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					                                     Ch’eghutsen’ A System of Care
                                      Fairbanks and Interior Alaska
                                           August 9–12, 2004


I.       Background

A.       Details of the Site Visit

The first system-of-care assessment visit to Ch’eghutsen’ A System of Care, operated by the
Fairbanks Native Association in conjunction with the Tanana Chiefs Conference and the
University of Alaska Fairbanks, in Fairbanks, AK, and the villages of Nenana, Stevens Village,
Allakaket, Huslia, Nulato and Koyukuk, was conducted August 9–12, 2004. Over a period of 3
days, a team of two site visitors from ORC Macro conducted a total of 22 face-to-face interviews
with representatives of the system of care, including the project director, members of the
governance structure, representatives of the core child-serving agencies, direct service providers,
caregivers whose children and families have been served by Ch’eghutsen’, staff responsible for
quality monitoring, and other grant-related staff members. The focus of the site visit was on
overall program operations and the urban (Fairbanks) service delivery; no village coordinators
were interviewed, although the supervisory staff at the Fairbanks office supervise the village care
coordinators. Thus, while the primary focus is on the Fairbanks office and operation, there also is
some discussion of Ch’eghutsen’ as implemented in the villages.

Site visitors reviewed randomly selected case records of children enrolled in Ch’eghutsen’. The
case records provided additional information regarding program development and adherence to
system-of-care principles.

The following report is based on information obtained from the system participant interviews,
case record reviews, and additional documentation provided by grant community staff. The
report is organized into five sections:

        Background of the project
        A description of the system of care at the infrastructure level
        A description of the system of care at the service delivery level
        System of care strengths and challenges
        Sustainability efforts and lessons learned

B.       History and Background

In 1998, the Fairbanks Native Association (FNA), the Tanana Chiefs Conference (TCC), and the
Psychology Department at the University of Alaska Fairbanks (UAF) formed a partnership to
address the need for mental health services for Native children in Interior Alaska. Through this
partnership, a 3-year SAMHSA Circles of Care planning grant was obtained to design a system
of care for Alaska Native children with serious emotional disturbance and their families in five
subregions of Interior Alaska.


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The Circles of Care planning grant, implemented during 1998–2001 under the guidance of an
Advisory Council, conducted a strategic planning process involving a broad array of input from
key stakeholders in the region. Subsequently, three legislatively mandated SAMHSA grants were
obtained to begin developing the system of care in the region. This process involved a series of
community meetings throughout the five subregions of the State, assessing needs, building
community readiness, and establishing working partnerships among multiple agencies. From this
planning process, Ch’eghutsen’ has developed a culturally specific model to treat serious
emotional disturbance that has been designed by and for Alaska Native people. In addition, a
range of “community readiness” activities and extensive training for rural and urban Native
service providers have been implemented to build the system’s capacity to implement services
for children and families. Service has begun in the urban Fairbanks area and six rural village
communities of the region.

Oversight and advice to Ch’eghutsen’ was provided by an initial Circles of Care Advisory
Council and a Circles of Care Steering Committee, which was charged with implementing the
planning process. The Circles of Care Advisory Council, renamed the Ch’eghutsen’ Council,
continued to provide advice regarding the project. With the initiation of the Children’s Mental
Health Initiative grant, the Ch’eghutsen’ Council was terminated in Fall 2003 with the Steering
Committee understanding that the Council would be reconstituted in early 2004 and would have
significant client family representation.

The overall goal of Ch’eghutsen’ is to meet the mental health needs of Native children and
families in Interior Alaska. Its mission is: “To take part in the healing of our children, families
and communities through a flexible, evolving process that returns us to our most basic belief that
children are precious (ch’eghutsen’)”. In particular, Ch’eghutsen’ is working to

        develop a system of care for children with serious emotional disturbance and their
         families through the implementation of the Alaska Native Wraparound System of Care
         model, designed by and for Alaska Natives/American Indians in Interior Alaska;

        support a broad array of mental health and other related services, treatment, and support
         to the target population through the creation of regional care teams, which will provide
         wraparound services through community development, prevention and treatment;

        evaluate the effectiveness of the system of care and its component services through a
         locally-based external process and outcome evaluation by the University of Alaska
         Fairbanks, internal evaluation personnel, and the national evaluation;

        involve families in the development of the system and services, and in the care of their
         own children by meeting with the Ch’eghutsen’ Council quarterly; and

        use culturally competent approaches for serving Interior Alaska Native children and their
         families through the implementation of the Alaska Native Wraparound System of Care
         model, designed by and for Alaska Natives/American Indians.



