Mental
Health Site Review
Providence
Kodiak Island Mental Health Center
May
17-19, 1999
Kodiak,
Alaska
Site Review Team:
Julie
Hill, Community member
Sheila
Major, Community member
Frank
Addrisi, Peer Reviewer
Barbara
Price, Facilitator
Pam
Miller, DMHDD Quality Assurance Unit
Nancy
Mathis, DMHDD Quality Assurance Unit
Dan
Weigman, DMHDD Quality Assurance Unit
A review of the mental health (MH) services provided by Providence Kodiak Island Mental Health Center on Kodiak Island, Alaska was conducted from May 17-19, 1999. Community mental health services have been provided in Kodiak since the first of April, 1970. The Borough oversaw the program until FY 98, with services being transitioned to Providence Alaska Health System from October, 1997 until January, 1998.
Providence's involvement has been generally well
received. Comments included "It's
a better agency now", that the "take over" was
"GREAT", bringing "a professional perspective to running the
program", that efficiency has increased, that this agency is now
"more together."
Providence defines its mission as continuing
"the healing ministry of Jesus"
especially to the "poor and vulnerable" and in "a spirit
of loving service." Identified
core values are "compassion, justice, respect and excellence."
PKIMHC serves the island population of some 15,000
from its base in the city of Kodiak.
The city itself has a population of 11,000 while the U.S. Coast Guard
base there has a population of 3,000 including active duty personnel and their
dependents. The remainder of the
population is spread over seven villages and scattered logging camps.
Services provided include the Community Support
Program (CSP), with outreach and case finding, case management, medical/nursing
treatment, family support, peer support and psychosocial rehabilitation
services for SMI, SED and dually diagnosed adults. SED youth and their families receive family skill development,
home-based therapy and skill development.
Emergency services are provided on a 24 hour/7 day a week basis through
a rotating on call system. Case
managers, in addition to their caseload, provide outreach to the homeless
mentally ill. The two case managers in
conjunction with the two behavioral specialists aid with training, job coaching
and other group activities. Home Health
Care nursing staff, contracted with Providence Kodiak Island Medical Center,
provide medication management services.
While residential services are not provided, the
Borough owns housing in the same complex that houses PKIMHC. This transitional housing is available to
CSP clients and medication management is provided there. Services are available in the apartments
during normal business hours. The
population varies from eight to nine residents. There is no specified maximum
length of residence and only a minimal amount of rent is charged for the
housing.
The agency is currently considering a contract for
a consulting occupational therapist.
Prevocational services are now arranged between DVR and the case
managers.
Out patient services are provided. Services are provided in the schools
throughout the island by the KIBSD Service Team. The school based services, provided by 4.5 FTE's (3 of whom are
Master's level) are assessment and evaluation, emergency response, crisis
intervention, therapeutic intervention and support, case consultation,
psychoeducational development, staff training and consultation.
The local hospital can accommodate Title 47
clients, providing 24-hour evaluation and 72-hour hold. The local magistrate presides over these
procedures. The mental health unit has
four rooms, one a locked seclusion room with a foyer area for observation. The director describes the unit as
underused. Emergency events number
eight to ten per month as well as emergency room visits of indeterminate number
which do not result in admissions.
PKIMHC serves a diverse population of Native
Alaskans, Filipino, Hispanic and other non-Native populations. The school population is 51% Filipino and
the Kodiak city population is 50% Filipino and Hispanic. The outlying villages are chiefly
Aleut. The staff includes one
individual of Hispanic heritage and one of Filipino heritage.
The agency is currently in transition, having new
administrative and clinical staff. The
case managers and support staff predate the change to Providence, but otherwise
the nineteen current employees are relatively new to the agency. The current director was contracted as a
psychiatrist with the prior agency.
A Policy and Procedure Manual specifically for
PKIMHC is under development. In the
interim the program is governed by Providence's policies.
This transition has been complicated by local
disputes, including legal and ethical issues, turnover of clinical staff, a
power shift from Borough oversight to oversight by Providence, past cost
overruns funded through the Borough's general fund. In short, the agency has a clouded past that continues to be
discussed in the community. In general,
the community response to the change wrought by Providence and the new director
has been positive with the acknowledgement of greater stability and improved
services, particularly in the villages.
