Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska 99901

(907) 225-6355

FAX 225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW
 
Providence Kodiak Island Mental Health Center
May 21-23, 2001
Kodiak, Alaska

 

Site Review Team

Linda Jackson, Community Member

Karen Perkins, Community Member
Wayne McCollum, Peer Reviewer

Robyn Henry, Facilitator

 

 

INTRODUCTION

 

A review of the mental health (MH) services provided by Providence Kodiak Island Mental Health Center (PKIMHC) was conducted from May twenty first to May twenty third, 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

 

PKIMHC is a program of Providence Health System in Alaska.  It was created in 1998 when the Kodiak Island Borough Assembly requested that Providence assume the management of the Kodiak Island Mental Health Center, which had operated since 1970.

 

The agency’s service area includes 15,000 residents who live in the Kodiak Island region including the city of Kodiak and the seven other villages on and around the island. The program is governed and administered by Providence Health System and takes advisement from a nine-member local advisory board.

 

The agency employs 20 full and part-time people. The PKIMHC MH program carries an active caseload of approximately 375 people including 30-35 people served in the Community Support Program.

 

Mental health services provided by the program for adults include outpatient individual, family and group therapy; emergency service; psychiatric services; psychosocial rehabilitation and case management services. Through the agency’s Community Support Program the agency provides outreach, case management, employment/education and recreation services to adults diagnosed with a major mental illness and severe emotional disturbances.

 

Services to children and youth include family support, counseling, and direct support to children in the schools. SED youth and their families receive family skill development, home-based therapy and skill development. The agency also provides services in the schools throughout the island.

 

Emergency services are provided on a 24-hour/7 day a week basis through a rotating on-call system. The local hospital can accommodate Title 47 clients, providing 24-hour evaluation and 72-hour hold.

 

While residential services are not provided, the Borough owns housing in the same complex that houses PKIMHC.  This housing is available to CSP clients. Services are available in the apartments during normal business hours.  Currently four people are receiving housing at this location.

 

Description of Process

 

To conduct this review, an interview team consisting of a facilitator, two community members, and a peer reviewer conducted 34 interviews over a three-day visit in Kodiak, Alaska. Seven interviews were with adults who receive MH services.  Three interviews were with parents of/or children who receive mental health services. Fifteen interviews were conducted with related service professionals and six interviews were with program staff. One of the interviews was with a person who serves on the PKIMHC advisory board.

 

Interviews lasted from 15 minutes to an hour and were held in person, at PKIMHC offices, by telephone and in the community.

 

The interview team members also reviewed personnel documents, the agency employee handbook, the program Policy and Procedure Manual and other administrative documents. After gathering the information, all the team members met to review the data and draft the report, which was presented to the administrative staff on the final day of the visit.

 

Open Forum

 

 A public forum was held in Kodiak at the Bayside Fire Department Training Room at 7:00 P.M. on May 21st. PKIMHC advertised the event by announcing it on the radio, posting flyers around town and publishing an announcement in the newspaper.

 

There were fifteen people in attendance at this meeting. In addition, three people requested and received individual meetings with team members. The feedback received during these meetings is summarized in the body of this report.

 

 

 

FINDINGS

 

Progress Since Last Review

 

The following recommendations were identified during the May 1999 site review as areas that need attention from the organization. Progress in these areas is noted:

1.       “The mission statement and program philosophy do not reflect the ways in which consumers and their families are empowered.  Revise mission statement and program philosophy to be particular to and appropriate for a publicly funded community mental health center.  (Administrative Standard #1)”

Progress: The program has revised its mission statement and program philosophy/values statement to reflect a more consumer- and outcome-oriented approach to services. Standard met.

2.       “Staff education and orientation do not reflect or do not make explicit a focus on consumer centered services.  Revise staff materials to include both the language and intent of consumer centered services.  (Administrative Standard #2)”

Progress: The program has developed a staff orientation and training process that reflects a more consumer-centered approach to working with clients including a new mission and values statements and the institution of more regular training to staff. Standard met.

3.       “No copy of the audit or of the management letter was provided.  Establish a means by which to provide the annual audit and its results.  (Administrative Standard #3)”

Progress: A copy of a summary of the 1999 financial audit for Providence Alaska Service Area was presented. The 2000 audit was not available at this time. Standard met.

4.       “The local mental health board does not participate sufficiently in the review of policies and their effect on local mental health consumers.  Include the local mental health board in policy discussions, allowing them to mold those policies to meet local needs, values and concerns.  (Administrative Standard #5)”

Progress: It is current practice that all new policies are reviewed and approved by the program advisory board. Standard met.

