MH/DD
Program Site Review
South
Peninsula Mental Health Association
Feb 16-19, 1999
Homer, Alaska
Scot
Wheat, Homer
Tim
Hamilton, Homer
Brian
Bennett, Homer
Wini
Crosby, Kenai/Soldotna
David
VanCleve, Co-Facilitator
Carl
Evertsbusch, Facilitator
A review of the mental heath (MH) and
developmental disability (DD) services offered by the South Peninsula Mental
Health Association (SPMHA) in Homer, Alaska was conducted from February 16-19,
1999. SPMHA offers MH services that
include emergency and general adult services, outpatient counseling, community
support, psychiatric services, intensive rehabilitation, treatment for
seriously emotionally disturbed (SED) youth, parenting classes, vocational
support, on-site assessment, job coaching, job development, case management and
transportation, and DD services that include respite, care coordination, case
management, foster care, transportation services, vocational support and core
services. This is the first review conducted
of SPMHA using the Mental Health, Developmental Disability and Early
Intervention Program Integrated Standards and Quality of Life Indicators.
To conduct this review, a team consisting of
a facilitator, a co-facilitator, three community members and peer providers
from both DD and MH, met for four days in Homer. The team conducted interviews, reviewed two individual DD records
and program and agency materials and interviewed 38 consumers and family
members, program staff, Board members, community members, and related service
providers. Of those, (2 MH, 9 DD) were
randomly selected consumers who receive services from SPMHA.
Interviews were in person at families’ homes, in the community, at the SPMHA’ offices, or by telephone. The interviews lasted from 30 minutes to an hour and forty minutes. After gathering the information, the team members met to draft this report, which was presented to the staff on the final day of the visit. This report is based on the Department of Health and Social Services combined Mental Health (MH), Developmental Disabilities (DD) and Early Intervention (EI) program standards.
Monitoring and reporting the quality of life and
the quality of services for individuals and families makes an important
contribution to the State of Alaska’s understanding of the effectiveness of
program services and supports. The
review team’s findings and areas for improvement are reported below. The report includes a review of the previous
findings, an administrative review, areas of programmatic strength, specific
services or procedures that need improvement, tables of personal satisfaction
with quality of life and quality of services and a list of areas of excellence.
During the previous review of the respite
program, the review team made several recommendations. Since then, the agency has taken the
following actions:
·
Regarding the recommendation that PRIDE explore
ways to include consumers on the CMHC Board of Directors, the Board expanded
from seven to nine members, of which one is a mental health consumer
representative. There is currently no DD representative on the Board, however,
they are currently recruiting for a member who will represent the DD
perspective. (1.3.2)
·
Regarding the recommendation that PRIDE consider
new methods of soliciting consumer input into program planning, a dinner is
currently offered as incentive for parent participation, but this has not
resulted in a significant increase. (1.4.1, 1.5.1)
·
Regarding the recommendation that PRIDE consider
bringing all language in agency documentation up to the standard demonstrated
in the current grant application, this has been completed. (1.6.2)
·
Regarding the recommendation that PRIDE consider
developing a way to involve consumers in the hiring of all staff, of the two
hires that occurred during this period, one was done without and one was done
with consumer input. Although there has been improvement in this area, this
goal has still not been met. (2.2.1)
·
Regarding the recommendation that PRIDE consider
developing voter education for the people it supports, this has been completed.
(3.5.8)
·
Regarding the recommendation that PRIDE consider
using a person centered planning process (futures planning, MAPS, PATHS) for
developing your individual plans as a means of reducing the clinical tone of
the plans, the program intends to implement this change in the near
future. (7.1.3)
·
Regarding the recommendation that PRIDE assure that
all individual plans are current, this has been completed. (7.1.5)
*Note: The items listed above are referenced to the
previous DD program standards.
Excellence is a measure used to denote
exemplary practices that are models for services. SPMHA has achieved excellence
in several areas of their operation and these are noted below:
1.
Project PRIDE is highly regarded by the
Homer community. The review team
received numerous citations of excellence from parents, other service
professionals and providers. Cited were
the dedication and commitment of the Program Coordinator and the program
staff. Families reported a high level
satisfaction with providers and the efforts that the staff make to honor their
choices and provide timely service.
