Northern Community Resources
(907) 225-6355
FAX 225-6354
Cindy
Triebel, Community Member
Ron
Adler, Peer Reviewer
Barbara
Price, Facilitator
A review of the Mental Health (MH) services
provided by Juneau Alliance for Mental Health, Inc. was conducted from June 18
through
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.
Juneau Alliance for Mental Health, Inc. (JAMHI), formerly JAMI, is a non-profit corporation that provides comprehensive community mental health services. These services include general mental health, 24/7 emergency services, outreach, clinical assessment, psychiatric and nursing care, crisis respite, support services, case management, prevocational training, psychosocial rehabilitation and residential services. Assessment of minors is offered through emergency services. All other consumers are adult.
Services are provided at four sites: a downtown
building that houses Green Doors, a day program; a five-bed crisis respite
facility for those in crisis but not in need of hospitalization or those
transitioning out of the hospital; transitional and independent apartments
where case management services are provided for those with the goal of moving
into the community or functioning independently; a five-bed long term
residence.
Approximately 100 individuals receive a full array
of JAMHI services. The newer services
(emergency services, general mental health), added after the closing of the
City and Borough supported mental health services (CBJ), are provided to
another 117 individuals. This
population, unlike those receiving full services, is increasing. Some 95% of those receiving services reside
in
Services are provided by a staff of 51 full and
part time employees and three contract psychiatrists who are attached to the
local hospital. There is significantly
less turnover among the staff of JAMHI compared to staff turnover in other MH
agencies in the state.
The annual budget of approximately $3,400,000
includes a state community mental health grant of some $1,300,000. Third party payments and additional grants
and contracts provide the bulk of the annual budget.
Description
of Process
A five member team including three community members, a
peer reviewer and a facilitator met for four days in
Additionally, the team interviewed 3 board members, 12 staff members and 16 staff of related human service agencies. Thus, a total of 58 interviews provided the information on which this report is based.
Interviews were conducted by phone or in person at the JAMHI office and in the community. Interviews were of 15 to 90 minutes in duration. The vast majority of consumer interviews were conducted in person. Team members visited all of JAMHI’s residential sites as well.
The facilitator reviewed the Residential Policy and Procedure Manual, the Clinical Policy and Procedure Manual, the Fiscal Policy and Procedure Manual, the Administrative and Personnel Policy and Procedure Manual, the New Employee Orientation, the October, 2000 financial audit, the minutes of the governing board for FY00 and FY01, the labor agreement, JAMHI publications and public service announcements, and eight personnel files.
Open
Forum
An Open Forum was held on the first night of the review at
the Juneau Library’s conference room.
The purpose of the Open Forum is to provide an opportunity for community
members to share their experiences and impressions of JAMHI’s services. The agency had posters at their facilities
advertising this opportunity, placed ads in the local newspaper and had public
service announcements on the local media.
The local
A further opportunity for input was provided by publicizing the local phone numbers of the facilitator and peer reviewer and encouraging community members to call and request an interview.
The Open Forum was attended by four members of the
interview team. No members of the public attended.
Eight interviews were conducted with consumer
volunteers. The information gathered in
these interviews is incorporated within the narrative of the report.
Progress
Since Last Review
The last Integrated Quality Assurance Review of JAMHI was conducted in April, 1999 and yielded the following Areas Requiring Response.
Best
Practices
The Quality Assurance Steering Committee has asked that teams identify practices that are exemplary based on a detailed criteria which can be found at the end of this report. The team nominates for this distinction and the agency is to provide documentation regarding these practices for the NCR Program Manager who will then forward the documentation to the Steering Committee.
Few “best practices” have been identified in the
State of Alaska. The review team is
pleased, however, to identify two such practices for consideration at Juneau
Alliance for Mental Health, Inc. They
are:
The continuum
of residential services (that includes a crisis/respite facility next door
to Green Doors, a residence offering intensive services, semi-supervised
housing and independent housing alternatives) is exemplary. JAMHI has created 41 owned and operated
housing alternatives for consumers. Not
only are these alternatives provided, but this housing is safe, secure,
accessible and of high quality. This is
housing that anyone would be proud to call home.
