Benefits of Aboriginal Community-based Collaborative Care
Our research shows that the Knaw Chi Ge Win collaborative care model has resulted in several benefits: improved illness care and cultural safety, managed wait times, and reduction in professional isolation.
Improved Quality of Illness Management
The quality of services has been enhanced for Aboriginal clients in many ways. Although health outcome data were not yet systematically collected, our research suggests that the overall local management of SMI has greatly improved. In-house program statistics show that prior to implementation of this model, 3-4 clients per year had acute care admission to psychiatric hospitals, with frequent recidivism. With the advent of collaborative care, this number was reduced to 0-1 clients per year. Providers explain that clients are more stable and care is more effectively handled locally with this service approach, which they believe explains this reduction in acute care admissions. A mental health worker illustrated why acute admission rates have been reduced with the following case scenario:
Our approach, it's based upon building capacity in the client to the highest level they can manage themselves...NOT doing it for them... You may walk someone through something the first time and then the second time, they want to do as much as they can. As a result you have individuals who are, managing things a lot more than they ever did in the past... There's a client who is schizophrenic [and], used to be in and out of a psychiatric facility every [few] weeks, back and forth, and back and forth... What's going on here? The psychiatrist believed that the community-based paraprofessional workers could support the client... [but] there was miscommunication there, and unrealistic expectations... So, Knaw Chi Ge Win team members, connected with the long term care program...and decided who was going to do what with the client. There were also housing issues that needed to be looked after, financial issues... the team could connect with the appropriate people [at the community] who could share this load.
Other indicators of quality in this service environment include the clients' right to choose clinical or traditional approaches without judgment from providers, or receiving care in their Aboriginal language. For example, many geriatric clients who access mental health services prefer to speak their Aboriginal language. Prior to the development of the collaborative services, mental health services were provided by English speaking providers. Now, the team strives to have at least one Aboriginal staff member fluent in Aboriginal language(s) involved in care for geriatric clients. In addition, an estimated 30 - 40 percent of geriatric clients request traditional healing services and information about Aboriginal herbal medicines is openly shared in this service environment. This is particularly significant since research elsewhere shows that the vast majority of clients will conceal the use of traditional medicine from clinical staff.
Privacy is another important consideration for many clients who access community-based care in small rural communities, where client anonymity associated with large urban centres does not exist and mental health services are often stigmatized. Clients felt that the services provided by the Knaw Chi Ge Win team were completely confidential. A client explains:
I phone all over for the Knaw Chi Ge Win team. If [my regular worker] isn't there, then I'm looking for [another team member]. I find them! They're more trusted... maybe it's because they don't live here and they're not part of our family they don't know me [personally]. I don't know how I'd feel if I had to go speak to the [paraprofessional] worker in my community if I had a drug and alcohol problem...with, the relationships we have in the community...You can't counsel your own family. (Client #8)
Further evidence of quality services are the high levels of client satisfaction:
"One of the counsellors told me to start keeping a journal of my thoughts, of my feelings so I did that for about a year. When I looked back on it I could see my attitude changing day to day in my writings."(Client #7)
"They helped me control myself in that sense, I guess. Because [before I received services] I couldn't talk to anybody. I was pretty messed up. I guess I... started coming out of my shell and that was a while ago. So now I'm just open and honest. I tell it the way it is and that's just the way I am now. Have my self-esteem, courage. I was scared to do anything, go anywhere, talk to anybody. Be me. So they taught me lots."(Client #11)
"It definitely helped me, even just having someone to talk to, that you could be confident with; that you could speak out and say what you really felt and know it wasn't going anywhere... For me it takes a lot to get my trust after everything that's happened to me in my life. The emotional things I've been through in my life. It's very hard for me to trust somebody, to 100% tell them how I really feel, and [my Knaw Chi Ge Win worker] was that one person I could do that with." (Client #3)
"If I ever needed to talk to anybody or needed help... we have the resources [at Mnaamodzawin] that I can phone...I would phone [the intake worker] right away if it ever came to that. But right now everything is good." (Client #13)
"I think everything was done really well. I was really comfortable talking with the counsellor, and when my husband went to talk to the counsellor too, he thought: "I don't think I'm going to take [mental health services]!", But then at the end of it all he was the one who did most of the talking, he said, he found it really good and it was helpful to him because there was a lot of things that he had to work out and he didn't know how to deal with it. So I think that he really liked the counsellor and so does my daughter." (Client #12)
Well Managed Wait Times for Mental Health Services
Keeping wait times to a minimum is a priority for the team and clients. Our research revealed that normal response time for urgent care is less than a week, whereas less urgent counseling is normally provided within 3 to 4 weeks. Wait times for traditional healing are longer, often 4 weeks or more, and access to psychiatric services may be several months for new clients. However, these specialized services were not accessible at all prior to the development of integrated services. Due to limited resources, approximately 40 percent of all clients who seek services through Knaw Chi Ge Win are however referred to private providers who operate under the FNIHB short term counseling program.
