INTEGRATED QUALITY ASSURANCE REVIEW
GATEWAY CENTER FOR HUMAN SERVICES
June
13, 2000 – June 16, 2000
Ketchikan,
Alaska
Cathy
Cooley, Community Member
Joyce
Lammers, Community Member
Terry
McLaughlin, Peer Reviewer
Mel
Henry, Alaska Mental Health Board Representative
Barbara
Price, Facilitator
A review of the mental health (MH) services
provided by Gateway Center for Human Services was conducted from June
thirteenth through June sixteenth, 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 their findings separately.
Gateway Center for Human Services, with a
thirty-year history of providing MH and substance abuse services in the area,
is a department of the City of Ketchikan.
It is governed by the City Council with the assistance of an Advisory
Board whose nine members are appointed by the Council.
Gateway’s service area includes Ketchikan Borough,
the City of Ketchikan, the City of Saxman, Metlakatla (a federally recognized
Indian Community) and Hyder. It also
receives referrals from Prince of Wales Island, Petersburg and Wrangell. One third of the population of the service
area is children. Significant cultural
groups within the service area are Alaska Natives and people of Filipino
descent.
Thirty-eight full time, one part time and additional
temporary employees serve a consumer population of 1200 (duplicated count) when
fully staffed. Twenty-five staff
members provide direct services. The
annual budget is $4,000,000 of which $880,000 is a MH grant.
Gateway provides 24 hour emergency psychiatric
services for clients and non-clients, a community support program for
chronically mentally ill adults, case management, residential treatment at two
sites (one providing supervised living with crisis respite capability and
another providing semi-independent living), pre-vocational and vocational
services, psychosocial rehabilitation, a drop in center, outpatient counseling,
support for foster parents and children’s services (for ages three and up,
including activity therapy, case management, outpatient counseling and
school-based services). As Gateway is a
co-located program, offering both MH and substance abuse services, it provides
integrated services to the dually diagnosed.
The site review team of 2 community members, a peer
reviewer, a representative of the Alaska Mental Health Board and a facilitator
met for 4 days in Ketchikan and completed 42 interviews. The team interviewed
18 consumers (4 parents/guardians of children and 14 adults) all of whom were
either taken from the random selection of consumer numbers provided by the
agency or were consumers who requested to be interviewed. Additionally, the team interviewed 13 staff
of 11 related agencies, 7 members of Gateway’s staff, 3 advisory board members
and the City Manager. Interviews lasted
from 10 to 120 minutes and were conducted at the agency, in person or by
telephone, and in the community.
The facilitator and peer reviewer examined 11
consumer files for consumer participation in treatment planning and notice of
consumer rights. The facilitator
reviewed 4 personnel files and 5 staff training files for compliance with
Administrative and Personnel Standards.
An open forum was held the evening of June
thirteenth. The agency was responsible
for advertising this opportunity in the community. It did so by faxing the announcement to related service agencies,
posting the meeting in the local newspaper and announcing it on 3 radio
stations.
Eight people used this opportunity to provide
information to the team: 7 in person and 1 by telephone. The issues presented at the forum are
incorporated into the body of this report.
Since this is the first review of Gateway Center
for Human Services using the Integrated Quality Assurance review process, there
is no prior review with which to compare these results.
The team recommends that the State consider the
following practices as candidates for the “model practices” distinction.
1.
The agency successfully blends MH and substance
abuse services. A staff member with
dual competency has been hired. The
director’s background is in mental health and the deputy director’s background
is in substance abuse. This combination
appears to be efficient for serving the dually diagnosed and allows for
prevention services in either area to those with a single diagnosis.
2.
Gateway has assisted in the addition of a
prevention specialist and a mental health clinician in the school system and
was prepared to bear the cost of that position if necessary. Gateway has assisted in planning the
addition of a social worker position in juvenile probation. This is an example of effective collaboration,
is cost effective and provides a continuum of care.
1.
Gateway has designated two employees to work with
juvenile probation. This allows for a
rapid and informed response and provides a continuum of care including
referral, assessment and treatment.
2.
Gateway has effectively meshed resources for
emergency services. The hospital, law
enforcement and Gateway work together with admirable coordination. Gateway provides these services for their
own clients and for others within the service area if identified by either the
hospital or by law enforcement.
