INTEGRATED QUALITY ASSURANCE REVIEW

Yukon Kuskokwim Health Corp.

Mental Health Program: “Pathways”

September 28-30, 1999

Bethel, Alaska

 

SITE REVIEW TEAM:

Lucy Sparck, Community Member

Olinka Nicolai, Community Member

Jim Gottstein, Alaska Mental Health Board Representative

Diana Strzok, Peer Reviewer

Robyn Henry, Facilitator

Dan Weigman, Lead DMHDD QA Staff member

 

INTRODUCTION

 

A review of “Pathways”, mental health (MH) services provided by Yukon Kuskokwim Health Corporation (YKHC) was conducted from September 28 to September 30,1999, using the Integrated Quality Assurance Review process.

 

This report is the summation of the impressions of a community team after interviewing consumers, staff members, community members and staff of other agencies.  It also includes a limited administrative review.  It does not represent or reflect a comprehensive review of this agency.  DMHDD Quality Assurance staff conducted the Clinical Record Review and provided that section of this report. 

 

YKHC provides services to 58 federally recognized tribes in over 50 Alaskan villages in the Yukon Kuskokwim Region. The region covers an area of some 75,000 square miles with a total population of approximately 21,500 people. MH services provided under “Pathways” include emergency services (24 hour a day clinician level on call response), hospital designated evaluation services, a 6 bed crisis respite program and a 5 bed residential crisis treatment center which provides evaluation and short term treatment for emotionally disturbed children. Clinical services include psychiatric services by two part time MDs and a full time PA. There are out patient services; rehabilitation services which include “wrap around” services to emotionally disturbed youth through the AYI program and residential, transitional living services for adults. Village based services include Elder Counselors, Outreach counselors and a variety of substance abuse and prevention programs. The agency is governed by a 12 member board of directors, each a representative of one of the 12 regional units. The board has an 7 member Mental Health and Substance Abuse Advisory Board. The agency’s total FY 00 proposed budget for mental health services is $2,188,770.

 

 

 

Description of the Process

 

To conduct this review, an interview team consisting of a facilitator, two community representatives, a peer reviewer, and a Alaska Mental Health Board member met for three days in Bethel, Alaska. The team conducted 29 interviews, of which 11 were with individuals who receive services from YKHC.  Nine of those were taken from DMHDD'S random selection of cases and two were identified by the agency at the team’s request to increase the number of adult clients interviewed.

 

During the review, six clients (all adults) either did not appear for their scheduled interviews or stated that they had not received services from the program within the last 5 years. The team is concerned about this relatively small sample of client interviews and with how well this minimal sample reflects the client population as a whole.

 

Ten interviews were conducted with related service professionals, one interview was with a board member and nine were with YKHC staff. Interviews were held in person at YKHC's offices, by telephone and in the community. The interviews lasted from fifteen minutes to an hour.

 

During the same period of time a member of the DMHDD Quality Assurance Unit did a record audit of a set of randomly selected client records.

 

The interview team members also reviewed six personnel files and reviewed the agency’s policy and procedure manuals. After gathering the information, all the team members met to review the data and draft the report, which was presented to the staff on the final day of the visit.

 

It should be noted that the interview team found it hard to stay within the boundaries of the standards and the report format. Many of the suggested questions seemed irrelevant to the services provided by the agency. Therefore the forms were often difficult to fill out. The quality of life indicators seemed to be more relevant to heavy service users and not for the out patient clients interviewed. The team suggests that the Quality Assurance process might be more effective if it could take into account the area’s Native culture.

 

The review team's findings are reported below. The report includes a review of the previous findings, 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.

 

Open Forum

 

 A public forum was held at YKHC’s administrative offices at 7:00pm on September twenty eighth.  YKHC advertised the event through the local radio station, on the local cable station, in the newspaper and by posting the event on public bulletin boards. Two people attended the forum, one a former employee of YKHC and the other a social worker. Their comments  suggested that there is a need for specialized services (for the dually diagnosis, abused woman, domestic violence and family services for men, adolescents, anger management) and the need for a focus on family systems and holistic healing. Feedback was positive regarding the mental health assessment process and the agency’s teamwork.

 

 

FINDINGS

 

Progress Since Previous Review

 

As this is the first review of YKHC using the new program standards, there is no previous action plan for these integrated standards. A plan for improvement required for the chart reviews will be addressed separately in the DMHDD QA report.

 

Model Practices

 

Employee Culture: The agency values the contributions of all staff members equally and includes everyone’s input into decision making. As described by the executive director, “This is something we work very hard at…everyone comes to the table.  Everyone is an equal.”

