Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska  99901

(907) 225-6355

FAX  225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW
Juneau Youth Services, Inc.
January 22, 2001January 25, 2001
Juneau, Alaska

 

Site Review Team

Wanda McDaniel, Community Member

Laura Rorem, Community Member

Lenne Musarra, Community Member

Jim Musser, Community Member

Rick Calcote, Peer Reviewer

Barbara Price, Facilitator

                                                                 

 

INTRODUCTION

 

A review of the Mental Health (MH) services provided by Juneau Youth Services, Inc. (JYS) was conducted from January 22, 2001 to January 25, 2001 using the Integrated Quality Assurance Review process.

 

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. 

 

Description of Services

 

Juneau Youth Services has provided services to Juneau’s youth since 1961. Currently, youth from ages three to twenty-one may receive MH services.  This includes outpatient care and, for youth ages ten to nineteen, residential care as well.  The agency also provides non-emergency respite, transitional living services, emergency services (shelter, counseling, crisis intervention, hospital diversion and a mobile crisis unit) and an outdoor “adventure-based” opportunity.  Services are provided in the schools and a separate program serves those expelled or suspended from the school system.  Under separate funding, chemical dependency services are also available.

 

JYS provides these services at eight schools, Head Start, an outpatient office and at two residential sites.  The agency serves some 800 individuals.

 

The agency is governed by a nine member executive board and is accredited by the Joint Commission on Accreditation of Health Care Organizations.

 

JYS services have been severely impacted by the closure of the City- and Borough-financed MH program at the end of FY00.  Since July first, JYS has extended services to this population as well.  The agency has worked hard to incorporate this caseload but that incorporation has been achieved at some cost.  The stress on staff and services is evident and to some extent colors the findings of this site review team.

 

Description of Process

 

The six members of the site review team met for four days to complete this review.  During this time the team interviewed 2 direct consumers, 24 parents or guardians of consumers, 11 direct service staff members, 1 board member (a second board member interview was cancelled) and 18 staff members of 13 related service agencies. 

 

Nine of the consumers and consumer families volunteered to be interviewed.  One consumer chosen through the random selection process was unable to keep their appointment.  The remaining interviews were with consumer families chosen by the random selection method.

 

Interviews were held by telephone or in person at the JYS offices or at a location chosen by the interviewee and were from 10 minutes to 75 minutes in duration. 

 

The facilitator also reviewed the agency’s policy and procedure manuals, financial audit, consumer satisfaction surveys for FY00, agency brochures and thirteen personnel files.

 

Open Forum

 

An Open Forum was scheduled for the first night of the review at the library in downtown Juneau.  The purpose of the Open Forum is to provide those who are not chosen for individual interviews an opportunity to provide information about the agency’s services.

 

JYS advertised this opportunity by placing an announcement in the local paper for two days.  In addition, the facilitator’s local phone number was advertised so that individuals could volunteer for interviews by leaving a message for her.  Two members of the public and five of the team attended the Open Forum.  Additionally, one consumer parent and one staff member of a related agency contacted the facilitator by phone. 

 

FINDINGS

 

Progress Since Last Review

 

The last review of Juneau Youth Services, Inc. using the Integrated Quality Assurance review process was completed in April 1999.  At that time the community-based team identified seven areas requiring response.

 

  1. Develop and formalize a Capitalization Policy.  Response: The agency has a formal capitalization policy.  Standard met.
  2. Develop and formalize an Investment Policy.  Response:  The agency has a formal investment policy.  Standard met.
  3. Advertise meetings to assure public participation.  (Standard #8)  Response:  The Board meetings are advertised.  Standard met.
  4. Involve consumers and their families in the hiring of staff.  (Standard #22)  Response:  Before a probationary employee is hired in a permanent capacity, consumers and consumer families are surveyed to determine their satisfaction with the employee.  Standard met.
  5. Develop a policy for supporting the development of non-paid natural supports. (Standard #26)  Response:  JYS operates a program within the schools that allows for the natural inclusion of consumers in school activities and interactions.  Team participation and attendance in community activities is supported.  Standard met.
  6. Provide more options for parents and guardians to participate in team meetings.  Response:  The agency provides options for parents unable to attend team meetings.  When an accommodation cannot be made due to scheduling difficulties, the parent is contacted and given the opportunity to revise or approve the plan.  Standard met.
  7. Assure that family therapy sessions are documented in client files.  Response:  The community-based teams no longer review MH files.  A review of Medicaid and non-Medicaid files was conducted by DMHDD QA staff concurrent with this review.  The team defers to their findings in this regard.

 

 

Best Practices

 

Site review teams have the option to identify certain programs, protocols or other aspects of agencies as potential “best practices.”  A best practice must meet several criteria including being inclusionary, age- and community-appropriate, based on assessed needs, modified based on consumer and family response, replicable, collaborative, cost effective and resulting in meaningful outcomes.  The reader is referred to the Draft Best Practices Checklist produced by the Technical Assistance Subcommittee of the Quality Assurance Steering Committee for the complete description.

