Mental Health and Alcohol and Drug Misuse Services. Framework for Service Delivery

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1 Mental Health and Alcohol and Drug Misuse Services Framework for Service Delivery

2 Acknowledgements The Ministry would like to acknowledge the Adult, and Child and Youth Provincial Standing Committees, the Regional Directors of Mental Health and Addictions, the Project Reference Group, and the Drug Treatment Funding Program Steering Committee for their contribution to document development. The Ministry would also like to acknowledge Greg Drummond for project facilitation and document development, and Health Canada for project funding under the Drug Treatment Funding Program. May 2012

3 Table of Contents Introduction... 3 Foundational Principle 1: Services are Person and Family Centred... 4 Foundational Principle 2: Services are Coordinated and Collaborative... 5 Foundational Principle 3: Services are Integrated... 7 Foundational Principle 4: Services are supported by Continuous Quality Improvement... 9 Foundational Principle 5: Services are engaged with Communities Summary Appendix 1: Tiered Care Appendix 2: Guiding Principles and Shared Values Resources

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5 Mental Health and Alcohol and Drug Misuse Services Framework ~ Services should fit the person, not the other way around ~ Introduction The Mental Health and Alcohol and Drug Misuse Services system is a client/patient (person 1 ) and family centered care delivery system that is designed to meet the health needs of those persons and families affected by mental health and/or alcohol and drug misuse issues. The system exists for and with patients, clients and families. This Framework document aims to provide the conceptual background and support for current operations, as well as future conceptual and practical developments within Mental Health and Alcohol and Drug Misuse Services in Saskatchewan. This framework provides the foundational principles to guide programs, services and staff in delivery of care. It is also intended to provide background for future developments including detailed clinical and program standards. This Framework reflects the change in relationships amongst the health regions and with the Ministry of Health for joint planning, improved collaboration and co-operation in the continuous development of Mental Health and Alcohol and Drug Misuse Services. The Framework advocates for the use of benchmarks to measure progress in the development and enhancement of Mental Health and Alcohol and Drug Misuse Services in Saskatchewan (for example, the use of Triple Aim benchmarks that include improving the health of a defined population; enhancing the patient care experience and or reducing or controlling the per capita cost of patient care). For the Framework to remain current and reflect developing knowledge and trends there should be an expectation of a review and where indicated updates in 2-3 years. Why Now Recently the focus on person centred care, the need for a collaborative and an integrated response, as identified in a number of health system improvement papers, has resulted in a closer link between the Mental Health and Alcohol and Drug Misuse Services systems in Saskatchewan. Some of these changes have been supported in Mental Health and Alcohol and Drug Misuse via system redesign and improvements to improve persons and family centered care. Systemic changes have resulted in the amalgamation of services, the restructuring of provincial leadership teams to reflect an integrated Mental Health and Alcohol and Drug Misuse Services Integrated framework, the development of an electronic client information system and most recently detailed work on standardization of screening and assessment tools, processes and discharge planning. These modifications are consistent with person/family-centred care and quality improvement initiatives. While achievements to date are aligned with work at the national level (list of documents under Resources) the focus continues to be primarily on system change. Mental Health and Alcohol and Drug Misuse Services in Saskatchewan are in need of a framework that is person and family focused, is aligned with other provincial and national strategies, reflects knowledge enhancements, and provides the foundation for the ongoing evolution of service delivery. It is the aim of this framework document to provide this foundation. Outline This Framework outlines the following five foundational principles for service delivery: 1 This term reflects the language in other national and/or provincial jurisdictions and will be used interchangeably throughout this and other document. 3

