MHDD Program Site Review

REACH

April 5-8, 1999

Juneau, Alaska

Site Review

Sue Achenbach, Juneau

Sharron Lobaugh, Juneau

Bo Johnson, Juneau

John Cannon, Wasilla

Dan Weigman, DMHDD

Nancy Mathis, DMHDD

Carl Evertsbusch, Facilitator

Introduction

A review of the developmental disability (DD) and mental heath (MH) services offered by REACH, Inc. in Juneau, Alaska was conducted from April 5-8, 1999. REACH offers DD services that include respite, care coordination, case management, foster care, family supports, supported living, core services, vocational supports and daily habilitation services, case management and transportation and MH services that include intensive rehabilitation services, supported living, outpatient counseling and treatment for seriously emotionally disturbed (SED) youth. REACH also offers Infant Learning services, but they are not subject to this review. This is the first review conducted of REACH 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 members, a peer provider from an agency that provides both DD and MH services and two members of DMHDD Quality Assurance Unit, met for four days in Juneau. The team conducted interviews, reviewed seven individual DD records, program and agency materials and interviewed 47 people, including consumers and family members, program staff, board members, community members, and related service providers. Of those, 15 (12 of 102 reported DMHDD funded consumers and three of six MH consumers) were randomly selected consumers who receive services from REACH. The DMHDD staff conducted a review of mental health charts.

Interviews were in person at families’ homes, in the community, at the REACH offices, or by telephone. The interviews lasted from 30 minutes to an hour and 15 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 summarizing personal satisfaction with quality of life and quality of service measures and a list of areas of excellence.

Program Response to Previous Review

During the previous review of REACH, the review team made several recommendations. Since then, the agency has taken the following actions:

· Regarding the recommendation that the agency continue to refine the newly developed customer satisfaction survey and use it regularly and administer it rigorously, this goal has been met. Local parents have been very involved in planning for transitioning high school students (1.5.1, 1.5.3).

· Regarding the recommendation that the agency develop a policy and mechanism for meaningfully involving consumers in hiring and evaluating agency personnel, this goal has been partially met (2.2.1).

· Regarding the recommendation that the agency take measures to insure the privacy and confidentiality of consumer records, this goal has been met (2.3.2).

· Regarding the recommendation that the agency continue to explore ways to facilitate expanding circles of support and community networks for community residents with developmental disabilities, there has been progress in this area, but REACH should continue to pursue additional strategies (3.6.6, 3.7.2).

· Regarding the recommendation that a comprehensive and meaningful vocational planning process be made available to the workers at Ready-Mail that includes members of these individuals circles of support, this has been partially met in that three of four staff have received training in person-centered planning and Ready Mail has a goal of completing six futures plan by October, 1999 (5.1.1, 5.1.2, 5.1.3, 5.1.4, 5.2.3, 5.6.3)

· Regarding the recommendation the program provide more assistance in locating and scheduling respite providers when families need help, this goal has been met in that the coordinator’s hours have been increased to 35 hours and she is contacting families at least monthly to ask their opinion on the respite they are receiving (6.1.2).

· Regarding the recommendation that the planning processes be better documented, the file review revealed that two of the seven files reviewed did not contain current individual service plans (7.1.1, 7.1.5).

*Note: The items listed above are referenced to the previous DD program standards.

Areas of Excellence

Excellence is a measure used to denote exemplary practices that are models for services. REACH has achieved excellence in several areas of their operation and these are noted below:

1. The continuity of support for families who enter REACH’s services at an early age is excellent. The interagency collaboration between ILP, Family Supports and Respite has resulted in an excellent continuity of support for families who have received services since their child was very young, especially those children who experience severe and multiple disabilities. These families reported a very high level of satisfaction with the ease at which they moved from one service to another. The families reflected that, in contrast to their experiences with moving into the school system, REACH has been exceptional in facilitating a smooth transition from one REACH service to another.

2. REACH is an excellent environment, which fosters staff creativity and exemplary performance. Many of the people interviewed commented on how accomplished REACH staff are at recognizing consumers’ needs. They spoke of the flexibility of staff in meeting their needs. Families spoke of an agency they have “grown up” with in regards to the necessary services for their family member. Individual staff have received recognition for their efforts (e.g., serving on the President’s Committee on Mental Retardation, Rotary Award for Vocational Excellence). People spoke of the overall high quality of staff. The staff spoke of the freedom they have to “wrap” individualized services around consumers, and gave much of the credit to the Executive Director and program directors.