3.
Gateway engages in a debriefing following each
crisis as a learning and a supportive experience for the staff.
4.
Case managers are based in the consumer clubhouse,
the Drop Inn, providing ready access, support to and interaction with
consumers.
5.
Gateway maintains an on-call system during the day
as well as after-hours.
6.
Gateway recruits, trains and supports foster
parents and provides a foster parent newsletter for additional information and
support.
7.
Gateway staff is responsive to the needs of the
community.
8.
Gateway surveys consumers upon termination of
services, as a group and by reviewing consumer suggestions in the suggestion
boxes placed around the agency.
9.
Gateway provides both child and adult psychiatric
services. The child psychiatrist, who
travels from Portland, is available once each month; the psychiatrist providing
care to adults is on site for three days each month. A psychiatric nurse is a full time staff member.
10. Gateway
has a close relationship with the Middle School, consulting regarding school
needs, responding promptly to individual needs, attending IEP meetings as
requested and facilitating groups held both within the agency and within the
school.
11. Gateway
has provided a crisis response team to an outlying area for prevention and
support.
12. Gateway
serves all transient mentally ill individuals with housing and meals. The Director states “No (chronically mentally ill person) here is homeless unless they
choose to be.”
13. The
Drop Inn features a consumer-produced newsletter, provides skills training and
organizes activities. It is clearly a
source of pride for many consumers.
14. Conscious,
kind efforts are made to buoy staff morale and reward excellence.
The team identified the following strengths under
Choice and Self-Determination for those receiving services:
+ Most
consumers stated that they had a choice of therapist.
+ Most
consumers stated that they have a treatment plan that reflects their personal
goals and that they participated in the plan’s development.
+ Services
are provided to outlying areas.
+ Services
are available in the school due in part to Gateway’s collaboration with the
school district.
+ A
mentoring program is maintained in the schools.
+
Prevocational services are provided to consumers including landscaping,
auto shop, woodshop.
+ The Drop
Inn provides a place for practicing life skills.
+ Case
managers and the psychiatric nurse are very accessible as they are based at the
Drop Inn.
+ Fees are
waived or reduced as needed to allow access to services.
+ Services are provided to the dually diagnosed (MH and substance abuse) including a MICA (mentally ill, chemically abusing) group, regular AA meetings and celebrations of sobriety.
+ A consumer has
benefited from moving to Horizon House where he can have pets.
The team identified the following weaknesses under
Choice and Self-Determination for those receiving services:
-
Children’s services are not coordinated between
Gateway and another local children’s mental health provider. (This is not the sole responsibility of this
agency.)
-
Gateway is the sole designated MH Medicaid provider
in the area, which limits choice for some consumers. (This is not the responsibility of this agency.)
-
Assistive technology for some physical disabilities
is not available. (Not necessarily the
responsibility of this agency.)
-
Some consumers have difficulty asking for help and
consequently may not receive all the services they need.
-
Gateway’s history of staff turnover has resulted in
a lack of continuity of care for some consumers. The team notes that turnover appears to have decreased at the
present time.
-
Some individuals cited a lack of expertise at
Gateway regarding Fetal Alcohol Syndrome and Fetal Alcohol Effects
(FAS/FAE). It should be noted that
Gateway has arranged for a major FAS/FAE training opportunity for its staff and
for other providers.
The team identified the following strengths under
Dignity, Respect and Rights for those receiving services:
+ In most
cases the case managers are seen as supportive. “(Case managers) are here
to help people, to offer a helping
hand.” -- consumer
+ In most
cases case managers are described as being eager to serve consumer needs. “They
go out of their way for you.” -- consumer
+ Case managers are available after-hours.
+ Consumer
involvement in treatment plans is clearly demonstrated and direct quotes from
consumers are frequently cited to illustrate this involvement.
+ Consumers
are well informed regarding their medications.
+ Staff
believe in consumers’ ability to change.
“You can see the change in
people’s lives: they come awake and make leaps and bounds.” – staff member
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving services:
-
Parents of child consumers frequently stated that
their opinions about the course of their child’s illness or behavior were not
honored by direct service providers.
-
Consumers are not aware of their right to refuse
medication when hospitalized. (Not
necessarily the responsibility of this agency.)