6 1) Services are Person and Family Centred 2) Services are Coordinated and Collaborative 3) Services are Integrated 4) Services are Supported by Continuous Quality Improvement and 5) Services are Engaged with Communities. Other documents or `chapters will provide further detailed information on key areas, for example clinical principles and integration. Foundational Principle 1: Services are Person and Family Centred There is recognition at all levels of the need to support a culture of client and family engagement. Persons and families are partners in determining care, in providing continuous feedback and in client/family ownership of their treatment. At a client/family level, services are delivered with rather than to clients, patients and families. At a systems level, persons, families and the community, as well as staff and physicians, are engaged in program evaluation and planning. At a community level persons and families are engaged in campaigning against negative stigma, in promoting positive health through education and employment and in the development of mental health and alcohol and drug misuse services. The cornerstone of this approach is the need for respectful, compassionate, culturally responsive care that meets the needs, values, cultural backgrounds and beliefs and preferences of patients [clients] and their families (Patient and Family Centered Care in Saskatchewan- A Framework for putting Patients and Families First, June 2011). Holistic care, addressing bio-psycho-social-spiritual needs is provided taking into consideration the persons unique needs, circumstances and readiness for change. For persons either unable or at a stage of unwillingness to initiate a change process, outreach services provides community based supports to bring awareness and help reduce high risk behaviours of the client through support and education. Person/Family centred services focus on the client s hopes and needs and engages them in their own health recovery. Through this process the person takes responsibility and control over their own treatment and recovery. Genuine partnerships are formed between persons/families affected by mental health and/or alcohol and drug misuse issues with the health care providers involved in their care. Services need to be designed to meet a person s current and immediate needs as well as anticipated future needs. Breaking down barriers to these services, which for the most part are system designed and supported, is essential. For Mental Health and Alcohol and Drug Misuse Services this means that: Services are accepting- welcoming, non-judgemental, hopeful, culturally sensitive, respectful, flexible and timely. Services are accessible via various means including reasonable travel demands, tele-health, online supports, mobile services, service relocation including co-location, extended hours of service delivery and outreach. Programs and services are aimed at empowering persons/families with mental health and/or alcohol and drug misuse issues to manage their care within their abilities. Program and service development actively engages the voice of the clients, patients and family members of the mental health and alcohol and drug misuse community. 4

7 Foundational Principle 2: Services are Coordinated and Collaborative The vision for Mental Health and Alcohol and Drug Misuse Services in Saskatchewan recognizes the mobility and complexity of clients within and across its regions including the chronic medical and social conditions affecting many persons with mental health and alcohol and drug misuse issues. Within a coordinated and collaborative health system, services are aligned with the broader health vision to ensure comprehensiveness of responses and leverage to eliminate duplication of services. The same is true for partnerships across the human service sector. A broad systems approach is necessary given the strong relationship of factors contributing to mental health and drug and alcohol issues. Some persons with psychiatric disorders may also have chronic health and significant medical complications such as those from alcohol and drug misuse, diabetes, Hep. C, HIV, intravenous drug use, as well as social conditions affecting housing, employment and education. Therefore, Mental Health and Alcohol and Drug Misuse Services requires a relationship to those services providing health information and prevention, primary care, public health, hospital and emergency (including detox) care, family and social services and supports, housing, corrections and education interventions. The developing cultural diversity of our communities, particularly as it reflects the growing immigrant populations, requires new ways of delivering services. Partnerships with First Nations and Métis organizations are necessary in engaging persons from those cultures. Services must be flexible and coordinated across departments and responses must be integrated to meet the person s needs and where practical within their communities. A framework for Mental Health and Alcohol and Drug Misuse Services must take into account these emerging trends. Partnerships have resulted in better outreach to children, youth and adults and needs to be a continued and evolving focus. There is a need to further develop a provincial vision that includes a single a provincial information system (data collection and information sharing), and some standardized processes such as screening, assessment, and clinical pathways. The provincial vision is about improving client care, improving outcomes and efficiencies and removing barriers and redundancies. Individuals and families have access to a range of services across tiers and up and down tiers (see Appendix 1 for a description of tiered care and stepped care) as their needs change through the course of engagement with Mental Health and Alcohol and Drug Misuse Services. For the persons/families accessing service, there are no boundaries. This includes persons with more serious or complex issues where there is a need for providers to work together and in partnerships, across agencies, departments, programs and regions to provide timely and responsive care, no matter where they live. The standardization of a provincial information system and other processes is expected to lead to better utilization of resources and supports a sustainable health care system where health regions collaborate and share work to realize a better product (i.e., service). continued 5

8 For Mental Health and Alcohol and Drug Misuse Services this means that: There are standard Mental Health and Alcohol and Drug Misuse agreements (protocols, policies) to support inter-regional client care. Access to integrated and collaborative Mental Health and Alcohol and Drug Misuse Services is assured in urban, rural and northern sites and across Health Regions. There is a high degree of partnership, (shared services and ensured access) across key health and human service sectors within and across Regions, in providing services for shared clients. Mental Health and Alcohol and Drug Misuse Services are delivered within a tiered model of care supporting a stepped care access to needed services. Effective partnerships exist (e.g., Public Health, Home Care, Social Services, First Nations, Metis and NNADAP organizations, and others) to address the increasing impact of intravenous drug use, HIV, Hep C, domestic violence and abuse, and other major health and social issues, and including services to those individuals and families with complex social/emotional/behavioural and psychiatric issues, in some cases resulting in homelessness. Standardization of forms and processes, including individual service plans, improve access to required services as well as the flow of information between providers. Continuous provincial level planning identifies and supports new and emerging directions in the provision of effective and efficient Mental Health and Alcohol and Drug Misuse Services. 6