The clinical staff has been reduced under the
current director from seven to two or three with, he asserts, no decline in
productivity. Typically, the agency
logs 140-150 encounters per month plus hospital visits. The director, a psychiatrist, provides
services and administrative oversight three days per week with the remainder of
his time committed to the hospital where he is chief of staff. There is, in addition, one program manager
and two clinical team leaders, the latter being psychologists. The director reports that this configuration
has resulted in increased clinical services and decreased administrative costs.
The director identifies a weakness in charts
predating his takeover. Improvement of
charting is an identified goal and he feels that substantial progress has been
made in this area. The results of the
file review process are included later in this report.
QA efforts now include weekly meetings by those
responsible for quality assurance, a reorganization of the file room, an index
of charts and the centralization of chart storage. At the time of transition, PKIMHC continued open cases with the
consent of consumers, updated files and destroyed old files.
This introduction would not be complete without
reiterating the relative newness of Providence's involvement with local
community mental health services on Kodiak Island. There is inherent in this mix a clash of culture and that will be
reflected more than once in this report.
It was brought to the team's attention that the
agency reflects hierarchical structure that reduces significant participation
in program development by staff.
"Decisions are made above and passed down." A more typical community mental health
center culture is egalitarian, loosely structured, with staff filling multiple
roles and participating in planning and program development efforts. In additions, the broadly defined mission in
such a setting tends to reflect the values of the community at large and of the
consumer community specifically and staff collaborate with the consumer of
services in effecting change.
In such a setting a board may be advisory in
nature, yet its role may well be afforded more value than the term
"advisory" implies. It can be used as an indicator of public opinion
and participate in planning efforts as well as in evaluation and community
education.
This cultural contrast, if left unaddressed, will work
against the gains already achieved by this agency and will endue the
environment of the agency with a level of stress and potential conflict that
can harm it, its staff and those it serves.
Review Process
This is the first review conducted of PKIMHC using
the Integrated Standards and Quality of Life Indicators.
To conduct this review, a team consisting of a
facilitator, two community representatives, a peer provider from a MH program
and three members of the DMHDD Quality Assurance Unit, met for three days in
Kodiak. The team conducted 19
interviews, of which 8 were individuals who receive services from PKIMHC, three
of the latter taken from DMHDD's random selection of cases. Eight were related service professionals,
one was a board member and two were PKIMHC staff. In addition, informal interviews occurred with six community
members who attended the public forum and one additional person who contacted
the team by phone. These latter seven
individuals included consumers, family members, board members and related
agency personnel, with many having multiple roles. The team also reviewed program and agency materials.
Interviews were held in person at PKIMHC's offices
or by telephone. The interviews lasted
from ten to sixty 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.
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 review of the previous
findings, a list of areas of excellence, an administrative review, areas of
programmatic strength, specific services or procedures that are recommended for
improvement and tables of consumer satisfaction with quality of life and
services.
As this is the first review of PKIMHC using the new
program standards, there is no previous action plan for these integrated
standards. A plan for improvement for
required chart reviews will be addressed separately in the DMHDD QA report.
This section need not be completed and, indeed, is
not in some site reviews. In this case,
however, the team agrees that PKIMHC clearly excels in the following two areas
based on the overwhelmingly positive response from consumers and their families,
related service providers, community members and other staff.
First, and without exception, the Community Support
Program (CSP) team received hearty praise from all sectors of this
community. This team was repeatedly
singled out for praise for their expertise, their flexibility, their effectiveness
and their accessibility. A sampling of
the many positive comments includes: "excellent", "SO
helpful", "on the ball" "conscientious and committed"
and being as well informed regarding resources as persistent in pursuing them.
The NCR
team noted that the CSP area within the agency building is a home like
environment with a complete kitchen and living room. Consumers appear to be relaxed and comfortable there and consider
it their own space. Organized
activities for CSP clients include swimming, bowling, fishing, hiking, weight
training for men and aerobics for women.
Two consumers interviewed had gained sufficient skills through CSP to be
employed successfully and it was clear they took great, and deserved, pride in
their jobs. As one CSP provider
commented "It's so good when you see them really get better."
Further praise received included a parent's comment that she
"thought that he was lost" until her son received CSP services. A related service provider stated "I
know one guy that wandered for nine years before he got to CSP" where his
life was changed. Clinical staff also
note the effectiveness of their CSP team, as they are "helpful, willing to
go out of their way" and that clients do improve with the aid of this
service. These triumphs rebound,
providing a rewarding environment for the CSP team while modeling hope and
pride for other consumers.