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Catchment Area and Target Population

Interior Alaska, the target area for Ch’eghutsen’, is larger than the country of France and
contains the urban Fairbanks North Star Borough with a population of 82,840 and an Alaska
Native and American Indian population of 8,174 (2000 Census). In addition, the Yukon-
Koyukuk subregion includes the villages of Galena, Huslia, Ruby, Nulato, Kaltag and Koyukuk,
with a total collective population of 1,823 and the Yukon-Tanana subregion includes the villages
of Evansville, Alatna, Allakaket, Hughes, Rampart, Minto, Manley and Stevens Village, with a
total population of 921. In the villages, approximately 80 percent of the population is American
Indian and Alaska Native. Since most of the villages have only a small number of jobs, many
families move to Fairbanks to look for work. People with significant health care needs also tend
to migrate to the city. Many Natives who relocate to Fairbanks retain strong village family ties.

Among the residents of Interior Alaska, unemployment is high (15.5 percent), literacy rates are
very low (with 60 percent of Native 10th graders scoring “not proficient” in reading, 76 percent
“not proficient” in writing, and 84 percent “not proficient” in math), and extremely high rates of
fetal alcohol syndrome, alcohol-related deaths, and suicide rates. Nearly 11 percent of the
Interior’s Native children have already been diagnosed as suffering from significant emotional
disturbance, and this is viewed as a major under-representation of the actual prevalence. Services
are fragmented, due to the large geographic distances covered. To address these needs,
Ch’eghutsen’ has identified its target population as the Alaska Native/American Indian children
and youth ages 0–22 and their families in Fairbanks, and all children and youth with severe
emotional disturbance in the six outlying villages. Children and youth who meet any of the six
indicators of serious emotional disturbance (suicide attempt, substance abuse, violence, sexual
abuse, fetal alcohol syndrome disorder, or trauma) are eligible for the program.

Alaskan Native youth are over-represented in the juvenile justice system, and that system is
severely limited in its ability to address the needs of juveniles with mental health problems.
Wraparound services have not been available to all Alaskan Native populations, and many of the
services provided have not been culturally sensitive and consistent with the indigenous culture.
Virtually no Native service providers have existed in the region. Service providers of all types
have high rates of turnover, exacerbating the disconnect between the local culture and mental
health service provision.

The physical challenges of Interior Alaska are significant. Only 11 of the 42 villages in the
region have road access, and that is often limited to the summer months. Travel between
communities is restricted to small one- and two-engine planes, river boats (in the summer), and
snow machines (in the winter). Most villages have sewer and running water only in a central
communal village facility. Telephone service is unreliable, and weather conditions are extreme,
with winter temperatures dipping below –60 degrees and only 3 hours of sunlight in December.

There are six publicly funded mental health programs for youth with serious emotional
disturbance in the Interior, which provide varying intensities of outpatient service. They are
Fairbanks Community Mental Health Center, Family Centered Services of Alaska, Tanana
Chiefs Conference, Railbelt Counseling and Addictions, Tok Area Counseling Center, Galena
Mental Health, and the Yukon Flats Care Center. Fairbanks Memorial Hospital offers limited

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services to stabilize or transfer children to the State mental hospital or a private short-term
inpatient provider for families with the resources to pay. Lastly, the Alaska Psychiatric Institute
offers limited inpatient care to youth. Because of the limited number of residential facilities and
other services available locally, youth are frequently sent out of State for treatment.

In the villages, in particular, professional resources to help families and communities address the
needs of children with serious emotional disturbance are very limited. School counselors, health
aides, public safety officers and extended family may be the only support for families. In some
villages, these are augmented by the local pastor, a paraprofessional Native counselor and an
itinerant mental health therapist. Such reliance on paraprofessionals and local, informal supports
is quite consistent with a wraparound model, given a core of mental health professionals and
paraprofessionals trained in the model who can help ensure that it is implemented appropriately.

