Northern Community Resources
Candy
Troupe, Community Member
A review of the Mental Health (MH) services
provided by Tok Area Counseling Center (TACC) was conducted from
This report is the summation of the impressions of a community team after interviewing consumers, staff members, community members and staff of other agencies. It also includes a limited administrative review. It does not represent or reflect a comprehensive review of this agency. The community team has collaborated on this report and the findings represent their consensus.
TACC is a private, non-profit corporation that has been providing MH services in this area of the state since 1979. The service area extends to 20,000 square miles and includes Tok and 11 additional villages, some of which are only accessible by air. Some services are also provided in Mentasta, outside of the service area.
The population center of the service area is Tok. The population of some 2400 year round residents is approximately one-third Alaska Native people and approximately one-third of the total population is under the age of eighteen. Tourists and transients through the area number from 100,000 to 150,000 each year.
TACC provides out patient services including 24 hr/
7 day a week psychiatric emergency services, core services, services to
chronically mentally ill adults (including outreach, case finding, case
management, evaluation, treatment, medication management), to severely
emotionally disturbed youth (assessment, individual/family/group psychotherapy
and medical/nursing services) as well as general mental health services.
Services are provided by two Master’s level clinicians
and a contract psychiatrist who travels to Tok every six weeks for a two-day
visit each time. The psychiatrist
provides assessments and medication management as well as case consultation
when off site. Some 150 individuals are
served each year, with one third of the caseload being Alaska Native people.
More than 95% of the agency’s funding is through a
state DMHDD grant. Additional funds are
received through Medicaid, a small amount from other third party payers and
consumers’ self-payment of fees. TACC also has a small contract with Head
Start.
The agency is governed by a seven member executive
board. Of the five seats that are
currently filled, two board members are current or past consumers and one is a
family member of a consumer. One board
member represents an outlying village and the two empty seats are being
reserved for members from additional villages and the board is recruiting those
members.
Description
of Process
The team of four met for three days in
The interviews were conducted with 8 adult
consumers of services, 4 consumers under the age of eighteen, 4 board members,
3 staff members and 25 related agency staff.
One person volunteered information by telephone as well. Interviews lasted from
Related agency interviews were conducted with staff
of the school district, DFYS, AYI team members, eight village professionals,
local substance abuse counselors, Head Start staff, the local physician, the
psychiatrist at Fairbanks Memorial Hospital, the magistrate, Alaska State
Troopers, EMT’s, UAF Tok Campus representative and the Public Health nurse.
Consumer interviews included four consumers from
outlying areas and seven interviews with related agency staff based in outlying
areas.
Open
Forum
An Open Forum was held the evening of April twenty-fifth to provide an opportunity for those not selected for interviews to provide the team with their perceptions of TACC's services and to gather information regarding the program from other interested community members.
The agency advertised this opportunity with a detailed announcement in the biweekly regional newspaper and with posters. The posters were visible in Tok and had been part of the agency’s monthly mailing to outlying areas.
No one attended the Open Forum, but one consumer from an
outlying area did contact the team by telephone in lieu of attending.
Progress
Since Last Review
The last Integrated Quality Assurance Review of TAMHC was conducted in June, 1999 and resulted in six areas requiring response.
Areas of Excellence
1. TACC has a clear commitment to outreach and has developed excellent relationships between the TACC team and many of the communities in the service area.
2. Without exception, TACC staff treat consumers as fellow human beings, worthy neighbors and valued members of the community.
3. Both consumers and related agency professionals note the empathetic connection between TACC staff and those they serve.
4. TACC staff go above and beyond duty in providing 24 hour a day/seven day a week emergency services, coordinating with the DMHDD regional coordinator and the hospital and personally transporting consumers to Fairbanks when necessary.
5. The composition of the governing board includes a variety of strengths, interests, backgrounds and tenure including having two consumers and one family member of a consumer on the five-person board.
6. TACC provides regular psychiatric services, fine medication education and management in collaboration with local medical personnel and has arranged access to local dispensary services.