Administrative and Personnel Standards Narrative

REACH plays an important role in Juneau and other parts of Southeast Alaska. The agency is an efficiently operated organization. Management staff are very comfortable with each other and are working to create a ‘seamless’ internal service system. REACH has grown substantially since its inception, and has continually worked to improve the qualities of its services. Recently, the presence of additional service agencies and an emerging need for additional Mental Health services has caused REACH to reconsider its mission. While this has resulted in increased options for families and individuals, it has created concerns internally. There are discussions underway within the organization that are focused on internal operations and regard potential changes in the way REACH provides services. Changes that are under consideration are intended to smooth communication and service delivery between departments. Regarding the mission specifically, the team recommends that REACH revise the mission to reflect People First language (i.e., “person with a disability” instead of “disabled person”)

The team received comments during various interviews which seemed to indicate that services were perceived differently depending upon when you entered the REACH system. Some families who have received services for child beginning with early intervention reported a high satisfaction with the continuity of care. Their family member has ‘grown up’ with REACH, and the family enjoys very strong and personal relationships with the staff. Other families, whose family member entered at a later age and who didn’t experience this continuity of care reported less satisfaction.

The agency obviously values including people with disabilities into the community, but staff also expressed frustration with the challenges associated with connecting people within the community. There were examples of people developing relationships with people in the community that seemed surprising to REACH staff. The team recommends that REACH revisit the topic of community connections and spend time developing more strategies to include people in Juneau

The Board has a significant consumer membership (five out of seven). They have quarterly meetings and interim monthly meetings in more informal settings to conduct business. The Board receives a monthly financial statement. REACH checks of $5,000 or more require a co-signature from the Board President. The current audit stated that REACH’s accounting practices meet acceptable standards. Board meetings are open to the public and are advertised in the local newspaper and the cable TV scanner, but some parents reported they were unaware of when Board meetings are held. They also expressed a desire for a more public process for selection of Board members.

REACH staff members are well respected by consumers and others in the community. They were described as upbeat, dedicated, professional and consumer-centered. Several staff talked about how much they “love” their jobs at REACH. Staff talked about the relationships they have developed with each other.

“I’ve never worked any place where I liked everybody. Everyone is so likable.”

The staff show an eagerness to learn and seek training to meet ongoing needs whenever possible. REACH budgets $45,000 annually for staff training. Training priorities are developed by each program director. Obviously, this attitude translates into a strong commitment to person-centered services and individual advocacy. Staff have been very creative in designing services for people they support.

According to the personnel files reviewed, REACH staff are very well qualified for the jobs they perform. They feel very supported by management and know that their ideas will be heard. The team heard comments of how hardworking they are, and people in the community spoke of successes that have resulted from this effort. Of the 10 personnel files reviewed, 8 did not contain current performance evaluations or work improvement plans. None of the personnel files contained documentation or reference to consumer participation in hiring and evaluating staff. The employee or supervisor did not sign most of the staff orientation forms.

Related service professionals gave the team several positive comments to the team regarding their collaboration with REACH staff.

“I have a lot of trust in REACH to come up with answers.”

"I’ve always had good experiences with the people at REACH.”

“They really act in the families’ best interest.”

“Staff are sincere; they really advocate for consumers.”

“This is the best agency I have ever worked with for over fifteen years. The job coach is prompt, supportive and always there when needed.”

“Success is dependent on the quality of employees - based on the ability to pay employees.”

Quality of Life

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 REACH. 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.

Choice and Self-Determination

The following are indicators for Choice/Self-determination for families receiving services from REACH that were identified by the team:

Families/individuals :

· are comfortable with asking for changes in their services and report that their requests are honored.

· families choose which agency respite provider they want.

· families choose when respite is provided.

REACH staff:

· are responsive to families’ requests.

· are willing to make changes to services

· listen to the family and help them get what they want

The following are examples of statements given to the review team:

“I wasn’t sure I liked the idea of him living by himself, but that’s what he wanted.”

“He wanted to try more things on the job, so we let him, and he is doing great.”

“I had a lot of choice with no conflicts with providers, including mental health services, Hope, legal, political and support from all organizations. I’m always included in every decision.”

“I was active in interviewing and selecting my caregiver.”

“We have lots of choice. Steve is foremost in their interests. We couldn’t have done better. They have gotten us to where we are.”

