Northern Community Resources
Sue
Moore, Community Member
A review of the Mental Health (MH) services
provided by Copper River Community Mental Health Center (CRCMHC) was conducted
from
This report is the summation of the impressions of a community team after interviewing consumers, staff members, community members and staff of other agencies. It also includes a limited administrative review. It does not represent or reflect a comprehensive review of this agency. The community team has collaborated on this report and the findings represent their consensus.
CRCMHC provides MH and other human services through its
parent agency, Copper River Native Association (CRNA). MH services are open to all residents of the
service area, a service area of approximately 14,000 square miles that includes
eleven communities. The population has
increased by about 12% in the last two years, now numbering some 5,500 year
round residents. In addition, CRCMHC is
available to serve the seasonal, transient and tourist population in excess of
70,000 per year and increasing with the recent construction of a major hotel
and a
CRCMHC’s MH services are integrated within a
Behavioral Health Services department that also includes substance abuse out
patient and residential treatment, a Safe Families program, support for
families at risk for FAS/FAE and services for those affected. The State MH grant of $200,000 represents
only 15% of the Behavioral Health Services budget.
The integration of services represented by the
creation of a Behavioral Health model results in integrated, non-categorical
services complicated only by funding and data collection systems which remain
categorical. It should be noted that the funding for Behavioral Health is
largely federal funding through Indian Health Services and SAMSHA. The requirements of those funding sources and
of those related to Native associations complicate the agency’s ability to
respond to the regulations that are unique to the State’s Division of Mental
Health and Developmental Disabilities (DMHDD).
Mental health services are provided by a full time
clinician (funded by SAMSHA), an administrator/clinician, a case manager and
contract staff. The contract
psychiatrist provides monthly services for a period of two to three days at each
visit and has been providing these services for five years in the
Additionally, a neuropsychologist is under contract
for the FAS/FAE program, as is a physician with a specialty in treating
developmental disabilities. The latter two contract staff are funded through the
FAS/FAE project. Clearly, there is some carry-over of these latter services to
MH services, although they are not funded through the DMHDD grant.
As a Native association, CRNA has a single
governing board. However, since the last
site review, the program has been successful in establishing an active advisory
board with eight core members and additional members who represent related
service agencies. The eight core members
are consumers, family members of consumers or elders.
The MH services provided are emergency services,
out patient treatment (individual, group, family, couples), community support
program for adults experiencing chronic mental illnesses, consultation and
training. Dually diagnosed consumers can receive treatment within the same agency. While Behavioral Health Services provides
care to some 300 individuals during a typical year, there are fourteen MH
consumers among this number who receive priority services as defined by DMHDD:
ten adults and four minors.
Description
of Process
The team of three met for three days in
Of the consumers interviewed, 7 were consumers chosen by the random selection process. Two randomly selected consumers originally scheduled for interviews were not available.
The facilitator’s local phone number was advertised so that those not chosen for an interview and not able or willing to attend the Open Forum could provide the team with their perception of CRCMHC’s services. An additional 3 consumers volunteered information to the team regarding their experiences with CRCMHC’s services.
The related agency staff members included
professionals from the school, local housing authority, district court,
juvenile probation, DFYS, Alaska State Troopers, the local pharmacy and a local
physician. All agencies identified by the DMHDD regional coordinator were
interviewed with the exception of DVR.
CRCMHC has not collaborated with DVR to date.
The facilitator also reviewed CRCMHC’s
publications, two personnel files, the employee handbook, CRNA financial
policies and CRNA personnel policies.
Open
Forum
An Open Forum was held the first night of the review in
order to provide an opportunity to community members and others who had not
been selected for individual interviews.
The Open Forum was held at
Progress
Since Last Review
The last Integrated Quality Assurance Review of CRCMHC was
conducted in June, 1999 and resulted in 17 areas requiring response. Currently the consumer-centered review team
does not review consumer files, therefore those areas requiring response that
are related to files are reviewed solely in the case file review to be
conducted by the DMHDD Quality Assurance staff.
In this report they are marked N/A.
Best Practices
The agency submitted two programs for consideration as “Best Practices” within the definition provided by the Quality Assurance Steering Committee. The requirements for this designation are an inclusionary philosophy; placement that is non-categorical and age appropriate; intervention that is community-referenced with goals and objectives that are based on an assessment; systematic and data-based instruction and management; involvement of the family and of consumers in planning, implementation and evaluation and provision of families with access to needed information and training; that it can be replicated; that it has meaningful outcomes; that it is cost effective and that it involves community collaboration. For the full text of these requirements, see the “Best Practices Checklist” attached to this report.