5.       “The local mental health board does not participate in a review of the annual budget nor does it have a role in program evaluation.  Inform the local mental health board of the annual budget and the value system it represents; include the local mental health board in meaningful program evaluation.  (Administrative Standard #7)”

Progress: The advisory board and program management recently established a policy that outlines the means by which the board will evaluate program effectiveness through consumer surveys. The advisory board was not presented with this year’s budget prior to submission. Standard partially met.

6.       “The local mental health board does not participate in the selection of the agency's director.  Define the role of the mental health board in this decision making process.  (Administrative Standard #9)”

Progress: While the advisory board does not have the ultimate decision-making authority of hiring the agency director, it currently does have the ability to give formal input in this decision as well as give input into the formulation and revision of the director job description. Standard met.

7.       “Currently there is not equal access to services for all people.  Formalize arrangements for translators; provide signage in multiple languages including Braille as possible; provide a TTY system as possible; seek direction in these efforts from local consumers, related agencies and advocates.  (Administrative Standard # 11)”

Progress: The program currently has access to the above stated services through the umbrella services of Providence. Standard met.

8.       “There exist insufficient means by which the agency solicits and utilizes consumer and family input in policy setting and program development.  Create a means by which to receive continuously consumer and family input through surveys, interviews and the like; develop and document the means by which this information is reflected in policy and in programming.  (Administrative Standard #12)”

Progress: As stated above, the advisory board has developed a new policy which outlines a formal process to survey consumers every two years and to then systematically use the results of the survey in policy making and program decisions. The program should follow though with this new policy. Standard met. 

9.       “There is not currently a process allowing for annual program evaluation, which includes staff, community and consumers together.  Together with the local mental health board develop a process for an annual program evaluation in which staff, community including other service providers and consumers and their families actively participate.  (Administrative Standard #13)”

Progress: Program management currently works with the advisory board annually to develop program planning. Efforts continue to be made to increase involvement of consumers, staff and community members in this process. Standard partially met.

10.   “There is no documentation of program planning based on the results of an annual evaluation performed by staff, community and consumers.  Develop a means by which the results of the evaluation referred to in item 9 above lead to program planning.  (Administrative Standard #14)”

Progress: Once the planned survey process is complete this standard can be addressed. Standard not met.

11.   “Agency publications do not uniformly reflect a consumer-centered focus.  Begin to revise or create new publications, which reflect consumer-centered services.  (Administrative Standard #16)”

Progress: The agency has created a brochure for each program within the mental health center. These publications reflect a focus on consumer-centered services. Standard met.

12.   “The agency does not have a procedure to incorporate consumer opinion into the hiring and evaluation of providers.  Develop an employee evaluation system that can include consumer opinion.  (Administrative Standard #22)”

Progress: Ideas for meeting this standard are currently being considered. Ideas were discussed with the site team facilitator. Standard not met.

13.   “Staff development plans included in each employee evaluation are perfunctory.  Include a staff development plan for each employee at the time of the annual evaluation and provide timelines for completion of each goal.  (Administrative Standards # 29, #31 and # 32)”

Progress: The agency has revised its staff evaluation system to include staff development plans that include goals and objectives and timelines. Standard met.

14.   “There is a concern on the behalf of a related service agency that Alaska Native people are hesitant to use PKIMHC's services as they are unaccustomed to paying for health services and may shy away from sites of conflict (a reference to the agency's past).  Continue efforts to provide culturally sensitive services to Alaska Natives.”

Progress: The program director discussed with the local Native provider ways to increase the ease of access and comfort for Native people seeking services. As a result of that discussion the agency sent referral packet information to the Native agency and explained the referral process. This issue did not arise during this site visit. Standard met.

15.   “There is a perceived disruption in the continuity of care for the transitioning from API to Kodiak; transitional housing does not meet all of these needs.  Explore the means of providing smoother transitions for consumers as they move from different levels of care.”

Progress: Issues regarding transitions continue.  Standard not met.

 

 

The Five Quality of Life Areas

 
Choice and Self Determination

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

+        Many people indicate that they are satisfied with their role and level of involvement in the development of their service plan and that the goals in the plan reflect their hopes and desires.

+        Many people say that they feel that the staff psychiatrist is very good at offering choices and including them in decisions regarding medications and treatment.

+        One person expresses gratitude and pride in the fact that they manage their own finances and control their own affairs.   

 

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

-          Several people indicate the need for more housing options and the need for more ongoing support to consumers in the community.

-          Several people indicate that the plan that was developed for them is not reflective of their goal and desires.

-          One person says that they were not made aware of the availability of CSP services for the first two years of getting psychiatric services from the specialty clinic.

-          Many people, including consumers, related agencies and staff express great frustration at the fact that the agency psychiatrist refuses to work with clients who are also receiving services from one of the psychologists in town.  

-          A number of people indicate that there are not enough choices for recreational and skill building activities for CSP clients and that CSP support is limited to business hours.