9 Foundational Principle 3: Services are Integrated Our service delivery system must continue to deliver an individualized service to address the needs of those with specific alcohol and drug misuse or mental health needs, but additionally be able to respond to those individuals with a mix of mental health needs and alcohol and drug misuse issues along with other health and social issues. A collaborative model exists across Mental Health and Alcohol and Drug Misuse Services, within Mental Health and Alcohol and Drug Misuse programs and at transition points, (e.g., from youth to adult and adult to senior services). Integration includes collaboration and partnerships within health (e.g. Long Term Care, Primary Care, Public Health, and Emergency Services) and with other service sectors (e.g. Education, Social Services, Justice, First Nations, Metis and Community Based Organizations). In an individualized approach to care there is no wrong door. For Mental Health and Alcohol and Drug Misuse Services this means that: Services are integrated and coordinated. Co-location and co-management become the norm rather than the exception. Services are accessed via a regional and integrated Mental Health and Alcohol and Drug Misuse Services intake system. Persons/families receive mental health and alcohol and drug misuse services delivered in the right way and at the right time to meet their immediate needs. Access is timely, appropriate to their need, and effective. A provincial, electronic mental health and alcohol and drug misuse client information system exists; to provide timely information for clients and providers in identifying, tracking, sharing and coordinating client care, and supporting regional and provincial data and indicator development. A coordinated and integrated approach to care is supported by a tiered approach to service delivery (National Treatment Strategy, 2008). This approach supports a flexible continuum of services designed to meet the needs of individuals rather than the individual needing to adapt to a rigid service delivery system ( On the Integration of Mental Health and Substance Use Services and Systems, December 2008,Rush et al). This approach lends itself to improved person and family focused care and can serve as a cornerstone in support of service integration. Health and Addictions Services needs to become a system that, is fluid enough to match intensity of need with intensity of service and flexible enough to accommodate transitions in intensity of services as required. While many Mental Health and Alcohol and Drug Misuse Services programs have as their clinical focus tiers 3-5, all programs and services play a role in supporting families and communities throughout the five tiers, including prevention and health promotion activities, and early intervention activities such as school based initiatives and primary care. As outlined in the Alberta Health Services document (Integrated Service Delivery Framework, 2009), Mental continued 7

10 For Mental Health and Alcohol and Drug Misuse Services this means that: Services are coordinated to support a person moving across tiers within and across Health Regions to access the services most suited to their needs. Timeliness of response is assured against agreed to standards and benchmarks. Services match the level and intensity of need and supports to address the specific nature of a person s problem. 8

11 Foundational Principle 4: Services are supported by Continuous Quality Improvement Mental Health and Alcohol and Drug Misuse Services interventions and harm minimization approaches are based on evidence from research and evaluation and take into consideration knowledge and evidence related to gender, sexual orientation, age, culture as well as other determinants of health (level of poverty, housing and employment). New programs or services, especially those that might be viewed as cutting edge, will be evaluated with a willingness to continue to adapt services as indicated by the outcomes of these evaluations. Provincial standardized approaches to quality improvement efforts, including indicators to measure and evaluate outcomes and process improvements are essential. Outcome indicators for all Mental Health and Alcohol and Drug Misuse Services programs (acute, residential and community) need to be identified, tracked and reported on in comparison to provincial, national and international benchmarks. Mental Health and Alcohol and Drug Misuse Services supports the application of new technologies and reviewing and measuring processes to improve client flow, reduce redundancies, improve connectedness across services and eliminate inefficiencies. For Mental Health and Alcohol and Drug Misuse Services this means that: Services are evidence informed through the application of evidence and consensus based practice and the evaluation of existing programs and service efforts. Services are accountable through the continuous evaluation and monitoring of outcomes and applying this knowledge to enhance services. Services are innovative through the continuous exploring of new approaches to be responsive to emerging trends and practices. Service evaluation is supported through partnerships, for example with the Health Quality Council, Departments of Psychiatry and Family Medicine and the Substance Abuse Research Chair at the University of Saskatchewan. Services and service processes are evaluated in order to reduce or eliminate activities that are inefficient and add no benefit to the person and family receiving service. There are outcome indicators for all Mental Health and Alcohol and Drug Misuse Services (acute, residential and community) and these are identified, tracked and reported on in comparison to provincial, national and international benchmarks. continued 9

