April
12, 2000 through April 14, 2000
McGrath,
Alaska
A review of the Mental Health (MH) services
provided by 4Rivers Counseling Services was conducted from April twelfth
through fourteenth, 2000, using the Integrated Quality Assurance Review
process. DMHDD Quality Assurance staff conducted the Clinical Record Review during
this time and provided the agency with a separate report of those findings.
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.
The McGrath-Anvik Educational and Mental Health Association, founded in 1977, provides outpatient mental health and substance abuse treatment under the name 4Rivers Counseling Services. 4Rivers’ service area is 48,000 square miles and includes the villages of Anvik, Grayling, Holy Cross, McGrath, Nikolai, Shageluk, Takotna and Telida and may be extended to include Lake Minchumina and Lime Village. This area is divided between the Yukon villages and those on the Kuskokwim River system; the Beaver Mountains bisect the service area. There is no road system and providers must fly to villages in order to provide services. The population of 2,500 is 73% Alaska Native.
Outpatient services, crisis intervention,
aftercare, education and prevention, consultation and outreach efforts in both
mental health and substance abuse are accomplished by a full time Master’s
level MH clinician, a full time certified substance abuse counselor and the
Director, a Master’s level professional, who provides both MH and substance
abuse treatment. The professional
staff, all relatively new to the agency, are aided by an administrative
assistant with 11 years of service. A
first year Rural Human Services (RHS) student provides services in Anvik and
the agency is currently recruiting for a similar position in Shageluk.
The program philosophy states that 4Rivers is
Jungian with a spiritual focus and provides substance abuse treatment using the
AA 12 Step program.
The agency is governed by an executive board having
10 seats, each representing a village in the service area. Nine seats are currently occupied and of
those nine members, 2 are consumers and 5 are family members of consumers.
4Rivers is funded by a mental health grant, a
substance abuse grant and funding for the education of the Anvik and Shageluk
village counselor positions. The
current budget for MH and substance
abuse services is $332,800 with the MH grant representing 52% of that funding. Most consumers have Indian Health Service
coverage which is provided directly to Tanana Chiefs Conference. While some consumers have private health
insurance, Medicaid or may be Medicaid eligible, there is minimal billing.
The current number of active, open MH cases is 32;
the active, open substance abuse cases are approximately one half of that
number.
4Rivers is actively collaborating with the Iditarod
School District, Yukon Kuskokwim Health Corporation, Kuskokwim Native
Association,Tanana Chiefs Conference, the McGrath clinic and with the
magistrate and has memoranda of agreement with urban-based treatment centers.
Some consumers describe the services at 4Rivers as
especially effective:
-
“This
is one of the best therapeutic experiences I’ve had.”
-
“What
do I think of services? It’s worked.”
-
(4Rivers
is) outstanding!”
-
“I
highly recommend them.”
-
“My
life feels different, better.”
-
“At
first it’s scary and hard but, once that is out of the way, it’s great!”
The team of three, consisting of a peer reviewer, a community member and a facilitator, interviewed 25 persons during the three-day period of the review. All consumers interviewed were from the random list generated by DMHDD QA staff with the exception of one consumer who volunteered for an interview. A DMHDD QA staff member conducted a clinical file review for two days during this same period. That report will be provided separately.
Interviews were held with 8 consumers, 11 related
service providers, 2 board members and all 4 staff members.
An Open Forum was held the evening of Wednesday,
April twelfth, in the Board Room of the Iditarod Area School District
Offices. The agency advertised this
opportunity to speak with the team over KSKO Radio at least once per day
beginning the sixth of April and hourly on Wednesday, the twelfth. No one attended.
This is the first Integrated Quality Assurance
Review of 4Rivers Counseling Services and so there is no prior review with
which to compare findings.
1. 4Rivers’ creative and energetic approach to services for children and teens including their involvement with area schools is well thought of by most informants and an efficient means of community intervention.
2. 4Rivers has undergone major changes in its history. All informants noted a marked improvement in services since the advent of the current Director and appreciate his ability to attract other professionals, fully staffing the center.
The team identified the following strengths under
Choice and Self-Determination for those receiving MH services from 4Rivers:
+ Most
consumers note their participation in treatment planning.
“I determine what steps I take and how
big they should be.”
+ Client
goals and dreams are honored and included in treatment.