 

The Use of Natural Supports: The agency’s practice of incorporating the area’s natural Native support systems including the use of Elders as counselors is exemplary.

 

Family Residential Services: One of the residential programs specializes in serving clients with families including providing housing and treatment for the client, their spouse and their children. One client stated that “It (the program) really helps me. I’m glad to have my kids with me while in treatment…Thank you to the person who made the program work”.    

 

 

Choice/Self-determination

 

The team identified these strengths in the area of choice and self-determination for those receiving MH services from YKHC:

+    Almost all clients interviewed felt their preferences were sought and honored

+    Generally people felt that their goals and desires were the focus of services

+    Many people stated that they were involved in problem solving processes that helped               them make positive changes in their life.

 

The team identified these weaknesses in the area of choice and self-determination for those receiving MH services from YKHC:

-  Several people reported that they did not remember signing or being involved in developing a treatment plan.

-  Most clients appear to be served through office visits at the center – clients appear to be expected to come to services. An “outreach” worker said that she generally does not go to people’s homes. There does not appear to be a choice about where to receive services.

-         One person reported that her only support after her child committed suicide has been visits from the psychiatrist when he visits the village once every two months.  No other staff contacts were made.

-          

Dignity, Respect and Rights

 

The team identified this strength in the area of dignity, respect and rights for those receiving MH services from YKHC:

+   Most people reported that they felt very respected and valued and that staff really cared about them. One person stated “no matter what, I could always see someone, they are always available”.

 

The team identified these weaknesses in the area of dignity, respect and rights for those receiving MH services from YKHC:

-  An interviewee came into the interview and said she could not talk to us because we needed a release of information. She had just signed a release prior to coming into the interview but had not known what she had signed. The form apparently was not explained to her.

-  A parent said that her wishes for her son to have a neurological evaluation done went unheard and that she felt that her concerns where not listened to.

 

Health, Safety, Security

 

The team identified this strength in the area of health, safety and security for those receiving MH services from YKHC:

+  Most people interviewed reported that YKHC, when called in for a crisis situation, prioritized helping people get to a safe secure environment.

 

The team identified these weaknesses in the area of health, safety and security for those receiving MH services from YKHC:

-  Two parents reported that their teenage children often ran away from the RDT and that this raised concern for the children’s safety.

-  There were a few reports that returning clients from API did not receive after care evaluation of API care and follow-up services.

 

Relationships

 

The team identified the following strength in the area of relationships for those receiving MH services from YKHC:

+  Whenever possible the agency seems to use the clients natural support system. The example give was a case where the agency trained a family member to support a client when the client showed that preference.

 

The team identified the following weaknesses in the area of relationships for those receiving MH services from YKHC:

-   Family involvement in treatment seems to vary from one program to the other. Several people reported a need for increased family oriented services.

-  Family counseling is needed in the villages and a focus on families with hard to manage children. Preventative interventions are needed before the child becomes suicidal or breaks the law.

 

Community Participation

 

The team identified the following strength in the area of community participation for those receiving MH services from YKHC:

 

+  Most people reported that they were involved in the community in which they live.

 

The team identified the following weaknesses in the area of community participation for those receiving services from YKHC:

-  More supports are needed in schools as reported by both parents and school social workers. It should be noted that there are seven school systems in the district. YKHC staff reported much of the in school support that they provide, with limited recourses, is in the schools that are with out other supports such as school social workers.

-  After a crisis in the village a more comprehensive response system is needed which would involve the persons’ possible direct support systems.  The clinician should involve the whole village as part of the healing process and provide more frequent follow-up visits.

-  The residential treatment needs to be more relevant to the person’s cultural setting so the interventions can be relevant once the client returns home.

 

 

Other Strengths

 

+  Several people interviewed said they thought the agency’s assessment process was very good.

+  The successful use of one elder as a counselor in a village has been replicated in another village.

+  When Alaska Native treatment modalities are used in the village settings,  positive outcomes have resulted.

+  The use of Yup’ik language in counseling, when appropriate and preferred, is a positive and necessary practice.

+  One parent reported that services received by the agency helped the parent communicate better with their child.

+  The longevity of the treatment staff.

+  Staff are generally friendly and helpful to clients who receive services.

+  The RDT program helps many children stay out of the hospital and in their home community.

+  The efforts of the crisis response services seem to have decreased the use of API.

+  The agency works hard to tap into additional funding sources aimed at improving services. As evidenced their recent grant award.

 

Other Areas of Need

 

-  Two parents reported that they felt that the RDT program was not effective and that they felt their teen-aged children were not any better after receiving services.

-  A client reported counselors reflected significantly different skill levels from poor to excellent.

