INTEGRATED QUALITY ASSURANCE REVIEW

ANCHORAGE CENTER FOR FAMILIES

February 8, 2000 – February 11, 2000

Anchorage, Alaska

Site Review Team

William Hostman, Community Member

Jan McGillivary, Community Member

Jesse Griffin, Community Member

Anne Dennis-Choi, Peer Reviewer

Barbara Price, Facilitator

Connie Greco, DMHDD Quality Assurance Staff Member

Pam Miller, DMHDD Quality Assurance Staff Member

INTRODUCTION

A review of the mental health services provided by Anchorage Center for Families (ACF) was conducted from Tuesday, February 8, 2000 to Friday, February 11, 2000, 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. DMHDD Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

Description of Services

The Anchorage Center for Families was founded in 1988 with the consolidation of the Anchorage Child Abuse Board and Family Connection. A consortium of related agencies secured funding in 1986 to construct the Family Resource Center in order to house a variety of child and family services at one site. This impressive building houses several human service agencies, improving access to services and destigmatizing their use, as many people may use any of a variety of services therein.

The agency’s mission statement is included prominently in all publications and is “to strengthen families and prevent child abuse.” The agency offers a continuum of care for families from prevention to treatment. ACF is currently participating in an outcomes study with Johns Hopkins.

The ACF programs are the Intermission Crisis Nursery (including prevention and education services); Preschool Day Treatment; Muldoon Family Center; Healthy Families (Mountain View); therapy service for individuals, family and groups; home based services (counseling and family support); parenting support and parenting education.

Among these programs and the fifty five permanent staff members and 12 contract providers employed in them, mental health funding accounts for 10 staff positions and partially supports the Intermission program, home based services, preschool day treatment and therapeutic services. Last year Intermission served 600 children with 1200 admissions; therapeutic services were used by 400 families; the preschool program served 25 families and home based services were provided to 103 families (that included 359 children and 167 adults). Currently there is a waiting list for the preschool program and the agency’s intention is to expand that program if possible.

Triage is accomplished at intake. There is an intake process for home based services and another for out patient treatment services. The agency is developing a series of mini-meetings among staff of its separate programs to aid in appropriate triage as well as increase rapport.

The FY00 budget is for $2,500,000 and the agency, by Board policy, maintains an emergency reserve fund equal to three months’ expenses. The sources of funding in FY99 included State grants (57%), Municipal funding (2%), Federal funding (2%), contributions (6%), United Way (7%) and fees (26% of which 21% is from Medicaid).

The agency is governed by a volunteer 19 member Board of Directors. The Board maintains a balanced budget, oversees financial and policy matters and hires and evaluates the Executive Director. Board committees include the Executive Committee, Finance Committee, Program Committee, Personnel Committee and the Nominations Committee. The Board is developing a strategic plan to manage potential agency growth while maintaining the quality of the programming. At least five members of the Board self-identify as past or present consumers of family services.

Description of the Process

During the four days dedicated to this review, the team, consisting of three community members, a peer reviewer and a facilitator, conducted 56 interviews. DMHDD QA staff had requested interviews with 30 randomly selected consumers of services. The team was scheduled for 33 such interviews, however 7 of these individuals were unable to participate when contacted by the team and 4 had used services too long ago to provide accurate, current information. DMHDD staff had requested interviews with 13 specific agencies and 12 of these were completed. The exception was the school district where personnel failed to return calls requesting an interview.

In addition to the 22 interviews with current consumers, the team interviewed 21 agency representatives from 16 agencies, 2 board members and 11 direct service staff members. These interviews were from 10 to 60 minutes in length and were conducted in person at the agency or by telephone. A team member spent 2 hours at the preschool day treatment program, observing and interviewing all staff members there.

Open Forum

An open forum was held from 7 PM to 8:30 PM the evening of February 8, 2000, at the staff lounge of the building ACF shares with other agencies. The agency had advertised the open forum in posters throughout the building; flyers were available at the reception desk; 200 copies of the flyer were mailed to related service agencies for posting at their facilities. Six community members attended the forum. The comments made at the open forum are incorporated into the narrative section of this report.

