Mental Health Site Review

Yukon-Koyukuk Mental Health Program

Galena, Alaska

June 8-10, 1999

Site Review Team:

Jack Cary, Community Member

Doug Pomeroy, Peer Provider

Robyn Henry, Facilitator

Pam Miller, DMHDD QA Staff

Introduction

A review of the mental health (MH) services provided by the Yukon- Koyukuk Mental Health Program (YKMHP) in Galena, Alaska was conducted from June 8-10, 1999. Community mental health services are provided through the City of Galena.

YKMHP serves the Yukon-Koyukuk Region. The communities within this region include Galena, Koyukuk, Nulato, Kaltag, Ruby, and Huslia. The population of this service area is approximately 2,500, the people of which are mainly Athabascan in culture and tradition.

YKMHP employs 7 staff including a full time Program Director, a full time Itinerant Counselor, a .75 time office manager, and four village counselors (three full time and one part time). YKMHP, through the city of Galena, holds a community mental health center grant from the State of Alaska. According to the FY 99 DMHDD mental health grant proposal submitted and funded, DMHDD funds 1.5 FTE staff including .5 of the Program Director's position, .5 FTE of a Counselor Coordinator position and .5 of the Itinerant Counselor position.

YKMHP services as described in the grant proposal include individual and group counseling mental health and alcohol /drug assessment, referral and aftercare services, case management, and emergency services.

Review Process

This is the first review conducted of YKMHP using the Integrated Standards and Quality of Life Indicators.

To conduct this review, a team consisting of a facilitator, one community representative, a peer reviewer and a member of the DMHDD Quality Assurance Unit met for three days in Galena. The team conducted 15 interviews, of which 5 were individuals who receive services from YKMHP, 4 taken from DMHDD'S random selection of cases. Six interviewees were related service professionals, one interview with a board member and 3 with YKMHP staff.

Interviews were held in person at YKMHP's offices, by telephone and in the community. The interviews lasted from 15 minutes to two hours. After gathering the information, 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.

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, 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.

Program Response to Previous Action Plan

As this is the first review of YKMHP 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.

Administrative and Personnel Standards

YKMHP has undergone many changes in the last six months. This week marks the fifth week

for the new Program Director after the position was vacant for 4 months. The Office Manager

has been on the job since March and the program's senior clinician has been in the position for the last 5 months. All of these staff are not only new to the job, but also new to the village and state. This means that in the last six months the entire center based staff has gone through a complete turn over. The program director has a great deal of enthusiasm for the organization's potential growth and her vision of its future. Already systems have been instituted that are in the process of being implemented that will change the complexion of the agency. Comments received from staff, consumers and community members were indicative of “relief” for the changes that have occurred and the potential for the future of the agency.

The City of Galena governs the Community Mental Health Program. In the past there was a mental health advisory board that worked with the program and the city council to develop recommendations for program improvement. At this time the advisory board is nonexistent.

Fiduciary responsibility for the program lies with the City Council and supervisory responsibility lies with the City Manager. Funding and program decisions requiring approval go before the Council. YKMHP receives funding from state, federal and local sources. The Program offers a sliding fee scale, which depends on client income. The scale starts at 5$ an hour.

Employee policies and procedures and new hiring protocol are in a great deal of transition at this time. In the last few years, agency practices in hiring, training and evaluating staff have been very sporadic at best. The last employee evaluation found in an employee file was done in 1995. The new Program Director is currently working on a new employee handbook and showed the team members drafts of several sections of it. The Program Director has also instituted quarterly staff meetings where the Village counselors will come into Galena for staff and program development meetings and trainings.

The YKMHP offices are not accessible. The building is on pilings and there is no ramp to the entrance. There is no TTY or RELAY information for the hearing impaired or any alternative

text format (e.g., Braille and large print for visually impaired) and the bathroom and most doors are not wheelchair accessible.

