Health Program Clusters

The following health clusters have been developed by the Kwakiutl Band Council (KBC) and Kwakiutl Health Department (KHD) and serves as a framework for all mandatory program and administrative requirements. These clusters identify goals / objectives, timelines and the evaluation mechanisms that may be modified as the Kwakiutl health priorities and the Band and department funding opportunities and partnerships dictate. These clusters represent the anticipated core programming of the Kwakiutl Health Department and do not detail each specific activity but rather the broad over-arching goals of the program within the cluster.

It will be the responsibility of each KHD staff member to ensure their role and their activities as outlined are fulfilled as much as possible, and that the collection of required information is performed and available for review / evaluation on an ongoing and basis.


Program Clusters: (As defined in our work-plan)

Children and Youth Cluster Program(s) 7


  1. Canada Prenatal Nutrition Program (CPNP)
  2. Children’s Oral Health Initiative (COHI)
  3. FASD Program – (Kwakiutl KHD Funded)
  4. Aboriginal Headstart on Reserve (AHSOR) 


Kwakiutl Aboriginal Head Start on Reserve (AHSOR)


  • Support the spiritual, emotional intellectual and physical growth of each child within the Kwakiutl  ages 0 to 6
  • Lifelong learning for children
  • Ensure parents, guardians and extended family members are the primary teachers of Kwakiutl children
  • Encourage relationship building and coordination with other Band, KHD and external  programs and services and the best use of existing resources for the children, their families of Kwakiutl 


Broad Child and Youth Cluster – Goals


  1. Assist to build capacity within the Kwakiutl through active engagement in providing educational opportunities and programs which identify and address risk factors that can contribute to a decrease in the health status of the community’s children and youth.
  2. Increase available programs while complimenting existing Child and Youth available to Kwakiutl.
  3. Decrease infant and child health problems linked to poor nutrition, alcohol and drug use, obesity, poor oral health, etc.



Community Wellness Cluster Program(s) 


  1. Brighter Futures (BF)
  2. Building Healthy  Communities (BHC) / Mental Health Program (MHP)
  3. National Native Alcohol and Drug Abuse (NNADAP)
  4. Youth Solvent Abuse Program (YSAP) 


Brighter Futures Initiative (BFI)

  • Improve the quality of, and access to holistic and community-directed mental health, child development and injury prevention services at the community level to help create healthy family and community environments in which the Kwakiutl community can thrive.
  • In conjunction with the KHD Mental Health, Addictions, Nursing, external service providers and other relevant Band and KHD staff,  deliver programs that promote holistic Kwakiutl community wellness including cultural and traditional values and mental health/ addiction support
  • Coordinate the integration of health services, internally and externally, for the community’s children, youth and family 
  • Information / education and referral if necessary addressing crisis intervention  and violence experienced within Kwakiutl

Mental Health Program (MHP) – (Building Health Communities)


  • Provides programming resources to address critical gaps with respect to mental health, solvent abuse and home nursing.
  • Recognize and assist to heal the long-term impact of colonization on Kwakiutl though traditional. Kwakiutl and contemporary practises,  bringing balance back into the lives of our community members.
  • Ensure appropriate programs and services are available to Kwakiutl community members which allow the unbiased and supportive recognition of past trauma / crisis and conditions  for individuals and their families and provide the mechanisms for community members to heal
  • Target the three areas of prevention, intervention and aftercare
  • Assist in ensuring KHD employees in reaching their maximum level of health and wellness


Program: National Native Alcohol and Drug Abuse Program (NNADAP)


  • Community based program providing prevention, intervention and aftercare services. Prevention strategies conducted by the program include culturally appropriate programs and services to educate and create awareness about addictions and addiction free lifestyles and in doing so, build capacity within the communities to identify high risk behaviours leading to addiction.
  • Reduction of incidences of alcohol and other substance abuse and addictions within Kwakiutl through a variety of educational, culturally appropriate programs and services including intervention and aftercare both internally and externally
  • Ongoing educational opportunities for KHD employees in regard to addictions


Youth Solvent Abuse Program (YSAB) - (Building Health Communities)

A community-based intervention, aftercare and in-patient treatment program that targets First Nation youth who are addicted to, or at the risk of inhaling solvents.


  • Increase Kwakiutl community knowledge about the dangers of solvent abuse and the benefits of choosing healthier lifestyles
  • Work collaboratively with both internal and external programs and services to ensure that Kwakiutl community  member needs are met


Broad Community Wellness Cluster – Goals


  1. Coordinated service delivery for existing and future mental health and addiction programs
  2. Assist to build capacity within the Kwakiutl through active engagement in providing educational opportunities, support groups and programs which identify and assist to address risk and contributing factors  experienced by individuals with mental health and addictions issues
  3. Through educational and participatory approaches within safe, non-judging environments, assist to decrease the stigma towards individuals dealing with mental health and addictions issues
  4. Decrease attempts at, and completion of, suicides and harmful self-actions of Kwakiutl community members
  5. Increase available programs while complimenting existing Mental Health and Addiction services within Kwakiutl and externally



Community Health Nursing (CHN)                    

Encompasses a spectrum of sectors and activities that influence health, including illness and injury protection. It is the delivery of a comprehensive range of primary health services through multi-disciplinary teams, including nurses and will include external Kwakiutl Nursing contractors. 