FINDINGS

Progress Since Last Review

As this is the first review of this agency using the Integrated Quality Assurance Review process, there is no prior review with which to compare findings.

Model Practices

The identification of model practices was new in FY00 and has been redefined for the second half of this fiscal year. Model practices are those that 1) exceed the expectations of the State; 2) are documented by the agency; 3) can be replicated by another provider; 4) are cost effective; 5) demonstrate positive outcomes. The team has identified 4 model practices at the Anchorage Center for Families. It should be noted that this is an extraordinary event given the rigor of the new definition of model practices.

The team wishes to recommend for this designation: the Intermission Crisis Nursery, serving children from 0 to 12, 24 hours a day every day of the year; Preschool Day Treatment for severely emotionally disturbed children ages 3 to 5 who are eligible for Medicaid funding; Home Based Services, short term intensive support and therapeutic services provided in the home; Parenting Education provided at the agency and throughout the community, including general parenting education, KidSmart parent groups, Parent’s Night Out, parent workshops and the 12 week Assertive Parenting course.

The team has asked the agency to attach to this document the information needed by DMHDD to consider these programs as Model Practices.

Areas of Excellence

The team has identified 6 areas of excellence at Anchorage Center for Families:

1. The positive, nurturing, professional and appropriate attitude of staff. Those interviewed singled out Dee, Sandy, Mieka (who “always asks ‘What more can I do to help?’”) Vivi and Debbie for particular praise.

2. The positive and lasting impact on families of the services provided as evidenced in consumer and collateral agency interviews.

3. The collaborative spirit of the agency internally (as evidenced in the multi disciplinary team approach) and externally (as evidenced in the high praise received from collateral agencies for the extent and quality of collaboration ACF offers them). Of particular note was the involvement of the school district in the preschool day treatment program.

4. The degree to which consumer families are empowered; a consumer commented that ACF is one place where the consumer is “in charge of treatment!”

5. The degree to which consumers mandated for services are received with dignity and respect and offered the degree of choice possible within that mandate. The positive evaluation of services by those self-identified as mandated for services is a unique testimony to the consumer-centered philosophy of this agency.

6. The high degree of involvement and visibility of ACF in the community as educator, advocate and evaluator.

Choice and Self Determination

The team identified the following strengths in the area of choice and self determination for those receiving services through ACF

+ the goals and modalities of treatment are thoroughly explained to consumers and the treatment or service plan is created in collaboration with the consumer or family

“They always told me the family is the boss.” – consumer

+ the staff are quick to respond to consumer needs and to acknowledge changing needs

+ consumer families are empowered by being taught what to do rather than told what to do

“(ACF) didn’t tell us what to do, instead they helped us learn how to do it on our

own.” -- consumer

+ services are modified to meet an individual need thanks to the flexible and creative staff

“They did a wonderful job of working within our schedule.” – a consumer

“They had never done this before but they listened to me and they tried it out and

it was great.” – a consumer

+ the family is an integral part of a productive and focused team

“(ACF services) are a team effort, including the family.” – a consumer

The team identified the following weaknesses in the area of choice and self determination for those receiving services through ACF

- there are waiting lists for some services

- Medicaid requirements may restrict some service availability

- the schedules of contract therapists lack flexibility

“Contract therapists have a high level of dedication but their schedules don’t allow for an increase in frequency of services.” -- consumer

- some consumers felt that they were not provided with adequate information regarding other resources and felt perhaps ACF tried to “do it all”

“I’ve had to do my own research on community resources. They should hand out resource material.” – consumer

- a consumer commented that violent children were not accepted at Intermission and that there

was no alternative (not necessarily the responsibility of this agency)

Dignity, Respect and Rights

The team identified the following strengths in the area of dignity, respect and rights for those receiving services through ACF

+ staff are seen as accessible and are “adored by the children”; particular comment was made regarding Dee and Sandy in this regard