12 Mental Health and Alcohol and Drug Misuse Services recognizes that improvements to person and family care require continuous adaptation of services through processes of continuous learning. Continuous learning means being able to listen to clients, families, staff and Physicians, to learn from their experiences, to be open to new ideas but also to be accountable for changes to services delivery. Planning will be necessary to ensure new ideas and directions are supported both regionally and provincially. The Mental Health and Alcohol and Drug Misuse Services system must recognize that people learn in different ways and must be prepared to offer different approaches to learning. A system open to ongoing learning must also be able to adapt to new services and new processes, yet remain focused and committed to person and family care. The pace of change, and therefore the pace of learning, is managed and coordinated. The need for training and education will grow further, especially as Mental Health and Alcohol and Drug Misuse Services evolves in further directions, e.g. partnerships with Primary Care, Corrections, Public Health, Education and working with individuals with increasingly complex medical and psychiatric conditions. For Mental Health and Alcohol and Drug Misuse Services this means that: Support competency based services by ensuring ongoing learning of evidence informed practices and services targeted to individuals with complex needs. Create a learning environment by providing knowledge exchange, clinical supervision and support for communities of practice. 10

13 Foundational Principle 5: Services are engaged with Communities Considerable steps have been taken to move Mental Health and Alcohol and Drug Misuse Services from an isolated service system dependent upon the person and family finding ways to access service to one which is engaged in work in and with the community and partnering with other human service sectors in promoting positive health, and identifying and preventing risk. Prevention and Health Promotion resources and activities are helping bring Mental Health and Alcohol and Drug Misuse Services from a primarily reactive service to one that responds to social issues affecting the mental health of the population. Preventing and reducing the harms associated with mental health issues and alcohol and other drugs and substances requires an integrated, culturally appropriate, comprehensive, and balanced response to ensure a range of appropriate activities, programs and policies that include a combination of population-based approaches and targeted interventions. For Mental Health and Alcohol and Drug Misuse Services prevention and health promotion is, across all five tiers, everyone s responsibility. Specific community driven-prevention and health promotion activities build on the readiness, unique needs, strengths and capacities of communities. The support of the community, including peer and support groups, is needed to ensure a healthy community. Mental Health and Alcohol and Drug Misuse Services can play a role in supporting these efforts. Mental Health and Alcohol and Drug Misuse Services clients often face negative stigma from the community and within the health system. It is generally agreed that a holistic approach to understanding and addressing people s needs and thus reducing the silos across our health systems, is needed. The Mental Health Commission of Canada and other reports speak to the need to remove the us and them mentality and to take steps to engage consumers, the public and the health system in continuing this process of change. Self-help groups help diminish the sense of isolation and stigma often experienced by the person/family with mental health and/or alcohol and drug misuse issues and provide a needed sense of community. On an individual basis these groups help by providing education, identify needs and advocating for change. In Saskatchewan individuals are supported to achieve their optimum level, including abstinence, if that is their goal. Additional involvement with self-help groups such as Alcoholics Anonymous is a resource to be considered in their treatment planning. Stigma is also reduced by recognizing mental health and alcohol and drug misuse issues as part of the continuum of health and not separate from it. continued 11

14 For Mental Health and Alcohol and Drug Misuse Services this means that: Those who are intended to benefit most; persons, family members and the Mental Health and Alcohol and Drug Misuse Services staff, physicians and communities, participate in and advise on the design, content and delivery of services. Peer based supports, community self-help programs and other community initiatives aimed at the person/ family are actively supported. Prevention and health promotion services are supported to address the unique needs of communities based on their readiness and capacity for action. Mental Health and Alcohol and Drug Misuse Services are aligned with primary care initiatives to promote positive life style choices, support behavioural change and secondarily help reduce stigma. 12

15 Summary Mental Health and Alcohol and Drug Misuse Services are person and family centered. The system exists for the client, patient and family, is informed by evidence based practices, is fluid and is accessible. Partnerships within Health and across Human Services are critical in delivering services that meet the cultural, social and health needs of persons and families. Continuous evaluation and evolution of the service as well as continuous learning helps match the system to meet the needs of client, patient and family. 13