1. The
In the opinion of the
team, this plan for integrated services should be viewed as a best practice,
although the plan has not been in place sufficient time to ascertain two
requirements: outcomes and cost effectiveness.
Documentation will be provided to the Quality Assurance Steering Committee
for their review.
2.CRNA has also submitted a proposal for a Comprehensive Service Plan for Families at
Risk for Fetal Alcohol Syndrome in the
In the
opinion of the team, this plan for intensive services should be viewed as a
best practice, although the plan has not been in place sufficient time to
ascertain two requirements; outcomes and cost effectiveness. Of particular import is the provision of
treatment services stressed in the plan.
This is not a plan that contents itself with identification and
labeling. Documentation will be provided
to the Quality Assurance Steering Committee for their review.
In the opinion of the team these two programs are
innovative to the extent that they view people as whole beings and provide for
fluid interaction among substance abuse, domestic violence, mental health and
social services. These programs utilize
a prevention model: primary, secondary and tertiary and a continuum of services
from prevention to rehabilitation.
Further, these programs are a fine example of the
bio-socio-cultural-psychological model in which respect for culture is
preeminent. The team applauds this
holistic approach to services and feels that other agencies would profit from
examining the work of CRCMHC and duplicating it.
Areas of Excellence
1.While not funded by DMHDD, CRCMHC provides fine, comprehensive case management services to MH consumers. This is not the norm in rural Alaskan MH programs. Cheryl Smith, case manager, represents the best of providers, one who generously presents a broad array of personalized support, information and guidance delivered in a respectful and compassionate manner.
2.Ed Krause,
Director of Behavioral Health Services and clinician, “lives the values he believes
in” and has developed a program based on his philosophy of respect for the
individual in their cultural context. Ed
is neither confused nor deterred by shifting enthusiasms, shifting funding or
shifting theories. He perseveres. And his staff and those they serve are the richer
for it.
3.The enthusiasm, involvement and pragmatic
approach of the Advisory Board is
exemplary. The Advisory Board serves to “train the agency” in the cultural and
personal needs of consumers. The core
members of the Advisory Board are all consumers, family members of consumers or
elders, all uniquely capable of guiding the development of Behavioral Health
Services. The Board enjoys direct
contact with the Director and freely provides him with direction. The Advisory Board provides constant, current
evaluation of the agency’s programs. The
Advisory Board is involved in future planning, is committed to self-education,
to review of current treatment literature and to increasing community
involvement. A long-time consumer and
Board member states that the Board is “very
organized, very steady.”
4.The team is impressed by the high degree of consumer satisfaction expressed by every
consumer interviewed, whether volunteers or randomly selected consumers,
despite their age, the type of service received, diagnosis or other
variables. Certainly, the variety of
services and modalities provided enhances consumers’ experience with the
program. The ingenuity, creativity and reality-based approach of clinician Adele Valenti should also be
noted in this regard.
The team identified the following strengths under
Choice and Self Determination for those receiving MH services:
+ Youthful
consumers are provided both individual and group sessions.
+ Consumers
are clear about their role in choosing treatment goals.
+ When
consumer and provider disagree about a goal, the disagreement is acknowledged
and worked through.
+ Consumers
are clear that they have the right to be medicated or not, to choose the type
of medication and to be fully informed about its effects.
+ Consumers
choose the activities provided during the monthly trip: where to stop, where to
eat, what to do, making these outings “fun
trips.” -- consumer
+ Consumers
can usually choose their counselor.
+ Consumers
have the choice of a male or a female clinician.
+ Art
therapy and play therapy are provided.
+ Consumers
have been able to reduce their medication as the result of their therapy.
The team identified no weaknesses under Choice and
Self-Determination for those receiving MH services.
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ Consumers
are well informed about medication and can exercise their right to be medicated
or not or to change medications.
+ Consumers
of all ages consistently describe their experience with providers as “comfortable.”
+ “People
here are real nice.” -- consumer
+ Consumers note that they have access to providers without waiting and often have access even if they do not have an appointment scheduled.
+ “They treat me like a human being, not like a
number.” – consumer
+ Consumers are aided in scheduling their time and
reminded of key appointments with other providers, allowing for a continuity of
care.
+ Consumers
uniformly report knowledge of their rights and that their rights are respected.
The team identified no weaknesses in the area of
Dignity, Respect and Rights for those receiving MH services.
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ Consumers
are aided in keeping medical appointments with reminders and with
transportation as needed.