-          Several people report that there are limited services available during the day to people in crisis. Many people identify the need for walk-in psychiatric services for those in “pre-crisis.”

-          Several people including consumers and related agencies identify the need for mental health

      and substance abuse services for both adolescence and adults.

-          Several people identify the need for more staff training, especially in specialized skill areas

      such as working with young children, working with children with ADHD, crisis prevention,

      anger management, and sex offender treatment.

-          Many people identify billing and insurance coverage as being a big problem, even to the point

      that these problems get in the way of accessing services. Several people indicate repeated

      mistakes in billing, non-coverage of services, and not being able to access services on a

      sliding fee scale because of being court ordered.  These issues are barriers to getting needed

      treatment.

-          Many people comment on the fact that there is often a long wait to get an appointment with the psychiatrist. A number of people note the need for “walk-in” psychiatric support.

  -     Several people identify the need for having a psychologist on staff.

 

Dignity, Respect and Rights

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

+        Most people say they are treated with respect and dignity by staff and that they appreciate staff efforts.

+        Most people say they are very satisfied with their services and the way they are treated by staff. “(Staff) are always agreeable to listening.”

+        “(Staff) are quick to respond to crisis.” 

+        “(The psychiatrist) is patient and is good about fine-tuning my meds.” and “(The psychiatrist) listens to input on medications and makes changes”.

+        Most people indicate that they know about their rights regarding confidentiality and that those rights are protected.

 

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

-          A few people say that they do not know about their rights and most people say they are not aware of a consumer grievance process.

-          Several people comment that the front desk staff are sometimes rude to them; that they usually ask them who they are and what they want; they repeat this information in front of others.

-          Several people identify one long-time staff person as being disrespectful to clients and at times talking about clients while in common areas of the agency and in front of other staff and other clients.

 

Health, Safety and Security

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

+        Most people indicate that they feel safe and secure in their living environments.

+        Most people say that they feel supported by staff in getting their health needs met. One person explains that the staff psychiatrist was instrumental in diagnosing a medical problem others had said was “all in (my) head”.

+        Many people express appreciation for the expertise of the staff psychiatrist in prescribing and managing their medication.

+        Several people say they feel the agency is a “warm and comfortable place to be”.

+        One person explains that “(The staff) saved my life”.

 

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

-          One resident in the housing program says that they have no idea what to do if there is an emergency.

-          Several consumers mentioned a fire that had occurred in residential housing several years ago, indicating that they feel that no safety precautions have been instituted to protect clients.

-          One parent says that their child could not get enough support in Kodiak so they had to send their child out of town.

-          One parent says that their child had to get into trouble to get any help.

-          Several people note the lack of supports provided to people in the agency housing program and the difficulties they have in getting support “after hours” even though there is a live-in staff member on the premises.

-          A couple of people indicate that there is a lack of support for ongoing health needs in the home.

-          One person reports living in their car and that they are frustrated by the fact that they can’t get housing.

-          Many people across all interviews cite high staff turnover as a major problem for the agency.

      Such turnover has a very detrimental effect on clients’ sense of security and on services. One

      related provider said “I don’t ever know who works here.”

      

 

Relationships

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

+        Most people say that staff support them in building and maintaining relationships.

+        Several family members report that the agency’s management is responsive to issues regarding services to their loved ones.

+        One person reports that the staff psychiatrist encourages them to set goals of building family relationships.

 

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

-          One person indicates that they get very lonely during the day and on weekends and that they want more support for building relationships.

-          One person reports that, although they are living with their child and the child is an integral part of their life, there is no inclusion of the child or of their relationship to the parent in the service plan.

-          A couple of people identify the need for parenting classes.

 

Community Participation

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

+        A couple of people commend the support they receive from the staff psychiatrist regarding work. One person says “Dr. Jensen has helped me in my work atmosphere.

+        Another consumer  indicates receiving help with work problems.

 

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

-          Several people report that they are not supported in accessing community activities and services. When requesting assistance with transportation they are told “We are not a taxi service.” and told to take the bus. One person reports that when they decided to try and take the bus they were given no support in learning how to use the bus for the first time.

-          Several people identify a lack of vocational services and support to CSP clients. Even a goal of volunteering in the community is not supported.

-          Several people identify places to go and activities they want to participate in the community, but said they do not get support.

 

Staff Interviews

 

Six staff members were interviewed. The strengths of the agency identified by staff are positive relationships and support from their peers and from administrative staff.

 

Areas of need identified are the need for more clinical support and more clinical staff; the need for more moral support to staff; the lack of leadership from management (despite the fact that they are nice people); the heavy workload with no relief in sight and a sense of separation between clerical staff and clinical staff, one group not knowing what is happening with the other.