Perhaps
of interest to the agency in general and the CSP team in particular, is the
concern of related agency staff and of consumers that these providers are over
worked and fears were expressed that they might "burn out"
Individual members of this team were also singled out for praise. Even a
generally disenchanted consumer spontaneously affirmed: "I have great
respect for my case manager" (in reference to Lola) and, in mentioning
Mary, said proudly "Mary talks to me like an equal!" Another CSP team member was described as
"top shelf...She'll know who I mean." (We don't, but hope you
recognize yourself!) And once again,
Lola was mentioned by name and described as "a great help" by a
consumer.
Dr.
Howes was recognized for his role in setting up a team meeting for
transitioning these consumers. Cisco
was described as a consumer's favorite person at PKIMHC. The closest thing to a "criticism"
was a consumer's response indicating that inappropriate dependence was not
encouraged!
This
report would not be complete without mention of the outreach program for the
homeless coordinated with the Brother Francis Shelter. The fact that contact is made at the
shelter, that services are generous and effective and that the shelter staff is
able to communicate effectively with PKIMHC staff adds a unique facet to this
excellent CSP program.
Secondly, a unique and outstanding feature of
PKIMHC is the provision of regular, continuous on-site psychiatric
services. Informants consistently
praised Dr. Jensen and the services he provides. A local booster observed: "Two psychologists and AN MD for a
population of 14,000 people! Pretty great
that we can attract that staffing for a population of this size!" A related service provider solemnly declared
"If you have to be afflicted with a mental illness, this is the place to
be afflicted."
Dr.
Jensen's dedication and clinical accessibility has eliminated the problems so
common to rural and isolated MH centers in Alaska: emergency services are
readily available, easily accessed and utilized seamlessly; medication
management is professional and complete; parents report that their ADHD diagnosed
children are treated appropriately, some with and some without medication, a
fact that increases their faith in the services and in positive outcomes for
their children. The hospital is more
than pleased to have this link with the local mental health services. A representative stated that Dr. Jensen is
single handedly repairing the past division between mental health and the
hospital and the marked absence of friction is applauded.
Other
agencies report vastly increased collaboration thanks to Dr. Jensen. Another service provider volunteered this
picture: "Consultation with Dr. Jensen has been excellent, above and
beyond. He is eager to help and calls
back promptly. In fact, even the
disgruntled state that they are, by and large, "comfortable" with
him. Comments revealed a balance of
professionalism and accessibility that is uncommon. Some examples: "There's no waiting list NOW!" and, in
describing the need for emergency hospital services "I told him what was
going on and he BELIEVED me! Then
everyone worked together."
The
team can only add that Dr. Jensen is seen as making a unique contribution to
this community and that the community is keenly aware of that fact.
Governance
The program is governed by a nine member advisory
board, one member holding a designated seat for a representative of the
Assembly. All seats are currently filled.
In addition, there are four ex-officio members representing KAMI, USCG
and Providence. Providence is
represented by the director and the manager.
One member of the support staff is also available to the board. A current board member notes that there are
"several parents of consumers" represented on the board and a
community member notes that one board member self-identifies as a direct
consumer of services.
Members include a representative from Safe Harbor,
the substance abuse treatment program, the Youth Service Center and the local
newspaper.
This board is not a policy making board as that
function falls to Providence. The
advisory board reviews and comments on proposed policies and on current
services. The board is not involved in
fund raising, nor in planning nor in the hiring nor in the evaluation of the
director. The board does provide
suggestions as to planning. No
documentation as to the agency's response to these suggestions was available.
The board is scheduled to meet monthly, although
recently meetings have been cancelled due to a lack of a quorum. Board member attendance is improving,
however, according to a current member.
Board openings are advertised in the local
newspaper. Interested individuals apply
to the Borough and their acceptance is dependent upon approval from
Providence. Although meetings are open
to the public, the meetings, held at the local hospital, are not well attended
by members of the public.
The existence of an executive board at a distance
from the program (Providence, Anchorage) and a local advisory board without
powers confuses the evaluation of the board in the Administrative and Personnel
Standards (Numbers 5-9). For reasons of
clarity and the intent of 07 AAC 071.0030, the board evaluation on the appended
checklist refers to the local mental health board.
