Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska  99901

(907) 225-6355

FAX  225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW
 
Islands Counseling Services
October 30-November 1,2000
Sitka, Alaska

 

Site Review Team

Tane Skultka, Community Member

Carol Goff, Community Member
Bill Aube, Peer Reviewer                                

 Robyn Henry, Facilitator

 

 

INTRODUCTION

 

A review of the mental health (MH) services provided by Islands Counseling Services (ICS) was conducted from October 30 to November 1, 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.

 

Description of Services

 

ICS is a non-profit community mental health center that provides services to children and adults who live in Sitka City and Borough. The agency is also available to provide telephone service to the surrounding communities but receives very few referrals from those communities. 

 

The agency’s service area population is 8,500 people in the city and borough and an additional 1,000 people in the surrounding areas. A separate agency provides general mental health services to Native Alaskans with some limited services to non-Natives.

 

ICS currently provides services to approximately 30 outpatient clients, 19 children and their families, and 20 people served through the Harbor Lights Community Support Program.  Adult services provided by the agency include outpatient individual and family therapy, and emergency services.  Through the agency’s Community Support Program, Harbor Lights, the agency provides outreach, case management, employment/education and recreation services to adults diagnosed with a major mental illness and severe emotional disturbances. 

 

Children’s services provided by the agency include activity therapy, family support services, home based therapy, intensive rehabilitation services, and crisis intervention services. Wrap-around services are offered to children with severe emotional disturbances in the Alaska Youth Initiative (AYI) program and a home based program offers services that focus on family preservation. The program also works closely with the Sitka School District to provide support to children in the school setting.

 

A seven-member board of directors, that meets quarterly, governs the organization. The agency employs twenty-five people, full and part time.

 

 

Description of Process

 

To conduct this review, an interview team consisting of a facilitator, two community members, and a peer reviewer conducted twenty-five interviews over a three-day visit in Sitka, Alaska.

 

Five interviews were with adults who receive services including three in the Community Support Program. Three interviews were with parents or guardians of children who receive services.  Given the size of their case load, ICS had been asked to schedule fifteen interviews.  The original schedule did include thirteen interviews from the randomly selected list.  However, five of those scheduled did not appear for their interviews.

 

Ten interviews were conducted with related service professionals and seven interviews were with program staff. Two of the interviews were with people who serve on the ICS board of directors and another was with the board president. Interviews lasted from 15 minutes to an hour and were held in person at ICS offices and by telephone.

 

The interview team members also reviewed five personnel files, the agency’s program policies and procedures, and other administrative documents. After gathering the information, all the team members met to review the data and draft the report, which was presented to the administrative staff on the final day of the visit.

 

Open Forum

 

 A public forum was held in Sitka at the Centennial Building at 7:00 P.M. on October thirtieth. ICS advertised the event by faxing a Public Service Announcement to service providers throughout the community, announcing it on the three local radio stations and advertising it in the local newspaper. Five people attended this event including a mix of related service agencies and people who receive services. The feedback provided by attendees of this event is incorporated in the findings of this report.

 

FINDINGS

 

Progress Since Last Review

 

This is the first review of ICS using these new program standards.  Therefore, there is no previous action plan for the mental health program.

 

Areas of Excellence

 

In-school Support – Several people interviewed, both clients and agency representatives, indicated that the support ICS provides children in the school is invaluable. It was noted that behavioral supports to the children are positive rather then punitive (in contrast to the school).  A guardian indicated that since ICS got involved in supporting the child, improvement has been like “night and day”. A school principal indicated that “there is always improvement when ICS is involved in the case”.

 

The Five Quality of Life Areas

 
Choice and Self Determination

The team identified the following strengths under Choice and Self Determination for those receiving MH services:

+        Almost all people reported that they feel they have choices about the services they receive and that they are happy with those choices.

+        Almost all people interviewed said that they were involved in the development of their treatment plan and that the goals on their plan reflect their own goals and desires. One person said, “All (my) needs, concerns and wants are in the plan”.

+        Many people reported that the agency provides flexible and responsive services. One person explained that staff are “right on top of things”.

+        One parent expressed her appreciation for the support she got from ICS staff in trying to get TEFRA (Medicaid) support.

+        One guardian indicated that they were very impressed with the support the ICS staff gave to a child who was moving to a community across the state. That support included two escorted visits to the new community prior to the move.

