Mental
Health Site Review
Juneau Alliance for the
Mentally Ill
Ellen Northup, Juneau
Erik Lindbeck, Juneau
Rosalyn Billingslea, Juneau
David VanCleve, Facilitator
Dan Weigman, DMHDD
Connie Greco, DMHDD
Nancy Mathis, DMHDD
Introduction
A
review of the mental health (MH) services offered by Juneau Alliance for the
Mentally Ill (JAMI) in Juneau, Alaska was conducted from April 26-29,
1999. JAMI offers MH services to
approximately 130-140 people. Current
services provided by JAMI include residential services, crisis/respite and
transition, outreach, a vocational program, day services, clinical support
services, family support, and education.
A psychiatrist and nursing staff provides psychiatric assessments and
medication management. Emergency
services for JAMI consumers are available 24 hours a day through on-call mental
health professionals in the community, crisis/respite care, and a call-in line
to Shattuck House, the JAMI crisis/respite center.
This
is the first review conducted of JAMI 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, three community
representatives, a peer provider from MH, and three representatives from DMHDD
met for four days in Juneau. The survey
portion of the team conducted interviews, reviewed agency material, personnel
files and interviewed 18 consumers and
family members, 6 program staff, 3 board members, 8 staff members, community
members and 7 related service providers.
Of those, 10 were randomly
selected individuals and families who receive services from JAMI. The file review portion of the team
conducted a quality assurance review of ten
(10) Medicaid files and five (5)
non-Medicaid files.
Interviews
were in person at the JAMI offices or by phone. The interviews lasted 20 minutes to an hour. 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 are reported
below. The report includes a list of
areas of excellence, an administrative review, areas of programmatic strength,
specific services or procedures that are recommended for improvement, tables of
consumer satisfaction with quality of life and services. File reviews were completed by the QA unit
during this review. The findings of the
file review will be shared in a separate briefing.
Our
report is based on a random sampling of consumers served by JAMI; interviews of
people representing collaborating agencies, and family of recipients of direct
services.
Areas
of Excellence
1. JAMI’s
case managers enhance the environment to the degree that consumers feel
empowered. Case
managers were consistently praised by consumers for always empowering
them. Case managers do not rest on
their laurels but continue to seek out ways to improve and strengthen
cohesiveness and keep consumers invested in the process of reaching
independence. Their exceptional
outreach efforts have resulted in services to people who might otherwise have
fallen through the cracks. For example
staff initiated a baby shower for an expectant mom and delivered needed but
unsolicited food demonstrating an exceptional sensitivity to the dignity of
service recipients.
2. JAMI
has developed relationships with other non-profits and related service agencies
to smoothly and effectively meet the resource need of consumer to an
exceptional degree.
One person interviewed stated that he had never seen the focus on the
mission of meeting the needs of those requiring assistance take such precedence
over the division of duties.
3. The
current board clearly sees the necessity for preparing, empowering and
supporting consumers to assume positions of responsibility and consequence on
decision making bodies within JAMI that include not only the board and advisory
positions but administrative positions as well. The team recognizes in particular the
efforts of Mr. and Mrs. Murphy (former board member) and the current board
president, David Crosby, for their commitment to consumer empowerment and their
clear awareness of the difficulties involved in that effort. The personal integrity of the board members
was evident in their insistent emphasis on the importance of initiating
structural and programmatic innovations toward this end.
Administrative
and Personnel Standards Narrative
JAMI
is a leader in offering MH services to adults in the Juneau area and sets a
high standard to all MH agencies in the state.
Most commendable is the administration’s recognition of its deficits and
the clinical director’s acknowledgement that these problems can be solved only
if consumers are elevated to positions of respect and consequence. Rollo May, the pioneer existential
psychologist, has said that, “When people feel their insignificance as persons
they also suffer an undermining of their sense of human responsibility.” What the team heard was a willingness to
make the adjustments to operations and intention to plan and implement
meaningful steps to remove the barriers to trust relationships that staff and
service recipients experience.