Cultural awareness, competence, sensitivity and safety have specific meanings that are debated in the academic literature. However these distinctions are less important to clients who seek good, appropriate and respectful care for themselves. To learn about local definition of cultural issues in mental health care we focused on eliciting clients' and providers' personal concepts of appropriate approaches for mental health services for Aboriginal people. Clients and providers generally believed that culturally appropriate care means providing a safe environment for clients to present concerns without judgment from providers. Participants articulated that a cultural focus should go beyond offering traditional healing services. Of great importance to many was provider acceptance of clients' beliefs, religions, backgrounds, and history, and a focus on building on the strengths of Aboriginal people.
This local definition is very much in line with the concept of cultural safety, which originates with the Maori People of New Zealand, and also describes a concept that goes beyond cultural competence and focuses on provider self-reflection and understanding of power differentials as well as the central notion that it is the client who defines "safe services" One participant explained this eloquently:
As an Aboriginal person I would say meeting people at their level means culturally competent care. Sometimes people assume that we all believe in traditional [Aboriginal] approaches but that's not necessarily so. A lot of our young people...are enmeshed in the main stream approaches so you have to meet them at their level. Yes, [often] they're very interested in learning about their traditional ways; or they're interested in some mainstream approaches. So you have to meet them...wherever they're at. Also culturally competent care means RE-building (emphasis by participant) their capacity [to heal]... We all have that capacity, it just needs to be RE-built. Versus saying," we need to build it" - No! Everybody has that innate strength in them to take care of themselves and we just need to help them in the right direction. (Participant)
Aboriginal clients consistently described high levels of cultural safety within the Knaw Chi Ge Win team members, regardless of the ethnicity of the provider(s). Clients saw this as a feature of the Knaw Chi Ge Win services which, in their experience, clearly differs from mainstream approaches. Many participants explained that the Knaw Chi Ge Win providers understand Aboriginal issues and are open to Aboriginal world views and healing practices. One client stated:
"Living on the reserve is a different way of life...a different way of thinking. Maybe some needs are different. A lot of people I talked to in the past who were counsellors that hadn't worked for Mnaamodzawin or Noojmowin. - they didn't understand certain things that seems like it's a part of your life when you're on the reserve. It's a different way of thinking. A different way the whole community deals with things. These two [Knaw Chi Ge Win] counsellors understand that; it's not even an issue."(Client #2)
Providers echoed this sentiment and explained that the cultural training they had received had taught them about cultural norms and experiences that could be easily misinterpreted and medicalized by less experienced clinical providers:
The every day experience of people in the communities, how these communities work, we understand that. We understand something about the culture... appreciate the fact that when clients talk about ceremonies, we have an idea what they're talking about, when they talk about spirituality, when they talk about spirits, when they talk about dreams, when they talk about different concepts that are really important in their culture. We understand what they're communicating to us... and what that experience might mean for them... Not that I have a great understanding of it, but, learning bit by bit, the client's cultural world view. We hear about the four directions and the four colours...and the meanings of balance in this world view and that's different than what you're getting in a non-native, euro-centric world view. [As a mental health professional] you got to understand that there are differences and you got to appreciate that. The people who come for the service, they are adhering to that world view to one degree or another and you got to figure out to what degree! (Knaw Chi Ge Win Team Member)
However, clients did express concern about the larger network of service providers in the region, many of whom are perceived as not taking traditional approaches and Aboriginal world views seriously. Consequently, a repeatedly identified issue was the need for more Aboriginal workers at all tiers of service provision. Furthermore, despite the fact that non-Aboriginal core team members are regarded as highly culturally competent, some Aboriginal clients felt much less comfortable with non-Aboriginal than with Aboriginal providers. The clients' life experiences with racism and discrimination appear to be a determining factor. One participant explained this as follows:
By sending someone to a counsellor who is non-native that puts the playing field where one person is an expert and one is below that - it creates that idea of when you were in school, teachers were non-native, doctors are non-native, everybody is non-native. I don't see that as a way to bring back personal power to a person. (Participant)
In contrast, a fair number of clients are not comfortable seeking help for mental health issues from community members, and therefore welcome a provider who is not from their community. These clients felt quite comfortable with non-Aboriginal providers as an alternative, while still others professed no preference regarding the ethnicity of their provider within the Knaw Chi Ge Win team. The collaborative care approach allows the team to be responsive to these diverse comfort levels of clients.