 

Consumer Satisfaction Chart

MH	Choice   N=9			Dig&Res. N=9			Hth,Saf,Sec N=9			Relatns. N=9			Com.Par. N=9
Outcome	Yes	No	*	Yes	No	*	Yes	No	*	Yes	No	*	Yes	No	*
Person/Parent/guardian	7	2		8	1		5	4		5	3	1	6	2	1
Staff Performance
Person/Parent/guardian	7		2	8		1	6	3		6	2	1	6	2	1

* Two people interviewed provided information that the team was not able to fit completely  into this grid.

 

 

Staff Interviews

 

Nine YKHC staff were interviewed including 7 from the mental health program and 2 from the substance abuse program. All staff reported feeling good about their job and about working for the agency. They described it as a great place to work. Several people reported that they felt they were treated as equals from staff that were higher up and that they felt their opinions were valued. Several staff reported that they felt they had excellent training opportunities, although one village outreach counselor said that he felt he didn’t have enough training. Staff generally described their work and agency programs with pride. When asked, staff reported that they have not gotten regular formal evaluations.

 

 

Collateral Agency Interviews

 

Ten people from collateral agencies were interviewed including representatives from DFYS, the hospital emergency room, the school district, corrections, the city police, the Native corporation, village substance abuse counselors, and the Bethel Youth Facility. The general consensus is that services at YKHC have improved over the years. Most people reported that they have a good working relationship with the program and that YKHC staff are generally responsive to referrals that are made. One person reported “seamless crossover”. 

 

The exceptions to this appears to be with the school system and DFYS where follow-up was inconsistent, often leaving the responsibility of service continuation up to the client. The police department indicated that there could be up to a three-hour wait in the hospital ER for a mental health worker to take over responsibility for a Title 47 client. They felt that this time could jeopardize the city's safety by tying up the time of one of the limited number of officers. YKHC staff indicated that there is a MOA currently in development with the police department that would address this issue.

 

Several agencies indicated that they thought that the mental health program is overloaded with cases and that they feel that the YKHC staff are doing the best they can given the high case loads. In general, other agencies hold the agency in very high regard.   One agency reported, “With the resources they have, they are doing a tremendous job.”

 

 

 

Administrative/Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 26 of which are completely met by YKHC Mental Health.  The additional 8 standards are either partly met or not met.  Those standards not fully met include:

1.      The agency actively participates with other agencies in its community to maximize resource availability and service delivery. (standard #17) This standard is partially met through the agencies participation on the community wellness team which exists in some of the villages. More of this type of coordinated effort is needed in the villages without a team.

 

2.      Staff who are employed by, contract with, or volunteer for the provider agency have appropriate training, experience, and supervision to perform their job functions and meet all necessary legal, ethical and regulatory requirements. (standard # 19) Of the 6 personnel files reviewed at least one employee did not have the proper degree required for the job held. It should be noted that the stated required degree is a high school diploma or GED and  that the person could not complete their GED because the instructor quit in the middle of the course. In two other files documentation of the person’s qualifications could not be found.

 

3.       The organization has and utilizes a procedure to incorporate consumer choice into the hiring and evaluation of direct service providers, and to ensure that the family or consumer has approved special individualized services. (standard # 22) There is no evidence that consumers are part of the hiring and evaluation of staff.

 

4.      The hiring process includes background and criminal checks for direct care providers and professional references and follow-up on required references. (standard #24) Some staff have a background check completed if they are in certain direct care programs; only a few personnel files contains reference information.

 

5.      The agency has policies and implements procedures to facilitate the development of non-paid relationships between consumers and other community members. (Standard #26)  The village wellness team partially meets this standard, but the agency should also work systematically on helping consumers build up their non-professional natural support system.

 

6.      The agency evaluation system provides performance appraisal and feedback to the employees…(Standard #28) and a staff development plan is written annually …(Standard #29) The performance appraisal system is adheres to reasonably established timelines (Standard #31) …and establishes goals and objectives for the period of appraisal  (Standard #32). Of the six files reviewed, two people had their last evaluation in ’98, two people had one in ’97, one person in ’96 and one person hired in ’96 had no evaluations.

 

7.      The agency identifies the available resources to meet the assessed training needs of staff (standard #30) Although several staff indicated that they get a lot of training, no training assessment was evidenced in the file and one staff reported that he felt he needed more training.  

 

 

CLINCIAL RECORDS REVIEW (conducted by DMHDD QA staff)

 

Introduction

The clinical records review consisted of only the “medical necessity” elements of the overall standards.  That is, many of the standards that pertain to documentation of the clinical process were not measured during this review.  Please continue to apply your internal quality assurance monitoring process using all of the standards that pertain to clinical documentation. 