Choice and Self-Determination
The
team identified the following strengths under Choice/Self-determination for all
people receiving services from JAMI:
·
find
that case managers provide them with adequate choices to help them reach their
identified goals
·
encourage people receiving services from JAMI to
participate in treatment decisions and treatment planning
The
following are examples of statements consumers/families gave to the review
team:
“They help me make choices they don’t do it for
me.”
“I have a lot of input in making choices. They help me maintain my high functioning
status. I’m involved and in total
control of my choices.”
Dignity, Respect and Rights
The
team identified the following strengths under Dignity, Respect and Rights for
all people receiving services from JAMI:
·
are
aware of the need for releases of information to protect confidentiality and
report knowledge of consumer rights
·
consistently
report the personal attention to the rights of consumers, dignity of the person
and respectful treatment by case managers and clinical staff
·
express
awareness of implicit and explicit on-going demonstrations of dignity and
respect by staff
·
demonstrate awareness and concern for language
issues
·
facilitate
work goals with an awareness of the importance of the contribution that
meaningful work makes to the self-esteem of the individual
The
following are examples of statements consumers/families gave to the review
team:
A consumer with a frame of reference said, “It’s
not like it’s prison!”
“The people I see give me more value and respect
than I have for myself. I have a hard
time with that . I look at Rose and
Sally as loving parental figures.
They’re emotionally warm.”
“Within JAMI and Bartlett I was treated like a
substance abuser. However, during Dr.
Roger’s tenure my rights were respected.”
“My rights are going through change. As my awareness has increased my
participation has increased. Testifying
before legislators has helped me realize I have an influence.”
Health, Safety and Security
The
team identified the following strengths under Health, Safety and Security for
all people receiving services from JAMI:
Families/people:
·
feel
safe at JAMI
JAMI
Staff:
·
the
clinical director has expressed an awareness of the need for outreach to meet
the needs of those more self-reliant consumers in the community
·
who
have related to people in their own social environments have been the most
successful in outreach efforts.
The
following are examples of statements consumers/families gave to the review
team:
“I’m independent enough to take care of my
housing. I don’t have to worry about
food resources.”
“They are trying to help me and make me feel
independent. I really trust them. They know what to do for medical and dental
services.”
Relationships
The
team identified the following strengths under Relationships for all people
receiving services from JAMI:
Families/people:
·
find
that Green Doors operating hours provide social opportunities that are not
available for consumers anywhere else in Juneau
JAMI
Staff:
·
teach
consumers social skills
The
following are examples of statements consumers/families gave to the review
team:
“My support group is my mom and son.”
“JAMI helps me process family issues which may be
good or bad with my mom or my son...They give me good support with little
things.”
“My two close friends are my case managers, Georgia
and Rose, who are more supportive than my family who only criticize.”
Community Participation
The
team identified the following strengths under Community Participation for all
people receiving services from JAMI:
Families/people:
·
participate
in volunteer activities
JAMI
Staff:
·
encourage
community participation by consumers
The
following are examples of statements consumers/families gave to the review
team:
“Participating in community and social affairs has
been important. I’m trying to get out
of my own little planet; JAMI has helped me achieve that. If it weren’t for JAMI my brain would’ve
taken a left turn.”
“Juneau is more receptive to mental health
[consumers] than Fairbanks or Anchorage”
Public
Comment
JAMI
scheduled a public comment meeting for Tuesday, April 27, 1999 in the public
library conference room. The Executive
Director, the previous clinical director, three board members one former board
member and two members of the survey team were in attendance. No others attended the public forum. The facilitator suggested before scheduling
that if JAMI staff were not present during the public comment period it might
encourage those with trust issues (for whatever reason) to attend and possibly
share their valuable perspective on how barriers to service could be
overcome. A member of the review team
from the community gave testimony, as did the previous clinical director of
JAMI.
The
team identified areas that need attention from the organization and makes
following recommendations:
1.
The
mission statement adopted 5 MAY, 1995 technically meets the requirement of the
standards but this empowering language is not consistent throughout policies
and procedures or proposals submitted for funding purposes. Person centered language is absent in most
documents and conversation. The term
"appropriate" in the cited statement is inappropriately ambiguous
(Admin Standard #1).