“I can always call. I never hesitate to call.”

“They help anyone to get services if they need it.”

Dignity, Respect and Rights

The following are indicators for Dignity, Respect and Rights for the team identified all families receiving services from REACH that:

The family/individual:

· understands their rights as consumers of services.

· is respected and treated with dignity by service providers.

· feel their privacy is protected and respected.

REACH staff:

· show respect and high regard for the family/individual.

· 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:

“I’ve always felt respected by the people at REACH.”

“I’m surprised with how well he has done here. We increased the hours that he works and have given him more responsibilities because of that.”

“Staff and the manager are very careful to get permission/releases.”

“The caregivers are strong advocates and help to obtain services, with legal action if necessary.”

“Staff are very careful to get permission/releases.”

Health, Safety and Security

The following are indicators for Health, Safety and Security for families receiving services from REACH that:

The family/individual:

· has access to needed medical and social services, including cost coverage.

· knows their child is safe and secure with the respite providers.

· REACH 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 worry sometimes about him being on his own (brother), but I’ve learned to step back more.”

“With maturity came more difficulty (with behavior).”

“We even drop in (unannounced) to the facility and feel she is safe.”

Relationships

The following are indicators for Relationships for all families receiving services from REACH that were identified by the team:

The family:

· has access to information about services that strengthen the family.

· is able to remain intact.

REACH staff:

· develop trusting relationships with the family.

The following are examples of statements received by the team:

“I would like for him to be in the community more and meet more people.”

“I think a lot of the success he has had here is due to one of his co-workers.”

“She has too many friends.”

“She loves her vocational support person.”

“She gets along well with caregivers. We caught them singing once.”

“I began to network with other families with special needs. I’m socializing more and developing social skills. Relatives are welcoming me (and his children) now more than ever.”

Community Participation

The following are indicators for Community Participation for all families receiving services from REACH that were identified by the team:

The family/individual:

· participates in community activities that add to their child’s personal growth and increased life satisfaction.

REACH staff

· provide the family information on community activities and supports.

The following are examples of statements received by the team:

“I wish there were more things for him to do.”

“We have had success with people who have worked here. I think it is a good thing.”

“We go to Tlingit Haida, Special Olympics and parents networks. I want to go to Pathways this year.”

“Now she is in Girl Scouts and ORCA and went to her first dance. She is really happy with her social life. I experienced relief for three or four hours at a time without guilt or fear”

DD File Review Summary

The DMHDD Quality Assurance Unit presented to the REACH staff a separate report on the file review they conducted on the Mental Health files.

The following comments are intended to provide REACH with useful information relating to the finalized DD File Checklist. This file review was conducted by two members of the site review team.

A total of seven consumer files were randomly selected and reviewed. Two individual service plans were not current. Staff reported that due to extended family illness it was difficult to conduct a meeting, however, the plan did not reflect any comments describing this situation. The individual service plans are very person centered, written in a language that is respectful of the consumer/family and give an extremely positive portrayal of each individual. Staff obviously spend a great deal of time and effort determining people’s likes and dislikes. The goals and objectives could be written in a way that provides clearer, more measurable descriptions of what the consumer/family want. The file review indicated that plans need to more clearly reflect evidence that the consumer/family were asked where and when it would be convenient to meet and that they were asked when it would be convenient to meet. Additionally, some plans that were reviewed did not clearly show a schedule for each activity or a description of both paid and unpaid supports.

Areas Requiring Response

The following recommendations were identified by the team as areas that need attention from the organization

1. Assure that individual goals are measurable and objective.

2. Assure that all individuals have current plans.

3. Assure that REACH gives timely notification to consumers of opportunities to be involved in decisions that affect their family member’s services.

4. Refine your grievance procedure to more effectively provide consumers opportunities for resolution of their concerns. Consumers should be informed of the grievance procedure at times of admission and when plans of care are revised (with signed copies in the files) and the procedure should be posted.

5. Reword your mission statement using language that describes “persons with disabilities”. (Admin Standard No. 1)

6. Assure that the public and consumers are notified of Board meetings (Admin. Standard No. 8).

7. Build on recent gains in working with other community entities to maximize the availability and service delivery (Admin Standard No. 17).

8. Develop a procedure to incorporate consumer input into hiring and evaluating of direct service providers (Admin. Standard No. 22)

9. Develop a policy and improve procedures that facilitate the development or strengthening of people’s natural support networks (Admin Standard No, 26).

