Northern Community Resources
P. O. Box 7034
Ketchikan, Alaska 99901
(907) 225-6355
FAX 225-6354
Wanda
McDaniel, Community Member
Laura
Rorem, Community Member
Lenne
Musarra, Community Member
Jim
Musser, Community Member
Rick
Calcote, Peer Reviewer
Barbara
Price, Facilitator
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
+ 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
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.
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