PRIDE continues to creatively apply limited resources they have in a
highly efficient and effective manner.
“It’s
the best thing that ever happened in this town.” – a parent
2.
SPMHA
staff are very dedicated and creative in their efforts to advocate for
consumers. Attending
court appearances on off times, advocating at the Division level for additional
services, arranging local radio appearances for MH consumers, encouraging
exercise through the creation of trail maps and exploration, finding swimming
partners and emphasizing health, safety and security in their collaboration
with DFYS are some examples of this dedication.
3.
The
improvement in psychiatric services has had a positive, community-wide impact. The efforts of the visiting psychiatrist to
improve services to consumers, to provide high quality inservices to Center and
hospital staffs, to improve the liaison between primary MDs and Mental Health
staff, to provide community training and information and that popularizes
mental health services in the community are some of the benefits identified
through interviews. This is a good
example of an excellent management decision to further the efforts of the local
CMHC.
4.
SPMHA
has excellent relations with key agencies in the community. Several related service personnel reported
to the team a very effective working relationship with the staff of the various
programs at the Community Mental Health Center and Project PRIDE. The Alaska State troopers, the local
schools, the hospital, the Homer Police Department and the court system are a
sample of the local agencies that are benefiting from their working
relationship with the agency. The
agencies characterized the relationship as one of mutual reliance.
“It’s
sure been great working with [the director] over the years. Tenured folks are a great asset. As long time residents we see one another in
the community and working relationships are stable.”- related service
professional
5. SPMHA has a very proactive Board of
Directors. The
Board is making a concerted effort to become more familiar with programs and
services and the people who provide them through monthly staff presentations,
visits to agency facilities and encouraging staff attendance at meetings. The Board desires a stronger voice both
locally and statewide. There is
interest for networking with other Boards of similar community mental health
centers and a means of improving communication and increasing influence on
statewide policy. The Board is very
interested in increasing consumer involvement in their business. They are currently recruiting for another
member who experiences a disability.
The Board sees a bright future for SPMHA, but recognizes it will take
strong effort and community-wide support.
The present Board seems prepared to take on this challenge.
6. The STEPS program in McNeil Canyon School is
an excellent example of inclusive education for children with disabilities. The STEPS program was made possible through
a federal grant though Central Peninsula Counseling Center as a means to
provide social skills and anger management training for school children on site. McNeil Canyon School requested that the
Children’s Program staff provide the curricula to entire classes, rather than
exclusively to those children identified as experiencing SED. This was accomplished while still providing
the necessary individualized services to the identified children. The Program’s responsiveness to the request
for this innovative approach is a good example of creative management.
SPMHA is well known and well respected in
the South Peninsula. Current management
has developed many new systems for improving the local service delivery
infrastructure. Relationships with
other service entities has continually improved and has gradually produced a
higher profile within these services.
However, the same service providers said that the community would enjoy
even greater benefits if the CMHC increased its visibility.
The Board is strongly supportive of the
director and has a high regard for the people who work at SPMHA. They have taken an active interest in the
current programs and are in the midst of strategic planning for the next three
years. The Board is currently
evaluating the director. This evaluation was not available to the review team.
However, the Board members stated they were very satisfied with the agency’s
direction. The CMHC continues to
develop services in communities across the bay. These communities have increasing needs for services and are very
appreciative of the Center’s presence.
The program enjoys a good relationship with
the schools in the South Peninsula area, and this was confirmed in interviews
with local school district personnel.
One product of this relationship is an increase in requests from the
district for additional on-site services.
The program manager of the children’s services told the team that they
have had to “creatively respond” to the additional requests from the schools,
because of an inability to provide certain services without compromising
certain regulations. However, it is
very clear from the both parties that there has been some very positive
outcomes from this relationship.
Interviews with consumers and other
community members indicate that SPMHA employs excellent staff. Consumers reported that staff consistently
go beyond what would normally be expected and are very thankful for the
dedication displayed. The CMHC
experiences a high turnover in respite providers, case managers and Activity
Therapists. Homer has many qualified
individuals, but it is difficult to retain these people for long term. However, SPMHA has a good record for
promoting within, providing hourly staff with scheduling flexibility and
budgeting nearly $50,000 for staff training, which are examples of the high
value management places on staff.