10. Assure that REACH obtains informed consent from consumers whenever there is ever a change or modification in service. (Admin. Standard No. 27)

11. Assure that employees receive timely performance appraisals and a staff development plan based on those appraisals (Admin Standards Nos. 28, 29,31,32).

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 REACH. 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=3			Dig&Res. N=3			Hth,Saf,Sec N=3			Relatns. N=3			Com.Par. N=3
Outcome	Yes	Part.	No	Yes	Part.	No.	Yes	Part.	No.	Yes	Part.	No.	Yes	Part.	No.
Person/Parent/guardian		2	1	2	1		2		1	1	1	1	1	1	1
Staff Performance
Person/Parent/guardian		1	1	1		1	1		1		1	1		1	1

Two responses were recorded for Staff Performance because staff reported for one consumer.

DD	Choice N=12			Dig&Res. N=12			Hth,Saf,Sec N=12			Relatns. N=12			Com.Par. N=12
Outcome	Yes	Part.	No	Yes	Part.	No.	Yes	Part.	No.	Yes	Part.	No.	Yes	Part.	No.
Person/Parent/guardian	7	4	1	9	3		10	1	1	8	2	2	5	5	2
Staff Performance
Person/Parent/guardian	11	1		10	2		9	2	1	9	3		5	5	1

Note: If the item is marked NA, then that will be entered in the No column.

The following are examples of statements the team received from consumers regarding their satisfaction with their quality of life and the quality of services.

“No matter how big the agency gets, it still feels small.”

“The best. The greatest crew out there. Always, our needs are met. Can’t think of any complaints. Everyone needs this (what REACH provides).”

Public Comment

REACH scheduled a public forum from 5:30 to 7:00 PM in their office building for members of the community to give public comment on developmental disabilities and mental health issues. The meeting was announced on the local radio station and the local newspaper. Seven people provided comment to the review team, all of which related to developmental disabilities. Participants all gave positive comments on the services provided by the REACH program.

“With REACH’s advocacy, we have been able to keep our daughter at home. We have received services here since early in our daughter’s life and have found the services to always be family focused. It has been a huge relief to our family. Their (REACH) adding the ability to provide therapy services to older clients has been wonderful.” – parents of a young adult

“I want to say that REACH does a fine, fine job. They have done a fantastic job with me. We all have to work to do away with the waitlist. People with disabilities should not have to wait for services. REACH has been a big help with getting People First started in Juneau.” A self-advocate

“We started out receiving services when our son was an infant. We didn’t use respite until he was older, and fairly recently, have been using our respite to help him learn some basic living skills. This has been really wonderful for us, and I feel fortunate to have received that support. We are on the wait list and hope that more services become available when he transitions out of school. REACH has always been responsive to us for twenty year. They have always been creative with us. I feel I’m friends with everybody who works here, and the caliber of the staff is very high.” – parents of a young adult

“We’ve been involved with REACH since just after the birth of our child, and we’ve always been satisfied with REACH’s services. The continuity of care has really been good for us. After our son transitioned out of the EI program, we came back to ask for therapy that we could pay for privately. We were told that REACH was now providing them to older children. We receive care coordination and core services, and Kate does everything for us. REACH even processes insurance for us. It’s things like that that make a difference. One thing I have noticed is that as they’ve (REACH) grown, it is more difficult to receive therapy in a quiet space. Also, I would like to be able to observe the therapy my son receives so I will know what to do at home.” – a parent

“REACH pushed hard to get us a partial waiver. Our daughter is able transition to independence. It has been a relief. We are very positive.” – a parent

Additional Comments

· With the increase in Medicaid services, it is important that staff inform families of their rights as consumers and clarify that services can be received from the provider of choice.

· The team encourages REACH to complete their agency restructuring.

· The team encourages REACH to develop standard procedures to continue to identify and treat the mental health needs for people who experience developmental disabilities. An appropriate focus might include interagency collaboration and intraagency staff development and service coordination.

Conclusion

The team thanks the REACH staff for their support during the site review. Processes such as these can be disruptive and stressful, and we hope we did not excessively disrupt staff and consumers’ lives. The team would also like to thank REACH 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. REACH, in cooperation with DMHDD, will be responsible for developing and implementing a plan addressing the issues noted in the Areas Requiring Response.

This review confirms that REACH meets most of the basic guidelines of the DMHDD and DPH EI/ILP Program Standards. 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.