+ Consumers
have been aided in qualifying for disability payments and for Medicaid.
+ Consumers
have been aided with energy assistance.
+ Consumers
receive good education regarding their medication.
+ The
contract psychiatrist provides services monthly.
+ A consumer
has been aided through a mini-grant for dental care.
+
Coordination with the local housing authority results in safe, secure
buildings where repairs are completed in a timely manner.
+ A local
physician, the local pharmacist and the contract psychiatrist coordinate services
routinely.
+ Consumers
have been able to decrease the use of medication as they increase their skills
through therapy.
The team identified the following weakness under
Health, Safety and Security for those receiving MH services:
- Some
consumers do not seem to be aware of the extent of case management services and
so do not bring to the providers the full range of their needs.
The team identified the following strengths under Relationships for those receiving MH services:
+ A consumer
is routinely assisted in visiting a family member in another community.
+
Relationships and social skills may be the focus of treatment, as
appropriate.
+ Youthful
consumers are provided with social skills training as part of their group
therapy experience.
+ The
monthly trips for consumers allow for the practice of social skills.
+ Consumers
are aided in developing and practicing assertiveness.
The team identified no weaknesses in the area of
Relationships for those receiving MH services.
The team identified the following strengths under Community Participation for those receiving MH services:
+ The monthly trip for consumers allows for greater
participation in the community.
+ Consumers
are offered volunteer opportunities.
+ Copper
River Native Association sponsors many community activities in which consumers
can easily participate.
+ Youthful
consumers are able to attend the local public school.
+ The
Director/clinician models community participation through his own extensive
community involvement.
The team identified the following weakness in the
area of Community Participation for those receiving MH services:
- Some
consumers, particularly those in outlying areas, remain isolated and need
increased assistance to participate in activities.
Staff Interviews
+ Staff are clearly willing to go the extra mile for their coworkers and for consumers while maintaining proper, professional boundaries.
+ The
addition of the case management position has improved services and provided for
continuity of care.
+ The
Director’s devotion to a consumer-centered philosophy pervades the agency and
motivates the staff.
+ One
employee describes the staff evaluation process as the best she has experienced
in her many years of employment and Ed as the best director for whom she has
worked.
+ The District Court reports reduced recidivism among those juveniles referred to CRCMHC.
+ A local
professional with twelve years experience in the area describes the current
services at CRCMHC as “the best they’ve
ever been.”
+ Another
local professional reports markedly decreased hospitalizations in the area
thanks to
CRCMHC, noting that many formerly hospitalized residents “essentially can be treated on an out-patient basis (now).”
+ A local
professional states that CRCMHC “responds
quickly” to suicidal ideation, suicidal gestures and suicidal actions.
+ “(CRCMHC) serves a very real purpose in our
community (and I am) very appreciative of its being here in the
community."
+ Another
local professional notes CRCMHC’s “progressive
ideas” and “innovative projects.”
+ While not
funded by DMHDD, the team wants to note the numerous positive comments received
regarding the work of Gaye Wellman,
coordinator of the Safe Families project, and her ability to interact
successfully with all related agencies to the benefit of consumers.
-Some regional agency staff state that CRCMHC
provides services chosen by the consumer rather than adhering to the dictates
of the related agency. They feel that
they, not the clinicians, should be in control of the case. These comments account for some of the
negative responses shown on the tally of related agency responses attached to
this report.
Community mental health centers must meet thirty-four administrative and personnel standards. CRCMHC fully meets twenty-eight of those standards and partially meets the other six.
1. Standard #10 “The agency maintains policies and procedures for preventing and correcting conflicts of interest.” There is a staff policy to prevent conflicts of interest and a CRNA policy to prevent nepotism. Currently there is not a documented policy to prevent conflicts of interest for members of the Advisory Board although the Board feels it deals effectively with this.
2. Standard
#13 “The agency systematically involves
consumers, staff and community in annual agency planning and evaluation of
programs, including feedback from its current and past users about their
satisfaction wit the planning and delivery of services.” While the Advisory Board effectively
represents consumer interests and facilitates community involvement, there is
currently no systematic means of gathering this information.
3. Standard
#17 “The agency actively participates
with other agencies in its community to maximize resource availability and
service delivery.” While most agencies
are quite pleased with their interaction with CRCMHC, some agencies either need
to be educated regarding the value of consumer choice and the consumer right to
release or withhold confidential information or need to be invited to clarify
their needs. Otherwise, the agency’s
commitment to consumer advocacy may be misinterpreted.