The providers of the Bay-Side Program serve
as a prime example of staff members who in spite of limited resources find the
inner strength to dedicate themselves fully to the mental well-being of fellow
Alaskans far above and beyond the call of duty.
The respite providers are generally well
qualified and have an excellent reputation with families. However, the program
experiences steady turnover and feels frustrated with their lack of success in
retaining providers. One possible cause
for this personnel drain was identified as the disparity in wages within the
agency for positions requiring similar qualifications. That, and an itinerant local population,
prevent long-term relationships from developing between families and respite
providers. As with many respite programs in the state, families advocate for
additional respite hours for themselves and for those on the waitlist.
The PRIDE Project is expanding its Medicaid
HCB waivers and TEFRA options and Core Services. The Project coordinator provides the care coordination for the
waivers and assists families with their Core Services applications and plans
SPMHA has experienced stability at the
management level. INTerviews from both
staff and other community members attibute much of this to the stabilizing
influence of the current Director, both within the organization and in the
community as a whole.As reported above, SPMHA has earned a reputation for
excellent collaboration with related service professionals (See attached form
for Related Service Agencies).
"I’m
am real happy. They are doing a good
job.” – school principal
“We
can always count on them. The Center is our safety net” – family worker
“We
really appreciate Dr. Burgess’ presentations.”- school principal
“I
am extremely pleased with our relationship.”- family worker
“They
bend over backwards.” – social worker
Several staff expressed frustration with the
“burden” of paperwork. They feel that
it does not add to the quality of services and uses valuable time and energy
that could be better spent working directly with consumers.
SPMHA values consumer input into creating
policy for the agency, but have limited success in attracting consistent
participation. The agency uses multiple
approaches to gather input from families regarding their satisfaction with the
services and the direction for the agency including an annual survey, case
logs, provider reports, the Parent Advisory Group and regular conversations
with families. This information is used
for self-evaluation and for making program decisions (e.g., parents voting to
be able to stockpile their respite hours, parents requesting a Christmas
shopping day, supporting inclusive childcare).
There were comments to the team regarding
the individual fees for the summer program and the fee for parenting classes
which prevent anyone who is not Medicaid eligible from availing themselves of
these services.
The Board receives copies
of a financial statement at the monthly meeting and reviews the budget at that
time. The difficulty with this process
is that the ECHO software package does not have an ideal accounting module to
meet state reporting requirements, therefore, a separate finance system has to
be maintained to produce financial information. The Board President has worked
closely with the financial staff and is very familiar with the accounting
practices. SPMHA recently received
their annual fiscal audit, but it was not available for this review. Copies of the previous year’s audit were
reviewed by the team.
This portion of
the narrative refers to the Quality of Life Values and Outcome Indicators, as
they relate to the two specific services offered by SPMHA. The items listed below are those that the
review team identified as strengths. If
the team concluded that any of the indicators warranted improvements, they are
listed in the Areas Requiring Response Section.
The
following are indicators for Choice/Self-determination for families receiving
services from PRIDE that were identified by the team:
Families :
·
have options from which to choose.
·
are comfortable with asking for changes in their
services and report that their requests are honored.
·
Families choose which agency provider they want.
·
Families choose when respite is provided.
PRIDE staff:
·
are responsive to families’ requests.
·
respond quickly when families express
dissatisfaction
The following are examples of statements
families gave to the review team:
“I’m
blessed with two wonderful providers.”
“Funds
have been used creatively to satisfy my individual needs.”
“_____
has grown leaps and bounds because of the respite program.”
“I think he’s (provider) wonderful.”
“I get two or three choices each time I call.”
The two families who have children with SED who
were interviewed reported they were satisfied with the choices they were given
regarding services for their child.
The
review team received feedback that described the comfortable relationships that
the children who have SED have with their Activity Therapists. The children are aware of these
relationships and are making positive comments about their therapists. This reflects a very good level of skill
effectiveness. Consumers identified one
area they would like to see improvement is, because of the high turnover of
staff, the transition period from one activity therapist to the next.