JAMHI has attracted a superb coterie of local volunteers, paraprofessionals and temporary
staff members of unique talents. These individuals contribute immeasurably to
the milieu and aid in the destigmatizing of consumers of services. These caring, energetic, optimistic people “capture the essence of meeting people where
they are.” JAMHI is to be commended
for its ability to attract and support these fine workers and allow them the
flexibility to connect with consumers in lively, improvisational and humane
ways.
Areas of Excellence
1. Green Doors is a welcoming, accepting, comfortable and comforting location where consumers
of services have easy access to activities, meals, prevocational opportunities, social contact
and recreation.
2. JAMHI’s case managers are repeatedly praised by consumers, family members and related agency professionals for their knowledge, energy, support, inventiveness and active participation in consumers’ lives. Many case managers were singled out by name in our interviews as people who have made all the difference in the lives of those they are pledged to serve. “They have worked their hearts out.” -- colleague
3. JAMHI’s approach to medication management speaks well of their concern with the dignity, health and safety of consumers. Consumers are well educated regarding their medications. Consumers are respected as adults and as such can exercise choice regarding initiating, modifying or stopping medication. Medication is carefully and safely monitored. The nursing and psychiatric offices are homey and congenial. The medical staff are easy to approach and inspire trust.
4. JAMHI maximizes the use of its facilities by coordinating events at Green Doors with those at the transitional housing next door.
5. JAMHI employees express a high degree of loyalty to their agency and this is exhibited in the relatively low level of staff turnover. JAMHI employees are supported in working their way up to positions of increased responsibility and training is provided on site to assist this process.
6. JAMHI’s governing board expresses a high degree of loyalty to their agency and is open to consumers and focused on their welfare and empowerment. As with employees, board members “catch the JAMHI spirit,” give generously of their time and talents and aid in creating a better place in the world for consumers of MH services.
The team identified the following strengths under
Choice and Self-Determination for those receiving MH services:
+ Consumer goals are validated in treatment
planning.
+ All consumers, despite their level of
functioning, take part in developing their treatment plans.
+ Consumers can choose to take medication
“holidays.”
+ Consumers can design their own care plans.
+ Consumers participate as part of their
“medication management team.”
+ Consumers choose their medication in
collaboration with the physician.
+ A consumer was able to choose their counselor
after their prior counselor left the agency.
+ Consumers are free to come and go.
+ Consumers are supported in moving toward
independence.
+ Consumers can exercise choice over the chores or
prevocational tasks they do.
+ “They show
you the avenue, but you have to walk it.” –consumer
+ Services
are provided in the home as needed.
The team identified the following weaknesses under
Choice and Self-Determination for those receiving MH services:
- Some consumers who had been receiving services through the now closed CBJ MH program state that they have been refused services at JAMHI. (The agency states that no former CBJ consumer is refused services. The agency further states that not all services provided at CBJ are provided by JAMHI.)
- There are
a limited number of groups and the loss of the MICA group is particularly upsetting to consumers.
-
A few consumers state their need for more
one-on-one therapy.
-
Some consumers feel that, as their level of
functioning improves, their options are too limited.
-
Court-ordered consumers have restricted
choices. (This issue is beyond the
control of the agency.)
-
Consumers desire greater self-determination
and greater empowerment, including the opportunity to run groups. (The agency states that their goal is to move
from the current level of active involvement of consumers to consumer-run
activities.)
-
Several consumers felt compelled to
participate in the site review’s interviews.
-
On one occasion, a staff member was heard
degrading a consumer’s personal goals in the presence of the consumer.
-
A seamless continuum of care does not exist
between corrections and MH services for individuals experiencing serious mental
illness. (This is a systems issue.)
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ “They work
real hard to make people happy.” --consumer
+ Consumer rights, including the grievance policy,
are posted in the agency’s facilities.