Benefits for Service Providers
Providers see the collaborative practice as a positive and desirable work environment which reduces professional isolation. Providers felt very supported in their work and able to draw on other interdisciplinary team members when necessary, as evidenced in this quote:
Ah, the support!...Basically, the communication is, is just tremendous. I've never worked with a bunch of people where we sit down and talk so much and discuss cases...It's really a benefit not only to everyone as a group to know, how things are going, but, it certainly benefits myself because, they've got the skills that I don't have and what I have I can augment a little bit on their side too. So I think, the shared care model as far as I'm concerned is the only way to go. (Knaw Chi Ge Win Team member)
Clinical as well as traditional service approaches are explicitly respected by all team members. Providers felt that this model had increased their confidence dealing with complex cases, and improved their professional abilities and their ability to ensure cultural safety. New care providers felt that the integration model allows them to work at full capacity soon after they are hired, because existing staff act as mentors during the weekly intake meetings and through informal consultations. The collaborative model has thus contributed to the creation of a relatively stable mental health team in a challenging, resource-scarce service environment.
While there are many benefits associated with this model of care, significant challenges still remain to maintain this model of care and to expend the services to a level of care that meets the needs of the community.
Chronic Under-funding of Aboriginal Mental Health Services
Severe funding constraints for Aboriginal mental health programs make it difficult to recruit and retain experienced qualified professional providers. Funding is often short term and inadequate to attract mental health professionals with sufficient qualifications. The mental health team cannot meet the increasing demands for services (e.g.: 8% increase in 2007). As a result, about 40% of clients must be referred to 'outside' providers for short term counseling under FNIHB's crisis counseling program and this rate will likely increase. There is no collaborative care with these providers once clients are referred out and while outcomes are therefore unknown, the ideal of holistic care is certainly not realized. Additional services in psychiatry, child psychiatry and traditional medicine are needed to meet community needs. Prevention activities for children, youth and parents are also urgently required. In order to expand integration, more time and resources are required for program development and reflection. Providers generally believed there is great potential:
When I get a chance to listen to what [the healer] has to say, I can hear what his perspective is. People think it's so far apart but I never see it that way, I always think there are so many possible meeting points, when I listen to him speak it's like: Okay! I'm with you on this and this...I think there is all sorts of potential, for more collaboration and more integration if we had the time to work on exactly that... And I think that's true for discussions with elders, you know, I wish we could have some process by which we regularly engaged in that because I'll bet you that there would be more convergence than divergence. That's just the way I see it. (Knaw Chi Ge Win team member).
Recruitment of Mental Health Professionals
Clients value experienced workers and the fact that many of the core team members have been employed with their organizations for many years. However, when positions need to be filled, recruitment of experienced workers is difficult. There is a need for long-term strategies to mentor and recruit Aboriginal students into mental health careers; funds to cover travel costs for student placements are also required.
Lack of Community Mental Health and Consistent Mental Health Services Data
Reliable mental health status and service data are required to evaluate services and track outcomes. Ongoing systematic data collection is necessary, including: (1) client service data and client satisfaction questionnaires, (2) client outcome data, including changes in client behaviours, symptoms and family situation, (3) local emergency use and hospitalization data in the Manitoulin district, and (4) health status data.
In addition, research is necessary to develop an Aboriginal approach to mental health service evaluation. Existing outcome indicators are based on clinical approaches in mainstream populations and do not take into account Aboriginal understandings of healing or the multi-generational effects of colonization on mental health .