Mental Health Site Review

May 24-26, 1999

Railbelt Mental Health and Addictions

Site Review Team:

Gayle Stevens, Nenana

Joanna Jensen, Nenana

Randy Moss, Peer Reviewer

Connie Greco, DMHDD

David VanCleve, Facilitator

Introduction

A review of the mental health (MH) services offered by the Railbelt Mental Health and Addictions (RMHA) in Nenana, Alaska was conducted May 24-26, 1999. RMHA offers services to children and teens that include identification, referral, case management and counseling services. MH services include intake, referral, case management and counseling services for individuals, families, couples and groups for adults, children and teens. RMHA offers medication management to people identified as having a serious mental illness. As a multi-service agency RMHA also employs a substance abuse counselor for assessments, referral, aftercare, and outpatient needs. This is the first review conducted of RMHA 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, one DMH/DD QA representative to review case files, two community/consumer representatives, and one peer MH provider met for three days in Nenana. The team conducted interviews, reviewed individual/family treatment records and program/agency materials. The team interviewed consumers and family members, program staff, Board members, community members, and related service providers. Of those interviewed, eight were randomly selected individuals and families who receive services from RMHA.

Interviews were in person at families’ places of work, in the community, at Tri-Valley School, at RMHA’s offices, or by telephone. The interviews lasted from 30 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 as areas needing improvement, tables of consumer satisfaction with quality of life and services and individual file reviews.

Areas of Excellence

RMHA is an organization that takes advantage of natural community supports in an exceptional way. Kinship and common community history are a connecting thread consistently mentioned by service recipients as being recognized and supported by RMHA staff. Consumers report that their natural support systems were understood, respected, and encouraged.

RMHA exists as a testimony to the determination of the communities served and the City of Nenana to provide essential services in a challenging environment. Mental health services for children and adults are costly and time-consuming to acquire because of the distances one must travel get that kind of help. RMHA has continued with the difficult job of providing the services and developing on-going relationships in very difficult settings by spending many hours on the road to meet consumers where they live. In this way affordable choices are available to people who need them when they need them.

Administrative and Personnel Standards Narrative

The City of Nenana contracts an independent audit annually but the management letter does not make specific recommendations or suggestions for the improvement of the program’s internal contract, financial procedures, revenue flow, or ongoing stability.

The agency’s governing body includes three consumers or their family members. Seven of thirteen board positions are currently filled.

Policies and Procedures do not actively involve consumer input in the shaping and delivery of services.

The agency makes every effort to participate with other agencies in its community to maximize resource availability and service delivery. Those service providers that RMHA has been successful with make every effort to be helpful and from them RMHA receives high praise.

Consumer choice is not part of the hiring and evaluation process involving direct service staff.

All new employees receive a general agency orientation. All employee files contained current performance evaluations and corresponding work improvement plans. RMHA budgets for staff development despite limited resources. Staff takes good advantage of hours spent on the road for in-service opportunities in transit when the psychiatrist is making his rounds.

Quality of Life

This portion of the narrative refers to the Quality of Life Values and Outcome Indicators, as they relate to the specific services offered by RMHA. 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.

Choice and Self-Determination

The team identified the following strengths under Choice/Self-determination for all people receiving services from RMHA:

Families/people:

· make their own treatment choices.

· report adequate choices in treatment.

RMHA staff:

· regularly travel significant distances to deliver services that facilitate consumer choice.

The following are examples of statements consumers/families gave to the review team:

“I chose to go back to Railbelt Mental Health on my own. I recognize the need.”

“I’ve been grateful for the service. It would have been hard for me to get to Fairbanks.”

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for all people receiving services from RMHA:

Families/people:

· are aware of their rights, including the control of information.

· are respected as worthy individuals.

RMHA staff:

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

The following are examples of statements received by the team:

“Services are not intrusive. I’ve been treated well.”

“I usually have problems I can’t tell anyone else so I tell Mr. ‘W’.”

“Privacy and stuff like that is protected.”

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for all people receiving services from RMHA:

Families/people:

· feel safe and secure in their homes.

· have safety issues addressed quickly in times of crisis.

RMHA staff:

· assure that services are provided in a safe manner.

· are available in times of need traveling significant distances on short notice.

Additional indicators for families in need of Respite that were identified:

The family:

· receives respite that promotes the health and well being of the child in times of crisis.

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

The staff:

· provide respite in accordance to the health needs of the child.

· make use of limited resources to creatively find available options in times of need.

The following are examples of statements received by the team:

“If you get hurt someone will stop and help you.”