+ Consumers are treated with respect and this
encourages them to continue to access services.
+ The high quality of JAMHI’s housing is an
important indicator of the respect afforded consumers and their residences
provide consumers with a sense of pride.
+ Consumers are not pushed to examine issues they
are not ready to discuss; their growth is encouraged, not directed.
+ The Consumer Council meets weekly; members are
invited to attend board meetings and participate in the proceedings.
+ A consumer states “(JAMHI’s staff) respect human lives.”
+
“I have been treated nice here.” – consumer
+ “All the
staff cares about me.” – consumer
+ “I have a
second chance with JAMHI. They picked me
up and got me back on my feet.” – consumer
+ “They treat
me like an adult.” – consumer
+ “They
listen to me.” -- consumer
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services:
- A consumer
is unable to access their CBJ file.
(This is a systems issue.)
- Many
consumers lack awareness of the grievance procedure.
- A consumer was unsupported by JAMHI staff when
appearing in court on some occasions.
- Some consumers state that they did not sign a
release of information for their interview with the site review team.
- In several instances, posted rules and
information use condescending language that is not respectful of the adulthood
of consumers.
- As above, on one occasion a staff member was heard degrading a consumer’s personal goals in the presence of the consumer.
- Some
consumers feel that there is a stigma attached to the building that houses
Green Doors and find its location too visible.
- Green
Doors’ common areas reflect an institutional, rather than a consumer-centered,
setting.
- A seamless
continuum of care does not exist between corrections and MH services for
individuals experiencing serious mental illness. (This is a systems issue.)
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ Through the MICA group, consumers were informed
regarding health issues related to substance abuse and addiction.
+ Some consumers have been aided with the cost of dental care.
+ JAMHI staff coordinate medical appointments and accompany the consumer to
those appointments as needed.
+ Consumers can be referred for substance abuse
services.
+ Consumers
receive a fine education regarding medications.
+ Consumers report improved quality of life through
the use of their current medications. “I am back on my feet (now that) my
medication is straightened out.” -- consumer
+ Consumers collaborate with their doctor in
managing medications.
+ Nursing and psychiatric care is available at
Green Doors.
+ Healing Touch is available to consumers.
+ JAMHI housing is secure.
+ JAMHI housing is safe.
+ JAMHI collects rent and is patient when checks
are late, unlike a landlord. This
increases consumers’ sense of security.
+ Consumers note being more secure in themselves thanks to JAMHI services and therefore are made less anxious when negative or alarming things occur in their lives.
+ “This is a
good resting place for me.” -- consumer
The team identified the following weaknesses under
Health, Safety and Security for those receiving MH services:
- Consumers
see the MH services of the local hospital in a negative light and resist being
hospitalized there. (This is not solely
within the control of the agency.)
- Some
consumers are unable to access dental care.
(This is a systems issue.)
- A large
rock at the head of the steep stairs at Green Doors is a potential hazard.
- Unsanitary
conditions in the lavatories at Green Doors were noted.
- Consumers’
sense of security has been challenged by the impending move of the agency’s
offices away from the building that houses Green Doors.
- A seamless
continuum of care does not exist between corrections and MH services for
individuals experiencing serious mental illness. (This is a systems issue.)
The team identified the following strengths under Relationships for those receiving MH services:
+ Consumers are aided in maintaining contact with
their families if they so desire.
+ Green Doors provides a place for consumers to observe and practice social
interaction.
+ Green Doors enhances friendships: “My
friends are right here.” – consumer
+ Social skills are taught.
+ The agency supports and informs consumers’
relationships including intimate relationships.
The team identified the following weaknesses under Relationships for those
receiving MH services:
- Some
consumers are left to mourn their loss of custody of their children, a process
in which JAMHI staff may have participated.
(While the loss of custody is not the responsibility of the agency, the
need to aid grieving is incumbent upon the service provider.) (The agency states that factual information
on custody issues has been provided recently in a multi-agency presentation.)