The
following are indicators for Dignity, Respect and Rights for the team
identified all families receiving services from SPMHA that:
The family:
·
understands their rights as consumers of services.
·
is respected and treated with dignity by service
providers.
·
feel their privacy is protected and respected.
·
controls the flow of personal information.
PRIDE staff:
·
show respect and high regard for the family.
·
respect family’s rights to privacy and protect
confidentiality.
·
provide the family information regarding their
rights.
The following are examples of statements
received by the team:
“My
providers and staff are very respectful.”
“Susan
made me well aware of my rights.”
“Except
for one provider, I’ve always been treated with dignity and respect.”
“One
of ______’s biggest achievements is his new attitude that it’s OK to be
different.”
“We’re always treated with respect and
our confidentiality is always protected.”
The two families who have
children with SED who were interviewed reported they were treated with respect
and dignity by the staff.
The
following are indicators for Health, Safety and Security for families receiving
services from PRIDE that:
The family:
·
receives services that promote the health, safety
and well being of the child.
·
has access to needed medical and social services,
including cost coverage.
·
The family knows their child is safe and secure
with the respite providers.
·
SPMHA staff are knowledgeable of and provide
respite in accordance to the child’s health care and personal safety needs.
The following are examples of statements
received by the team:
“I’m
a nurse, and I always feel my daughter is safe and secure with her providers.”
“PRIDE
has helped me with some specialized funding for dental services for one of my
foster sons.”
“I trust my provider to keep ________
safe.”
The
following are indicators for Relationships for all families receiving services
from PRIDE that were identified by the team:
The family:
·
has access to information about services that
strengthen the family.
The
families remain intact.
PRIDE staff:
·
develop trusting relationships with the family.
·
provide services that enhance, not replace, the
family’s natural supports.
The following are examples of statements
received by the team:
“My
son is more able to meet new friends.”
“Respite
has allowed us to talk about building our new home in peace without interruptions.”
“Respite gives us time
to be together.”
The
following are indicators for Relationships for all families receiving services
from PRIDE that were identified by the team:
The family
·
Family participates in community activities that
add to their child’s personal growth and increased life satisfaction.
PRIDE staff
·
Assist the child and family to participate in
inclusive community activities and services.
·
Provide the family information on community
activities and supports.
The following are examples of statements
received by the team:
“Respite
has allowed _________ to become more active (in the community).”
“It
would be nice to have more activities (in Homer).”
“I’ve been able to testify in Juneau, take
vacations and attend regular church services because
of respite.”
File
Review Summary
The DMH/DD Quality Assurance Unit will present a
separate report on the file review.
Comment on the treatment
plans and implementation:
The Quality of Life
community-based portion of the review team did not have access to treatment
plans, as did the QA unit of DMH/DD.
However, interviews with program staff revealed some concerns with the
plans and their application. One
instance was a CSP staff person describing a consumer’s treatment goals and
objectives in overly general terms (e.g., ‘_____ will improve self-management
skills.’) that were not measurable and objective. In addition, the recording requirement was simply to note that he
(the staff) had “worked on self-management skills”. There was a lack of understanding of the need to report the
current status of the treatment goals in ways that would indicate progress, or
lack thereof. It is important that
treatment goals be written in a manner that clearly define what is expected of
staff and requires recording whether or not there is a change in the
individual’s behavior, and that staff are adequately trained to implement the
plans.
The
following recommendations were identified by the team as areas that need
attention from the organization
1. Assure
that treatment goals are measurable and objective and that staff are trained to
implement and evaluate progress towards these goals.
2. Complete
the revision of its mission statement to effectively focus the use of its
diverse resources to empower the consumers of services and their families.
(Admin Standard No. 1)
3. There
is no documentation of a systematic agency wide education and orientation about
mission philosophy and values that promote understanding and commitment to
consumer-centered services in daily operations. (Admin Standard No. 2)
4. Employee
records are incomplete. Required
documents are consistently missing from personnel files. Could you include checklists that would
remind record keeping employees of the absence of required documents are not
evident in each employee record? (Admin Standard No. 4)
5. SPMHA’s
governing body should increase its membership to reflect a more diverse
representation for all consumer groups.