“I looked forward to going to treatment.” -- consumer

+ consumers are informed regarding their rights

+ all family members are included in services and efforts are made to include those not easily available

+ the preschool program evidences rational and consistent discipline; when serious infractions occur, the child’s dignity is preserved by being spoken to privately rather than in front of the group

+ staff are consistently non judgmental in their dealings with families

“They do understand what you are going through.” -- consumer

+ the therapeutic interventions with children are so naturally incorporated into staff interactions with those children that “the kids don’t know it’s therapy!” – consumer

+ clerical and billing staff were singled out as being respectful and supportive; of particular note was the fact that billing staff were described as helpful, understanding and supportive while a family waited to be eligible for Medicaid; at no time did the family feel stressed or uncomfortable due to their inability to pay promptly

+ families were treated with such high regard that even parents who lost custody of their children were pleased with and supportive of the services they received from ACF

+ a measure of the dignity afforded families is their willingness to return for services at different times in their lives

+ services are provided as needed whether or not they were fully funded

“The therapist went above and beyond the call of duty, including the provision of

non-billable services.” -- consumer

+ administrative and support staff as well as clinical staff are dedicated to children

“It’s clear clinical and administrative staff care about and advocate for kids.”-- consumer

The team identified the following weaknesses in the area of dignity, respect and rights for those receiving services through ACF

- comments were received that the atmosphere was less welcoming and personal than it had been in the past

Health, Safety and Security

The team identified the following strengths in the area of health, safety and security for those receiving services through ACF

+ the main building is seen as safe and secure

“(ACF) is a safe haven.” - consumer

+ the Intermission program aids in protecting the health and safety of children

“Intermission was a life saver. I don’t know what I would have done without them.” - consumer

+ the mission of the agency is to maintain the health and safety of children and this is evidenced in every aspect of the agency

+ staff are quite aware of appropriate professional behavior

+ family support services aid in protecting the health and safety of children

+ the agency supports removal from the home when that is required in order to maintain the health and safety of children

+ the homey environment of the agency provides a feeling of security

“This is a comfortable place.” - consumer

The team identified the following weaknesses in the area of health, safety and security for those receiving services through ACF

- consumers identified the need for integrating substance abuse services into the services received at ACF (not necessarily the responsibility of this agency)

- the larger system does not provide for ongoing services once funding ends (not necessarily the responsibility of this agency)

- consumers worried that Intermission did not provide follow up contacts with families

- one consumer felt threatened by the intake process at Intermission, concerned that it would affect her future custody of her child

“I was so afraid of the consequences…that (they) would take my child away. They should do more to ease fears and tell people they’ve done the right thing.” – consumer

- the lack of on-site psychiatric services especially in regards to medication management

- while the building that houses the preschool program is clean, warm and accessible, the fact that it is a shared space suggests a lack of security; the agency is aware of this concern

Relationships

The team identified the following strengths in the area of relationships for those receiving services through ACF

+ the focus on families strengthens family ties

“(ACF) didn’t just focus on the child, they focused on the whole family and the

individuals in the family.” -- consumer

+ the agency actively facilitates reunification of families when that is appropriate

+ parents are empowered to help their children themselves, honoring their parental role

“They help the family to help the child.” – consumer

+ the relationship with the child clearly outlives the period of treatment

+ staff access the consumers’ support network and then aid in creating supports or strengthening the existing supports

+ the agency provides extensive parenting education

The team identified the following weaknesses in the area of relationships for those receiving services through ACF

- the need for a support or therapeutic group for siblings of SED youth (not necessarily the responsibility of this agency)

- the need for a support group or family night for parents (not necessarily the responsibility of this agency)

Community Participation

The team identified the following strengths in the area of community participation for those receiving services through ACF

+ the agency provides access to community events, for example tickets to sporting events

+ strengthened families can enjoy community activities together

+ improved skills allow children to participate with their peers

“(After receiving services at ACF, my child) is more assertive in a positive way.” - consumer

The team identified the following weaknesses in the area of community participation for those receiving services through ACF