16 Appendix 1 Tiered Care A tiered system provides a way of thinking of the range of services across mental health and alcohol and drug misuse and related services. The intention is that a person/family could access services across the five tiers depending on need, and up or down the tiers (stepped care) as their needs change. The outline and definitions below from the Alberta Health Services; Addictions and Mental Health, Integrated Service Delivery Framework, September 2009 provides a good framework for this concept. Tier 1 reaches the most people, with each subsequent tier offering more focused, often more specialized, and generally more intensive services for an increasingly smaller population. TIER 1: Prevention, health promotion, community supports, and self-help Mental Health Co-occurring Alcohol and Drug Misuse SERVICE PARTNERS HEALTH PROMOTION, PREVENTION Increasing intensity / decreasing # of clients Client may access services from several tiers simultaneously or sequentially according to need TIER 2 First Contact Screening Primary care (screening and brief intervention) Consultation, liaison and referral TIER 3: Diagnostic and assessment for referral Consultation, liaison and referral TIER 4: Assessment completed and individual placed in program(s) Consultation, liaison and referral TIER 5: Acute and tertiary care Housing support Educational Services Social/ recreational support Community development Family/ community services Consultation, liaison and referral Important features of tiered model of service Clients and their families may enter at any point and then move within these tiers, based on their needs (for example, detoxification facilities offer an acute treatment service and are often an entry point for people who need a variety of other alcohol and drug misuse and mental health services). The tiered model does not prescribe any direction of movement through the system, does not preclude skipping tiers (for example, moving from Tier 4 to Tier 2), and does not imply that any level of service is more important than any other. 14

17 The five-tier framework is not intended to be distinct, separate levels of service. For example, the support of family and communities identified in tier 1 is also critical in services at all tiers. Similarly, a single client may require services from more than one tier such as attending a self-help group at the same time as counselling for depression is received. The model emphasizes the importance of consultation, liaison and referral between tiers in creating and maintaining an effective continuum of care. Prevention and health promotion happen at every service level. Cross-level supports (for example, housing supports, educational and vocation supports) are needed at all levels. A given staff member may have responsibilities across two or more tiers. A given function (for example, assessment) may happen in several tiers. Where specific services reside in this model will become clearer as the framework is implemented. Guiding concepts of the tiered model Any door is the right door: A person may enter the continuum of alcohol and drug misuse and mental health services and supports at any of the five tiers and, upon entry, should be linked to other needed services and supports, either in the same tier or in a different tier. Co-ordination of these links is the responsibility of the system, not the individual. In practice, this would mean that screening people for alcohol and drug misuse and mental health problems should be routine for as many health providers as possible and that there should be ready access to comprehensive assessment services if needed. Availability and accessibility: Services in all tiers should be available and accessible within reasonable travel time of each person s community, or should be facilitated by different means (for example, tele-health, online or mobile services). Matching: A person should be matched to services of the intensity appropriate to his or her needs and strengths. Matching implies a need for standardized screening and assessment tools, and for processes that allow for each person s informed choice of the type of care that works best for him or her (based on culture, language or other factors). Choice and eligibility: If more than one service meets a person s needs, the person should be able to choose from those for which he or she is eligible. A person should be able to step between tiers based on changing need (stepped care), though the focus might be in a particular tier at any given time. Flexibility: A person should be referred from a lower tier to a higher tier (stepped up) or from a higher tier to a lower tier (stepped down) as appropriate to his or her needs. Responsiveness: The type of support each person needs will change over time. In responding to these needs, the goal is to help people move to services in lower tiers and ultimately to be healthy independently of our services. Collaboration: Providers of distinct services and supports must work together at the clinical level (for example, through shared service protocols) and at the administrative and organizational levels (for example, through partnerships and inter-agency agreements). Collaboration should always include the person seeking help. Co-ordination: To facilitate service delivery as well as planning, monitoring and evaluation, health information systems must make it easy to share clinical information without compromising client or patient privacy. A tiered model and stepped approach requires not only strength and connectivity across Mental Health and Alcohol and Drug Misuse Services but collaboration across the human service sector in the region and provincially. Tiered Care and within this a stepped care approach, provides a way of thinking to be the most responsive to the needs of persons and families as their needs dictate. 15