- Some
families are left to mourn their loss of parental roles as their children reach
adulthood. (While this is a legal issue,
the need to aid the grieving of consumer parents could be aided by the agency.)
- Several consumers state the need for a class on
relationships.
-
Professional boundaries limit the relationships between providers and
consumers. (This is an ethical
necessity, although the agency could aid in consumers’ understanding of this.)
The team identified the following strengths under Community Participation for those receiving MH services:
+ Consumers participate in picnics and ice cream
socials.
+ Consumers participate in fishing and camping.
+ Consumers participate in ceramics and a reading group.
+ Consumers can obtain free bus passes and the
agency has vans to aid with transportation.
+ Some
consumers are especially active in the community as volunteers, students and
participants in civic responsibilities.
+ Consumers
are referred to DVR and other community agencies for employment services.
+ Area churches are accepting and supportive of
consumers, providing a safe place and a loving community.
+ A consumer
reports the restoration of their sense of community thanks to JAMHI’s community
referrals and their increased ability to participate in the life of the
community.
The team identified the following weaknesses under Community Participation for
those receiving MH services:
- Consumers
feel that they were not included in the decision to move the offices nor were
they included in planning for the move.
- Consumers
feel that they do not have true employment opportunities.
- Several consumers note the stigma the community
of Juneau attaches to mental illness and to consumers of MH services. (This is not solely the responsibility of
this agency.)
- The
community of Juneau lacks sufficient education regarding mental illness and MH
services. (This is not solely the
responsibility of this agency.)
- Some
consumers are not aware of their options for participating in the community.
- Former CBJ
consumers note the increased stigma attached to accessing services at JAMHI.
Staff Interviews
Interviews were conducted with 12 staff members. The team identified the following positive points regarding staff:
+ JAMHI staff are optimistic regarding the agency’s future, feeling they have weathered the storm of recent and multiple changes.
+ Most staff are aware of the agency’s mission and philosophy.
+ JAMHI staff work as a team and are a hard working team. “We have a sense of family at JAMHI.” – staff member
+ JAMHI staff are seen as accessible and always available to consumers.
+ JAMHI staff are consumer-centered.
+ JAMHI staff are resilient which is a credit to their faith in the agency and excellent modeling for consumers.
+ JAMHI staff know their strengths and their competencies.
The team identified the following concerns:
- Many staff feel the need for further training relevant to their work duties.
- Some staff
are “still reeling” from multiple
stressors in recent months.
- Many staff
feel that they did not receive an adequate orientation to their jobs.
- There is
an inadequate number of management staff.
- Staff find that paperwork impedes their performance of their duties. (This is a systems issue.)
- The impending
move of case management to another building, at a distance from Green Doors,
will complicate daily contact with consumers.
The DMHDD regional coordinator requested that interviews be conducted with Juneau Police Department, Alaska State Troopers, Bartlett Hospital, Alaska Psychiatric Institute, Juneau Recovery Hospital, Lemon Creek Correctional Center, Division of Vocational Rehabilitation, board members, Glory Hole, court system, local NAMI chapter, Juneau Youth Services, SEARHC and Gastineau Human Services. All of these interviews were conducted by the team.
These related service professionals identify the following strengths in their work with JAMHI:
+ When JAMHI is fully involved in a case, the results are positive.
+ JAMHI maintains a high degree of collaboration in their newly developed emergency services. “I have had great cooperation from JAMHI on emergency services since they took over the contract for the city.” -- related agency
+ JAMHI’s recent interagency training regarding the changes in the agency, whom to contact for what service, etc. was a great help to other service providers.
+ JAMHI is complimented for having gracefully assumed its new duties. “They came up to speed quickly.” – related agency
+ JAMHI’s case managers are described as “cooperative,” “insightful,” “flexible,” “open,” providing “outstanding support” and, in a crisis, “partnering real good.” – related agencies
Concerns expressed by these professionals are:
- Some collaboration is impeded by the lack of releases of information.
- There is a delay in JAMHI’s provision of medical records.