- the community lacks activities for children ages 5-8 (systems issue)

- consumers seem unaware of the possibility of participation on the Board

- individual assistance workers are scarce and often untrained (not necessarily the responsibility of this agency)

“(There is) not enough community support for integrating kids back into activities.” - consumer

- the community lacks adequate transportation for children and their families (systems issue)

Staff Interviews

The team cannot overemphasize the respect and affection that consumers have for the entire staff at ACF. While certain staff members happened to be mentioned by name, it is clear that all staff share in creating the welcoming environment of the agency. It is equally clear that staff treat one another with the same dignity and respect that they evidence toward consumers. The result is a natural, warm and relaxed environment that benefits all (even, let it be said, site reviewers!).

The agency is described by staff as open to suggestions, an agency in which ideas are encouraged and staff creativity is honored. The egalitarian nature of ACF allows for clear and complete communication while maintaining proper boundaries. The Executive Director is described as “very approachable.” Where communication issues arise, as between the home based services and the preschool, there is ample good will to identify and solve those issues.

Staff enjoy working for ACF, even to the extent of working for less pay than they could expect elsewhere. While pay may not be high, it was noted that staff benefits had recently improved. Staff members benefit from strong supervision; in house training; an open system of evaluation that includes setting one’s own goals for the coming evaluation period; the time allowed for evaluation by both supervisor and by peers on a weekly basis. This regular system of meetings enhances the collaborative nature of the agency as well. One employee stated “I’ll be very spoiled when I leave here!”

Long time staff and many consumers note that the quality of services has improved noticeably in the last 12 to 24 months.

While training is offered on site, staff noted the particular need for additional training in attachment disorders, FAS and early childhood depression.

Collateral Agency Interviews

ACF is active in Common Ground, an interagency group whose mission is “to bring together mental health providers, consumer agencies, and consumer families in a community partnership to help establish the best mental health services possible for Anchorage’s children and families.” Forty different agencies, State departments and advocacy groups are listed as members. Common Ground is facilitated by ACF staff member Dee Foster. This is only one of the ways that ACF excels at collaboration with other service agencies.

As the table at the end of this report shows, ACF enjoys a reputation for excellence among other human service agencies. ACF ranks very high in collaboration with agencies of all types including those that serve primarily Alaska Native people and those serving primarily women. The agency is described as actively advocating for families and it is said that “(ACF) is one of the most responsive mental health agencies in town.”

ACF’s flexibility allows for easy transitions from other services to ACF and from ACF to other agencies. Services are described as “following the family” and it is noted that clear, concise case plans keep families on track and help them to recognize their accomplishments. Inclusive team treatment meetings further maximize services.

Consumers benefit from this collaboration and are provided a continuum of care as well as an increasing sense of their competence. The fact that the building itself is described as “the family center” by consumers, indicates how strategic is the location of ACF in relation to the other collateral services with which it shares space. It was described by one professional as “one stop shopping for family (services).”

ACF provides in-house cross training regarding other services and specialties and provides training to other agencies as well. This respect for other professionals further enhances the quality of services throughout the community. One provider notes that ACF helps her “see the bigger picture and do my job better.”

Other human service providers also note that in the last 12 to 18 months communication with ACF has improved noticeably, that services are easier to access and that the quality of professional staff has also improved. “(ACF) is user friendly.”

Criticisms were few, but the team noted a concern regarding staff turnover and one specific reference to the need for more details on progress reports received by DFYS. While ACF is described as “the best in town”, it is still clear that not enough services are provided to meet the community’s needs. This is a community and system issue, not a criticism of ACF’s work.

Administrative and Personnel Narrative

As only 10 positions are funded by MH grant monies, 4 of those personnel files were reviewed. All completely met the standards. The personnel files were complete and orderly and evidenced every safeguard for the employee as well as those they serve. (See the Administrative and Personnel Standards checklist at the end of this report.)

There is currently no exhaustive Policy and Procedure Manual for the agency as a whole, although there are abbreviated versions for different programs. The full manual, required by DMHDD, is currently under revision. Contracted providers expressed concern about not being able to access the Policy and Procedure Manual.