-
Two groups of adult consumers feel unattended to:
those who have difficulty stating their needs and those who usually function
quite well but occasionally need increased services. “Some people need help asking for help.” --
consumer
-
Parents of child consumers stated that they were
unaware of the consumer grievance procedure.
-
The files reviewed did not contain a signed copy of
consumer rights or the consumer grievance procedure. (The agency has a new form
included in their procedure revisions that, when used, will meet this need.)
-
There has been a vast improvement in the
consistency and quality of services.
There may be room for further improvement as some comments indicated an
inequality of skills among staff and inequality between programs.
-
Some adult consumers complained that some staff
were frequently late for appointments, seemed too busy and therefore were
unwilling to converse informally with consumers.
The team identified the following strengths under
Health, Safety and Security for those receiving services:
+ Gateway
maintains an intricate and interrelated on-call system allowing for complete
coverage.
+ The
on-call system allows for the smooth delivery of emergency services by Gateway
in the hospital.
+ On-call staff are described as responsive and their help is described as effective.
+ Some
consumers have received individual “mini-grants” for dental services.
+ A child
psychiatrist provides monthly services to outlying areas as well as in
Ketchikan.
+ A
psychiatrist provides services to adult consumers for a three-day period each
month.
+ The Drop
Inn provides showers and meals.
+ Gateway
provides two residential options for adult consumers.
+
Transportation is provided to children if needed.
+ A
psychiatric nurse provides services daily.
+ Consumers
are provided with education about their medications and, in conjunction with
Public Health, receive health screenings.
The team identified the following weaknesses under
Health, Safety and Security for those receiving services:
-
The parents of some child consumers felt that
family safety needs were not met.
-
Emergency room physicians have difficulty accessing
follow-up consumer information at Gateway if the involved staff member is in
session when the request is made.
-
Response to requests for assessments of prisoners
is not timely.
-
Many consumers have unmet needs for dental
care. (This is not necessarily the
responsibility of this agency.)
-
Consumer anxiety is elevated by the possible loss
of Medicaid eligibility should they become employed.
-
Adult consumers are in need of further education
regarding hygiene.
The team identified the following strengths under
Relationships for those receiving services:
+ Gateway
produces a newsletter for foster parents.
+ Gateway
staff have good rapport with youth referred by juvenile probation.
+ Foster
parenting classes are offered.
+ Some
parents are involved in treatment planning for their child.
+ Providers
develop relationships with children that exceed expectations.
+ The Drop
Inn provides a place to meet friends and improve relationship skills. One consumer described the Drop Inn as “a lifesaver.”
+ Consumers
are supported in maintaining contact with their families.
The team identified the following weaknesses under
Relationships for those receiving services:
-
Adult consumers state the need for social skills
training.
-
Families of children receiving services need
additional support and information.
-
Staff turnover may result in broken relationships
and diminished trust.
-
Foster parents who wish to attend foster parent
training do not have funding for the respite or day care needed while
attending.
-
There are issues of dependency: some staff state
that consumers expect too much; some consumers state that their independence is
not respected; other consumers state that dependency is fostered (“We’re treated like children.”).
The team identified the following strengths under
Community Participation for those receiving services:
+ A van
provides transportation to activities for adult consumers.
+ Many
activities are organized through the Drop Inn; child consumers benefit from
activities such as the recent camping trip.
+ Skill
building such as Smart Shoppers, information on budgeting and assistance with
errands allow consumers to participate more fully in the community.
+ Gateway,
in conjunction with the Ketchikan chapter of NAMI and the former director of
Gateway, is planning to provide the community with education regarding mental
illness to increase awareness and decrease stigma.
+ Gateway provides a link to vocational services
through the Department of Vocational Rehabilitation.
The team identified the following weaknesses under
Community Participation for those receiving services:
-
Consumers feel that the community at large has a
negative view of people with mental illness.
-
Transportation for individuals is limited. (This is not necessarily the responsibility
of this agency.)
-
The location of the bus stops, none within an easy
walk of the agency, presents a difficulty for some consumers. (This is not the responsibility of this
agency.)
-
There is no van transportation of consumers to
appointments at the agency.
-
Many adult consumers need further social skills
training in order to participate more easily in the life of the community.
-
Some consumers described activities as “disorganized,” late in starting or
frequently cancelled.