4. Standard
#22 “The organization has and utilizes a
procedure to incorporate consumer choices into the hiring and evaluation of
direct services providers, and to ensure that special individualized services
have been approved by the family or consumer.”
Non-credentialed or paraprofessional staff are hired and evaluated with
community and consumer input. Currently,
credentialed staff are not formally subject to this scrutiny although the
Advisory Board is outspoken in presenting the consumer perspective on this and
other topics.
5. Standard
#24 “The hiring process includes
background and criminal checks (when appropriate) for direct care providers,
personal and professional references and follow-up on references.” The facilitator reviewed two personnel
files. Comments from references are
documented in both files. Background and
criminal checks are limited to a review of the driving record. Currently CRNA has an attorney researching
and drafting a policy regarding these checks to comply with ICWA
requirements. The issue has been
complicated by the cutback in Troopers who no longer will do the fingerprinting
or background checks locally.
6. Standard
#25 “The agency provides new staff with
a timely orientation/training according to a written plan, that includes, as a
minimum, agency policies and procedures, program philosophy, confidentiality,
reporting requirements, cultural diversity issues and potential work related
hazards.” The agency does have a written
orientation that includes policies and procedures, program philosophy and
confidentiality. Cultural knowledge is a
requirement for hire. There is not a
specific review of mandatory reporting (which may differ for Native
associations) nor is there a review of work related hazards.
Program Management
+ The Advisory Board provides active advocacy for consumers.
+ The Director enjoys the full support of the Advisory Board.
+ The
Director’s style is consumer-centered philosophy in action. His strong values and irrepressible
enthusiasm create a positive, can-do work environment. “Ed
doesn’t take ‘no’ for an answer. He
finds a way.”
+ “Ed has a mission, not a job.”
+ The
Behavioral Health Services program is an integrated, holistic approach to human
services.
+ CRCMHC has
successfully diversified their funding sources in order to support their
integrated service approach.
+ CRCMHC
takes a realistic and effective approach to the human service needs of rural
residents. This is based on an
understanding of the cultural and life style values of those served.
+ CRCMHC is
no longer plagued by high staff turnover despite the prevalence of this problem
in DMHDD programs throughout the state.
The team notes the frustration of human service staff with the lack of understanding by regulatory agencies of the realities of rural needs. Their description of this lack is compelling. In the opinion of the team, CRCMHC has been successful despite the limitations of these regulatory agencies and presents a model for how rural services can be integrated and can result in high consumer satisfaction.
Areas Requiring Response
The team notes no faults in this program outside of the administrative requirements listed below.
1. Develop a
policy for the Advisory Board to prevent conflicts of interest. Standard #10
2.
Systematize the survey of consumer, staff and community opinion in
planning and evaluation. Standard
#13 (Prior and current reviews)
3. Engage
representatives of child service agencies in discussion and coordinate with
them to avoid consumers experiencing the negative consequences of interagency
conflict. Standard #17
4. Provide a
means of utilizing consumer opinion in the hiring and evaluation of
credentialed staff, possibly as a part of the proposed consumer survey. Standard #22
(Prior and current reviews)
5. Develop
and institute a policy for the completion of background and criminal checks for
direct care providers. Standard #24
6. Include
in the employee orientation materials an explanation of reporting requirements
as they relate to staff, a statement of the mandatory cultural knowledge policy
and information on work related hazards.
Standard #25
7. Develop a
Policy and Procedure Manual specific to Behavioral Health Services to augment
the more general CRNA policies. (Prior review)
Other
Recommendations
The team feels that staffing, while it has increased in the last two years, is still not adequate to the intensity of services provided and recommends the addition of a clinician should funding allow.
Closing Note
The team wishes to thank Cheryl Smith for her work
in scheduling interviews and gathering the documents necessary for the site
review. Her work reduced our work and we
thank her for that. Thanks also to all
the staff of CRNA who cheerfully tolerated our comings and goings for three
days and juggled room assignments to allow for our work to be completed.
The final draft of this report will be sent to
Northern Community Resources for review. You will receive the final report
within approximately thirty days, including a Plan of Action form, listing the
Areas Requiring Response. You will then have an additional thirty days to
complete the Plan of Action. The directions on how to proceed from there will
be included in a cover letter you will receive with the final report and Plan
of Action form.
Once NCR has reviewed the completed Plan of Action,
it will be sent to the DMHDD Quality Assurance Section. The QA Section will then contact you to
develop collaboratively a plan for change.
Attachments: Administrative and Personnel
Checklist, Interview Form for Staff of Related Agencies (tallied), Report Card
(averaged), Best Practices Checklist
NCR 8/00