“They left it completely up to me.”
+ The
option of art therapy is appreciated and valued.
“(Art therapy) is really fun. And you can see right there what your issues
are.”
+ The
presence of a young counselor is valued by students who feel she is in tune
with them.
“She’s young like us and that makes it
easier.”
+ The
availability of both male and female counselors provides an important choice.
“I would really have an issue with a male
counselor.”
+ The
diversity of therapeutic styles provides additional choices.
+ The
inclusion of the spiritual dimension of healing, stated in the program
philosophy, is valued
by some
consumers.
“The spiritual content is important.”
+ The
staff’s willingness to do home visits offers further choice and, for some, a
more acceptable
means
of access.
+ The
agency’s inclusion of RHS trained providers provides further choice.
+ The
sliding fee scale and lack of profit motive encourages the seeking of services.
The team identified the following weaknesses under
Choice and Self-Determination for those receiving MH services from 4Rivers:
-
One consumer wants an alternate, more private place
to meet in the village.
-
Some concern is voiced about the Western approach
to counseling services not being appropriate in rural Alaska.
-
Some concern is noted about the directness and
confrontational nature of some therapeutic interventions.
-
Some concern is stated regarding the Director’s
religious background as implying a value system that might be exclusionary.
The team identified the following strengths under
Dignity, Respect and Rights for those receiving MH services from 4Rivers:
+ One
consumer cites the accommodations made to meet her special needs as respectful
of her
feelings.
“I got a lot of respect.”
+ Most
consumers feel that they are respected by staff.
“They treated me very well.”
“(I am) always welcome.”
“They respected me and my culture.”
+ All
consumers are informed of their rights.
“They told me (about client rights) right
up front.”
+ Client
rights are posted in the waiting area as is the grievance procedure.
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services from 4Rivers:
-
There is inadequate sound protection between
offices; conversations can be overheard.
-
Some people find direct, confrontational
therapeutic techniques to be rude or abrasive.
-
Some consumers are described as reluctant to return
for services since they are “(made) to
feel so small” or because of “how bad (the provider) made me feel.”
The team identified the following strengths under
Health, Safety and Security for those receiving MH services from 4Rivers:
+ The
agency coordinates medical needs and medication with the health clinics.
+ Most
consumers state that their health and safety needs are met.
+ The
agency posts emergency contact lists in every village.
+ The
agency provides a crisis line.
+ The
agency is discussing with the magistrate the possibility of a “drug court” to
allow treatment
as an
option to jail time.
+ The
RHS-trained village counselor in Anvik can provide on-site services and another
village
position has been funded.
The team identified the following weaknesses under
Health, Safety and Security for those receiving MH services from 4Rivers:
-
The agency is physically removed from the clinic,
VPSO, school, school district offices, TFYS and DFYS offices, making rapid
referrals more problematic.
-
Protocols for an interagency crisis response and
suicide response are needed.
-
Area emergency responders do not have access to
Critical Incident Stress Debriefing.
-
One family member of a consumer would like
aftercare services for youth once treatment is terminated: informal contact or
support.
The team identified the following strengths under
Relationships for those receiving MH services from 4Rivers:
+ Staff
are willing to include significant others in treatment as appropriate.
“Family and other important people are
consistently involved (in my treatment) as I request it.”
+ Family
relationships have been strengthened by interventions with students.
“(Our family life) is greatly improved. (The MH clinician) helped (the consumer)
mature and
realize that he needed to take
responsibility for his actions.”
+ One
consumer notes that the agency has aided her to connect with peer support as
well as
therapeutic services.
+
Consumers note their ability to relate to the MH clinician.
“(She) has a young attitude and is very good
at working with young people.”
+ Regular
mailings by the MH clinician to her clients maintain the therapeutic
relationship despite
distances and travel limitations.
The team did not identify any weaknesses in this
area.
The team identified the following strengths under
Community Participation for those receiving MH services from 4Rivers:
+ The
provision of support groups aids consumers’ participation in the community.
+ The
communities are generally accepting of differences.
The team did not identify any weaknesses in this
area.
The facilitator reviewed 6 client files to gauge the involvement of consumers in their treatment planning and the information provided consumers regarding their rights. Of those, 3 files had current plans signed by the consumer, 2 were in need of treatment plan reviews (and that need was noted in the file by the Director), 1 included an undated and unsigned treatment plan. All 6 files contained information regarding consumer rights and the consumer had signed those documents.
