
cost-effective basis with an average per day cost of approximately
$100 per client, representing good value for money. The value and
quality of programming is being recognized by other agencies, departments
and governments in the form of joint ventures and other synergistic
activities.
Treatment centers suffer as do community-based programs from a
lack of integration with a National system of treatment. As with
community-based services the lack of the network is clearly evident.
Many centers offer the same types of services using the same approaches
for the same clients as do others. This has resulted in a lack
of specialization or differentiation of services. Thus many potential
client groups are unable to access services within the network.
Due to financial constraints, the viability of many centers is
in question and indeed continued survival of smaller centers is
dependent on subsidies from the viable centers that have managed
to attain economies of scale. The funding freeze that has been
in place over the past number of years has resulted in a decline
in the number of trained personnel available for the treatment
centers. A high turnover of staff has occurred creating major difficulties
in many centers.
5. The System of the Future
Principles:
- Sustainability
- Viability
- Effectiveness
- Responsiveness
The landscape has changed since the NNADAP program was established
and, in fact, changes have occurred more rapidly within First Nation
and Inuit communities. Addiction patterns and challenges are different
and in many cases the NNADAP program does not reflect these changes.
To ensure that the status quo changes, it is essential to have
a system that allows funds to move to areas of greatest need and
to provide incentives for changing programs to respond to these
changing needs. For example; if programming for males 25 to 40
is underutilized, capacity should be reconfigured in order to accommodate
services for women or other unserviced groups.
To accomplish specialized and differentiated programming, it is
essential to ensure that timely information systems are available
on which to base both program decisions and future planning. To
achieve quality assurance, it is necessary to ensure that quality
is an integral part of program from the initial client assessment
to the accreditation of the program itself. Research will also
be required to ensure that the best practice approach is used in
the NNADAP program.
To ensure that the NNADAP system meets the challenges of the future,
it is vital that the following principles guide all activities:
Sustainability
The NNADAP network cannot continue to lurch from financial crisis
to financial crisis. Decisions need to be made that ensure that
the system of the future is able to plan and operate on a sound
basis within funding parameters. To achieve this principle, decisions
will need be to be taken that resolve program issues with issues
of costs.
Viability
It is clear that many spokes in the NNADAP system are not viable
in their present form. Decisions regarding resources in these extreme
examples will need to be made. It is clear from the Financial Review
that a number of Treatment Centers; in particular are not viable
at current funding levels. It will be beneficial to examine these
situations with a view to reconfiguration in order to meet local
needs within funding parameters.
Effectiveness
As funding is limited, it is vital to spend funds in the most
effective manner possible. It is clear that outcome measurement
will be the best means of facilitating necessary decision making.
Responsiveness
First Nations communities and challenges have changed since the
inception of the NNADAP program. For the NNADAP Network to remain
relevant, the Network must be proactive in offering programs that
meet emerging needs.
First Nations communities and challenges have changed since the
inception of the NNADAP program. For the NNADAP Network to remain
relevant, the Network must be proactive in offering programs that
meet emerging needs.
6. Action
In order to achieve the goals identified in the NNADAP Review,
action will be required in 4 distinct areas.
- Co-ordination/integration
- Quality and specialization of care
- Information management
- Sustainability
Co-ordination/Integration
To achieve and facilitate coordination, planning between various
program components is essential to establish structures to broker
discussions regarding planning and strategy development. It is
recommended that Regional Partnership Committees be established
to address a variety of issues including:
- co-ordination
- integration issues
- differentiation of service and evaluation
The composition of the Partnership Committees will be dependent
on the current governance structures in each region and on the
extent transfer.
The Partnership Committees on a practical basis will review client
information, including recidivism and trends and patterns in the
addictions field. The Committees may also coordinate and target
all new expenditures to ensure that the system remains relevant
to and meets the needs of the communities it is intended to serve.
The Regional Partnership Committees will also facilitate quality
assurance activities as well as program reviews.
To support regional work it is further recommended that a National
Partnership Committee be formed comprised of regional members and
other partners. The National Partnership Committee will focus on
activities such as:
- program innovation
- research and continuity
- program direction in macro terms
- development of accreditation standards.
Quality and Specialization Care
It is recommended that Regional and National Partnership Committees
be established.
A national accreditation program should be established.
NNADAP must provide a full range of services based on the continuum
of care and on a case management philosophy. The services must
be consistent and easily accessible. Case management with other
agencies and interested parties should be common practice and a
network of programs and services should have flexibility to adjust
to new services as needs are identified.
The NNADAP network should be providing a complete range of different
community-based treatment approaches and delivery methodologies
recognizing that not all clients respond in a similar fashion to
specific approaches. Treatment programs should therefore be available
for distinct target groups such as children, youth, couples, family
and female clients. To ensure that this occurs, links must be maintained
with prevention or community-based programs.
It is essential that quality be recognized as important and formalized
in as many different manners as is possible. It is therefore recognized
that accreditation is likely the quickest and most efficient manner
to establish credibility for the network as a whole. Peer review
leading to formal recognition of program quality will establish
the NNADAP network in the forefront of the addictions world.
Information Management
A new information system must be developed that will serve
users needs.
The existing treatment activity reporting system (T.A.R.S.) has
outlived its usefulness and must be replaced. In the short-term
a substance abuse reporting system will be installed that will
enable treatment centers to collect useful information for both
analytical purposes as well as for local management issues. A new
information system must be developed that will serve users' needs
both in terms of program development and utilizing available capacities
efficiently. The primary motivation for such a system should be
to ensure that the case management approach is taken to maximize
benefits for all clients interfacing with the system and to collect
data necessary to substantiate program resources. This will enable
program decision-making to be based on the collected evidence and
experience of all treatment centers within Canada.
This approach fits well with the Health Information System (HIS)
currently being developed in partnership between First Nations
and Medical Services Branch. All systems contemplated for the NNADAP
network should be compatible with the Health Information System
(HIS)and should be an integral portion of the larger information
system under development.
Sustainability
- Funding parameters should be stabilized.
- Strong capacities should be strengthened
and weak components deemphasized.
To develop a viable and sustainable long-term Network integrating
preventative and treatment programs, it is essential to stabilize
the financial parameters within which the program operates. To
achieve this goal, it is vital to ensure that effectiveness can
readily be demonstrated. The resolution of items noted for attention
by the Partnership Committees are essential in providing a solid
foundation for future planning and stabilization of programs.
Only by resolving basic issues will it be possible to identify
the stable base that will serve to meet the needs of clients for
future. Once basic resolution has been attained, it will be possible
to address many long-standing funding issues.
To stabilize staffing salaries must be competitive with other
potential employers. In most cases salaries follow regional patterns
and as a result solutions should also be devised by Regional Partnership
Committees. Performance and training are key components in any
potential salary resolution. It is clear that creativity will be
required.
Strategies must be developed which strengthen strong capacities
and deemphasize the weaker components of the system. It is quite
likely that the end product will be a better functioning but smaller
system. The timing is now as there exists the potential at present
to reconfigure centers in other roles. When the restructured system
is in place it will be possible to evaluate accurately the long-term
financial requirements that will be appropriate for the system
of the future.
7. What's Next
- Release the NNADAP Review to all stakeholders.
- Facilitate discussions to discuss findings and develop strategies
to address findings and conclusions of the Review, with particular
emphasis on the establishment of Regional and National committees.
- Implement the NNADAP accreditation program.
- Develop and implement, in conjunction with First Nations, a
new and improved information management system.
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