The team identified the following strengths under
Choice and Self Determination for those receiving MH services:
+ Clinical
staff and consumers collaborate on the development and revision of treatment
plans.
+ Consumers
may choose to be medicated or not and may choose among appropriate medications.
+
Disagreements between clinician and consumer are respected and resolved
to the satisfaction of the consumer. “We work together on this. I can disagree or refuse and we work it out.”
-- consumer
+ Despite
being a small center, consumers have the choice of a male or a female
therapist.
+ Clinicians
are flexible as to where services are provided including providing services in
the home.
+ TACC’s
consumer-centered philosophy is pervasive in consumers’ discussion of choice
and self-determination.
+ Youthful
consumers have a choice as to when and to what extent to include a parent in
their therapy.
+ TACC
provides individual, couple and family therapy.
+ Consumers
note that “No one is turned away (from TACC)”.
+ TACC
discusses optional sites for voluntary hospitalization with the consumer.
+ Local professionals
note that the two clinicians at TACC have different strengths and different
styles and thus provide a healthy balance and a choice for consumers.
+ “They leave it up to you: they don’t try to
push you or steer.” -- consumer
The team identified the following weaknesses under
Choice and Self-Determination for those receiving MH services:
- Group
therapy or group skill building experiences are not provided.
- Consumers’
options are limited by the limited transportation available outside of the
service area. (This is not the
responsibility solely of the agency.)
- The lack
of local crisis beds results in some consumers being detained by the
Troopers. (This is not the
responsibility solely of the agency.)
- One
village professional states that some appointments have not been kept and no
follow-up is provided in those cases.
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ Despite
the small town settings for TACC’s services, not one concern is expressed
regarding confidentiality.
+ “I can come to Jon about anything because I
feel I won’t be judged.” -- consumer
+ “(The
clinician) understands exactly where I’m coming from.” –consumer
+ “They listen good.” –consumer
+ “(Seeing the clinician) is more like talking
to a friend.” – consumer
+ “They accept me and treat me as… a human
being, not an invalid.” – consumer
+ “I can call
Susan…and she’s there. She’s somebody I
can depend on.” – consumer
+ “I’ve never
had a problem with calling (the clinicians) at the office or at their
home. They asked me to call anytime I
needed to talk.” -- consumer
+
“If they have an agenda here it’s only to get someone stabilized and on the
road to recovery.” – consumer
+ “There’s no
tags on you when you walk in this door.
You’re treated with respect and dignity.” –consumer
+ Several
people note the important role of the Administrative Assistant whom they
describe as friendly, willing to listen and helpful.
+ Consumers
repeatedly describe the staff as “dependable.”
+ Consumers appreciate that
when clinicians transport consumers to Fairbanks for care, they remain with the
consumers during the entire process. “(The clinician) drove me up to Fairbanks
and was with me every step of the way. I
am blessed to have Jon’s help.”
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services:
- A consumer
complains that TACC could not provide a referral to adequate legal services. (The agency responds that they did provide
information to a consumer on Alaska Legal Services in Fairbanks.)
- One
village professional stated that village appointments were not kept and there
was no follow-up regarding those missed appointments.
- The lack
of crisis beds in the region sometimes results in consumers being detained by
the Troopers. (This is not the
responsibility solely of the agency.)
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ TACC’s
psychiatrist carefully discusses the appropriateness of medication with
consumers.
+ Consumers are provided with good
education regarding their medication.
+ The agency has access to a local
dispensary as a result of the collaboration between a local physician and the
agency’s psychiatrist.
+ Staff have
successfully applied for a mini-grant to provide dental and vision care to a
consumer.
+ Staff have
provided information on Denali Kid Care for a consumer.
+ The agency
provides overnight accommodations at a local motel for consumers for whom this
is appropriate.
+ The agency
has successfully provided medication management services to transient consumers
when their medical history is available.
+ The agency
aids in placing women at the local safe house, WICCA in Fairbanks or other safe
location as needed.
+ Staff
provide emergency transport to Fairbanks when appropriate.
+ Clinical
staff are easily accessible after hours as they use both a cell phone and a
radio in order to stay in contact.
