Mental Health Site Review

Tok Area Mental Health Center

June 1-3, 1999

Tok, Alaska

 

Site Review Team:

Jan Persson, Community member

Mark Snipes, Peer Reviewer

Kathleen Karella, Facilitator

Connie Greco, DMHDD Quality Assurance Unit

 

 

 

 

A review of the mental health (MH) services provided by Tok Area Mental Health Center (TAMHC) in Tok, Alaska was conducted from June 1-3, 1999. TAMHC has provided community mental health services since incorporation in July l979. 

 

On March 15, l993 the Board approved a name change of TAMHC to Tok Area Counseling Center (TACC). TAMHC remains on the Articles of Incorporation, by-laws and state & federal reports.

 

TAMHC defines it’s mission statement as “Tok Area Counseling Center seeks to provide outpatient mental health services that are of a high professional quality, accessible, area wide, and sensitive to cultural differences. It especially seeks to create access for populations who wouldn’t otherwise utilize services, through outreach to villages and to seriously or chronically mentally ill individuals”.

 

The Tok Area Counseling Center's outpatient services are for the rural residents of the catchment area, as defined by the Alaska Division of Mental Health. Since 1990, the population of this catchment area has slowly but steadily increased. Below is a compilation of the residents by community in our catchment area.

 

COMMUNITY	NATIVE	NON NATIVE	CHILDREN (under 18)	TOTAL
Tok	188	1136	407	1324
Northway	257	82	115	339
Tetlin	110	4	36	114
Tanacross	95	1	29	96
Dot Lake*	57	19	23	76
Eagle**	41	199	46	240
Healy*	39	1	18	40

*Chicken number is included with Tok

*Dot Lake and Healy l998 statistics by Delta Public Health

**Eagle Statistic by FBX Regional Public Health Center

All other totals are provided by Tok Health 1/99

The catchment area is 24,825 square miles. Staff travels by car, boat and plane to residents in this area.

 

At one time, TAMHC regularly offered services to the outlying areas. Currently services to those areas are limited to scheduled appointments only.  Referrals to TAMHC come from the local community health aide, alcohol counselor, Tribal Family Youth Service employee Division of Family & Youth Services or a village public safety officer.

 

Tok is by far the largest community in the service area and accounts for the vast majority of individuals served.

 

Services provided are emergency on-call, (24 hour per day, 7 days per week), individual, family, or group psychotherapy, and consultation/education with local agencies and psychiatric evaluation and medication management to children, adolescents, adults and seniors. Although not specifically defined as such, TAMHC serves Seriously Emotionally Disturbed (SED) children and Chronically Mentally Ill (CMI) adults.  TAMHC does not offer Rehabilitation services at this time.

 

The staff positions are an executive director, mental health clinician, an administrative assistant and a contract psychiatrist, two day, every six weeks and consultation by phone.

 

This introduction would not be complete without mention of the recent resignation of the executive director and the projected departure of the mental health clinician. Their tenure has been among the longest in rural Alaska mental health service delivery. This professional team has been a stabilizing influence for the community of Tok. Their commitment, competent professionalism and sincere involvement with the community will be missed.

 

Review Process

 

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

 

To conduct this review, a team consisting of a facilitator, one community representative, a peer provider from a MH program and one member of the DMHDD Quality Assurance Unit, met for three days in Tok, AK.  The team conducted seventeen interviews, seven of which were individuals who receive services from TAMHC. Eight were related service professionals from Tanana Chiefs Conference Upper Tanana Alcohol Program, Division of Family & Youth Services, Division of Public Health nurse, Alaska Gateway School District school psychologist, Health Clinic physician and emergency services technician (EMT), Upper Tanana Head Start Program and the local Magistrate.  In addition, one board member and one TAMHC staff member was interviewed.  Informal interviews occurred with three community members who attended the public forum.  These three individuals included one related agency personnel, and two active community members, with many having multiple roles in the community.  The team also reviewed program and agency materials. It is important to note that all but one of the interviews were with non-native consumers.