Much of the duties / responsibilities of the CHN and KHD nursing wellness team have been outlined through other cluster groups within this TWP document.


  • Provide urgent and non-urgent health services to Kwakiutl  members
  • Provides referral and consultation to both internal and external health service providers for the Kwakiutl community members
  • Provide programs and services specific to both men’s and women health and wellness
  • Pandemic / emergency planning

Communicable Disease Control Cluster


  1. Air Borne Diseases – Tuberculosis (TB)
  2. Blood Borne Disease and Sexually Transmitted Infections – HIV / AIDS
  3. Vaccine Preventable Diseases – (VPD) – Immunization
  4. Drinking Water and Sewage Program (DWSP)


Broad Communicable Disease Control Cluster Goals


  1. Reduce the incidence and spread of TB infections through detection and diagnosis
  2. Provide life-time control and TB treatment for active and latent cases, while preventing drug resistance
  3. Increased awareness of HIV/ AIDS to promote testing, increased access of information, education and support
  4. Strive to immunize 95% of targeted Kwakiutl community members both in regard to routine and newly recommended vaccines
  5. Coordination of services through the collaborative multi-disciplinary approach
  6. Community education in prevention and control regarding TB and HIV/AIDS                                                                                                                                                      



  • Increase awareness and educational opportunities for community members  and KHD employees around TB screening, prevention and treatment
  • Detection of community members with TB (latent and active) and the implementation of preventative actions / treatments to stop the spread of the disease within Kwakiutl
  • To decrease the incidence of morbidity  within Kwakiutl
  • Identify and eradicate sources of infection

Blood Borne Disease and Sexually Transmitted Infections – HIV / AIDS

  • Provide HIV / AIDS education, prevention and related health services to Kwakiutl.
  • Provide culturally sensitive, coordinated  educational opportunities to  Kwakiutl membership regarding the prevention of HIV / AIDS
  • Coordinate, increase and strengthen relevant partnerships with new and existing organizations / governments to increase awareness, access to care and support in an integrated manner for individuals within Kwakiutl living with or affected by HIV / AIDS 

Vaccine Preventable Diseases – (VPD) – Immunization

  • Improve the coverage rates for routine immunizations, reduced VPD incidents, outbreaks and deaths and the development of an integrated immunization surveillance system.
  • Increase / improve the rates of routine  and newly recommended vaccines / immunizations administered within Kwakiutl
  • Increase community education on vaccine preventable diseases
  • Increase and support the development of KHD staff knowledge and skill sets


KHD Chronic Disease and Injury Prevention Cluster

Aboriginal Diabetes Initiative (ADI)

FNIH Program Description: Funding for prevention and promotion programs emphasizing healthy eating, active living and building awareness of diabetes around issues such as risk factors and complications. The program also provides resources for screening and care and resources to train health service providers and improve access to their services within Kwakiutl.

Broad ADI Goals

  1. Raise Kwakiutl awareness about the risk factors for diabetes and the need for regular preventive health care visits including screening for those at risk / family history.
  2. Educate community members around diabetes and the important role that a healthy lifestyle, screening, early diagnosis, education, treatment and support services play in addressing the disease.
  3. Assist KHD clients with diabetes to improve self-care management skills
  4. Enhance diabetes partnerships / collaboration both internally and externally, utilizing “Best Practices” as able and in doing so provide Kwakiutl  a comprehensive range of quality diabetes resources and services
  • Increase physical activity and healthy eating habits within Kwakiutl to decrease prevalence of risk factors
  • Improve the quality of life of community members living with diabetes
  1. Improve community members participation in program delivery and increase community supports
  2. Increased access to screening and improved detection of diabetes, improving community supports
  3. Improve collaboration and partnerships with service providers  within Kwakiutl  and externally



First Nations and Inuit Home Care and Community Care (FNIHCC)

Home Care and Community Care (HCC) 

HCC Program Description – The HCC programs provides a continuum of home and community care services that are comprehensive, culturally sensitive, accessible and effective which respond to the unique health needs of Kwakiutl. The program is designed to be a coordinated system of homecare and community-based health care services for community members of all ages regardless of disability, chronic or acute illnesses, to receive access to a range of home and community care services provided by trained, qualified and professional personnel.

The HCC programs will assist and advocate for community members with chronic and / or acute illness in maintaining optimum health, well-being and independence in their own homes and in their community. All clients with an assessed need for home care services will have access to a comprehensive continuum of services within the community. The program will ensure client / family involvement in development of individual client care plans, and will seek to eliminate Elder abuse within Kwakiutl including financial, emotional, physical, sexual and spiritual abuse. 

