Northern Community Resources
(907) 225-6355
FAX 225-6354
Carol
Huntington, Community member
A review of the mental health (MH) services
provided by Yukon Koyukuk Mental Health Program was conducted from June 11 to
June 13, 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.
Yukon Koyukuk Mental Health Program (YKMHP)
provides outpatient mental health services to a population of 1,755 people in
the villages of Galena, Koyukuk, Kaltag, Nulato, Ruby and Huslia.
The services are: 24/7 crisis intervention
services; individual, group and family therapy; anger management training;
referrals to residential treatment and coordinated discharge planning; services
to youth in collaboration with the school system; case management;
prevention/education services, village wellness teams and suicide prevention
programming.
These services are funded in FY01 at approximately
$343,000, of which $126,000 comes from a state community mental health center
grant and $57,000 from Tanana Chiefs Conference to provide Fairbanks-based MH
services and transportation to and from Fairbanks services. There is essentially no income from client fees;
all funding is received from grants.
The Galena based staff of YKMHP includes two
Master’s level counselors (a full time director/clinician and a 0.75 FTE
itinerant clinician). There are four
full time village-based counselors. Two
other village-based counselor positions are vacant and unfunded. The Galena office also employs a
secretary/receptionist. The staff
provides clinical services to some 245 individuals each year while many others
are served by prevention, education and wellness programs.
Psychiatric services are provided in Fairbanks
through Tanana Chiefs Conference and hospital care is coordinated through the
psychiatrist on staff at Fairbanks Memorial Hospital or by Providence or
API. Medication is coordinated with the
local clinics.
The agency is governed by a six person advisory
board with one member representing each of the villages of the service
area. There are also six alternate
members to assure the presence of a quorum at each quarterly meeting. This board has recently been reactivated by
the new director. The agency is also a
department of the City of Galena and is ultimately governed by the City Council
of Galena, which acts in collaboration with the advisory board.
Description
of Process
A team of three, including a community member, a peer reviewer and a facilitator, met for three days in Galena, Alaska and interviewed 14 consumers of MH services (9 adults and 5 children). Additional interviews were conducted with 5 staff members, 2 board members and 11 staff of related service agencies for a total of 32 interviews.
These interviews were conducted in person at the
Galena office or by telephone and included interviewees from all six
villages. The interviews were from 15 to
60 minutes in duration.
In addition, the facilitator reviewed all seven
personnel files, the agency’s Policy and Procedure Manual, the annual audit,
the City of Galena’s Personnel Policy and pamphlets created by YKMHA staff.
Open
Forum
An Open Forum was held the first evening of the review at 7:00 P.M. at the offices of the Louden Village Council. The agency had advertised this opportunity to provide information to the team by repeated announcements on the regional radio station, by faxing posters to all village council offices in the region and by posting notices at key public locations in Galena.
The facilitator and the peer reviewer attended the Open Forum. No members of the public attended.
Community members were also urged to call the team directly to provide information or to state concerns. No calls were received.
Progress
Since Last Review
The last Integrated Quality Assurance Review of YKMHP was conducted in June 1999 and resulted in ten Areas Requiring Response related to seventeen standards.
Areas of Excellence
1.The new director
is to be commended for the amazing progress she has made in administrative
matters in just four months’ time while also providing intense, crisis
intervention services throughout the region.
It is clear that the director is held in high regard by one and
all. She is particularly complimented in
these interviews for her cultural sensitivity, her team approach to services
and her ability to work with the community and at the speed with which the
community is comfortable. “Diana’s approach is more of a community
approach. She will wait until people are
ready.”
2. Despite the intensity of recent casework, the staff morale is high and staff
express optimism regarding the future of MH services in this region.
3. The Village
Based Counselor (VBC) program is the oldest such system in the
Interior. The four current VBC’s include
two graduates of the Rural Human Services program at UAF with many years of
experience in their positions. One VBC
holds a Master’s degree from Harvard University and is a former clinical
supervisor of the VBC program. The
fourth VBC is about to begin the Rural Human Service certificate program in the
fall.
The team identified the following strengths under
Choice and Self Determination for those receiving MH services:
+ Consumers report that their treatment is self-directed and pursued cooperatively with their counselor.
+ Consumers
report that their treatment proceeds at the pace they set.
+ The provision of services through the Village Based Counselor program allows for locally based services in each village.
+ Services
are provided in homes as needed. “They really help me. They come to my house and I tell them what my
problems are and they help me with them.”