 

Interviews were held in person at TAMHC offices, by telephone and in the offices of other agencies.  The interviews lasted from fifteen to seventy-five 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 previous findings, areas of excellence, an administrative review, 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 TAMHC using the new program standards, there is no previous action plan for these integrated standards.  A plan of improvement for required chart reviews is 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 TAMHC clearly excels in the following areas based on the overwhelmingly positive response from consumers, related service providers, and community members.

 

1.      Community members, services providers, and consumers noted the job performance of the administrative assistant as an area of excellence of the program. Her organizational skills, follow up with information, timely reports, sensitivity to confidentiality, fiscal capabilities and friendly manner were noted as an area of excellence.

2.      Tok is a small rural independent minded community with a strong value of privacy. The lack of privacy can be a problem in small communities and a deterrent to mental health treatment. TAMHC has taken efforts to protect confidentiality. The protection of privacy and confidentiality that TAMHC offers emerged time and again from respondents as highly valued, greatly appreciated and respected by all. Virtually every interview mentioned what an exceptional job the staff of TAMHC does in protecting the privacy of its client population.

 

 

 

Governance

 

A board of directors governs TAMHC.  Currently there are three board members. Members include a consumer, an American Native and an Alaska/American native. The only physician in Tok has recently been recruited as the fourth board member.  Including the newest board member three members will be from Tok and one from Dot Lake.

 

The board meets monthly at times and dates when members are available.  Meetings are open to the public.

 

The TAMHC Council Board of Directors (CBD) with clinic staff are responsible for identifying needs for written policies and procedures (P & P). The CBD review the P & P at least annually. Changes are made with the approval of the Board. 

 

The manual includes Personnel Administration P & P for the selection of personnel, position descriptions, staff training, salary structure, and annual evaluation process of employees.

 

The P& P manual does not include a policy or procedure for, disciplinary action.

 

A review of staff personnel files met standard including annual training plan.

 

It is the stated function of the CBD to recruit and hire the executive director (ED) position and complete the annual evaluation once employed.

 

Currently, the board is actively recruiting for the executive director and mental health clinician positions.

 

Accessibility

 

The TAMHC building is free from architectural barriers and is accessible to the physically handicapped.

 

Services are available regardless of ability to pay full fee.

 

Services are not routinely scheduled to communities outside of Tok but are available by referral or request.

 

Finance

 

TAMHC is primarily funded through a DMHDD state grant, with other limited monies from Medicaid, third party payments and contract services.  MEDICAID consumers are charged the same fee for service as non -MEDICAID consumers.

 

The agency has a sliding fee scale for those unable to pay full fee for service.

 

The last financial review was completed for the period ending June 30, l998. Based on review, no modifications of financial statement were required. The last full audit was completed for the period of June 30, l997. (Cover letter is attached)

 

 

 

This portion of the narrative refers to the Quality of Life Values and Outcome Indicators, as they relate to the specific services offered by TACC.  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 and Self-Determination for all people receiving services from TAMHC:

 

·        Consumers reflected consistent theme of choice as the base of therapeutic interactions.

Comments:

      “I’m offered a lot of options to consider”

      “I appreciated having the choice of working with a woman”

      “She is good at finding out what I want”.

      “Even when we have different opinions it is up to me”

      “They help me clarify what’s to be done”

 

Dignity, Respect and Rights

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

 

·        Staff treat people in respectful manner

·        Confidentiality is maintained

·        Staff are on time, keep agreements and have good follow up

Comments:

“I’ve always been treated with courtesy and respect”

“I can trust that my business won’t be all over town”

“They treat me fairly”

      “They are respectful and kind”

      “Always respectful”

       “Confidentiality is so good, I hardly ever run into another client in the waiting room”

       “Very sensitive to desire for privacy”

                       

Health, Safety and Security

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

 

·        Availability of staff promote safety of clients

·        Therapeutic interventions empower clients to make healthier decisions

Comments:

“I was brought back from the dead”

“Available 24 hours a day”

“My safety is definitely better since coming here”

“I had to call late one night and talk for a long time, it was helpful”

 

Community Participation

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

 

·        Consumers are encouraged to develop a role in the community

Comments:

“I’m encouraged to participate in community organizations”

“My church is my extended family

“I’m aware of community events but do not participate, yet.”