 

In most cases, teams do not identify practices that they consider worthy of consideration for this designation.  In this review, however, the team has nominated three programs for this designation.  This evaluation will be referred to the Steering Committee and the agency may be asked to provide further details.

 

Wilderness Experience  This program has been operated by JYS since 1986 and features expeditions into wilderness areas of the state.  The agency’s brochure describes this program as “an intense adventure based therapeutic/educational approach.”  The team is convinced that this approach can be effective for many youth including those who are generally considered to be difficult to reach.  Further, the team believes that the skills acquired during this experience are transferable to other life challenges.

 

Eclipse  This relatively new program is a joint effort between JYS and Tlingit and Haida Head Start.  It provides for the assessment and treatment of child mental health issues for youngsters ages three to five.  This program has a strong focus on family.  Eclipse is currently transitioning from an outpatient program to what is expected to be a day treatment model.  Both the bicultural aspect and the prevention aspect of this endeavor are worthy of commendation.

 

B.A.S.E.  This program provides day treatment within the schools.  Faculty members, JYS staff and parents collaborate on this effort.  This program receives high praise for being inclusionary, for its utilization of natural supports and for its informal role in mediation.

 

Areas of Excellence

 

The dedication of direct service staff has been repeatedly made evident to the site review team.  The sincerity, optimism and energy level of the staff, especially those working within the BASE program, are commendable.

 

The agency’s response to change has been characterized by flexibility, tolerance and a “can-do” attitude.  While the team has been impressed by the enormous increase in case load experienced by JYS in the last six months, no one at JYS complained of this challenge, but rather, strove to meet it.

 

 

The Five Life Areas

 

Choice and Self Determination

The team identified the following strengths under Choice and Self Determination for those receiving MH services:

+  Many families are satisfied with the choices available to them.

+  Families are especially satisfied with the choices offered in and the flexibility of the BASE program.

+  The opportunity for families to be full team members allows them both choices and opportunities for self-determination.

+  Youngsters may self-refer to the BASE program.

+  Many families state that they have been aided by JYS’ referrals to other agencies for adjunct services.

 

The team identified the following weaknesses under Choice and Self-Determination for those receiving MH services:

-  Many families are unable to access or are dissatisfied with family therapy.

-  Some families have been unable to make changes in their direct service provider either because their request has been denied or because no option has been available.

- For some, their choices are limited by their diagnosis. (This is a system issue and not the primary responsibility of JYS.)

- Choices are limited by the cost of services which some families find to be beyond their means or taxing to their private insurance.  “I thought it was expensive for what we received.” – privately insured parent of consumer

- Staff turnover restricts choice.  (This is a system-wide issue as well as an agency issue.)

-  Some families feel pressured to accept medication for their child in spite of their desire to seek an alternative.

-  The waiting list for services is a restriction of choice.  “We had to hurry up and then wait.” –parent of consumer (This issue may be particularly affected by the recent increase in JYS’ case load.)

 

-  Families need more choice in respite services.  (This is at least partly a systems issue.)

-  Some families feel that services are provided to the most assertive families first.  This may be a cultural issue as well as a personal one.

- Some families feel that they cannot receive services until their child’s behavior escalates and this escalation limits the choice of response.  “I wanted weekly contact and immediate services.  My expectations are too high.” – parent of consumer

-  Some families feel that the choices provided to them are not applicable to their situation.

-  A lack of success in JYS programs leaves a family with little choice beyond placement outside of the area or out of state.  (This is a systems issue.)

-  Choice is limited by the community stigma associated with a MH diagnosis or behavioral difficulties.  (This is a community issue, at least in part.)

-  Some families feel that their freedom to continue or return to services is negatively impacted by a prior treatment failure at JYS.

-  Some families feel that services such as psychological testing have been denied due to their cost.

-  Some families feel that services are inconsistently available, limiting their choices.

 

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:

+  JYS staff offer encouragement to consumers and their families.  “They care about us.” -- consumer

+  JYS staff begin services “where the child is.” – parent of consumer

+   Families are pleased with the time and care taken in the intake and assessment processes.  “They gave me LOTS of time.” – parent of consumer

+  JYS offers access to cultural activities.

+  JYS staff continue to acknowledge youngsters even after they have completed or terminated treatment.

+  Families state that they receive “total respect and total support.” –parent of consumer

+  Consumers assert that they are respected by being neither yelled at nor threatened in any way.

 

The team identified the following weaknesses under Dignity, Respect and Rights for those receiving MH services:

-  Families feel that providing respite services at Cornerstone, as it is a site for residential treatment, is inappropriate.