ACF’s values and practices are clearly consumer centered. The Board and the administration as well as staff are routinely described as strong advocates for children. While formal written policies are not evident in all areas, as noted above, program descriptions reveal that consumer centered standards are operative. Formalizing these practices would be beneficial.

Of the thirty four specific standards for Mental Health grantees, ACF fully meets thirty one. This is an unusually high level of compliance. The standards requiring additional effort are:

1. Standard 8 “Governing body meetings are open to the public.” While the meetings are held at a regular time and place (7 AM in the Board Room), there is no evidence that they are advertised as open to the public. There is no indication that the public is excluded, however in order to meet this standard fully, an effort should be made to announce Board meetings in agency publications and bulletin boards and, if feasible, in calendars of community events. The standard is partially met.

2. Standard 12 “The agency actively solicits and carefully utilizes consumer and family input in

agency policy setting and program delivery.” Consumer satisfaction surveys are completed

and reviewed by supervisors and there is every indication that the information is utilized. Full

compliance would require a written policy and a formal procedure to accomplish this task. The

standard is partially met.

3. Standard 22 “The organization has and utilizes a procedure to incorporate consumer choice

into the hiring and evaluation of direct services providers…” Consumer surveys are reviewed

and acted upon inasmuch as they reflect on the quality of staff performance. There is no

indication of the inclusion of consumer opinion in the hiring of direct service staff. The

standard is partially met.

Program Management

In the pre-review teleconference the DMHDD regional coordinator requested interviews with DFYS, school district personnel, McLaughlin Center, Southcentral Counseling, Parents, Inc., Common Ground, health provider, Alternatives, Head Start, court system, Native associations, substance abuse treatment programs and Charter North. All of these interviews were scheduled with the exception of the school district staff who did not return calls requesting their involvement.

The program has a clear organizational chart and, as a further example of its consumer centered approach, lists “children and families” at the top of that chart, then staff and lastly the Executive Director and the Board of Directors.

The Board is respected for its abilities and volunteerism. Staff and consumers seem disconnected from the Board and its work and, as meetings are not advertised, that distance may need to be bridged through Board initiative. This is not to suggest a confusion of boundaries, merely that the Board may benefit from a free flow of ideas from users of services as well as providers on a regular basis. The Board might also consider formation of a subcommittee or an advisory board to specialize in those services funded by mental health funds.

Upper and middle management are open and accessible to all staff and communication within the agency is very good. All employees feel empowered to effect change and the vitality of the environment thus created enhances services and job satisfaction.

File Review

The facilitator and peer reviewer had access to the charts of those consumers scheduled for interviews. All had provided a release of information for this. The vast majority of these files (20 of 31) were closed. While this is explained in part by the provision of brief services, in some cases the files appeared to have been left open for a considerable time after the last contact. Only 11 of the 31 files had treatment plans signed by the consumer or family, although review plans were more often signed. Most files contained signed consent forms and client rights. In short, the excellence of the services is not given their just due in the records of those services.

This note includes only the impressions of the two team members as they quickly reviewed charts prior to the interviews. The formal chart review was conducted by the QA team and is included below.

Clinical Records Review

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what information the agency needs to be able to generate documentation that reflects good clinical practice. Another reason for the review was to conduct a mini-event audit for the Division of Medical Assistance (DMA) to determine that the services delivered are reflective of the services billed to Medicaid. The charts reviewed were determined by a random sample taken from data supplied by DMA for Medicaid cases and by Anchorage Center for Families (ACF) for the chart reviews of non-Medicaid All client Interviews were taken from lists provided by ACF. The number of charts to be reviewed was determined by a Range Table based on the total number of cases supplied by DMA. The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews. The team reviewed a total of fifteen (15) Medicaid charts and eight (8) non-Medicaid charts.