+ The
experience of the psychiatrist at Fairbanks Memorial Hospital has been very
positive and no TACC consumer to date has had to return for a subsequent
hospitalization at FMH.
The team identified the following weaknesses under
Health, Safety and Security for those receiving MH services:
- Consumers
have limited aid with transportation to non-psychiatric medical appointments
outside of the service area. (This is not the responsibility solely of the
agency.)
- The lack
of local crisis beds results in some consumers being detained by the
Troopers. (This is not the
responsibility solely of the agency.)
- Crisis
response and transport is not always available given the long distance
clinicians must travel to provide these services.
- One
village professional notes that some appointments have not been kept and that
there is no follow-up on these appointments.
The team identified the following strengths under Relationships for those receiving MH services:
+ The
agency’s contractual arrangement with Head Start aids families in relating to
their children.
+ “(The
clinician) helps my mom understand what’s going on with me and that’s a really
big help.” --- consumer
+ Consumers note that Jon is adept at separating personal and professional
relationships.
+ The agency
provides family and couples therapy.
+
Relationships are simply assumed to be an integral part of therapy by
the clinicians.
+ Jon has
provided local classes on parenting.
The team identified no weaknesses under Relationships for those receiving MH
services.
The team identified the following strengths under Community Participation for those receiving MH services:
+ Despite
the intensity of their services, children can be maintained in the public
school system.
+ Children who are consumers of service
do not experience stigma attached to their use of MH services.
+ By and large, the communities of the
service area are open and accepting of people who experience personal
difficulties and differences.
The team identified the following weaknesses under Community Participation for
those receiving MH services:
- Some
consumers are extremely isolated and would benefit from a focus on their
support network or on how to go about building a support network.
- There is a
lack of group therapy or group social skills training experiences.
Staff Interviews
+Staff consider themselves to be a team and are happy with the functioning of that team and with their work setting.
+Staff clearly operate from a consumer-centered
perspective. One clinician states "I’m not the expert to fix (consumers). I empower them. I tell them ‘You’re the pilot and I’m the
copilot. You’re in control.’”
While the staff had no complaints, the team feels that the agency’s salary structure is inadequate, especially in light of the quality and quantity of services being provided. Those low salaries may make retention of staff difficult. The team further feels that the staff would be supported by a more extensive orientation, regular written evaluations, increased office space and the use of a reliable four wheel drive vehicle.
+ Several professionals note that the agency provides an immediate response to local emergency referrals.
+ Related
agency staff report that TACC maintains absolute confidentiality and that
consumer rights are respected.
+ TACC’s involvement
with Head Start is highly valued.
+
Professionals note the clinical staff’s skill in diagnosis and in “finding the roots of the problem.”
+ School staff value the close collaboration
with TACC in those cases where a release of information has been provided.
+ All
related agency personnel interviewed state that services have improved markedly
since the current staff have been in place.
+ Particular
appreciation is expressed by professionals in Tetlin and in Dot Lake and by
those impacted by the recent emergency response in Eagle.
+ Related
agency staff repeatedly refer to the three staff members of TACC as a “team.”
“This team has been nothing but good.”
“They’re the team we’ve always wanted.”
+ TACC is
described as a “great asset” to law
enforcement.
- Emergency Medical
Technicians express discomfort with their role in the emergency care of MH
consumers. “I’d like to see a contract on paper for transporting patients. It
would probably tie us in more.”
- Local Troopers also express discomfort with their role in detaining MH consumers. (The agency responds that for more than one year they have been actively but unsuccessfully involved in attempting to establish a Memorandum of Agreement with the Troopers. In addition, the agency has had a meeting with the local Troopers and reviewed the State’s civil procedure for MH commitments.)
- One
professional was negatively impacted by TACC’s inability to attend a key
meeting in spite of attempts to schedule the meeting at TACC’s convenience.
- Some
professionals are concerned that they are not receiving prompt return of phone
calls.
- The court
system needs follow-up from TACC regarding the non-compliance of those referred
or the closure of those cases.