The team identified the following weaknesses under
Choice and Self-Determination for those receiving MH services:
- There are
currently no male counselors employed by the agency. (There are two vacant but unfunded
positions.)
- Families
report having to seek services in Fairbanks since specialized services are not
always available through YKMHA. (This is
an understaffing issue related to funding.)
- Families
report having to seek services in Fairbanks when counselors are not accessible
within the region. (This is an
understaffing issue related to funding.)
- Consumers
must travel to Fairbanks for psychiatric care.
(This is an understaffing issue related to funding.)
- Services
have been disrupted in Huslia while the VBC position was vacant. The new VBC there has not yet received an
orientation or responded to consumer needs.
(This is an understaffing issue related to funding.)
- One
consumer complains of having their counselor changed without notice and without
explanation.
- In some
instances, kinship ties argue against village residents using the services of
the VBC. (This is a cultural issue
beyond the control of the agency.)
- Staff
turnover has restricted consumer choice.
- Two
consumers complain that services have not been available during the
weekends. (This is an understaffing
issue related to funding.)
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ The
counselors offer suggestions rather than directives to consumers.
+ The counselors
fully explain everything the consumers wish to know.
+ The
counselors are described as good listeners.
+ The
counselors are described as courteous.
+ The
counselors are described as “friendly”
and welcoming.
+ A
counselor providing services to children is described as “fun and playful.”
+ The
counselors respond promptly to crises. “I was very impressed with the agency’s
response (to a crisis).”
+ The
counselors are culturally sensitive and respectful.
+ The counselors advocate for culturally appropriate services.
+ A child
consumer says, “I’d give them an A!”
+ A village based counselor
is described as “always giving out
information; her door is always open.”
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services:
- One parent
complains that her child’s severe difficulties were disregarded by the
counselor as simply a “need to grow up.”
- Two
consumers report breaches of confidentiality by counselors. One incident occurred one year ago with a
counselor who is no longer employed by YKMHP.
The other incident is a recent one involving current staff.
- The
counselors have been unable to provide prompt follow-up work following a
crisis. (This is an understaffing issue
related to funding.)
- Some consumers are unaware of their rights, especially of the right to file a grievance and the process by which to do so.
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ All
consumers report having access to medical care.
+ Local clinics coordinate medications.
The team identified the following weaknesses under
Health, Safety and Security for those receiving MH services:
- One
consumer feels that a sudden, unannounced change in counselor diminished their
sense of security.
- Last year,
consumers report, YKMHP referrals were not being accepted by other
agencies. (There has been a change in
administration since then.)
- Services
have been intermittent due to the high volume of crisis intervention and staff
turnover. (This is an understaffing
issue related to funding.)
- Staff express some confusion regarding the protocol for crisis intervention.
The team identified the following strengths under Relationships for those receiving MH services:
+ Parenting
information provided by YKMHP has aided families in dealing with their
children.
+ Consumers report improved family
relationships as a result of receiving services.
+ Relationship concerns are regularly
addressed in counseling sessions.
The team identified the following weaknesses under Relationships for those
receiving MH services:
- One
consumer reports that a sudden change in counselor resulted in a “broken relationship.”
- One parent states that, given the intermittent nature of services, her child’s relationship skills have decreased. (This is an understaffing issue related to funding.)
The team identified the following strengths under Community Participation for those receiving MH services:
+ Youngsters
receiving MH services can be maintained in the school system.
+ The communities of this region are
very accepting of people with differences.
There is no exclusion.
The team identified no weaknesses under Community Participation for those
receiving MH services.
Staff Interviews
The current director has held her position for just four months and the itinerant clinician for eighteen months. The secretary/receptionist has been employed in her position for six months. Of the four village based counselors, two are experienced in their positions and two are new to their positions.
Five of the seven staff members were interviewed. The following are the agency’s strong points and the concerns regarding the agency and its services expressed by staff.
+ Staff appreciate and benefit from the team approach to program changes and evaluation.
+ The VBC’s profit from the weekly staff conferences.
+ Staff are willing
and able to improvise when resources are scarce. “This is a bare bones
operation and we make do with what we have.”
+ Staff get along
well and provide each other with mutual support. “I’m
just happy in this job!”
- The agency has had 3 directors in 2 years.
- The counselors must maintain some social distance due to the nature of their work and at times feel isolated.
- All staff remark on the inadequacy of funding. (This is a systems issue.)
- VBC’s would profit from more visits from the Galena based clinicians. (This is an understaffing issue related to funding.)