“Has helped me increase sports activities”           

 

 

 

 

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

Part

No.

Yes

Part

No

Yes

Part

No

Yes

Part

No

Person/Parent/guardian

7

5

1

1

7

6

1

7

Staff Performance

Person/Parent/guardian

7

5

1

1

7

3

4

7

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

 

Related Agency Response

 

Respondents view TAMHC as a good resource for various problems and make referrals frequently.

“Care about people, intelligent, know their business, very helpful”

            “Staff is connected to community”

            “Is only facility between the villages”

“Very helpful with critical incident debriefing”

“Always call in an emergency”

 

Interviewees implied collaboration between service providers; however service providers develop separate parallel treatment processes rather collaborative with a shared service plan.

“Offer complimentary services but not together”

                “No, no shared service plans”

 

*See attached Questions for Related Service Agencies table.

 

 

The following recommendations were identified by the site review team as areas that need attention from the organization: (The numbered items represent areas of concern and the bulleted areas require a response.)

 

1.       The mission statement does not reflect consumer empowerment. Revise mission statement to be particular to and appropriate for a publicly funded community mental health center. (Administrative Standard #1)

2.       Train staff on philosophy and values of psychiatric rehabilitation. (Administrative Standard #2)

3.       Staff education and orientation do not reflect a focus on consumer centered services. Revise training materials to include both language and value of consumer centered services. (Administrative Standard # 2)

4.       Currently there is not equal access to services for all people within the Tok catchment area; specifically noted were lack of consistent services to outlying areas and limited services for youth. (Administrative Standard #11)

·         Design and implement plan to meet the mission of TAMHC of outreach to villages.

·         Work in collaboration with DMHDD regional coordinator, community members and/or other providers of services to develop resources to provide consistent outreach services to villages.

·         Recommend TAMHC take the lead in coordinating a community effort to identify SED children, needed services and develop an array of resources to serve this population in their respective communities.

5.       There is currently not a process that includes staff, community and consumers in the annual evaluation of the program and identification of community needs. Together with the CBD and community members develop a process for an annual program evaluation in which staff, community including other service providers and consumers actively participate. (Administrative Standard # 13)

6.      Currently there is not a written personnel policy for disciplinary action. Develop written policies for disciplinary action. (Administrative Standard # 33)

 

 

 

The State DMHDD QA staff conducted the mental health file review portion of the integrated site review.  A total of 10 files were reviewed, comprised of adult Medicaid cases, child Medicaid cases, adult non-Medicaid cases and child non-Medicaid cases.

 

TAMHC is encouraged to refer to the Integrated Standards Mental Health File Review checklist for required components for good clinical practice and documentation.

DMHDD QA provides detailed training and your agency is encouraged to make arrangements for a training session to ensure that Medical necessity is being fully addressed in documentation and to gain more awareness of the availability and proper use of rehabilitation services.

 

 

 

TAMHC scheduled a public forum to allow community members, not included in the regular interview process, to air their concerns, comment and question the site review process. 

 

Three community members attended the forum along with two site review team members and two staff members.  Discussion lasted for one hour and fifteen minutes.

 

Attendees were apprehensive about the potential loss of mental health services to their community. They identified TAMHC as a vital member of the community’s network of support for its citizens and agencies.

 

 

 

Individuals implied or overtly stated that when living in a rural community as Tok it is easy to discover personal private information about each other.  Consequently, the seeking of mental health services in this atmosphere could stigmatize and potentially ostracize the individual from the community.  The site review team applauds the courage of the clients who seek mental health services as well as the staffs who live and work in this rural community.

 

 

TAMHC is in transition from several years with stable staffing to hiring new clinical personnel. The community of Tok has learned to rely on the professionalism and involvement of the current staff. The site review team wishes the community of Tok a speedy resolution to this transitional period.

 

The team also thanks TAMHC for their kind assistance during the site review.

 

A finalized report will be received within 30 days of this review. TAMHC in cooperation with DMHDD, will be responsible for developing a plan addressing the issues noted in the Areas Requiring Response.