2.
Agency-wide
education and orientation is not complete.
Person centered language is absent in most conversation. Staff recognizes the inconsistency in
language between documents. The team
noted the importance of referring to consumers as such rather than as
clients. This will demonstrate a clear
direction regarding respectful ways treat consumers in the effort to meet their
service needs. It may be said that even
consumers refer to themselves as clients.
The patron/client terminology places the service recipient the passive
role of someone that something is being done to rather than an active
participant in ones own rehabilitation.
The clinical director expressed a clear awareness of this deficit and
willingness to correct it. Reported
behavior of support staff by consumers indicates that there is a vague
understanding of the focus of service (Admin Standard #2).
3.
Policies
for correcting conflicts of interest are documented for clinical relationships
but not noted for other employees (Admin Standard #10).
4.
The
Green Doors is a locked facility and normalizing activities involving public
participation are minimal (Admin Standard #11).
5.
Family
participation in the setting of policy and program delivery underpins the
program. Consumer input lags. People who receive services at JAMI are not
actively involved in the planning and policy development of the organization. Involvement of consumers in this way may
mitigate the feeling often expressed that decisions are made in a punitive and
arbitrary way regarding housing selection and eviction or in preference for
case managers or services offered.
Policies and procedures are being updated (Admin Standard #12).
6.
Follow
through with plans to engage the services of a consultant to address nagging
consumer/provider trust issues that have made politically active consumers
reluctant to contribute to the improvement of services.
7.
There
is no formal documentation of involvement of consumers staff and the community
in annual agency planning and evaluation (Admin Standard #13).
8.
There
is not a written policy and procedure requiring the development of annual goals
and objectives in response to consumer, community and self-evaluation
activities (Admin Standard #14).
9.
All
staff do not consistently have the appropriate training and supervision to meet
all necessary, ethical, and regulatory requirements (Admin Standard #19).
10.
Consumer
choice is not used consistently in the hiring of direct service providers. Evaluation of providers does not involve
consumers (Admin Standard #22).
11.
The
agency does not provide new employees with a timely and comprehensive
orientation and training according to a written plan (Admin Standard #25).
12.
Policies
to facilitate non-paid relationships are not present (Admin Standard #26).
13.
Follow
through with plans to engage the services of a consultant to address nagging
consumer/provider trust issues that have made politically active consumers
reluctant to contribute to the improvement of services.
Consumer
Satisfaction
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
JAMI. The questions were taken from the
Consumer Satisfaction section of the five Outcome areas, and the responses are
presented according to type of service.
|
MH |
Choice N=18 |
Dig&Res. N=18 |
Hth,Saf,Sec
N=18 |
Relatns. N=18 |
Com.Par.
N=18 |
||||||||||
|
Outcome |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
|
Person/Parent/guardian |
17 |
1 |
|
16 |
2 |
|
15 |
3 |
|
15 |
3 |
|
16 |
2 |
|
|
Staff
Performance |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person/Parent/guardian |
14 |
4 |
|
15 |
3 |
|
16 |
2 |
|
15 |
3 |
|
16 |
2 |
|
File
Review Summary
The
DMHDD Quality Assurance Unit will present a separate report on the file
review. Designated members of the team
reviewed the files of those consumers who provided their consent.
Inconsistencies were found in documentation, and some plans were out of
date. As noted in a previous section,
some staff have found it increasingly difficult to keep pace with the demands
of documentation.
Other
suggestions and comments
People
who receive services from mental health service providers have repeatedly said
that they want to be referred to as consumers.
It is essential that adult roles be reinforced in language so that
providers can benefit from the unique and valuable perspective that people who
receive services have to offer. One
person who is a service recipient put it this way, ”I’ve been and inmate,
patient, client, then consumer. When do
I get to be a person?”
This
is a subtle but powerful issue that one would not expect to be commonly
understood in other areas of business and public endeavor but is fundamental in
this one. Whether only perceived or
real the foundation of the fear people experience asking for what they want can
be rooted out only when the rules of civility are carefully observed by
providers of services as well as recipients.
