APPENDIX SEVEN

Alternatives

· ‘Tobacco’ taints all questions. Could make results look like all substance abuse problems when it’s only tobacco.

· Ask substances separately.

· Add ‘N/A or never used’

· There are three different, separate issues and need separate questions. These questions (6 &7) do not usually apply to children.

· Add ‘N/A’ response

· Delete tobacco

· ‘tobacco’ – This is different than using alcohol or drugs and needs to be separate. Each could be separate questions: alcohol, drugs and tobacco

· Client doesn’t use at all

· Not applicable for children (‘n/a’ was written in next to each answer)

Norton Sound

· Language choice – something else besides referring to clients as ‘mentally ill’

· ‘Mentally ill’ – Ouch!

· ‘We’…‘not here to judge you’. Really? I feel mentally ill, watched by an unseen ‘we’, and judged!

SCC

· Several of the consumers stated tobacco or caffeine was what they needed (in response to ‘d’). Caffeine was not a choice, though is often considered an addictive substance. Client noted this.

· The overall consensus was that the wording was poor! In asking about substance use, it may be helpful to simply state that substance use/abuse is a common problem, etc.

· It does not include caffeine in the choice of used substances, which is very common and problematic.

· In not being specific in these questions, if a person had answered ‘yes’ to all (or any) and their substance of choice was caffeine or tobacco, it could appear as if this person had an alcohol or drug problem.

· Time frame? The consumer answered ‘yes’, though time period was quite some time ago (10+ years), with the exception of tobacco & caffeine.

· It does not give a time frame to look at, like the other questions (2 months? 2 years?).

· Client does not use (drugs/alcohol)

· Although, this is not a current problem, apparently it has been in the past and appeared to be embarrassing (for the client).

· Client answered these questions, but said that they did not apply to him because he is now clean & sober. Should there be a timeframe?

· 6c discusses guilt with drinking or use – use of drugs & tobacco?

· Might offer a range, like ‘sometimes’ instead of just yes or no

· Some clients have been in remission for years and would still answer ‘yes’ to these questions for past use. What is the purpose of this question? If it is to determine the prevalence of comorbidity, you might ask ‘Are you currently using drugs or alcohol?’ and

SCC cont’d

‘Have you ever had a problem with drugs or alcohol?’ If in remission, how long in remission?

· I also think it is a mistake to include tobacco with drugs and alcohol as the vast majority of clients smoke or use tobacco. Many clients also abuse caffeine and OTC drugs. You might not include tobacco with drugs and alcohol and ask ‘Do you smoke or use tobacco products?’ And ‘Do you use over-the-counter drugs?’

· The questions asked in #6 are those asked in assessing whether or not someone has a dependence or abuse problem. Our clients are not social drinkers; either they use to excess or they don’t use at all.

· Finally, if the purpose of this question is to determine prevalence of comorbidity, this information can be gotten from the charts. If the purpose is to assess improvement (outcomes) in the client, then these questions do not work as it stands. Perhaps if you put the time frame in front of each question: ‘In the last six months, have friends…’

· Many clients use OTC drugs – might specifically mention OTC drugs

· Most clients smoke – might want to differentiate between smokers who do not use alcohol or drugs

· Tobacco is this person’s targeted substance of choice, but on this form it could be perceived as ETOH or other drugs

4Rivers

· Definition for ‘regular health care’ leaves out everyone in the Bush.

· The stated assumption of this question is that the patient has access to regular health care from a primary or family physician. In the entire 48,000 square miles of the Iditarod area, there is not one physician.

· Regular medical care is provided by health aides or, at best, Physician’s Assistants or Family Nurse Practitioners who operate in health clinics in the villages. In the four Yukon River villages, those health aides are supervised by staff of the Yukon-Kuskokwim Health Corporation in Bethel. In the four Kuskokwim River villages of the area, the village health aides are supervised by the Physician Assistant based at the McGrath Health Clinic. At present, because of the inadequate and gross mismanagement of the McGrath Health Center by Tanana Chiefs Conference, Fairbanks, there is no Physician Assistant or other mid-level health care provider in the McGrath Health Clinic. In the past, when there was a mid-level in the Clinic, the clinical supervision for that position was provided by Alaska Native Medical Center, but not the management. So you can begin to get a sense of the confusion we have here.