STRENGTHS

An overview of ASSESSMENT material indicates that assessments are present for most charts and that the components of the assessment meet the Integrated Standards. In

some charts there were excellent prognosis statements that could be used as a guideline for documenting prognosis. TREATMENT PLANS found in charts were current for most charts reviewed and a professional clinician’s signature was found on the treatment plans. The treatment plans generally referred to the recommendations found in the assessments. An overview of PROGRESS NOTES show that notes were found in charts for most billings, that dates and units are being included (exception is Parenting Program), and that signing and credentialing is being done. An overview of TREATMENT PLAN REVIEWS indicates that reviews are consistently present in the file when due and that the format for the treatment review meets the requirements of the Integrated Standards.

AREAS FOR IMPROVEMENT

ACF should make sure that a comprehensive ASSESSMENT is conducted by a Master’s level clinician and that the forms used for assessment are fully completed and the content is well developed. It is also important that these forms be legible. Please be sure that all assessments contain a section for a Summary of Mental Health Problems and a Recommendations section. The multi-axial diagnosis in the assessment should be based on information contained in the assessment. TREATMENT PLANS should be individualized. The goals should be client goals. In some of the treatment plans reviewed, goals were either therapist goals or goals for the parent rather than the child. There appears to be some confusion as to what is an intervention opposed to a service. An intervention is what the therapist will do and the service is what the therapist will use to provide the intervention. It is recommended that ACF obtain training of goal writing and clarification of interventions and services. An overview of PROGRESS NOTES indicates that some notes are not easily read. Please be careful to document the intervention that the therapist provided and the goal from the treatment plan that was addressed during the session. In TREATMENT PLAN REVIEWS, there did not appear to be any outstanding problem.

SUMMARY:

The charts reviewed indicated that the ACF staff is dedicated to providing services to families and children. There were no areas that appeared to be extremely weak. Supervisory staff are very vested in making sure that the documentation is strong and expressed their appreciation to the DMHDD Quality Assurance section for providing insight into the ACF process. There are training needs surrounding documentation, particularly in the preschool day treatment program, and a need to review some of the processes to determine effective ways to encourage client services being delivered more easily between programs There were indications from review of services offered, that there may be under utilization of services. Under utilization may be the result of the need for coordination between programs. It is recommended that the agency consider ways to more closely integrate programs. It is also recommended that this agency look at ways to document their service delivery that are more efficient than handwritten assessments and progress notes. The Division of Mental Health and Developmental Disabilities Quality Assurance staff is available for technical assistance upon request.

Areas Requiring Response

1. Actively seek public attendance at Board meetings by public advertisement or in agency publications. Standard #8

2. Formalize the utilization of consumer and family input in agency policy setting and program delivery. Standard #12

3. Seek a means of incorporating consumer choice in the hiring of direct service providers. Standard #22

4. Develop a strategy for reducing the waiting list for services.

Other Recommendations

The following suggestions are related to the larger picture of community services and some of the gaps in them. While these items are not necessarily the responsibility of this agency, they do impact the lives of ACF’s consumers. Perhaps ACF or Common Ground could facilitate collaborative efforts to address these issues.

1. There is an unmet need for non-crisis respite care for grandparents who are raising their grandchildren.

2. There is a need to provide follow up services for consumers in programs that provide only 90 day services.

3. There is a need for activities for children ages 5-8

4. There may be a need for on-site psychiatric services.

5. There may be a need for a community-wide resource list

6. There seem to be few resources for children with violent histories.

7. There is a need to integrate substance abuse services.

8. There may be a need for training in DD services.

9. There is a need to support siblings of SED youth.

10. There is a need for a family activities night or similar activity to link families and so allow for mutual support.

11. There is a need for transportation services for adults and children to aid in community participation.

Closing

The team wishes to thank the staff of the Anchorage Center for Families for their gracious acceptance of our invasion of your space. You made us feel very welcome and everyone was helpful to us. Our special thanks to those involved in the time consuming preparations for the review: Lupe, Marian, Dee and Mark.

Attachments: Administrative and Personnel Checklist, Questions for Related Agencies (tallied), Report Card (tallied)