-  Some families report that their child is discussed in the child’s presence as if the child were not there.

-  Some parents feel that they are blamed by the agency for their child’s behavior.  “I was blamed by the counselor for being a bad parent.” – parent of consumer

-  Many families are not well informed regarding consumer rights.  “I was just given a piece of paper but no education about rights.” –parent of consumer

-  Biological parents feel that they do not have the same access to services as that offered to foster parents.

-  Families not involved with DFYS fear that admission to services is delayed until after their child’s behavior has escalated dangerously.  (This is at least in part a systems issue.)

-  Some families feel that the information they provide and their perspective on their child’s behavior is not listened to.

-  Some parents feel that medication is urged on them.

-  One parent observed that a confidential file had been left in an unsecured location.

 

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for those receiving MH services:

+  The consumer’s medical condition is assessed as well as their psychological state.
+  The agency reacts immediately and skillfully to health issues.
+  JYS staff are regularly trained in first aid, CPR, medications and work-related hazards.

+  Consumers are aided in developing safety plans to be used when angry or depressed.

+  JYS staff are trained to de-escalate consumer behavior.

+  The staff provide appropriate limits to behavior and so increase the consumer’s sense of security.

+  The Mobile Crisis Team can provide for health and safety needs.

+  Families feel that the residential units are safe for their children.

+  Consumers are taught safe and appropriate boundaries.

 

The team identified the following weaknesses under Health, Safety and Security for those receiving MH services:

-  Some families feel ill informed regarding the use of medications for their child.

-  Some consumers and families feel that peer confrontation in the residential setting may threaten the safety and security of some consumers.

-  Staff turnover impacts on consumers’ sense of security.

-  Some families report a lack of support and information in dealing with teen pregnancy.

-  Some families feel that their homes are unsafe while they await services and they fear their child’s escalation.  “I was told she wasn’t bad enough for services.  She had to commit a crime first and be more violent.” – parent of consumer  (This is in part a systems issue.)

-  Some families want to have medicated consumers regularly tested to determine blood levels and this protocol has not been established in their case.

 

Relationships

The team identified the following strengths under Relationships for those receiving MH services:

+  Families report improved family relationships due to treatment.
+  Families report improved peer relationships for their children due to treatment.
+  Foster families report the healing of their relationship with the child in their care.

+  Consumers gain social skills.

+  JYS staff maintain a cordial relationship with consumers even after the closure or termination of services.

+  Families report improved communication with their child due to treatment.

+  The BASE life skills curriculum aids in relationship building.


The team identified the following weaknesses under Relationships for those receiving MH services:

-  Not all families who desire it receive family therapy.

-  Some consumers successfully pit family against staff and vice versa.

-  Staff turnover breaks relationships.

-  Some parents who participate in teams still feel disenfranchised.

-  The limits on respite result in stress for families.

 

Community Participation

The team identified the following strengths under Community Participation for those receiving MH services:

+  The BASE program allows students to attend their school while receiving services during the school day.
+  JYS facilitates the participation of consumers in community activities.
+  JYS facilitates the participation of consumers in culturally appropriate activities.

+  The BASE program especially facilitates the participation of consumers in community activities and provides transportation to those activities.

+  The BASE transportation does not label the vehicle as a JYS vehicle.


The team identified the following weaknesses under Community Participation for those receiving MH services:

-  The stigma attached to MH issues by the community limits community participation.  (This is a community issue.)

-  Some families feel that JYS does not adequately advocate for consumers in this community or provide community education that might decrease the stigma attached to mental illness.

-  The vehicle that transports consumers of residential services to activities is marked as a JYS vehicle.

 

Staff Interviews

 

+  JYS staff are dedicated to their work.  Those who end up staying are strong, proactive and committed.” – staff member

+  Staff are described as loving their jobs and loving kids.

+  Staff feel that they can move to positions that utilize their strengths and balance their lives.

+  Staff find JYS to be a cooperative rather than a competitive work environment.  “I feel very supported.” – staff member

+  Staff generously aid one another.

+  Staff genuinely like each other.

+  Staff can work up through the agency to positions of greater responsibility.

+  Staff may work a flexible schedule to accommodate their needs.

+  Teamwork is essential and visible.

+  Staff find the evaluation process to be helpful.  “Looking back…it was helpful.  It’s why I’m in my position today.”  -- staff member

 

-  While staff did not complain, the team feels that JYS salaries are low, especially for entry-level staff.

-  Benefits are limited for entry-level staff.

-  Some staff lack opportunities for cross training.

-  Some staff feel ill prepared by their orientation.

-  Some staff feel inadequately trained for their positions.

-  Staff may need to finance continuing education and training.  “I pay for my own training.  It’s a problem.”  -- staff member

-  Some staff feel that the work environment does not allow them to succeed.

-  The loss of some key staff members has impacted remaining staff.