- One
village professional is concerned about missed appointments and no follow-up on
those appointments.
- One
village requests village-based services and a team approach with their village
professionals.
There are 34 Administrative and Personnel Standards for Community Mental Health Centers. TACC fully meets 21 of those standards and partially meets an additional 6 standards. The partially or unmet standards are:
1. Standard #10 “The agency maintains policies and procedures for preventing and correcting conflicts of interest.” Neither the personnel policies nor the governing board bylaws contain a conflict of interest policy.
2. Standard #12 “The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery.” At present the agency does not utilize a consumer satisfaction survey, although models of surveys have been examined and are being discussed for future implementation.
3. 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.” As stated above, no consumer satisfaction survey is currently in use. Staff informally discuss planning and evaluation and the board is currently devoting part of their meeting time to planning. An attempt has been made to gather community opinion but to date there has been no community response to this effort.
4. Standard #20 “The agency implements and maintains a system for review and revision of all job descriptions.” There is no specific policy regarding the review and revision of job descriptions. Job descriptions are contained in the agency’s Policy and Procedure Manual and the Manual is, by policy, to be reviewed annually by the Board. However, the job descriptions contained in the Manual are dated 1992 and the last documented review of the Manual by the Board is dated 1999.
5. Standard #23 “The agency’s personnel system complies with all applicable laws, statutes, regulations and equal employment opportunity mandates.” See Standards #24, 25, 28, 29,31,32,33
6. 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.” All three of the personnel files were reviewed. None documented a background or criminal check and no policy states the need for this. One file documented a reference check. The team received verbal verification that reference checks had been completed for the other two employees but those checks were not documented in the personnel file.
7. 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 does have a written orientation plan for employees that includes a review of the Policy and Procedure Manual, mission statement and confidentiality. Reporting requirements, while mandated by the credentials of the clinicians, are not specifically reviewed in the orientation nor are cultural diversity nor work related hazards.
8. Standard #26 “The agency has policies and implements procedures to facilitate the development of non-paid relationships between consumers and other community members.” The agency does encourage community involvement for consumers and this goal may be addressed in treatment planning, however no policy exists that explains the procedures used.
9. Standard #28 “The agency evaluation system provides performance appraisal and feedback to the employee and an opportunity for employee feedback to the agency.” The evaluation form does contain a section entitled “Additional Comments” but it is not clear whether employees are encouraged to use this section for their response. The form does include a place for the employee’s signature.
10. Standard #29 “A staff development plan is written annually for each professional and paraprofessional staff person.” The evaluation form includes a section for “comments and goals” following each area of performance that is evaluated. However, the one completed evaluation did not include any goals or plan for development.
11. Standard #31 “The performance appraisal system adheres to reasonably established timelines.” The personnel policy provides for an evaluation to be completed upon completion of the probationary period and at each annual anniversary of hiring. The Director, who has been in place since 9/99 has been evaluated by the Board once. The clinician that has been in place since 12/99 has not been evaluated in writing nor has the administrative assistant who has held that position since 4/00.
12. Standard #32 “The performance appraisal system establishes goals and objectives for the period of appraisal.” Although the evaluation form does include a section in which to state goals, the one written evaluation form that had been completed did not include goals for the coming period.
13. Standard #33 “The agency maintains written personnel policies for disciplinary action.” While there is a written policy for dismissal, there is not a policy for disciplinary action.
Program Management
The current director assumed his post in late September, 1999 and the clinician joined the agency staff three months later. The administrative assistant has held that position for one year. The response of the communities has been largely favorable and all agree that the current staff have improved the quality and availability of services.
The team notes the following management issues:
+ The governing board is actively involved in agency planning.
+ TACC has been inventive in reducing the cost of transportation to villages by sharing flights with other professionals.
+ TACC’s clinicians have vastly increased the after hours availability of services.
+ TACC is described as a “steady presence” in Tok, Northway and Tetlin.
+ TACC’s collaboration with Head Start is a fine prevention effort.
+ Local communities respect clinical services to the extent that they are requesting more frequent visits and a variety of services including consultation, training, outreach and direct care.