A core principle of the program is that it will support families in the care of their family member and does not replace care by family.  It is not in place to take on the role of family members or to provide 24 hour a day service. 

The HCC program is comprised of essential and supportive service.  However, only the essential service elements are considered mandatory as the funding formula was based on the delivery of the following nine essential service elements:

  1. A structured client assessment process that includes on-going reassessment and determines client needs and service allocation;
  2. A managed care process that incorporates case management, referrals and service linkages to existing services provided both on and off reserve/settlement;
  3. Home care nursing services that include direct service delivery as well as supervision and teaching of personnel providing personal care services;
  4. Home support services: personal care and home management that are determined by the client assessment and care plan and that do not duplicate, but enhance existing AANDC Assisted Living program;
  5. In-home respite care;
  6. Program management including  professional supervision/ consultation to ensure  the program is delivered in a safe and effective manner;
  7. Established linkages with other professional and social services that may include coordinated assessment processes, referral protocols, discharge planning and service links with such providers as hospitals, physicians, respite and therapeutic services;
  8. Access to specialized medical equipment, supplies and specialized pharmaceuticals to provide home and community care; and                                 
  9. A system of record keeping and data collection to carry out program monitoring, ongoing planning, reporting and evaluation activities.


NIHB Health Benefits Cluster

Program: Non-Insured Health Benefits – Patient Transportation (NIHB)

FNIH Program Description: Provides a limited range of medically necessary health related goods and services to eligible recipients within Kwakiutl, not provided through private insurance plans.


Broad NIHB Goals

  1. Provide coordinated, timely and accessible NIHB services to eligible Kwakiutl community members, as per NIHB policy and the KHD Flexible Transitional Funding Agreement in a transparent, fiscally accountable fashion, maintaining all required documents and program information
  2. Ongoing informational updates to community members regarding the scope of services covered under the NIHB program including client eligibility and eligible rates of remuneration
  3. Ongoing identification of new partnerships with external organizations to assist in reducing the overall cost of the NIHB, maximizing program dollars, while continuing to provide respectful, responsive and quality services to the membership
  4. When required, liaison and advocate for NIHB clients accessing medical services, including but not limited to dealing with / referrals to; hotels, taxi companies, hospitals, hospices, Friendship Centres, First Nation Liaisons, etc.

Broad Health Planning and Management Cluster Goals – Health Director

  1. Ensure staff professionalism, at all levels, while delivering the programs and services of the health department, enhance capacity of KHD employees
  2. Ensure KHD programs and services are designed and implemented through community collaboration, input and consultation, based on community, KBC and departmental priorities
  3. Demonstrate capacity and accountability through transparent, flexible and strong management of programs, services and resources, thus ensuring Kwakiutl, KBC funders and associated Kwakiutl stakeholders trust.
  4. Various other initiatives to ensure quality and responsive operations of the Band and Health Department based on Kwakiutl health needs and priorities

Health Planning and Management Cluster:

FNIH Program Description:  Supports community health planning and development of both health services and programs and their requisite infrastructure at a community level.

Development of Kwakiutl Comprehensive Community Health and Wellness Plan (CCHWP)

  1.  Development of Kwakiutl CCHWP

Broad Cluster – Goals

  1. The development and maintenance of a CCHWP for use by the community, KBC and Health Department as a guide for Kwakiutl health programs and services, future directions / activities of the community, KBC and Health Department, a base for periodic and ongoing program evaluations and to meet the necessary requirements for the Band to enter in the Flexible Health Transfer funding relationship.
  2. Through community engagement and direction, outline the clear and comprehensive health program and service directions of the KBC and KHD, both that are currently engaged  and those targeted for the future
  3. Develop a Comprehensive Community Health and Wellness Plan outlining the directions, capacity and goals of the KBC and KHD incorporating the required FNIH or FNHA format, information and mandatory elements


Kwakiutl Health Department Policy and Procedure Review, Revision and Development

  1. Review incorporated KDC nursing and health related policies and procedures, implementing necessary changes per Kwakiutl community and Band Council and Health Department need. Ensure compliance to relevant FNHA, provincial, federal and licencing requirements and coordination with existing KBC policies and procedures while ensuring the incorporation of Kwakiutl culture, values and practices.   
  2. Review and update of incorporated and established KHD program and operational policy and procedures
  • Review, orientation and clarification of KHD expected staff roles and responsibilities
  • Review / update and provision of necessary safety and program related equipment within the Kwakiutl Health Centre
  • To develop a proposal for the FNHA and other possible funders for the development and implementation of a Kwakiutl specific suicide / crisis response program (based on Kwakiutl culture, the Aboriginal Suicide Critical Incidence Response Team (ASCIRT) and other models as needed
  • Supplement existing KHD Community Wellness programs and services thus contributing to the overall health status of Kwakiutl
  • Work in partnership and complement existing programs and services that may be offered externally within the region