The director is proud of his staff, saying “The staff are so productive here!” And
the staff members interviewed were uniformly proud of and enthusiastic about
working at this agency. Said one staff
member: “We love what we do!”
Other comments included:
+ There is
an increased sense of teamwork.
+ Gateway
is “a healthy workplace committed to
quality service” where staff “feel
respected and supported.”
+ Staff are
comfortable in the knowledge that, should they have a concern, they could state
it openly and be responded to appropriately and honestly.
+ Staff express
their intention to stay at Gateway.
+ Staff
receive service awards, morale boosters such as wintertime “secret pals,” an
annual dinner, potluck lunches, etc.
+ Staff
accept and support the accountability measures that have been instituted.
+ Staff
wholeheartedly support the agency’s philosophy that upholds the dignity of the
consumer. Said one staff member: “The client is first in this agency.”
+ Staff
express satisfaction with the availability of supervision.
+ Staff
express satisfaction with the frequency of staff meetings and the level of
internal coordination.
+ Staff
respect and enjoy one another. “We have a lot of cool people who work
here!” – staff member
One experienced staff member, familiar with many
other agencies, described Gateway as “the
most fulfilling and sane” of all.
Turnover seems a particular issue in adult consumer
services where it is “hard to keep
staff. This is a very high powered, emotional job.” Despite the history of
turnover at Gateway, the current staff expresses a willingness to put down
roots. Should this stability be
achieved, consumers will benefit.
The majority of the interviews with related service
providers were positive:
+ Services
are coordinated between Gateway and the schools. “Gateway is an active
partner in bringing in ideas.” –
school representative
+ Services
are coordinated between Gateway and the hospital.
+ Services
are coordinated between Gateway and juvenile probation.
+ Gateway
is repeatedly described as “very
responsive” to agency requests. “Now when you call, the response is quick and professional.”
– related agency staff
+ The
Director of Gateway is very active in developing interagency cooperation and
expects staff to be responsive to the needs of other agencies.
+ The
Director of Gateway meets regularly with the hospital resulting in improved
services; Gateway’s development of a new chart system was favorably mentioned
by hospital representatives.
+
Communication with most other agencies has increased and improved.
+
Collaboration with most other agencies has increased.
+ Other
agencies view Gateway staff as increasingly professional.
+ Other
agencies express increasing confidence in Gateway’s quality of services.
+ Gateway
spearheaded a successful interagency effort to receive federal funding for a
Prevention Coalition.
+ Gateway
staff were described by one tribal representative as culturally sensitive and
very receptive to further education regarding cultural differences.
Concerns voiced by other agency representatives
were:
-
Children’s services are not sufficiently
coordinated due to lack of joint planning and obstacles to communication with
another provider of children’s services.
This negatively impacts both consumers and other agencies serving
children. (This is not the sole
responsibility of this agency.)
-
There has reportedly been insufficient response to
the needs of the prison population.
-
Gateway’s dominance in the Prevention Coalition and
in human services in general causes concern for some. Other agencies expressed fear that their existence might be
threatened by Gateway’s expansion.
-
One tribal representative described Gateway as
lacking in cultural awareness and unwilling to partner with them.
-
There is a need for more consistency in quick
responses to the needs of youth in emergency care.
There are thirty-four Administrative and Personnel
Standards for community mental health centers.
Of those, Gateway fully complies with twenty-nine and partially complies
with the remaining five. The five areas
in which a response is required are:
1.
Standard #11 All facilities and programs operated
by the agency provide equal access to all individuals. One residential housing unit is not
wheelchair accessible. A TTY system is
not available. Signage is not uniformly
in Braille. There are no handicapped
parking spaces set aside.
2.
Standard #14 The agency develops annual goals and
objectives in response to consumer, community and self-evaluation
activities. While Gateway has an
extensive Quality Assurance process and does solicit consumer opinion in a
variety of ways, at this time the setting of annual goals and objectives does
not occur.
3.
Standard #17 The agency actively participates with
other agencies in its community to maximize resource availability and service
delivery. While this is largely the
case, the difficulty of working with at least two key agencies remains.
4.
Standard #22 The organization has and utilizes a
procedure to incorporate consumer choice into the hiring and evaluation of
direct service providers, and to ensure that special individualized services
(e.g. foster care, shared care, respite care providers) have been approved by
the family of consumer. While Gateway
meets the second half of this standard and does incorporate consumer opinion
into the evaluation of staff performance, at this time consumers are not
involved in the hiring of direct service providers.