Adults must feel safe expressing their desires as well as assisted in
that effort by those paid to do so.
The
team noted that there are many consumers who are interested in meaningful
social and job opportunities that meet their more complex psychosocial
needs. The team discussed the
exceptional social and skill development opportunities that Green Doors provides
for people who prefer the privacy of that environment. Green Doors is a welcoming place for still
others who may have chronic or episodic difficulty with conspicuous symptoms or
experience social skill deficits that are understood and accepted or respectfully
addressed in the familiar surroundings of JAMI.
The
extensive and exceptional property resources that JAMI controls offer
extraordinary possibilities to provide work and social opportunities for
consumers who function well and for long periods of time in more integrated
settings. The barriers to providing
meaningful opportunities to consumers with more complex needs have been
persistently difficult to overcome for many mental health service providers. Part of the difficulty has been the risk of
the loss of necessary services and resources to people as a consequence of
“significant gainful activity” whether for wages or not. Another has been the nuance of the corporate
structure that makes creation of meaningful opportunities under that umbrella
difficult.
The
JAMI office location is ideal for a consumer operated and controlled business
that could provide normal social opportunities and the necessary supports
required to overcome any lapse of confidence a participant might experience. Consumers would be a visible presence in the
community and in that way confront and reduce the stigma of mental
illness. This would be a social benefit
to everyone not just those labeled with mental illness.
The
development of a caring community is the process that will empower staff to
deliver services effectively and will also give consumers the security that
they need to participate in their own rehabilitation. If these goals are accomplished the social and vocational needs
of people diagnosed with a serious mental illness can be met. They can be met because the disabling
tension over physical, security, and support needs for consumers of mental
health services will have been addressed.
Empowering
social skills can only be developed in supportive real world settings. Social and enrichment opportunities should
be abundant in natural environments that encourage and invite pedestrians to
participate. A club for people
diagnosed with a serious mental illness is a contrivance that is meaningful for
transitional, episodic, or on-going needs.
All consumers, however, may not benefit from an overriding concern for
confidentiality that isolates more resilient people who could benefit from the
challenges of building meaningful relationships in natural settings.
JAMI
staff expressed awareness that greater productivity and more efficient use of
scarce resources is possible if healthy trust relationships are developed
carefully between and among staff and consumers as full partners in the
delivery of services. This understanding
was evident in speaking to one administrator who is arranging to bring in a
consultant to address those nagging trust issues that drain energy and reduce
efficiency. JAMI has developed trust
relationships among other diverse service providers in Juneau. It would be noteworthy if the same
exceptional focus on the use of resources to meet objective goals could be
accomplished in service to a clearly defined mission within JAMI as well.
If
policies and procedures can be implemented to institutionalize an on-going
revitalization of trust relationships among all administrative, clinical,
maintenance, direct service staff and consumers there could be more confidence
in the sustainability and relevance of JAMI.
The
site review and file review team thanks the JAMI staff for their wonderful
enthusiasm, professionalism and hospitality during the site review. We
appreciate your patience and help.
You
will receive a final report within 30 days 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. JAMI, in cooperation with DMHDD will be responsible for
developing a plan addressing the issues noted in the Areas Requiring Responses.
The
team recognizes that all programs, regardless of how good they are, can always
get better. We trust that the
recommendations we have made will help you consider ways to improve services.
Everyone
on the team was impressed with the potential JAMI demonstrates to play an
exemplary role as a mental health service innovator. JAMI holds, as few other mental health service providers do, the
potential for consumers of services and the providers of those services to
become partners in the advancement of the Mental Health Center to a dynamic
position in the community.
The
typical community mental health center has developed so that its concerns are
divided among a number of identified groups in need. People diagnosed with a serious mental illness find that they may
not receive the level of service they need because of the divided attention of
the agency. JAMI’s mission is to serve
the needs of adults diagnosed as having a serious mental illness and has the
advantage that it’s attention is not divided on so many needs that those it has
chosen to serve would be neglected.
Once
again, thank you for your many successes with some very difficult challenges.