Opinion of Related Service Providers:

The six related agency service providers interviewed maintained a very positive relationship with YKMHP, some acknowledging that this had not been the case in the past. A couple of service professionals commented on the improvements at YKMHP in the last year and specifically in the last few months. They described the staff as competent and caring and very responsive. Almost all of those interviewed specifically mentioned the new program director as a positive new addition to the program. Collaboration also occurs on the village level. One provider stated, "I depend on them (Village counselor) a lot... the are always willing to go with me on a client visit when I need extra support". The mental health program staff's involvement in the Community Care Team was also mentioned as an asset.

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 YKMHP. The items listed below are those that the review team, through their interviews, 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 and Self-Determination for people receiving services from YKMHP:

· Service plans and interventions address the concerns and goals of the clients.

· One client specifically indicated that the program respects choice and self-determination. "I have made some serious life changes... I am starting to think differently"

Dignity, Respect and Rights

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

· YKMHP supports their clients and show much respect for them as people. Several people interviewed voiced this. " I feel respected by mental health staff"

· Clients report that they were informed of their rights.

· Staff interviewed conveyed a great deal of enthusiasm for working with their clients.

Health, Safety and Security

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

· Clients reported that they feel secure in their living environment and that that their basic needs are met.

Relationships

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

· Most people interviewed felt satisfied with their current support system, which in many cases primarily includes family and friends.

· Two clients reported that their relationships have improved following the program's support. "I am more open about myself with others... more mature with others".

Community Participation

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

· Most people reported that they feel they are well integrated into the community including holding jobs and being involved in community activities. " I am much more active in the community... I now do volunteer work."

Areas Requiring Response

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

1. Up to this point the program has not instituted a means for formally educating staff throughout the agency about the mission, philosophy and values of the program. The new program director indicated that she has developed a plan to do so and will implement it with both existing staff and new hires (Admin. Standard 2)

2. The City council mental health advisory board is dormant. It is strongly suggested that this board be activated again in order to get consumer and family input in decision making for the Program. (Admin. Standard 6)

3. Physical accessibility to the program center and its services is very limited. Although it is true that most services are provided in the community, the program center needs to be handicap accessible. (Administrative Standard 11)

4. Consumer involvement in program planning, evaluation and development is vital. There is evidence that this has been sporadically accomplished informally and that the new program director has written plans, in draft form, to do so in the future. Create policies and document their implementation in regards to systematically surveying consumer opinion and incorporate that perspective into program practices. (Administrative Standards 12, 13,14, 22)

5. The agency does not have any brochures, ads or program publications in print at this time. (Administrative Standard 16)

6. The agency currently has no procedure for validating staff credentials or a process for regularly reviewing job descriptions. These practices are currently being developed in the new staff handbook. (Admin. Standards 19 & 20).

7. There is no evidence that consumers have been involved in the hiring or evaluation of staff. (Admin. Standard 22)

8. Up until now, background checks have not been done on new hires. The new director plans to institute this practice. She has had all current staff finger printed and is currently running a background check on them (Administrative Standard 24)

9. According to the employee files reviewed, the last employee evaluation was done in 1995. There is no evidence of employee orientation or training of staff. Again, the draft employee handbook shows evidence of the intention of correcting this. (Admin. Standard 25, 28, 29,30, 31,32)

10. In the past consent forms / and releases of information forms were not always received from clients when they entered services. This practice is critical. Documentation of consumer involvement in the development of treatment plans and in the revision of treatment plans is uneven. It is important to standardize documentation of consumer involvement in treatment Planning and the revision of those plans. (Administrative Standard 27)

File Review Summary

State QA staff reviewed a total of 8 files. One of these files was a Medicaid / Child chart, 4 were Medicaid /Adults, 1 was non-Medicaid /Child, and 2 were non-Medicaid /Adults.

There were improvements noted from the last DMHDD QA site review conducted in 1997. Most of these improved areas were noted in the comprehensive assessments and included the addition of consumer statements, multi-axial diagnoses, services and treatment recommendations, signatures and credentials of the author. Treatment plans appear to be signed by the consumer, and in most cases, by the supervising MHPC. This also is an improvement from the last review.