 

Interviews with Staff of Related Agencies

 

+  JYS is described as adaptable, flexible and responsive by other agencies.  “A great resource…” – related agency staff

+  JYS is described as a problem-solving agency dealing with “tough clientele.” – related agency staff

+  JYS provides good documentation to other agencies.

+  JYS provides good continuing care plans to other agencies.

+  JYS responds immediately to other agencies’ requests.  “They are very responsive to the behavioral or academic needs of youth.” – related agency staff

+  JYS provides ongoing support for youth according to other agencies.  “They do a great job helping kids through difficult times.” – related agency staff

+  JYS provides a good crisis response team.  Their crisis services are the most effective.” –related agency staff

+  The collaboration between JYS and DFYS results in effective early intervention and prevention efforts.

+  AYI services are seen as greatly improved since JYS has taken responsibility for them.

 

-         Agencies report that the intake and assessment processes are slow and cumbersome and fear that they may be used to screen out some potential consumers.

-         Agencies state that JYS staff need training in dual diagnoses (MH and DD or MH and substance abuse).

-         Some agencies find JYS to be culturally insensitive.

-         Some agencies consider the Positive Peer Culture model to be outmoded and hesitate to refer to JYS.  “(This model) is not kind, not hospitable and exhibits a punitive mentality.” –related agency staff

-         Some agencies are concerned about the waiting list for services and the impact of delays in providing treatment.

-         Some agencies feel that JYS needs to do home visits in order to serve their consumers well.

-         Staff turnover in the intake area has negatively affected other agencies.

-         Some agencies find the communication within JYS to be limited or confused and negatively impacting collaboration. 

-         Some agencies feel that long-term tracking of consumers is necessary.

-         Some agencies report what they describe as the “premature discharge of difficult consumers.” –related agency staff

 

Administrative and Personnel Narrative

 

Grantees of the Division of Mental Health and Developmental Disabilities are expected to meet 34 administrative and personnel standards.  JYS fully meets 30 of these.  The four remaining standards are:

 

Standard #1  JYS does have a clear, written mission statement that includes a statement of values and vision.  It is not entirely clear as to the degree to which the statement reflects the empowerment of consumers.  The team requests further refinement of the mission statement in order to emphasize both the services provided and how consumers and their families are empowered by those services.

 

Standard #6  JYS is governed by a nine-member board.  The agency is aware of only one board member being or having been a consumer or a family member of a consumer.  The team does not feel that this, should it be accurate, represents “significant membership” in the words of the standard.

 

Standard #16  JYS’ well-prepared brochures are unequal in their expression of a “consumer-driven system,” support of the service principles and respect afforded consumers.

 

Standard #25  JYS has a fine written employee orientation plan and the personnel files clearly document the use of it.  The plan incorporates all of the elements listed in Standard #25 with the exception of cultural diversity issues.  While staff report receiving this information in the course of their work, the orientation plan itself does not address cultural diversity.

 

Program Management

 

+  The use of work groups within the agency enhances the cooperative, collegial and non-hierarchical nature of the agency.

+  JYS is an agency open to new ideas.

+  There is open communication within the agency.

+  JYS is a flexible rather than a rigid system.

 

-  The team is concerned that the stress of the recent increase in case load has sorely taxed the agency and requires further investment in staff and in the stability of the work force.

 

Areas Requiring Response

 

1. Review and revise the mission statement, vision and values to clarify the services provided

 and how consumers and families are empowered through those services.  Standard #1

2. Seek to increase the representation of consumers and family members of consumers on the

governing board.  Standard #6

3. Review and revise agency printed materials to clarify the consumer-driven nature of services,

support of the service principles and respect for consumers and their families.  Standard #16

4.  Include cultural diversity issues in the new employee orientation.  Standard #25

5.  Develop a plan to increase sensitivity to the multi-ethnic nature of the community.

6.  Consider a long-range study of outcomes of the Positive Peer Culture system.

7.  Consider the causes of staff turnover and develop a plan to increase the stability of the work force.

8.  Seek to further engage, support and educate the families of consumers.

9.  Examine the expanded use of case management or care coordination especially in the areas of after care and transitional services.

 

Other Recommendations

 

1.  Foster the development of a parent group.

2.       Consider the development of a parent mentor program to educate and inform the families of consumers.

3.       Consider further outreach efforts.

4.       Consider ways in which the agency might educate the community regarding MH issues to decrease the stigma attached to them.

 

 

 

Closing Note

 

Thank you for your hospitality in sharing space with the six members of the team and for assisting us in our work.  This is often a disruptive process for an agency, not matter how carefully the team tries to be inconspicuous, and we appreciate your tolerance.

 

The final draft of this report will be sent to Northern Community Resources for final 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), Score Sheet (averaged)

 

 

 

NCR  10/00