A comprehensive file review was conducted by DMHDD
QA staff and the results of that review will be contained in a separate report.
Staff
Interviews
“I hope they stay!”
– a consumer
The team is impressed with the positive energy and enthusiasm of the staff. All are full of ideas, plans and the drive to improve and expand services. The staff are supported by good collaboration with other agencies, especially with the health clinic and YKHC Behavioral Health.
The staff note some limitations that are difficult
to overcome: 1) the configuration of the service area includes two separate
regions, three Alaska Native groups and several dialects; 2) the cost of and
decreasing options for transportation to the villages and the time involved in
travel including weather delays; 3) the need for clinical supervision including
psychiatric consultations; 4) the lack of support for staff including the need
for counselor wellness options; 5) the limitations on salary caused by budget
constraints; 6) the need to overcome the agency’s “unfortunate history”; 7) the
cost of continuing education opportunities.
Collateral
Agency Interviews
The responses of related agencies are mixed. Positive or supportive comments are:
+ the
inclusion of elders in programs for youth is respectful and appropriate
+
confidentiality is respected
+
salaries for staff should be raised
+ work
with the schools is productive and valued
“(The MH clinician) is very well liked and respected and often
requested (to provide services).”
+
collaboration has increased with the current staff
“They have done a good job of identifying key organizations to
network with.”
+ staff
travel is posted in community centers
“(The staff is) really making an effort.”
+
referrals have yielded “only
positive results.”
“They do a really good job where people have been willing.”
The concerns of other agencies’ staff were:
-
the need to do “whole
community work” rather than individual interventions
-
lack of awareness of the services offered, the cost
of services and “zero contact” with
some staff
-
that staff “are
spread too thin.”
-
that rural Alaskans and especially Alaska Natives
would respond better to a less direct, less confrontational style
-
that the chronically mentally ill are not being
served
-
an “unwillingness
(of 4Rivers staff) to work with differences.”
-
There is a concern regarding potential role
confusion or role conflict for a clergy-therapist in a public setting.
Administrative
and Personnel Narrative
Of the thirty-four standards for Mental Health programs, 4Rivers completely met twenty-nine. Those standards not met or not fully met are:
1. Standard #8 “Governing body meetings are open to the public.” While not closed, board meetings are not posted or advertised; board meetings by teleconference do not include a call-in number for interested members of the public.
2.
Standard #10
“The agency maintains policies and procedures for preventing and
correcting conflicts of interest.”
While the Board’s Code of Ethics includes prohibitions against personal
gain and the improper use of influence, the Policy and Procedure Manual of the
agency itself does not.
3.
Standard #11
“All facilities and programs operated by the agency provide equal access
to all individuals.” The program is
seeking funding for phase two of their ADA compliance effort. A ramp has been constructed although
modifications are needed. Phase two
will, if funded, allow for handicapped access to rest rooms, improve the ramp
and include signage in Braille. The
agency has made every effort to comply with ADA requirements within their
financial limitations.
4.
Standard #12
“The agency actively solicits and carefully utilizes consumer and family
input in agency policy setting and program delivery.” Although an excellent
needs assessment was completed in January, 1999, the program currently does not
actively solicit consumer and family opinion of services on a continual
basis. An instrument has been
developed, however, and is to be initiated in the near future. The needs assessment, scheduled every two
years, does provide for the systematic collection of data from various sources
and was used in 1999 for planning, evaluative and goal setting purposes, thus
meeting Standards #13 and #14.
5.
Standard #29 “A staff development plan is written
annually for each professional and paraprofessional staff person.” While the Director has completed these
evaluations, the Director himself has not been evaluated by the Board since his
hiring some two years ago nor has a staff development plan been written for
him. This is a Board responsibility.
Program
Management
4Rivers’ FY 99 needs assessment pointed out the following needs: increased village travel or village-based services; services based on community needs rather than State mandates; greater cultural sensitivity including the use of Native counselors; assistance to youth; greater community participation by staff; greater longevity of professional staff; a statistical analysis of treatment success and failure.