- Substance abuse, FAS/FAE and mental health services are not well integrated. (This is a systems issue.)
- Agencies feel that consumers have inadequate opportunities for pre-vocational activities.
- There are limited services for consumers who experience multiple disabilities.
- There is inadequate collaboration between JAMHI and advocacy groups and between JAMHI and law enforcement.
- Agencies report that former consumers of services at the CBJ MH program are ineligible for services at JAMHI and are essentially abandoned. (This is in part a systems issue.)
- Agencies report that since the closure of the CBJ MH program, MH services are harder to access.
- Agencies report that they are not routinely informed when JAMHI discharges a consumer.
- Agencies report that “Medicaid requirements have had a negative impact on individual mental health treatment.” – related agency (This is a systems issue.)
There are 34 Administrative and Personnel Standards for community mental health centers. Of these, 24 are fully met and 10 are partially met. The partially met standards are:
1. Standard #2 “Agency-wide education and orientation about mission, philosophy and values
promote understanding and commitment to consumer-centered services in daily operations.”
The degree to which consumer-centered values are exhibited by staff, consumer-centered
values are represented, and consumer-centered language used, is inconsistent among all
JAMHI staff. (Prior and current reviews)
2. Standard #11 “All facilities and programs operated by the agency provide equal access to all individuals.” The Green Doors facility is on the second floor of a building, accessible only by climbing a steep set of stairs. Services for hearing impaired consumers are reportedly insufficient and exhibit an inadequate understanding of deaf culture. On the other hand, the newer agency buildings are accessible. Multiple language groups are served by translators. Services are offered in home as needed.
3. Standard #12 “The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery.” The agency is formalizing this process and needs to create a written policy affirming the use of consumer opinion in agency policy setting and program delivery. (Prior and current reviews)
4. 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 with the planning and delivery of services.” The agency is formalizing this process and needs to create a written policy affirming the use of consumer opinion in the planning and delivery of services. (Prior and current reviews)
5. Standard #14 “The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities.” The agency is formalizing this process and needs to create written policy affirming the use of consumer opinion in the development of annual goals and objectives. (Prior and current reviews)
6. Standard #22 “The organization has and utilizes a procedure to incorporate consumer choice into the hiring and evaluation of direct service providers, and to ensure that special individualized services (e.g. foster care, shared care, respite care providers) have been approved by the family or consumer.” Consumers are involved in the hiring of direct service providers. Consumers do not participate formally in staff evaluation although their opinions are gathered informally. (Prior and current reviews)
7. Standard #24 “The hiring process includes background and criminal checks (when appropriate) for direct care providers, personal and professional references and follow-up on required references.” Of the eight personnel files reviewed, five had documented reference and/or background checks. The remaining three did not. Those three personnel files belonged to long term employees.
8. 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 (abuse, neglect, mistreatment laws), cultural diversity issues, and potential work related hazards associated with serving individuals with severe disabilities.” The agency’s orientation and training meet these standards except in the area of cultural diversity training. Given the concern noted in Standard #11, cultural diversity issues should include deaf culture as well as that of diverse ethnic groups. (Prior and current reviews)
9. Standard #29 “A staff development plan is written annually for each professional and paraprofessional staff person.” One personnel file was for an employee too recently hired to have been evaluated. Of the seven remaining files, three included evaluations with staff development plans for the coming year.
10. Standard #31 “The performance appraisal system adheres to reasonably established timelines.” Of the seven personnel files in which an evaluation should have been completed according to agency policy, two had no documented evaluations after 1997 and two had no documented evaluation after 1999.
Program Management
The team notes the following strengths of JAMHI’s management team:
+ The current executive director has held that position for 10 years.
+ Many staff
are long term employees and there is significantly less turnover in this agency
than in most MH programs in the state.
+ Despite the need to adjust to new service demands
with the closure CBJ and the need to move from being a provider of specialized
services to a community mental health center, JAMHI has rapidly included
emergency services and general mental health services to their repertoire and
has done so, by all reports, with considerable grace.