- Staff deal with “extinct” office equipment.
- The current director was handicapped by an inadequate orientation to her position. (This is a systems issue.)
- The agency is in need of a new building as well as new office equipment.
- The agency is understaffed, increasing the stressful nature of the work and increasing the risk of professional “burnout.” (This is a systems issue.)
Interviews were held with representatives of the
school system, tribal councils, Catholic Church, TFYS, DFYS, medical providers,
TCC, court system and the regional radio station. The following are the strengths and weaknesses
of YKMHP services as seen by the staff of these related agencies.
+ The
clinicians have fine assessment and writing skills.
+ Clinical
reports are timely and effective.
+ Staff “make every effort.”
+ Medical referrals are
responded to promptly and good communication exists between YKMHP and medical
providers.
+ Recent
changes in the agency are positive and have already resulted in increased
collaboration.
+ “Diana has improved the quality of the
program. She has the community in mind
and she deserves a lot of pats on the back and I hope she gets a lot of pats on
the back.”
+ YKMHP is
seen as a collaborative agency, not a directive one. “(Diana)
wants to collaborate … instead of telling us what to do.”
+ “They make every effort to understand the
needs of (this agency).”
-
Many related agencies note the need for a
certified substance abuse counselor at YKMHP.
(This is an issue beyond the scope of this review.)
-
Agencies note the need for expanded anger
management services.
-
Agencies note that clinical staff are not
licensed and not all are certified.
-
Agencies note that YKMHP is ineffective with
young men at risk.
-
Agencies note the lack of continuing care
for those returning from residential treatment or from incarceration. (This is an understaffing issue related to
funding.)
-
Agencies feel disconnected from the village
based counselors and would like to maintain direct contact with them.
-
Agencies feel that YKMHP, like other
services in the region, are in a constant reactive mode, dealing with multiple
crises. “There are only two of them!”
(This is an understaffing issue related to funding.)
-
Agencies note the need for a separate crisis
response service or a larger staff to deal with crisis intervention in order to
prevent professional “burnout.” “We burn people out so easily.” (This is a systems issue.)
There are 34 Administrative and Personnel Standards for community mental health centers. Of these, YKMHP fully meets 24 and partially meets the remainder. It should be noted that the current director has been in her position for only four months and the results of this administrative and personnel review constitute an evaluation of the work of three different directors.
Those standards not fully met are the following:
1. Standard #12: “The agency actively solicits and
carefully utilizes consumer and family input in agency policy setting and
program delivery.” While a new policy
has been developed and the advisory board is eager to participate in this
process, it has not yet been implemented.
(Prior and current reviews)
2. 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 recent agency planning exercise involved
staff and community members as represented by the advisory board. The current director is developing a policy
for the involvement of consumers as well but it has not yet been
implemented. (Prior and current reviews)
3. Standard #14 “The agency develops goals and
objectives in response to consumer, community and self-evaluation
activities.” The recent goal setting
work included the staff and advisory board members. The current director is developing a policy
for the surveying of consumer opinion and incorporating the results into the
planning process. The policy has not yet
been implemented. (Prior and current
reviews)
4. Standard
#17 “The agency actively participates
with other agencies in its community to maximize resource availability and
service delivery.” The interviews
indicated areas of disconnection between YKMHP and other agencies.
5. 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.”
Only one of the seven personnel files documented reference checks. No background or criminal checks have been done
on current employees. (Prior and current
reviews)
6. 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 new orientation plan is written and does
include policies and procedures, the vision/mission statement and ethical
issues including confidentiality and reporting requirements. Cultural awareness is a condition of
employment, especially of the village-based counselors, but is not included in
the written orientation plan. The
orientation does not include work-related hazards. (Prior and current reviews)
7. Standard
#26 “The agency has policies and implements procedures to facilitate the
development of non-paid relationships between consumers and other community
members.” There is no policy specific to
this issue. The procedures are in place
as part of good clinical practice and simply need to be written in order to
meet this standard.
8. Standard
#29 “A staff development plan is written annually for each professional and
paraprofessional staff person.” Only 2
personnel files include a written annual development plan. (Prior and current reviews)
9.Standard #31 “The performance appraisal system
adheres to reasonably established timelines.” The City’s personnel policy
establishes a timeline for evaluations.