· How do we get the State of Alaska to understand that we have no physicians out here?

· How do we get the Division of Mental Health to understand that the requirement for rural mental health centers to have a physician make regular

4Rivers cont’d

· monthly supervision in the clinics is a stupid regulation? Clearly, it is evident to me that the people making up these rules have not bothered to leave the comfort of their urban offices in Juneau and Anchorage.

· The point is that Question 8a is totally inappropriate here.

· ‘In physician’s office or clinic’ doesn’t apply to rural Alaska at all. There are no physicians anywhere in the McGrath service area.

· The clinic here is managed by Tanana Chiefs who won’t provide services to non-native persons.

· It’s stupid to include this requirement for the Bush. It shows absolute ignorance of rural service areas.

· Not pertinent to McGrath

· No MD in McGrath

Alternatives

· Answer 1: ‘Denali Kid Care’ was written in

Norton Sound

· Phrasing is offensive.

SCC

· This was difficult for most of the consumers to follow and determine which was most appropriate for them as Medicaid has clear limitations about health care to be received, and most of the people receive care only when needed and do not receive health care services on a regular, on-going basis.

· These questions do not clearly include eye/dental care in reference to regular health care.

· In referring to ‘access’, is it that one can or does receive regular health care?

4Rivers

· Questions are wordy and convoluted

Alternatives

· Maybe a place for age of consumer or year of birth on this form.

· If a child, who is answering most of the questions (primary caregiver or consumer)? Add a place to specify this.

· This parent has two children in services and it has asked if that information needed to be either asked or a place to check off.

· Client does not understand how questionnaire relates to client satisfaction.

· Add 'age, caregiver, and length of time as caregiver'

· No comments (9)

SCC

· The person who completed this survey has low intellectual functioning and does not read/write (very limited). This person required assistance in understanding the words and content of most questions.

· The survey seemed more like a quality of life assessment vs. a skill or resource need assessment, which is critical in developing an effective treatment plan.

· The order of the questions seemed out of place. The questionnaire didn’t seem to flow in an organized manner.

· When developing a form for consumers to complete with the goal of completion of the form being independently done without use of case management services, it may be helpful to have the wording as basic as possible as there is a wide range of education barriers with the population.

· Participants were willing to complete the questionnaires. This questionnaire asks some useful questions and, with some changes, could be very beneficial to clinicians.

· I am enclosing psychosocial assessment tools that used to be implemented which we found helpful in the past. Some of these questions would be helpful if added to the questionnaire.

· After administering the questionnaire, I noticed it might have been more beneficial to let the client read it as well, instead of just asking the questions. I still believe, however, that it would be difficult for her (DD client) to understand.

· Client felt it was helpful to have the questionnaire to read off as the questionnaire was being administered to her.

· Consumer had no additional comments.

· Some people we see don’t identify with the term ‘mentally ill’. This seems to make some people defensive.

· This seems to assume that people have very serious problems. Sometimes people are just getting a little help and they might not like being asked all of these questions, especially the term ‘mental illness’.

· The timeframe given is 2-3 months. I am not sure how often clients are to be assessed. I’m thinking it might be every six months. If it is every six months, then perhaps these questions might be based on the entire six-month period between assessments (question 7 does use the six-month criteria).

· Client reports questions on first survey were hard to answer.

· Clients do not understand funded programs vs. Medicaid

· Most clients don’t understand ‘funding vs. insurance

· No (4)

APPENDIX ELEVEN

Qualitative Comments:

MHSIP (YSS-F)

Were any of the questions hard to understand? Which ones? Why?

· No

Were any of the questions unclear? Which ones? Why?

· No

Was the questionnaire too long?

· No

Did we ask everything that you think is important about mental health services?

· Think so

Are there any questions we should add?