(Admin Standard No. 6)
6. There
is no documentation that SPMHA actively solicits and carefully utilizes
consumer and family input in agency policy setting and program delivery. However, Project PRIDE does support a
consumer advisory group and conducts annual satisfaciton surveys. (Admin
Standard No. 12)
7. SPMHA
should continue its strategic planning to develop a shared vision, identify
core competencies and prioritize goals.
Within this process, SPMHA could explore ways for staff and the
consumers to provide mutual support toward a common mission. Could SPMHA include even the most severely
impaired or those they choose to represent them, which would demonstrate an
exemplary effort at inclusiveness contribute to the effective use of scarce
resources? (Admin Stan #s 13)
8. SPMHA
personnel records are consistently incomplete.
Many records show no evidence of thorough orientation, certificates
documenting required training or training deficits, criminal background checks,
oaths assuring adherence to expected standards of confidentiality. (Admin Standard No. 19)
9. SPMHA
has no system for review and revision of all job descriptions. (Admin Standard No. 20)
10. SPMHA
has and utilizes a procedure to incorporate consumer choice into the hiring,
but, except for Project PRIDE’s
evaluatoin of respite providers, not the evaluation of direct service
providers, and to ensure that special individualized services have been
approved by the family or consumer.
(Admin Standard No. 22)
11. No
consistent documentation of criminal checks for case managers and coordinators. (Admin Standard No. 24)
12. SPMHA
has no written plan to guide the timely orientation/training of staff 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.
(Admin Standard No. 25)
13. SPMHA
has no policies and implemented procedures to facilitate the development of non-paid relationships between
consumers and other community members.
(Admin Standard No. 26)
14. SPMHA’s
evaluation system provides performance appraisal and feedback to the employees
and an opportunity for employee feedback to the agency. Employee records show that these appraisals
are not consistently scheduled from year to year. The most recent evaluation in evidence for one program
coordinator is dated June, 1994 and for another program coordinator there is no
record after 14 months in his/her current position. Assure that all employees receive a timely evaluation and staff
development plan. Plans should include goals and objectives for the period of
appraisal and new or revised goals and objectives for the coming period. (Admin Stan #s 28, 29, 31)
15.
Could the CMHC find ways for all eligible MH
consumers to be given the opportunity to participate in special projects
(summer camps, parenting classes) via the sliding fee scale and use of grant
funds?
Each consumer interviewed by the team was
asked whether or not they were satisfied with the quality of their lives as
they relate to each of the five Outcome areas and with the quality of the
supports and services they receive from SPMHA.
The questions were taken from the Consumer Satisfaction section of the
five Outcome areas, and the responses are presented according to type of
service. Some families receive more
than one service from SPMHA, so for the purposes of this review, the response
recorded is for the service the interviewer determined was “primary”.
MH
|
Choice
N=2
|
Dig&Res. N=2
|
Hth,Saf,Sec N=2
|
Relatns. N=2
|
Com.Par. N=2
|
||||||||||
Outcome
|
Yes |
Part. |
No |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Parent/guardian
|
2 |
|
|
1 |
1 |
|
2 |
|
|
1 |
|
1 |
1 |
|
1 |
Staff Performance
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Parent/guardian
|
2 |
|
|
2 |
|
|
2 |
|
|
1 |
|
1 |
2 |
|
|
DD
|
Choice
N=2
|
Dig&Res. N=2
|
Hth,Saf,Sec N=2
|
Relatns. N=2
|
Com.Par. N=2
|
||||||||||
Outcome
|
Yes |
Part. |
No |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Parent/guardian
|
9 |
|
|
8 |
|
1 |
9 |
|
|
6 |
|
3 |
6 |
1 |
|
Staff Performance
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Na=1 |
|
Parent/guardian
|
9 |
|
|
8 |
|
1 |
7 |
|
2 |
8 |
|
1 |
8 |
Na=2 |
|
The
results from this survey demonstrate a high level of satisfaction with both the
quality of the outcomes families are experiencing and the performance of the
organization. The small size of the
sample of MH consumers compared to the number of service recipients the CMHC
reports serving minimizes its value as an accurate measure of overall consumer
satisfaction. It may be helpful to explore,
with DMH/DD and Northern Community Resources, why mental health consumers were
not as well represented as other recipients of services. Trust building opportunities that could
enhance service delivery would possibly be revealed if this course of action
could be pursued. This could also be an
opportunity to initiate a consumer driven exploration as a collaborative effort
with MH service recipients in coequal roles.