+ The governing board is supportive and proud of their TACC team.
+ Positive interest is expressed by village professionals in participating on the governing board.
- The governing board has difficulty maintaining a monthly meeting schedule and has some difficulty establishing a quorum.
- Some members of the governing board seek training in the oversight of the agency’s budget. The team feels that the board deserves thorough board training, including financial management issues.
- The size and informality of the agency may diminish the level of documentation and policy setting. These are good business practices, however, and need to be addressed.
- The team notes that this hard working staff is endangering itself by the intensity of services provided and the geographical expanse in which they must work. A high case load, the rising expectations of all sectors of the service area and their own obvious skill and sincerity put them at risk of promising more than they can consistently deliver. These issues combined with the limited salaries and benefits cause a retention risk or a risk of professional exhaustion.
- There are inadequate resources to support this excellent program.
1. Establish
a village presence with consistent services on a reasonable, sustainable
schedule.
2. Consult
with Tanacross about their desire for village-based services.
3. Develop
options for the care of emergencies to decrease the use of detention by
Troopers and decrease the need for clinicians to transport consumers over long
distances.
4. Provide
board training.
5. Develop
both a staff and a board policy to deal with conflicts of interest. Standard #10
6. Develop
an instrument to use as a consumer satisfaction survey and a policy by which
the results of that survey are utilized in policy setting and program
delivery. Standard #12
7. Utilize
the results of the consumer satisfaction survey as well as staff and community
opinions in a formal effort of annual agency planning and evaluation of
programs. Standard #13 (Prior and current reviews)
8. Implement
and maintain a system for review and revision of all job descriptions. Standard #20
9. Complete
the necessary personnel policies (see below) in order to meet all applicable
laws, statutes and regulations. Standard
#23
10.
Institute a policy by which all direct care providers undergo a
background and criminal check and document follow-up on required
references. Standard #24
11. Include
in the written employee orientation mandatory reporting requirements, cultural
diversity issues and potential work related hazards. Standard #25
12.
Formalize a policy to reflect your efforts to assist consumers with
social interactions in the community.
Standard #26
13. Clarify
the employee evaluation form to provide space for the employee’s response to
the evaluation. Standard #28
14. Develop
and institute a policy for the inclusion of a staff development plan in the
annual evaluation. Standard #29
15.
Institute the existing policy of regular employee evaluations and
document those evaluations in the personnel files. Standard #31
16. Develop
goals and objectives for the subsequent evaluation period in each employee
evaluation. Standard #32
17. Develop
a personnel policy for disciplinary action. Standard #33 (Prior and current reviews)
Other
Recommendations
1. Seek funding for a four-wheel drive vehicle.
2. Consider providing group or community-wide interventions for skill building and other training opportunities.
3. Develop a plan for staff retention.
4. Enhance case management with the use of a full directory of resources and referral options. Statewide directories can be purchased.
5. Attempt to increase the pool of on-call personnel to prevent exhaustion.
6. Consider cross training with EMT and law enforcement personnel.
Closing Note
TACC’s Administrative Assistant did an
exceptionally fine job of scheduling the interviews for this review and in
preparing the written materials for review as well. Her fine work assured that the site review
process would proceed smoothly and made the team’s task easier. Thank you, Joyce.
The team appreciates the intrusion that a review of
this sort causes and thanks the staff and board members of TACC for their
cooperation and grace under pressure.
The final draft of this report will be sent to
Northern Community Resources for review. You will receive the final report
within approximately thirty days, including a Plan of Action form, listing the
Areas Requiring Response. You will then
have an additional thirty days to complete the Plan of Action. The directions
on how to proceed from there will be included in a cover letter you will
receive with the final report and Plan of Action form.
Once NCR has reviewed the completed Plan of Action,
it will be sent to the DMHDD Quality Assurance Section. The QA Section will then contact you to
develop collaboratively a plan for change.
Attachments: Administrative and Personnel Checklist,
Interview Form for Staff of Related Agencies (tallied), Report Cards (averaged)
NCR 8/00