+        One parent expressed how pleased they were with ICS staff when they created a crisis plan with the family when the child was having problems.

 

The team identified the following weaknesses under Choice and Self-Determination for those receiving MH services:

-          One person indicated the need for a support group for veterans. (systems issue)

-          Several people indicated the need for dual diagnosis services for people who have co-occurring substance abuse and mental illness.

-          One person expressed their frustration when their services were discontinued because their insurance did not cover the services indicated in the treatment plan.  Although a sliding fee scale was offered, they indicated they could not afford the out of pocket expense.

-          Two people and the team members identified the need for early intervention and prevention services for children. This would include affordable services and supports for children who have behavior problems but are not diagnosed as severely emotionally disturbed.

-          One person indicated and the team noticed that the agency is serving a relatively low number

      of children and adults with serious and severe mental illnesses in relation to the overall

      population of the service area. The agency reported that although the numbers are

      relatively low, in the last year they have doubled the number of children they are serving.

 

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:

+        Almost all people interviewed said they felt respected and valued by staff. One person explained “It really feels like they listen to me.”

+        Most people reported that they feel that staff are very collaborative and responsive to their needs. Several people specifically said that they feel they get “really good services”.

+        Most people interviewed were aware of their client rights including the grievance procedure.

 

The team identified the following weaknesses under Dignity, Respect and Rights for those receiving MH services:

-          One person reported that they did not get information about their client rights.

-          The team noticed that the current offices had walls through which you can hear conversations. This was such a concern that team members hesitated to interview in the offices for fear of a breach in confidentiality. This situation also raised confidentiality concerns about people who have therapy sessions and meetings in the offices. 

 

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for those receiving MH services:

+        Most people reported that they feel safe and secure in their current living environment.

+        All people reported that their health needs are being met and that, when needed, the agency helps them access those services.

+        One guardian indicated that ICS staff went out of their way to protect a child that was in an unsafe environment.

 

The team identified the following weaknesses under Health, Safety and Security for those receiving MH services:

-          Several people indicated that they are in need of dental services (system / agency issue)

-          Several people talked about the problems people have in accessing services at SEARHC and the need for more coordinated services. (community issue)

-          One person reported and the agency’s quarterly report confirmed that one client experienced long delays in receiving needed medication.

-           

Relationships

The team identified the following strengths under Relationships for those receiving MH services:

+        Most people reported being very satisfied with their relationships and the agency support in this area.

+        Both a parent and a guardian indicated that ICS staff were very supportive and encouraged their participation on the treatment team.

+        Two adults indicated that ICS staff are very supportive of their relationships with their family members.

 

Community Participation

The team identified the following strengths under Community Participation for those receiving MH services:

+        Two adults said that they were getting support by ICS staff to return to school.

+        One parent said they felt positive about the children’s in-school program and that the services helped their child stay in school.

+        One adult expressed appreciation regarding the support they get from ICS staff to access community services and activities such as shopping, paying bills etc. Another person said that staff really helped them reintegrate into the community after a period of isolation

+        Two clients indicated that they really enjoy the recovery program at Harbor Lights. One added that they would like to see the pool table accessible again.

 

The team identified the following weaknesses under Community Participation for those receiving MH services:

-          One person identified the need to integrate non-disabled children in activities to reduce stigma and singling out. The program indicated that they have started several programs that do this.

-          One person reported that they really wanted to go back to work but that no one was helping them with this goal, including lack of support from DVR (system / agency issue)

-       The team noticed a need for community outreach and education about services available both

         to reduce stigma and to increase the possible use of the services for those who are

         unserved.

 

Staff Interviews

 

Most of the staff in the agency are new. Of the twenty-five staff, only five have been with the agency for more than a year. Seven agency staff were interviewed during the site review. Overall the staff interviewed were very positive about their work environment and about the clients and staff with whom they work. Staff appear to embrace the client centered philosophy of the agency with a strong commitment to the people they serve.  One person summed it up by saying, “we never give up on someone”.

 

Strengths of the agency reported by staff include open communication or an “open door policy;” support and feedback from supervisors; support for training; orientation during the beginning of employment. Areas of need identified by staff include a new building which would include windows; more training for direct care staff, especially those at a bachelor’s level or below; more funding to hire additional staff and to help provide more services.