The following are examples of statements the team received from
consumers regarding their satisfaction with their quality of life and the
quality of services.
“The program was so
good.”
“What it did for us was
say beyond what we expected.”
“Molly saved our lives.”
“I am very satisfied with
the way PRIDE provides our respite.”
“Since they (SPMHA) have
become involved, our lives have changed so much.”
“I didn’t really know
what we were going to do. Having our
son in the program has made all the difference in the world.”
SPMHA
scheduled separate two-hour public forums for public comment on developmental
disabilities and mental health issues.
The meeting was announced on the local radio station and the local
newspaper. Four individuals at each forum
provided comment to the review team.
Issues presented were:
DD
1. Participants all gave positive comments on
the services provided by the PRIDE program.
“The folks at PRIDE are always working to meet our needs.”
“I
just want to say that the PRIDE program has really been great.”
2. Participants all expressed a desire for
more service options from the state for people living on the South Peninsula.
“I would like to know what is available
(at the state level) for services for ___________ (a person receiving DD
services.).”
“The person living with me will need more
services next year, and they just aren’t there.”
MH
1.
One participant spoke of the “good
working relationship between the hospital and the CMHC”, the fact that this had
“not always been the case”. This person reported that “MH workers had been granted privileges at the hospital and that
physicians now had access to psychiatric services”. This person is also “impressed with the way the CMHC has worked closely with the local
judicial system to develop systems for 72-hour holds for emergencies.”
2. Two
participants expressed concern over the qualifications of the staff at the
Annex. Upon further discussion, this
concern was confined to specific selected staff.
3. One
participant expressed concern for the “lack of sensitivity” of some Annex
towards the people who frequent the program.
The suggestion was that staff have sensitivity training.
4. One
participant expressed a desire for transitional support when one no longer
requires the level of support supplied at the Annex. This comment was prefaced with the perception that this was a
“system” issue that could be resolved through additional funding or
restructuring at the local level.
5. Three
people commented on breaching of confidentiality. The feeling was that staff talk about consumers at inappropriate
times.
6. Two
participants encouraged the Center to increase their presence in the community.
“If they (the Community Mental Health
Center) would do more community outreach, things could be better.”
“I think awareness and participation can
always be improved upon.”
The
forums were informative, and the team was appreciative of those who chose to
share their comments. The team
encourages SPMHA to develop similar venues for consumers to express their views
and to review their existing avenues for feedback to determine if there are
ways they can be made more comfortable for consumers. The emerging chapter of NAMI-AK is an encouraging sign that
mental health advocates will develop a stronger voice for the South Peninsula.
The
review team expressed concern that the very limited sample of MH consumers who
consented to be interviewed prevented them from acquiring an adequate picture
or the quality of life of people receiving services and of the organization
itself. Interviewing consumers is the
cornerstone of the community-based review and is essential for determining the
quality of life of persons receiving services. The team recommends that DMH/DD
and Northern Community Resources, in collaboration with Alaska’s providers of
MH and DD services, develop a process for encouraging consumer participation in
this process.
The team thanks the SPMHA staff for being
their support during the site review.
Processes such as these can be disruptive and stressful, and we hope we
did not excessively disrupt yours and the consumers’ lives. The team would also like to thank SPMHA for
their willingness to be one of the first programs to participate in a joint
review using the new program standards.
You will receive a finalized report of this
review, an overview of the agency's compliance with the standards and a format
for developing an action plan in response to items identified in the
review. SPMHA, in cooperation with
DMH/DD, will be responsible for developing and implementing a plan addressing
the issues noted in the Areas Requiring Response.
This review confirms that SPMHA meets or
exceeds the basic guidelines of the DMH/DD and DPH EI/ILP Service
Principles. The team recognizes that
all programs, regardless of how good they are, can always get better. We trust the recommendations we have made
will help you consider ways to improve your services.
Once again, thank you for welcoming us into your house and allowing us the opportunity to evaluate your program.