There was considerable local concern expressed
regarding what some saw as an emasculation of the local board. Board members express sincere concern for
their responsibility to the community and the consumers. Board members expressed feelings of being
marginalized, lacking an effective place in the running of the agency, lacking
input into the evaluation of staff and programs. Their frustration was increased by the community's expectation
that they, though an advisory board, represent the place to go to voice
concerns. Having received some concerns
and complaints but lacking an effective means of inserting themselves into the
system of the agency has caused frustration and possibly fostered some distrust
of the agency's intent.
Financial Issues
The funding for PKIMHC is outlined in their recent
Summary of Operations (1998) as follows: a total budget of 1.4 million dollars,
37% of which is the DMHDD state grant, 28% from the Kodiak Island Borough to
fund the school based programs, 28% from third party payers, 5% from other
client fees and the remainder from contracts and agreements.
As for fees, the agency does maintain a sliding fee
scale for those unable to pay the entire fee.
That scale allows for two variables: annual income and size of
household. The scale indicates
reductions of between 0 and 97% of the full fee.
There is a community and consumer perception
sufficiently pervasive as to be worthy of noting: that PKIMHC is unduly
concerned with money. This may be a
result of the cultural differences between community centers and the medical
model of effective billing and profitability.
A concern was expressed that there was a lack of motivation to engage in
certain forms of helping as long as "no money was generated." One comment was "They are awfully
interested in money!"
The agency's ability to turn operations around from
running at a deficit of some $600,000 (in the last year of operating through
the Borough) to a positive balance in one year is seen as laudable by some and
alarming by others. Some consumers and
agencies view with alarm the reduction in staff and fear a future decline in
the number and breadth of services based on financial exigency. "The bottom line", states one
consumer, "is the only thing they're ruled by." Such a perception could undermine the
agency's community image if not counteracted.
Audit
The last audit was performed in February of the
current year and is still under review by Providence in Anchorage. The audit of PKIMHC is part of the overall
organization's audit. It was not
available at the time of the site review.
A letter was received from Providence Alaska Medical Center's Director
of Finance confirming that fact.
The prior audit was part of the Borough audit. It was unavailable at the time of the site
review.
Personnel Policies
The draft policies include annual evaluation and an
extensive orientation as to eligibility guidelines, assessment processes,
consumer involvement in planning, treatment planning including periodic review,
medical necessity, case notes, billing and the like. Examples were provided.
Part of the orientation process is the signing of the job description
and of the confidentiality agreement.
Personnel files were not accessible due to a
concern on the part of the agency with confidentiality. The second page of the annual evaluation,
which included the goals for the coming period, were provided (minus
identifying information) for six current employees.
The review of these six plans showed one listing
training needs for the coming year without specific time lines other than that
of the next annual evaluation. The
other five lacked specific training goals.
Each form included a space for employee response
along with the signature of the employee and of the supervisor.
All were dated in January of the current year.
All identified at least one resource for the
employee including financial support for continued training available through
Providence. An interview with the
director confirmed the agency's dedication to the continuing education of
employees, especially that leading to licensure.
PKIMHC provided a copy of the 1999 training
schedule. Training is provided monthly
and all but one training (on ADA) focused on clinical skills.
Staff
Agency staff are contrasted in that most clinical
and management staff are relative newcomers to the agency, while CSP and
support staff have greater longevity.
The change in benefits from a generous government
package in past years to an adequate but more modest one is noted as a loss by
some. Former employees, now retired
with PERS benefits, are viewed with some envy.
The decrease in clinical salaries since Providence's involvement with
the agency is a source of contention.
Given the history of the agency prior to Providence's
involvement and the rapidity of the transition added to the change in the
culture of the organization itself, the support staff may have taken the bulk
of the impact of the changeover. There
were several comments from those interviewed that when entering the center they
are met with an impersonal attitude that is neither warm nor inviting.
Above we repeated some of the kudos received by CSP
and clinical staff. We will expand that
here to include the special mention of:
--Dr. Howe's successful and highly appreciated
collaboration with the local substance abuse program, Safe Harbor; praise for
his effectiveness and sensitivity working with psychiatric clients; his image
as a helpful and well accepted clinician.
A consumer opined: "I liked HIS approach." A provider of a related service praised Dr.
Howe's success in advocating for a client's individual preferences.
--Those Clinician I's working in the school
program, especially Carlin and Melody, were described for us as working with
tenacity in the best interests of the students. Those providing services in the villages were described as well
liked, flexible and "very much appreciated."