· No

Do you have any other comments? (Please use the reverse side if needed)

· None

APPENDIX TWELVE

<Agency>

Client Functional Assessment – Adult (Revised)

c Initial Assessment c 3-Month c 6-Month c Annual

Text Box: For current clients, timeframe is from the date of the last functional assessment; for new clients, the last 6 months.

Client Number Date

Program

1. How often are you involved in activities that are important to you? (Such activities might include subsistence activities (hunting, fishing, berry picking, etc.), full or part time employment, volunteer work, church activities, school, sports, or social activity.)

c 1 Usually every day

c 2 2 – 5 days a week

c 3 1 – 4 days a month

c 4 5 – 10 days a month

c 5 Not active

2. Which of the following categories describes your legal involvement?

c 1 None

c 2 Limited (no threat of jail such as truancy or minor litigation, misdemeanor charges, non-criminal divorce or child custody proceedings, filed TRO or been served TRO, court-ordered out-patient mental health/substance abuse TX)

c 3 Significant (probation, parole, felony charges pending, awaiting sentencing, SIS)

c 4 Extreme (incarcerated in jail or lock-up facility, Title 12 hospitalization, in-patient TX in lieu of incarceration with charges pending TX outcome)

c 5 Unable to determine

3. Which of the following best describes your financial situation most of the time?

c 1 Very secure financially (enough income to pay for all basic needs, such as food, housing, clothing)

c 2 Financially secure most of the time (some financial problems that are manageable)

c 3 Many financial problems (not enough income to pay for some basic needs)

c 4 Extreme financial hardship (not enough income to pay for most basic needs)

c 5 Unable to determine

4. Which of the following categories best describes your housing situation most of the time?

c 1 Independent (own or rent safe, adequate house, apartment or trailer, or I chose to live with others)

c 2 Live with others (family or others who helped care for me)

c 3 Residential facility (Domiciliary, group home, assisted living facility, staffed apartment, half-way house with 24-hour staff supervision)

c 4 Sheltered care (supervised SRO, adult foster home, supported apartment program)

c 5 Institution (hospital, prison)

c 6 Homeless (shelter, on the street, vehicle, unsafe, inadequate apartment/house/trailer, transitional housing such as hotel, staying with family/friends temporarily)

5. Please answer the following questions about drug and alcohol use:

a. Have friends or relatives asked you to Cut down on alcohol or other drugs, or quit entirely?

c Yes c No

b. Are you Annoyed by friends or relatives who question your use?

c Yes c No

c. Have you experienced Guilt because of your drinking or use?

c Yes c No

d. Do you need an Eye opener in the morning (alcohol or other drugs) to get started?

c Yes c No

Clinician: How many of the above questions were answered “Yes”: _______

6. How many times have you been hospitalized for mental health treatment? (Indicate length of stay for each hospitalization.)

c 1 None

c 2 Once _____________________________________________

c 3 2 times _____________________________________________

c 4 3 times _____________________________________________

c 5 4 or more times _____________________________________________

7. How often can you get the physical health care that you need? (Physical health care includes dental and eye care, and is defined as care received from your primary/family doctor, physician’s assistant or nurse in a doctor’s office or clinic.)

c 1 All of the time

c 2 Most of the time

c 3 Sometimes (occasionally use the Emergency Room (ER) and/or Emergency Medical Technicians (EMT))

c 4 Limited (use the ER and/or EMTs most of the time)

c 5 Almost Never (use ER and/or EMTs all the time)

c 6 Other _________________________________________________

8. How often do physical health problems keep you from doing your normal activities?

c 1 Never

c 2 Occasionally

c 3 Often

c 4 Regularly

c 5 Always

c 6 Other _________________________________________________

9. How do you pay for your physical health care?

c 1 Fully insured or use an Indian Health Service facility (with no charges)

c 2 Insured (includes Medicaid/Medicare or Indian Health Service facility; pay for some of the charges, such as percentage or co-pay)

c 3 Some insurance (pay about half of the cost)

c 4 Very little insurance (pay most of the cost)

c 5 No insurance (pay all of the cost)

c 6 Other ______________________________

Additional comments:

______________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

APPENDIX THIRTEEN

<Agency>

DEMOGRAPHIC QUESTIONNAIRE (Adult) - Revised

This questionnaire is part of the attached Consumer Satisfaction Survey. These questions will help us better understand the consumers who use mental health services and how those services affect our different population. There is no place that asks for your name or any other information that could identify you. There are no codes on the forms or envelopes. A random number will be added after the agency receives these questionnaires that will be used only for the purpose of analyzing your responses. This is a completely anonymous survey.

Date __________________

1. How old are you? ____________

2. Do you have a guardian, conservator or payee? c Yes c No

If yes, please indicate which one. _________________________________________________

3. Which of the following best describes the race or ethnic group that you consider yourself?

c African American c Alaska Native/American Indian

c Asian/Pacific Islander c Caucasian

c Hispanic/Latino c Other

4. Gender: c Female c Male

5. Which of the following services have you received in the last year from <agency>? (Check all that apply)

c Therapy/Counseling c Case Management

c Housing c Employment

c Family Services c Substance Abuse Treatment

c Transportation Services c Advocacy Services

c Psychiatric Services/Medication c Other ______________________________

6. Are you still receiving services from <agency>? c Yes c No

7. How long have you been receiving, or did you receive, services from <agency>?

c Less than six months c 2 to 5 years

c 6 months to 2 years c More than 5 years

8. About how often do (or did) you receive services from <agency>?

c Daily c Twice a month

c Once a week c Every other month

c Twice a week c Every three months

c Once a month c Other ______________________

9. Comments. Is there anything else that you would like to tell us about yourself or the services that you receive that might help us to better serve you? (Please use the reverse side if needed.)

____________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to answer these questions about yourself.
APPENDIX FOURTEEN

<Agency>

DEMOGRAPHIC QUESTIONNAIRE (Child & Family) - Revised

This questionnaire is part of the attached Consumer Satisfaction Survey. Your answers will help us better understand the consumers who use mental health services and how those services affect our different population. There is no place that asks for your name or any other information that could identify you. There are no codes on the forms or envelopes. A random number will be added after the agency receives these questionnaires that will be used only for the purpose of analyzing your responses. This is a completely anonymous survey.

Date ________________________

Completed by: c Biological Parent c Foster Parent c Guardian

c Adolescent c Other __________________

1. How old is your child? _______________

2. Which of the following best describes the race/ethnicity that you consider yourself?

c African American c Alaska Native/American Indian

c Asian/Pacific Islander c Caucasian

c Hispanic/Latino c Other

3. Gender: c Female c Male

4. What is your school situation? c Grade ______ c Not in school c Working on GED

c Other _________________________

5. Are you (or is the child/adolescent) in protective custody? c Yes c No

If yes, please select one of the following and indicate for how long? ______________________

c Division of Family and Youth Services (DFYS)

c Division of Juvenile Justice (DJJ)

c Parent-Guardian

c Other ________________________

6. Who referred you (or your child) to <agency> for mental health services?

c Self-referred c DFYS c School

c Parent/Guardian c DJJ c Other ________________________

7. Which of the following services have you received in the last year from <agency>? (Check all that apply)

c Therapy/Counseling c Treatment Foster Care

c Life Skills Specialist Services c Psychiatric Services/Medication

c Family Skills Development c Other ____________________________

c Case Management

8. Are you still receiving services from <agency>? c Yes c No

8. How long have you been receiving, or did you receive, services from <agency>?

c Less than six months c 2 to 5 years

c 6 months to 2 years c More than 5 years

10. About how often do (or did) you receive services from <agency>?

c Daily c Twice a week c Twice a month c Every three months

c Once a week c Once a month c Every other month c Other ______________

11. Comments. Is there anything else that you would like to tell us about yourself or the services that you receive that might help us to better serve you? (Please use the reverse side if needed.)

Thank you for taking the time to answer these questions.