 

Interviews with Staff of Related Agencies

 

Fourteen people from related agencies were interviewed. Agencies represented in the interviews included: DFYS, the local police, three people from the school district, the local hospital, the court system, the Department of Corrections, juvenile and adult probation, the “specialty clinic”, the local shelter, Kodiak NAMI, the Coast Guard and the women’s crisis and resource center.

 

Strengths of the program identified by the agencies interviewed include high praises for the school counselor program and the improvement in communication and collaboration between staff and the agencies.

 

Areas of need identified by the related agencies are: more visits and involvement in the villages; the need for outreach services; more prevention and education services to the general public; the need for employment services and increased collaboration with DVR; the need for sex offender treatment services and anger management service; the need for more in-depth counseling services in the school program and the need for a more rapid response to supporting people in the process of a Title 47.

 

High turnover of PKIMHC staff is a concern as is a concern for the agency’s lack of participation in community-wide service networking groups like the Child Abuse Task Force.

 

Administrative and Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 28 of which are completely met by PKIMHC. Those standards not fully met include:

 

1.       The governing body oversees the agency budget and ensures program quality. (Standard #7)

 

2.       The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery. (Standard #12)

 

3.       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. (Standard #13)

 

4.       The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14)

 

5.       The agency actively participates with other agencies in its community to maximize resource availability and service delivery. (Standard #17)

 

6.       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. (Standard #22)

 

Program Management

 

It has been three years MH services were transferred from the borough to Providence Health Care System. The agency has made many positive changes in that time but continues to be in a state of flux. The program is a picture of contrasts. It does some things well, such as crisis intervention, yet falls short of providing comprehensive services to people in the community. It is perceived by some to be a lifesaver and to others as non-responsive to their needs.

 

The program psychiatrist is seen as more accessible to some clients than to others in the community.  For example, a client accessing services though the specialized clinic (where the clinical director has a separate contract) reportedly gets appointments sooner then those seeking services through the mental health center. The psychiatrist appears to be hard working and responsive to clients and yet is perceived as less accessible to staff and community agencies.

 

The school program seems to be mostly successful, yet it falls short of meeting the needs of young children and seriously problematic youth.

 

While there seems to be an abundance of low cost housing as well as vacant agency-controlled housing, many residential and home-based service needs go unmet.

 

There is an across-the-board dissatisfaction with staff turnover and staff vacancies. There appears to be an abundance of clerical staff, yet there are many complaints about billing errors and about being turned over to a collection agency without warning.

 

Areas Requiring Response

 

  1. Ensure that the advisory board participates in the development and monitoring of the program budget. (Standard #7)  (Prior and current reviews)
  2. The agency needs to devise a process to actively solicit and carefully utilize consumer and family input in agency policy setting and program delivery. (Standard #12)
  3. The agency needs to systematically involve 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. (Standard #13)  (Prior and current reviews)
  4. The agency needs to develop annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14) (Prior and current reviews)
  5. Identify ways the agency can further collaborate with other community agencies including participating in community wide task forces and collaborating more on mutual projects that enhance client services. (Standard #17)
  6. The organization needs to create and utilize 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. (Standard #22)  (Prior and current reviews)
  7. There continues to be a perceived disruption in the continuity of care for transitioning from API to Kodiak.  Identify the means of providing smoother transitions for consumers as they move from different levels of care.  (Prior and current reviews)
  8. Resolve and/or address with the clients involved the refusal of the agency to provide medication management services to clients who receive services from the local psychologist.  Frustration appears to be very high regarding this issue and some explanation or action to address this frustration needs to be taken.
  9. Develop a method to inform consumers of the grievance process.

 

 

Other Recommendations

 

  1. Develop services to address the need for increased in-home support to CSP clients including increased support to clients “after hours.”
  2. Increase the range of services to CSP clients including rehabilitation/skill development services (living, vocational and social), group and peer counseling and vocational development activities.
  3. Increase support to parents of children who need specialized services such as ADHD and services to young children.
  4. Develop a wider range of services to support people in crisis such as crisis respite services, screening services and “pre-crisis” psychiatric support services.
  5. Continue to address issues related to staff turnover.
  6. Address issues that contribute to errors in billing and inequity in insurance coverage.
  7. Identify ways to make psychiatric and support services readily and rapidly available to those who are having a difficult time but are not yet in crisis.
  8. Explore the possibility of hiring a psychologist to expand and enhance clinical services.

 

 

 

Closing note

The team wishes to thank the staff of PKIMHC for their cooperation and assistance in the completion of this review. A process such as this can be very disruptive to the office environment and your hospitality was much appreciated by all of the team members.

 

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), Score sheets (averaged)

 

 

 

 

 

 

 

 

 

 

 

 

NCR 8/00