+ The nine
person governing board is noted as especially open to consumer opinion and the
governing board has six consumer or family-of-consumer members.
+ JAMHI does
an exceptional job of managing residential services.
+ Both the
administration and the board are keenly aware of the financial status of the
agency.
+ Board members are open to consumer contact and
opinion.
+ The Board
clearly holds the Director in high regard.
“The Director is a very skilled
and creative person.” – board member
+ “As
nonprofits go, this one works.” – board member
The team notes the following issues facing JAMHI’s
management team:
-
JAMHI’s new role as the provider of
community mental health services requires a role expansion for management. There is a need for JAMHI to assume a
leadership position and to become the spokesperson for mental health needs in
the community. As the service provider
closest to the seat of power in this capital city, JAMHI’s leadership is key to
the provision of quality MH services in Alaska.
-
JAMHI’s management needs to enhance their
gathering, networking and utilization of Quality Assurance data to comply with
Medicaid regulations and to create a feedback loop such that QA data is used in
the setting of goals, evaluation, planning and delivery of services.
-
The agency is understaffed administratively.
-
Newer board members may be out of the loop
and in need of careful orientation and training in order to participate fully
in their important role in governing the agency.
-
Supervisory staff need to be especially
articulate in their presentation of the services they provide and the
philosophical context in which those services are provided.
1. JAMHI’s role as a service provider is key. Collaboration with all related agencies needs to be
enhanced for the good of all consumers of services. Develop and implement a plan to be
easily accessible to all stakeholders including being proactive in establishing releases of
information to facilitate the continuum of care.
2. In the light of JAMHI’s new responsibilities, develop as many memoranda of agreement as possible with other human service agencies including law enforcement (see Other Recommendations).
3. Develop and implement a system to review consumer rights with all consumers on a regular
schedule.
4.
Standard #2 Develop and implement
a plan to educate and orient all staff to consumer-
centered values, language and mission.
5. Standard #11 Address physical accessibility issues in Green Doors and develop a plan for providing services to the hearing impaired.
6. Standard #12 Initiate the use of the consumer satisfaction survey and develop a policy to include the results of those surveys in policy setting and program delivery.
7. Standard #13 Initiate the use of the consumer satisfaction survey and develop a policy to include the results of those surveys in annual agency planning and evaluation.
8. Standard #14 Initiate the use of the consumer satisfaction survey and develop a policy to include the results of those surveys in developing annual goals and objectives.
9. Standard #22 Formalize the process of using consumer opinion in the evaluation of direct service staff.
10. Standard #24 Document reference checks and background/criminal checks in all employee files.
11. Standard #25 Include issues of cultural diversity including deaf culture in staff orientation/training.
12. Standard #29 Develop and institute a policy of writing annual staff development plans for each professional and paraprofessional staff person.
13. Standard #31 Complete and document all staff evaluations as required by the agency’s personnel policies.
Other
Recommendations
1. Develop a plan to maximize the use of software packages for outcome measurements and the coordination of all relevant data in a highly accessible and informative manner.
2. Consider individualized safety contracts with law enforcement, the courts, corrections, JAMHI and consumers that would constitute a protocol for response to escalation and as a means of coordinating appropriate responses to the behavior of those who experience mental illness.
3. Consider allocating resources for consultation in order to facilitate JAMHI’s metamorphosis from its prior identity and role to the leadership role that the agency will now need to assume.
4. Consider collaborating with other agencies to provide needed family and community education.
Closing Note
The team wishes to express its gratitude to
JAMHI. Having endured recent tragedies,
a major redefinition, changes in Medicaid requirements and an impending move,
the agency still managed to assume a brave face when confronted with a gaggling
group of interviewers. Staff made every
effort to facilitate graciously the completion of this review.
The final draft of this report will be sent to
Northern Community Resources for review. You will receive the final report
within approximately 30 days, including a Plan of Action form, listing the
Areas Requiring Response. You will then
have an additional 30 days to complete the Plan of Action. The directions for 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
(tallied)
NCR 8/00