In contrast, one staff member was repeatedly
described as judgmental, "punitive and arrogant", disrespectful, retaliatory
and condescending. These comments were
many and voiced with great intensity by consumers and community members
alike. The team considers this to be a
serious concern and, if not addressed, one that may tarnish the improving image
of the center.
Repeated requests were heard for the addition of a
female clinician. Clearly the agency
had already heard and agreed with this need.
A female clinician has been hired and will soon be joining the staff.
Service Coordination
PKIMHC describes working cooperatively with the
Borough, the local Native association and the school district. It is part of the Kodiak Area Child Abuse
Task Force, a network of seventeen social service agencies. In addition, services are coordinated with
the medical community, Providence Kodiak Island Medical Center, AST, the local
police department, public defender and the court system. Client care is coordinated with Kodiak Youth
Services Network, Kodiak Council on Alcoholism, Safe Harbor, Brother Francis
Homeless Shelter, Kodiak Women Resource and Crisis Center and DFYS.
Community Opinion
The perception of the agency by those who have had
no direct service contact is positive especially in relation to Providence's
presence.
Compliments were received for PKIMHC's May, 1999
series of public presentations on mental health topics in honor of Mental
Health Month. These were provided at no
cost.
Opinion of Related Service Providers
From the representatives of local agencies, we were
provided with vastly differing responses.
On the positive side, agencies are pleased with the training provided by
PKIMHC including an internship for a psychiatric advanced nurse practitioner in
training. The comment from another
service was "Collaboration has been real successful. We are where the other folks in our field
would like to be."
The Native Association voiced appreciation that
"when Providence came on board they stepped up and asked how they could
help with the needs that were identified." In addition, PKIMHC's rapid response to a village suicide was
warmly praised: "It felt so good to finally work together as an
interagency team with a coordinated effort." An attendee at the public forum described the village services
provided through the schools as "the best I've ever seen" in the
history of services on Kodiak Island.
Some school
district representatives praised the availability of mental health services
within the schools, saying, "It's great that there is an emphasis on MH
services in the school" and
"Support for kids with a mental health focus is a good
idea." At the same time issues
were raised regarding who was responsible for the supervision of school based
staff; the cost of the services which was considered excessive and not clearly
explained; questions regarding role definitions; possible duplication of
services in the elementary grades when the in-school provider is not a Master's
level person and a school counselor is present; charges for even informal
consultation with agency staff.
A strong request was received for collaboration
with the local transit system which apparently stands ready to modify schedules
if necessary to meet mental health consumers' needs.
Accessibility
Both the apartments and the offices of PKIMHC are
housed in two story units. There are
ground floor entrances to some of the offices and to the first floor
apartments. There is a wheel chair ramp
from the parking area to the buildings.
Consumers needing wheelchair access can be seen in a first floor
office. There is a rest room with handicapped
access on the first floor of the agency.
If necessary, PKIMHC states that consumers can be seen in their
home. The meandering halls and
staircases are labyrinthine, but doors are labeled and there are some arrows
indicating locations as well.
Signage is not in Braille. No TTY system is currently in place as the
agency is just now separating its phone system from that of the borough. Translation is generally provided by family
members, although translators are employed by the hospital as needed and might
be shared in the future.
Training on the Americans with Disabilities Act has
been provided to staff by the manager and one of May's training opportunities
(open to the public at no expense) provided information on sensitivity to the
needs of the hearing impaired.
This portion of the narrative refers to the Quality
of Life Values and Outcome Indicators, as they relate to the specific services
offered by Providence Kodiak Island Mental Health Center. The items listed below are those that the
review team identified as strengths. If
the team concluded that any of the indicators warranted improvement, they are
listed in the Areas Requiring Response section of the report.
The team identified the following strengths under
Choice and Self-Determination for all people receiving services from PKIMHC:
·
Consumers participated in the development and
periodic revision of their treatment plans
·
Choice is seen as greater with the advent of
Providence
Consumer comments:
"I
can choose my therapist."
"I
have seen my mental health plan every three months and reevaluated every six
months."
The team identified the following strengths under
Dignity, Respect and Rights for all people receiving services from PKIMHC:
·
Most staff treat consumers in a respectful manner
·
Rights are carefully explained to the consumers
·
Confidentiality is maintained
Consumer comments:
"I
have always been treated with respect and dignity here."
"
The doctor is respectful."
The team identified the following strengths under
Health, Safety and Security for all people receiving services from PKIMHC:
·
Case managers effectively link clients with
benefits and services to provide for their needs.