The agency has clearly made progress in providing services to youth and is making efforts in other areas. The Director is very visible in the community, clearly enjoys being here and is known to many. The MH clinician’s work with the schools has also allowed many to know her. The involvement with RHS counselors may allow for more village-based and culturally appropriate counselors. Informing the villages of scheduled visits and regular mailings have improved contact with the outlying areas.
Many note the improvement in services (“They are better than ever.”) since the
current Director took over management of the agency and are aware that there is
a “long history to be overcome.” The Director is described as “more in tune with the needs of the
community.”
Travel is increasingly problematic with the decline
of local air service and the recent denial of passenger service on mail
routes. Charter flights are now the
only option and are costly. Monthly
visits by both MH and substance abuse treatment staff are still the expectation of the agency. Expansion of the Rural
Human Service training option for village based counselors is being considered
and may provide a partial alternative to constant travel.
There is no psychiatric oversight nor are there
psychiatric visits. Medication is
overseen by the local health clinics.
The agency has been unable to contract for itinerant psychiatric
services. Collaboration with Yukon
Kuskokwim Health Center may yield access to psychiatric services and this is
being negotiated.
Areas
Requiring Response
1. Standard #8 Advertise board meetings in advance, listing day, time and location and a call-in
number for those in other areas.
2. Standard #10 Develop a policy regarding conflicts of interest for agency staff.
3.
Standard #11
Continue to seek funding for further ADA compliance.
4.
Standard #12
Institute the consumer satisfaction instrument that has been developed
and create a policy to use the information gathered in setting policy and
designing program delivery.
5.
Standard #29
The Board should complete an evaluation of the Director and include with
it a staff development plan detailing the expectations of the Director for the
coming year. This should be completed
annually.
6.
Devise a way to provide services to the Chronically
Mentally Ill population, a priority group, by outreach, collaboration with
health clinics or other means.
7.
Arrange for psychiatric services including clinical
supervision.
8.
Develop stronger and more numerous linkages to the
Native community, Native village councils and Native leaders.
9.
Develop a plan to increase the cultural sensitivity
of therapeutic services.
10. Seek
to decrease the ability to overhear what is said in offices either structurally
or by the use of “white noise” machines, radios, fans or air filters.
11. The
Board should develop a plan to meet in different villages as requested.
Other
Recommendations
1. Attempt to coordinate travel with the schools, health providers and others in order to share the costs.
2.
Attempt to coordinate with other human service
providers through a traveling health fair or similar activities. Substance abuse issues could also be identified
as health concerns. Multiple funding
sources could be tapped.
3.
Network with other rural providers throughout the
State for support and information.
4.
Investigate the options for providing counseling
support to staff including telephone contact, Internet connections, bringing
services to them and taking full advantage of any trips to urban centers.
5.
Ask the Board to develop a long range or five-year
plan based on the needs assessment and the results of consumer satisfaction
surveys.
6.
Expand your involvement in and support of village
counselors and the Rural Human Service program.
7.
Develop crisis response and suicide response
protocols.
8.
Consider offering Critical Incident Stress
Debriefing for emergency providers.
9.
Focus on the community-as-client using a mass mailing,
newsletter, radio programming, community meals or etc. Consider using speakers of Native languages
and translators in these efforts.
10. Focus
on public relations: inform people in the region about who you are, what you
do, what resources you have and what cost is involved.
11. Investigate
and offer more diversified materials for consumers to balance the substance
abuse materials with MH-focused materials.
12. Consider
alternate group approaches to treatment of people with dual diagnoses (i.e.
MICA consumers).
13. Attempt
to decrease staff turnover by providing for staff support, networking and
increased incentives.
14. Include
in the consent to treatment form, under exceptions to the confidentiality law,
the right
of
the State and its representatives to have access to consumer information
including charts.
Closing
The team wishes to thank the staff of 4Rivers for their hospitality and cooperation with the site review process. Thanks also to the many community members who assisted the team by sharing their impressions of the agency and its work.
This report will be reviewed by Northern Community
Resources, finalized and provided to you within approximately thirty days. When received it will have attached a plan
of action listing the Areas Requiring Response. The actions to be taken in each instance are to be detailed by
the agency and returned to NCR. NCR
will then forward the report and the completed plan of action to DMHDD.
Attached: Administrative and Personnel Checklist;
Questions for Related Agencies (tallied), Report Card (tallied)