18 Appendix 2 Guiding Principles and Shared Values Guiding principles and values have been identified within the National Treatment Strategy and work of the Alberta Health Services Mental Health and Addictions. Borrowing from that work, Mental Health and Alcohol and Drug Misuse Services in Saskatchewan embraces the following principles: Be person (client, patient) and family centred. Eliminate or at least reduce barriers within and between Mental Health and Alcohol and Drug Misuse Services programs, and where necessary, with other health and social services. Provide continuity and connectedness across programs to meet the immediate needs of clients and families and to respond to changing needs over time. Be accessible along the continuum of mental health and alcohol and drug misuse programs and services. Be comprehensive and efficient within the mandate and resources available. Be effective in meeting client, patient and family needs. The Saskatchewan Mental Health and Alcohol and Drug Misuse Services system also shares a common set of values to ensure that services are: Aligned: Services are planned and designed to align within the broader health services vision and system, to ensure collaboration, comprehensiveness and leverage, and eliminate duplication. Accessible: People with alcohol and drug misuse or mental health problems can access either a alcohol and drug misuse service or a mental health service, and be provided with or connected to the unique combination of services they need. Prevention, health promotion and clinical services and programs are delivered or accessible in rural, urban and northern communities across the province and are relevant to local needs. Consumer-driven: Services are responsive to clients and families needs; transitions across multiple providers and care settings are properly managed; people using the system have input, and system design and delivery are driven by the goal of optimizing client outcomes. Community-driven: Prevention and health promotion services build on the readiness and unique needs, strengths and capacities of communities. Those who are intended to benefit most from services will participate in and advise on the design, content and delivery of those services. Sustainable: Services are designed within available resources to have fundamental capability to meet the alcohol and drug misuse and mental health needs of clients and communities at both a system and local service delivery level. Enhancements to existing services will maximize capacity within available resources. Accepting: Everyone in the health system, particularly the health care provider, is welcoming, non-judgmental, hopeful, culturally sensitive, respectful and clientcentred. Services are designed and delivered in a culturally appropriate manner. Staff within the system are committed to reduce stigma and discrimination. Client-centred: Services are individualized to accommodate the specific needs, goals, and cultural perspectives of people in different stages of change, regardless of whether the concern relates to alcohol and drug misuse, mental health or both. Informed choice is a key element. Recovery-based: Services are based on the belief that every person, regardless of degree of disability, has the capacity for recovery. Strength-based: Services focus on the positive, recognize the strengths and skills of people, and aim to promote and enhance health and human potential. 16

19 Collaborative: Services will work closely with other professionals and partners within, across and outside of health to support change among specified client groups and target populations, and within settings that are appropriate to those populations. Attentive to risk and protective factors: The scope of health promotion and prevention services exists from preconception to end of life. Key life transition points provide important opportunities to address common risk factors for and protective factors against mental health problems, and alcohol and drug misuse. Innovative: Services continually explore new approaches, including new staffing models, and strive to be innovative and responsive to emerging trends and practices, recognizing that the evidence base for integrated services is growing and emerging. Creativity, e.g. internet use, will be encouraged in order to develop and improve methods. Accountable: Alcohol and drug misuse and mental health services are driven by a common vision, goals and objectives. Services are evaluated and performance outcomes monitored and applied to enhance services. Evidence-informed: Services reflect the importance of the partnership between science and practice. Services support the application of evidence- and consensusbased practices, and evaluation of existing programs and service efforts. 17

20 Resources Mental Health and Alcohol and Drug Misuse Services Framework 1. The National Treatment Strategy-Tiered Care October 2008, A Systems Approach to Substance Use in Canada- Recommendations for a National Treatment Strategy. 2. Toward Recovery and Well-Being, A Framework for a Mental Health Strategy for Canada November The Alberta Health Services framework document (Alberta Health Services-Addiction and Mental Health Integrated Service Delivery Framework, September 2009). 4. The Saskatchewan Mental Health and Addictions Services framework document (Mental Health and Addictions- Integrated Service Delivery Framework, draft November 2010). Mental Health and Alcohol and Drug Misuse Integration Framework In addition to those listed above: 1. On the Integration of Mental Health and Substance Use Services and Systems: Main Report-Brian Rush, Barry Fogg, Louise Nadeau and April Furlong, December Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada; Ten Key Principles for Successful Health System Integration; Esther Suter et.al ;Healthcare Quarterly Vol. 13, October Substance Abuse and Mental Health Services Administration- 5. Addressing Integration of Mental Health and Addictions; paper presented by the Canadian Mental Health Association, May Every Door is the Right Door; Towards a 10-Year Mental Health and Addictions Strategy (Ontario), A Discussion Paper, July How can we build skills to transform the healthcare system?; Helen Bevan, Journal of Research in Nursing,

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