·
Transitional housing is provided.
·
Consumers' living arrangements are respectfully
monitored
Consumer comments:
"They've
helped me a lot in the basic stuff."
"
I have my own place that mental health helped me with."
The team identified the following strengths under
Relationships for all people receiving services from PKIMHC:
·
CSP activities aid in the development of
relationships skills
·
Families and couples are strengthened by the
services received
Consumer comment:
"I
want those relationships with peers. I
can do that."
The team identified the following strengths under
Community Participation for all people receiving services from PKIMHC:
·
Consumers are aided in being part of the community
with life skills and prevocational skills
·
Consumers are provided with tickets to community
events
·
CSP outings provide a sense of freedom and
competence
Consumer comment:
"Now
that I'm stable I get out more on my own."
The following recommendations were identified by
the team as areas that need attention from the organization:
1.
The mission statement and program philosophy do not
reflect the ways in which consumers and their families are empowered. Revise mission statement and program
philosophy to be particular to and appropriate for a publicly funded community
mental health center. (Administrative
Standard #1)
2.
Staff education and orientation do not reflect or
do not make explicit a focus on consumer centered services. Revise staff materials to include both the
language and intent of consumer centered services. (Administrative Standard #2)
3.
No copy of the audit or of the management letter
was provided. Establish a means by
which to provide the annual audit and its results. (Administrative Standard #3)
4. The
local mental health board does not participate sufficiently in the review of
policies and their effect on local mental health consumers. Include the local mental health board in
policy discussions, allowing them to mold those policies to meet local needs,
values and concerns. (Administrative
Standard #5)
5.
The local mental health board does not participate
in a review of the annual budget nor does it have a role in program
evaluation. Inform the local mental
health board of the annual budget and the value system it represents; include
the local mental health board in meaningful program evaluation. (Administrative Standard #7)
6.
The local mental health board does not participate
in the selection of the agency's director.
Define the role of the mental health board in this decision making
process. (Administrative Standard #9)
7.
Currently there is not equal access to services for
all people. Formalize arrangements for
translators; provide signage in multiple languages including Braille as
possible; provide a TTY system as possible; seek direction in these efforts
from local consumers, related agencies and advocates. (Administrative Standard # 11)
8.
There exist insufficient means by which the agency
solicits and utilizes consumer and family input in policy setting and program
development. Create a means by which to
receive continuously consumer and family input through surveys, interviews and
the like; develop and document the means by which this information is reflected
in policy and in programming. (Administrative
Standard #12)
9.
There is not currently a process allowing for
annual program evaluation which includes staff, community and consumers
together. Together with the local
mental health board develop a process for an annual program evaluation in which
staff, community including other service providers and consumers and their
families actively participate.
(Administrative Standard #13)
10. There
is no documentation of program planning based on the results of an annual
evaluation performed by staff, community and consumers. Develop a means by which the results of the
evaluation referred to in item 9 above lead to program planning. (Administrative Standard #14)
11. Agency publications do not uniformly reflect
a consumer-centered focus. Begin to
revise or create new publications which reflect consumer-centered
services. (Administrative Standard #16)
12. The agency does not have a procedure to
incorporate consumer opinion into the hiring and evaluation of providers. Develop an employee evaluation system that
can include consumer opinion.
(Administrative Standard #22)
13. Staff development plans included in each
employee evaluation are perfunctory.
Include a staff development plan for each employee at the time of the
annual evaluation and provide timelines for completion of each goal. (Administrative Standards # 29, #31 and #
32)
14. There is a concern on the behalf of a related
service agency that Alaska Native people are hesitant to use PKIMHC's services
as they are unaccustomed to paying for health services and may shy away from
sites of conflict (a reference to the agency's past). Continue efforts to provide culturally sensitive services to
Alaska Natives.
15. There
is a perceived disruption in the continuity of care for those
transitioning from API to Kodiak; transitional housing does not meet all
of these needs. Explore the means of providing smoother
transitions for
consumers as they move
from different levels of care.
Team members reviewed the charts of those consumers
interviewed during this site review.
They noted a marked difference between the detailed treatment plans for
CSP participants and the rather perfunctory treatment plans of other
clients. In the latter group there were
files in which treatment plans had not been updated for up to one year and ones
in which goals and modalities were stated in vague terms.