“There are no quick fixes. Working with mental health has made things easier.”

“I live in a safe place.”

Relationships

The team identified the following strengths under Relationships for all people receiving services from RMHA:

Families/people:

· describe supportive community relationships.

· trust those providing services and are aware of necessary professional boundaries.

RMHA staff:

· develop trusting relationships with the consumer/family.

· understand, respect and encourage natural support systems.

The following are examples of statements received by the team:

“There’s a great support system here.”

“She has helped me understand that I am not as isolated as I thought... she has helped me mature in my relationships.”

Community Participation

The team identified the following strengths under Community Participation for all people receiving services from RMHA:

Families/people:

· are accepted and are valued in the community.

· have strong relationships in the community based on kinship, tradition, and common history.

RMHA staff:

· use creative means to get the person included in the community.

The following are examples of statements received by the team:

“My son is involved in sports and other school activities.”

“I’ve pulled away in the last little while.”

“Only a couple of people who judge me without knowing me.”

Areas requiring response

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

1. The stated mission of RMHA is too global and does not meet the requirement of the standards by using empowering People First, non-stigmatizing language to offer consumer centered services (Admin Standard #1).

2. The team did not observe that staff and key people communicate in the presence of and away from the person using People First, non-stigmatizing language. (Admin Standard #2).

3. Formalize inclusion of consumer input in policy setting and program delivery in the policies and procedures (Admin Standard #12).

4. There is no policy and procedure documenting how involvement of consumers, staff and the community will be facilitated in annual agency planning and evaluation (Admin Standard #13).

5. Document policies and procedures developing annual goals and objectives in response to consumer, community and self-evaluation activities (Admin Standard #14).

6. Person centered language regarding people who receive mental health services is absent in publications and documents (e.g., "this population", "client", "in a nutshell, no pun intended"). Services focus on situational and substance abuse needs. Referrals from citizens concerned about others in the community should take a back seat in agency publications while focusing on support services available to those who identify a need and consent to receive services from professionals they choose and trust (Admin Standard #16).

7. Personnel policies and procedures do not document a system for review and revision of all job descriptions (Admin Standard #20).

8. Create a procedure to incorporate consumers into the hiring and evaluating of direct service staff (Admin Standard #22).

9. Include a policy that staff identify, respect and encourage local natural supports for consumers (Admin Standard #26).

10. Assure that staff receive necessary training in Medicaid documentation.

File review summary

The DMHDD Quality Assurance Unit will present a detailed report on the file review. A designated member of the team reviewed the charts of randomly selected consumers for Medicaid and non-Medicaid compliance with the Integrated Standards. The file review report will include detail on individual chart review, and a statistical summary of the findings that pertain to medical necessity. Overall findings support QA’s providing training to the entire staff, administrative and clinical, on the utilization of rehab services and the medical necessity and documentation requirements of the Integrated Standards and Medicaid regulations.

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 RMHA. 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=7

Dig&Res. N=7

Hth,Saf,Sec N=7

Relatns. N=7

Com.Par. N=7

Outcome

Yes

No

Part.

Yes

No

Part.

Yes

No

Part.

Yes

No

Part.

Yes

No

Part.

Person/Parent/guardian

6

1

7

7

6

1

7

Staff Performance

Person/Parent/guardian

6

1

6

1

7

6

1

7

Public Comment

RMHA scheduled a public comment meeting. The meeting was announced in the local newspaper, on the local cable TV bulletin board, through community fliers and through the agency newsletter. One person attended the meeting, and gave the comment that she felt that services could be expanded to better meet the needs of others in the catchment area. The person also stressed the good and steady increase in cooperation among diverse communities.

Other suggestions and comments

Because of the direct service demands on the administrator it has hampered the ability of RMHA to add new programs, enhance services and increase revenues. The organizational skills and initiative of administrative assistant has added significantly to the successful operation of the program.

Conclusion

The team thanks the RMHA staff for their wonderful hospitality during the site review. The team would also like to thank RMHA 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 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. RMHA, in cooperation with DMHDD and DPH, will be responsible for developing a plan addressing the issues noted in the Areas Requiring Responses.

There is no doubt that RMHA is committed to developing and providing supports in ways that people prefer. The high regard staff have for the people they support adds to the quality of service they deliver.

This review confirms that RMHA meets or exceeds most of the basic guidelines of the DMHDD and DPH EI/ILP Service Principles. The team recognizes that all programs, regardless of how good they are, can always get better. We trust the recommendations we have made will help you consider ways to improve your services.

Once again, thank you for making us feel at home and allowing us the opportunity to review your supports and services.