 

Interviews with Staff of Related Agencies

 

Ten people from related agencies were interviewed. Agencies represented in the interviews included: DFYS, the local police, the Sitka school district, the local hospital, the Division of Vocational Rehabilitation, a local substance abuse program (SPATS), a staff member from the SEARHC program and two private providers including an Occupational Therapist and a Licensed Social Worker.

 

Overall, the comments about the agency given by the related service providers were very positive. Agency strengths cited by the interviewees included the agency’s openness to collaboration and its being easy to work with. One person noted that ICS invites clients from their agency to some of ICS’s activities. The same person indicated that ICS agreed to sub-contract services to a client who also experiences mental illness symptoms.

 

Two people expressed their appreciation to ICS for sharing training resources with the community. Other providers echoed this sentiment of appreciation to ICS for their willingness to partner on projects and services to clients. Several people identified the effectiveness of the new executive director, citing her as a real asset to the agency.  She was described as “very proactive” and “very sharp.” 

 

Areas of need cited by agencies included: the need for children respite beds (they did not know about the upcoming program) and the general need for all agencies in the community to collaborate and maximize the use of the community resources.

 

Administrative and Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 30 of which are completely met by ICS. Those standards not fully met are:

 

1.       The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery. (Standard #12) The agency does not currently have a formal process for getting consumer and family input for policy setting and service delivery decisions.

 

2.       The agency systematically involves consumers, staff and community in annual agency planning and evaluation of programs, including feedback from its current and past users about their satisfaction with the planning and delivery of services. (Standard #13) The agency currently does not have a method for systematically including consumers in their annual planning and evaluation process.

 

3.       The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14)  While the agency does set agency goals annually, the agency currently does not formally include consumers’ input in its agency goal setting process.

 

4.       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 or consumer. (Standard #22)  The agency does not have a process for including consumers in the hiring and evaluation of staff.

 

Program Management

 

The agency had been in transition for just over a year following the departure of the last executive director. The hiring of the new executive director was the result of a careful and thorough hiring process designed to select the best match for the position.

 

The current director has been with the agency for almost a year now and has implemented many positive changes. The organization appears to be well managed. There is an expressed feeling of optimism about the program when talking to almost all of those interviewed.

 

Areas Requiring Response

 

1.  The agency needs to develop a process to actively solicit and carefully utilize consumer and family input into agency policy setting and program delivery.  Standard #12

 

2.  The agency needs to systematically involve consumers, staff and the community in annual agency planning and evaluation of programs, including feedback from its current and past users about their satisfaction with the planning and delivery of services.  Standard #13

 

3. The program needs to develop a process to develop annual goals and objectives in response to consumer, community and self-evaluation activities.  Standard #14

 

4. The agency needs to develop and utilize a procedure to incorporate consumer choice into the hiring and evaluation of direct service providers.  Standard #22

 

Other Recommendations

 

  1. Modify the current office building to address the issue of conversations being overheard. (For example, get white noise machines for the hallway or add noise-absorbing panels to rooms.)
  2. In your efforts to attain a new building, include input from consumers, staff, and community members.
  3. Increase outreach efforts to people who may be eligible for but are not receiving services.
  4. Continue to work in the community to educate the general public about the services offered and to reduce stigma.
  5. Develop affordable services for children who are having problems but who have not been diagnosed as SED. (For example: Big brothers/sisters program, mentor program, other volunteer programs such as the Jesuit VP)
  6. Develop a dual diagnosis program to serve people with mental illness and chemical dependency.
  7. Continue to work with other community agencies to maximize community resources to ensure people get needed services.

 

 

The team wishes to thank the staff of ICS for their cooperation and assistance in the completion of this review. A process such as this can be very disruptive to the office environment and your hospitality was much appreciated by all of the team members.

 

The final draft of this report will be sent to Northern Community Resources for final review. You will receive the final report within approximately thirty days, including a Plan of Action form, listing the Areas Requiring Response.  You will then have an additional 30 days to complete the Plan of Action. The directions on how to proceed from there will be included in a cover letter you will receive with the final report and Plan of Action form.                                                 

Once NCR has reviewed the completed Plan of Action, it will be sent to the DMHDD Quality Assurance Section.  The QA Section will then contact you to develop collaboratively a plan for change.

 

Attachments: Administrative and Personnel Checklist, Interview Form for Staff of Related Agencies (tallied), Score sheet (averaged)