The State DMHDD QA staff conducted the mental
health file review portion of the integrated site review. A total of 16 files were reviewed, comprised
of 5 adult Medicaid cases, 5 child Medicaid cases, 3 adult non-Medicaid cases
and 3 child non-Medicaid cases.
The Quality Assurance team will present a separate
and detailed report on the file review.
They have asked this team to include here a brief summary of their findings
and recommendations.
The Quality Assurance team reviewed randomly
selected consumer files and concluded: 1) several files do not contain current
assessment information; 2) treatment plans and treatment review documents are
identified as not meeting standards for the second consecutive review; 3)
consumer involvement in treatment planning was not consistently evidenced in
the file documentation.
The QA team's recommendations are 1) to provide
training and technical assistance on documenting the medical necessity of the
services provided; 2) that files inactive for a period of 120 days or longer be
considered for discharge; 3) that a six month re-review of clinical records be
conducted by DMHDD QA representative to ensure that the agency documentation
meets the Integrated Mental Health Standards.
MH
|
Choice
N=8
|
Dig&Res. N=8
|
Hth,Saf,Sec N=8
|
Relatns. N=8
|
Com.Par. N=8
|
||||||||||
Outcome
|
Yes |
Part. |
No |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Yes |
No |
Part. |
Person/Parent/guardian
|
7 |
|
1 |
8 |
|
|
8 |
|
|
8 |
|
|
8 |
|
|
Staff Performance
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person/Parent/guardian
|
5 |
|
3 |
4 |
4 |
|
6 |
2 |
|
6 |
2 |
|
6 |
2 |
|
Note: If an item is marked Un (Unknown) or Not
Applicable (NA) it will be entered in the No column.
PKIMHC scheduled a public forum to allow for
community members not included on the interview list to air their concerns,
comment and question the site review process.
The forum was advertised by faxing the announcement to local radio
stations and to all local agencies; it was posted throughout the community with
the aid of a consumer and it was published in the local newspaper.
Six community members attended the forum along with
three NCR team members and two PKIMHC staff members. Discussion lasted for one hour and forty five minutes. Three attendees self-identified as parents
of consumers, one as a provider of services and two self-identified as direct
consumers.
Other
suggestions and comments:
1.
Consider ways to counteract the perception that the
agency is motivated by profit while still maintaining appropriate financial
practices.
2.
Provide AYI families with an effective means by
which to express their concerns and to gain accurate information and develop
appropriate expectations regarding this program.
3.
Consider the possibility of a wider range of
services for the villages where current services have been so gratefully
received.
4.
Consider the utility of collaborating with the
local transit authority as a benefit to consumers and to interagency
cooperation, if appropriate.
5. Consider
the very negative perceptions of some staff as an opportunity to clarify agency
culture and values.
6.
Consumers commented on services and contacts with
the agency as being less "personalized" than in the past. Consider encouraging a warmer, more
welcoming atmosphere for clients from the time of their entry into the
building.
7.
Several consumers and families expressed concerns
that treatment was insufficiently individualized.
8.
There were several complaints regarding
billing. Continue your efforts to
streamline the billing process.
9. Consumers
who were non-Medicaid recipients commented on the perceived high price of
care. One stated "It was not a
good value for the money" when paying $125/hour. Review the sliding fee scale with this in mind.
10. Some consumers expressed interest in expanded
vocational services and closer collaboration with DVR.
11. Repeatedly, consumers brought up the desire
to receive some mental health services elsewhere while receiving other mental
health services through PKIMHC. Develop
a policy regarding this collaboration.
12. There were requests for more information on
diagnoses, medications and medication side effects.
13. A consumer commented on the high level of
reading skills needed to fully understand the client rights as presented. Review for appropriateness.
14. Many community members expressed fear that
there would be repercussions if they criticized the program in any way. This was a unique reaction not noted in
reviews elsewhere. This may be related
to another fear that was heard: that Providence would just leave, abandoning
the community.
15. Continue
to refine the shared responsibilities of the school based
program and work to
diminish conflict.
PKIMHC has undergone a major restructuring and is
continuing to adapt to the demands of entering the community mental health
arena. Much has been done and done
well. Increased inclusiveness during
the remainder of the process could be fruitful.
The team thanks the PKIMHC staff for their kind
assistance during the site review. We
hope that we were not disruptive to your vital work this week.
You will receive a finalized 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. PKIMHC, in cooperation with DMHDD, will be
responsible for developing a plan addressing the issues noted in the Areas
Requiring Response.