 

Assessments

With some exceptions the charts reviewed show great improvement in the area of assessments since the last QA review.  A new strength is that for the most part assessments now clearly document the problems that need mental health treatment.  It is obvious that staff have worked hard to improve in the area of assessments.  Keep working on this so that all staff consistently document assessments in the same way.

 

For those cases reviewed that involve people who periodically emerge in crisis situations but do not receive ongoing support/treatment, no assessments or treatment plans were found in the charts.  In those cases CRC is often used and funded through Emergency Intensive Rehabilitation services but no documentation exists that authenticates the need for the service.  Please focus on this area and begin providing (and documenting) an appropriate crisis assessment and short term treatment planning to ensure thoughtful quality services are provided.

 

Treatment plans

For nearly all charts reviewed great improvement is shown in the area of treatment plans.  Almost always goals written in treatment plans are directly related to problems identified and documented in assessments.  This improvement is due to doing a better job in the assessment area as well as focusing on that relationship while writing the treatment plan.  In addition, written goals were found to be very much more measurable than ever before, and interventions were found to be clear and appropriate. Staff have obviously work hard to achieve the improvement demonstrated in this area. 

 

Treatment plans, however, were not found in charts for those adults who periodically emerge in crisis situations but don't receive ongoing services.  This is a very weak area that needs attention.

 

Progress notes

The area of progress notes needs some attention and is the area recommended to prioritize now during staff education/training.  Many progress notes reviewed contained client  "observations" only, and did not indicate any ACTIVE INTERVENTIONS or TREATMENT provided by staff. .  If one assumed these notes to be accurate then staff are not providing any services, only observing clients.

 

While there are many reasons for progress notes one main reason involves authenticating that a service was actually provided.  To do so, the note must contain some comments about what staff did.  In addition, what was actually provided (the thing that staff did) must be consistent with what the treatment plan calls for.  Further, what staff actually do must meet the Medicaid definition of the service billed.

 

Treatment reviews

The treatment review is also an area where great improvement is shown.  Some of the latest treatment review documents appear to contain ALL of the required ingredients.  The score in this area may look quite low but that is because some review documents didn't contain 2 of the 4 items that were reviewed for.  Again, the newer review documents do contain all the required items.

 

Although there has been great improvement in this area, you are encouraged to continue working on treatment reviews to help staff consistently get all the required items included in all the review documents.

 

Program Management

 

Overall the program appears to be well managed. Many people, including staff, reported their gratitude regarding the changes over the recent years that have resulted in better services. The Program Administrator is well organized and the staff have clearly defined policies and procedures. During the site review the agency was given notification of a large federal grant award for children and family services in the village. This award will greatly enhance the agency's capacity to provide services in the villages. The agency is also in the process of assuming responsibility for the MH services currently being provided by Bethel Community Services.

 

 

 

Areas Requiring Response

 

1.      Increase participation with other community agencies to maximize resource availability and service delivery.  (Standard #17)

 

2.      Update staff credential information in personnel files and revise job duties, if needed, to match staff skills. (Standard #19)

 

3.      Create a system for using consumer input into the hiring and evaluation of direct service staff. (Standard #22)

 

4.      Institute background checks for all direct care staff. (Standard #24)

 

5.      Follow through with the planned expansion of the community wellness teams program and consider expanding your practice having staff facilitate consumer use of non-professional natural supports in their community. (Standard #26)

 

6.      Update your personnel files by practicing regular annual evaluations that include goals and objectives for the period of appraisal. (Standards #28, #31, #32)

 

7.      Consider developing a systematic method for evaluating and providing staff training, especially to the village counselors. (Standard #29)

 

8.      Identify available resources to meet the assessed training needs of staff.  (Standard #30)

 

9.      Ensure that all clients are involved in the treatment planning process and that clients understand all forms that they sign, especially when signing a release of information.

 

10.  Increase staff outreach efforts to go out to people’s homes or other places in the community when providing services to clients.

 

11.  Increase services in the villages, especially prevention and follow-up services to youth at risk.  YK-HC has already initiated steps in this direction by writing and receiving a large SAMHSA grant for this area of need.  

 

12.  Increase Alaska Native treatment modalities.

 

13.  Consider developing an independent counseling evaluation system for and by Alaska Natives.

 

 

Other Recommendations

 

·        The agency should work closely with Bethel Community Services to ensure that any transfer of services does not interrupt client care and that any newly acquired client cases receive the best quality care possible.

 

·        Open forums and other public meetings should be advertised and presented in Yup’ik and Cup’ik language.

 

 

 

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

.

 

The final draft of this report will be prepared within 7-14 days and sent to DMHDD.  DMHDD will then contact YKHC with in 30 days to develop collaboratively a plan for change.