5.
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
orientation plan is extensive and meets most of these standards but lacks
specific reference to cultural diversity training and does not address the full
range of work related hazards.
The current director took over the management of
Gateway less than two years ago. He
envisioned a three-year plan to increase and improve services and is
instituting it. It is clear that in a
short time he has had a major positive impact on the agency. Under his
direction, the agency has been described as a “whole new entity.”
The team
identified these strong points:
+ Gateway
functions within a highly organized and rational structure.
+ The
community identifies its priority as children’s services and children’s
services have been expanded.
+ Gateway
is increasingly professional in image.
+ Staff
training has increased.
+ The City
has given the director increased autonomy.
+ The
director has been successful in obtaining increased funding.
+ The
director is described as consistently following through and doing what he says
he will.
+ The
Quality Assurance system is nearly fully developed and is effective. A consultant is to assist the agency with
the organization of a database.
+
Productivity measures of staff have been developed and are acceptable to
staff.
+ Staff are
held accountable for their work.
+ Mental
health and substance abuse services have been integrated.
+ A single
contact person for each of Gateway’s services facilitates interaction with
other agencies.
+ The
personnel files maintained by the City of Ketchikan are models of clarity and
completeness.
+ Services
are being provided to outlying areas.
The team heard concerns about:
-
The subordination of the specialized mental health
board to the larger, more generalized City Council.
-
The changes at Gateway in the last year and a half
have given rise to concern among some sectors of the community that this
expansion is driven by a desire to “compete
with and discourage (other service providers)” and “create a monopoly.”
Gateway was described by one community member as “insensitive to the existing community structures.”
-
Concern was expressed that the director works too
hard and might consider delegating some tasks.
-
Telephone screening does not recognize the urgency
of physicians’ requests.
In addition, Board members expressed the need for
further cultural diversity among Board members and Board orientation and
training.
1.
Seek to increase the accessibility to all
facilities and programs by all individuals.
(Standard #11)
2.
Develop annual goals and objectives in response to
consumer, community and self-evaluation activities. (Standard #14)
3.
Increase collaboration with additional tribal
entities, the correctional facility and with another children’s mental health
provider. (Standard #17)
4.
Develop a policy to incorporate consumer choice
into hiring. (Standard #22)
5.
Include cultural diversity issues and potential
work related hazards associated with serving individuals with severe
disabilities into new employee orientation/training. (Standard #25)
1.
Seek the manner in which parents of child consumers
can be informed about and invested in the treatment received by their
children. (Note that one such parent
stated “We’ve been made to feel like failures.”)
2.
Provide further social skills training to adult
consumers.
3.
Explore optional sources for dental care for adult
consumers.
4.
Enhance the cultural sensitivity of administration,
staff and clinical care to all population groups.
5.
Provide adult consumers with further training in
hygiene, STD’s, family planning and other health concerns.
6.
Increase awareness of the consumer grievance
process.
7.
Post consumer rights throughout agency facilities
and include the newly developed clients’ rights form in consumer files.
8.
Coordinate with Public Health to provide consumers
with information regarding family planning, STD’s and other health issues.
9.
Consider providing Board orientation and training
to newer members.
10. Consider
supporting locally based services in outlying areas.
11. Seek
to assure that there is a procedure for handling urgent physician requests for
information.
Within 30 days Northern Community Resources will
provide you with a final report and Plan of Action form, listing the Areas
Requiring Response and requesting your plan for change and the timelines for
those changes. You will have 30 days in which to complete this task and provide
the proposed plan to Northern Community Resources. The directions for this will be sent along with the final report
and Plan of Action form. If you have
questions regarding this next step in the review, please contact Northern
Community Resources.
The team wishes to thank the communities of
Ketchikan, Saxman and Metlakatla, the consumers and parents of consumers of
Gateway Center for Human Services, other human service providers in the area
and Gateway staff for aiding us in accomplishing our goals. The successful conclusion to a site review
requires many hours of work on the part of all. We thank you for the fine job you did in setting up this
review. Gateway staff and
administration extended the warmest hospitality to the review team and for
this, too, we thank you.