Only two personnel files included an evaluation although four employees
have been working long enough to have been evaluated. (Prior and current reviews)
10. Standard
#32 “The performance appraisal system establishes goals and objectives for the
period of appraisal.” Only 2 personnel
files include a written set of goals and objectives for the upcoming period of
appraisal. (Prior and current reviews)
Program
Management
The new director, with just four months of tenure in her position and no prior experience in Bush Alaska, has worked quickly to review, revise and create policies in order to comply with the standards. This work is incomplete and understandably so, as the director has also been providing direct services including crisis intervention and a caseload increased by the recent absence of the itinerant clinician and vacancies in the village-based counselor positions.
The director has a team approach both to treatment
and to program and policy development.
Her work with the newly revived advisory board is worthy of praise as is
the collaborative work on the vision and mission statement. Those policies initiated by her reflect
consumer-centered values and language.
The director has plans for full compliance with the
standards and for the active and effective participation of the advisory
board. She also has established a fine
working relationship with the City.
The program is jeopardized simply by the demands
placed on the staff in terms of intensity of services, the high degree of
crisis work, the complexity of the case load and the expanse of the service
area. The continued existence of the
village-based counselor program is an invaluable resource.
The director has applied for increased funding from
a number of sources in order to create a clinical supervisor position, which
would allow her to concentrate on her case load and on administrative matters.
This program is managed with respect and
sensitivity for the Native culture as it is evidenced in each village and the
traditional village resources are integrated into the program in an appropriate
manner, including the elders and the village councils. The director is described as especially sensitive
to the communities and their culture.
Board members are particularly optimistic and
enthusiastic regarding their task.
Several board members are experienced in human services and half are
consumers or family members of consumers.
Board members represent each village and serve as liaison between the
agency and the village. They note their
good working relationship with the City and their ability to work toward
consensus as a board. “I have a lot of faith in this board.”
The team noted four areas of concern regarding the
management of the agency.
-
Many people in the villages are unaware of
the professional nature of the VBCs’ work, unaware of their training and
expertise and unaware of their credentials.
-
Clinicians are not licensed which may
complicate interaction with other agencies’ legal or professional requirements.
-
The agency lacks a plan for the recruitment,
care and retention of staff.
-
Board members are unclear regarding their
role in the selection and evaluation of the director.
Areas Requiring Response
1. Develop a specific plan to serve at risk young men. Consider the ability to serve this population
when selecting staff.
2. Develop a plan to provide on-site psychiatric services in order to assure quality services and increase services to those with serious mental illnesses or serious emotional disturbances.
3. Participate in an interagency effort to bring Critical Incident Stress Debriefing training to the region.
4. Participate in an interagency effort to provide culturally appropriate grief work in each community.
5. Further inform consumers regarding their rights including posting the Client Bill of Rights, reviewing the rights regularly with each consumer, including a review of consumer rights in the newsletter or other publications, etc.
6. Implement the plan to survey consumer satisfaction and use this information in agency policy setting and program delivery. Standard #12 (Prior and current reviews)
7. Implement the plan to survey consumer satisfaction and use this information in the planning and delivery of services. Standard #13 (Prior and current reviews)
8. Implement the plan to survey consumer satisfaction and use this information in setting annual goals and objectives. Standard #14 (Prior and current reviews)
9. Develop and implement a plan to increase collaboration with other human service agencies in the region. Standard #17
10. Conduct and document background and criminal checks for employees. Standard #24 (Prior and current reviews)
11. Include in the employee orientation and training cultural diversity issues and information on work related hazards. Standard #25 (Prior and current reviews)
12. Develop a policy to reflect the agency’s work toward fuller inclusion of consumers in their communities. Standard #26
13. Include a staff development plan in each staff evaluation. Standard #29 (Prior and current reviews)
14. Maintain the timelines for staff evaluation established in the City’s personnel policies. Standard #31 (Prior and current reviews)
15. Include goals and objectives for the coming period of appraisal in each staff evaluation. Standard #32 (Prior and current reviews)
Other
Recommendations
1. Encourage licensure and/or certification of all
staff.
2. Develop dual diagnosis treatment for those
having both MH and substance abuse needs.
3. Participate in an interagency effort to develop
a plan to recruit and retain human service staff.
4. Educate the communities regarding the training
and credentials of staff, especially of the village based counselors.
5. Continue to provide orientation and training to
the advisory board.
Closing Note
The team wishes to thank the staff of YKMHP for
their excellent pre-review preparation, their flexibility, hospitality and
openness. This review process,
complicated by concurrent DMHDD QA file reviews, Medicaid training and medical
billing training, was no doubt a trial to this hardworking staff but they were
gracious, uncomplaining and hospitable to all.
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 10/00