Areas of concern include: ensuring that assessments are conducted by an MHPC (person with at least a Master's Degree in a MH related field). MHPCs are the only level of qualified professionals that can make DSM diagnoses and establish medical necessity; substance abuse treatment is not funded through MH grants or Medicaid (for MH); there is a continued absence of treatment review documents. This was a problem identified in the 1997 review, and a plan of correction was submitted by your agency that stated these documents would be included in files.

For further details of the QA chart review, please see the enclosed report "Clinical Review Report" dated 6-9-99.

Recommendations

1. It is recommended that YKMHC be placed on a special status with DMHDD. This status includes supervision and technical assistance to be provided through the State, by the Regional Coordinator and QA section.

2. It is recommended that a QA training be scheduled to educate YKMHC staff on clinical documentation and MH standards.

3. It is recommended that a plan be designed and a schedule set to assist YKMHC in bringing their clinical files into compliance with the MH standards.

4. It is also recommended that appropriate staff receive training regarding billing issues.

Consumer Satisfaction

MH

Choice N=5

Dig&Res. N=5

Hth,Saf,Sec N=5

Relatns. N=5

Com.Par. N=5

Outcome

Yes

Part.

No

Yes

No

Part.

Yes

No

Part.

Yes

No

Part.

Yes

No

Part.

Person/Parent/guardian

5

5

5

4

1

5

Staff Performance

Person/Parent/guardian

5

5

5

5

5

Note: If an item is marked Un (Unknown) or Not Applicable (NA) it will be entered in the No column.

Public Comment

YKMHP scheduled a public forum to allow for community members not included on the interview list to air their concerns, to comment and to question the site review process. The forum was advertised on the local radio station and was to be held at the Center. No one showed up for the forum. It should also be noted that a large regional native conference was being held concurrently with the site review. The activity occurring at the time of the public forum was a potlatch. It is strongly suspected that this had an influence and effect on the attendance of the forum.

Other Suggestions and Comments

The team felt that uniformly those staff interviewed presented a genuine commitment to quality care.

1. Due to the fact that all center-based staff are relatively new, it is suggested that particular attention be paid to providing those staff with the opportunity to become familiarized with village culture. From the conversations we had with staff there appeared to be high motivation to do so.

2. It is suggested that the office manager be given the opportunity to get training in state administration, documentation and data collection protocol perhaps by visiting a peer agency. One team member offered Fairbanks Community Mental Health as one resource option to consider.

3. One client indicated that he would like more one-to-one information about anger management and not just books to read. Perhaps the program should consider providing more educational and support groups for special populations.

4. A client voiced concerns and objections regarding seeing one of the village counselors. She said the issue was addressed by having her see the itinerant counselor when she is in town. Specific concerns expressed about the village counselor could not be corroborated in subsequent client interviews.

5. The PA suggested that the program consider moving its offices to the health clinic. This move would facilitate integrated care and perhaps lesson the stigma associated with going to the "mental health building”. This is a suggestion that may be worth serious consideration.

6. The PA indicated that his contact with the TCC psychiatrist in Fairbanks is minimal and perhaps strained. This is of great concern to the team in that the PA is the primary resource for people receiving prescribed medication and the TCC psychiatrist is their primary source for psychiatric over site and consultation.

7. The community is very fortunate to have a PA that is sensitive to psychiatric issues. In the interview, the PA was informed and appeared sensitive to mental health concerns.

8. During the exit interview the staff discuss their concern for the lack of on sight support in the village of Ruby. This village has no village counselor and, although the itinerant counselor does the best she can to cover the village, the need for a full time counselor there was discussed.

Conclusion

The impact of the arrival of four persons into a small office space is enormous, and the YKMHP staff bore it with flexibility and grace. The team appreciates the warm welcome and aid provided by a very busy staff. We also appreciate your hospitality and patience.

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. YKMHP, in cooperation with DMHDD, will be responsible for developing a plan addressing the issues noted in the Areas Requiring Response.