Funding

The planning of Ch’eghutsen’ has benefited from funding from a 3-year SAMHSA Circles of
Care planning grant awarded in 1998, followed by three legislative SAMSHA-funded mandates
to begin implementation. These funds allowed significant planning and the development of
training for staff. With the award of CMHS Children’s Mental Health Initiative grant to
implement a system of care, there has been minimal funding from State mental health
organizations, because of State budget shortfalls and reorganization. However, match funds have
been received from other partner agencies, local businesses, and an Alaska Native Corporation.
Funding for the current fiscal year includes the following:

        CMHS Grant                           $2,000,000
        Volunteer match                      $ 119,502
        Donations                            $ 61,946
        State Office of FAS                  $    2,800
        Doyon, Ltd.                          $    1,500

Flexible funding is reported to be available, but with changes in the management of the project,
staff reported that it has become less clear what is eligible for funding through flexible funds,
and flexible funds are not as accessible as they had initially been. Requests from care
coordinators must pass to program assistants, and then must be approved by a clinical supervisor
and the project director.

Managed Care

Funding for intensive mental health services comes primarily from Indian Health Services (IHS).
While Ch’eghutsen’ hopes to increase its funding from IHS and Medicaid, it is not clear, given
the current status of the State’s funding of health and social services, how this will occur. Since
many of the services provided by Ch’eghutsen’ fall outside Medicaid categorical funding,
obtaining Medicaid funds to support Ch’eghutsen’ is expected to be a challenge.




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II.      Description of the System of Care at the Infrastructure Level

A.       Governance

From the initial efforts to seek the Circles of Care funding, Ch’eghutsen’ has been a
collaborative effort of three key organizations. The fiscal agent and lead agency for Ch’eghutsen’
is the Fairbanks Native Association (FNA), which has since its incorporation in 1967 provided a
wide range of services to Alaskan Natives in the Fairbanks area. It provides behavioral health,
social and educational services, and has implemented eight SAMHSA projects prior to the
current Children’s Mental Health Initiative grant. The Tanana Chiefs Conference (TCC) has
been the sole provider of health care for Interior Alaska Natives, and is primarily responsible for
providing services to the Native villages. The Psychology Department at the University of
Alaska-Fairbanks (UAF) operates the Rural Human Services Certificate Program (RHS) through
which all grant program staff and rural service providers will be trained and also is developing
culturally appropriate evaluation strategies. In addition, UAF is conducting an independent
process evaluation.

The governance structure of Ch’eghutsen’ has evolved since the initial Circles of Care project.
During the Circles of Care planning effort, two groups were created to provide advice and
guidance to the Ch’eghutsen’ effort. A Steering Committee, comprised of key staff from the
three primary collaborators, has provided ongoing direction and guidance to the Project Director.
The Steering Committee is described in the proposal as the governing body for Ch’eghutsen’. In
addition, the Ch’eghutsen’ Council was developed during the Circles of Care Planning process to
provide input from Alaska Native representatives from each service region, including family
members of children with serious emotional disturbance to help create a system of care that was
culturally responsive to the needs of the Alaskan Native people to be served.

About the time that the Children’s Mental Health Initiative grant was awarded, the Ch’eghutsen’
Council became less active, with irregular meetings and less involvement in the initiative. In
fact, at the time of the site visit, there was considerable confusion about whether the Council
continued to exist and if so, in what form. At the same time, the Steering Committee expanded
its numbers but continued to consist solely of members of the three primary partners; it assumed
a greater role in guiding the day-to-day operations of the program. However, at the time of the
site visit, it was reported that the Steering Committee also had ceased meeting regularly. The
lack of an active, broadly based governance body has contributed to a limited level of
engagement by potential partner organizations, such as the educational and juvenile justice
systems.

While a number of committees were developed to address specific aspects of the initiative (e.g.,
Evaluation, Budget and Grants, Social Marketing, Clinical), and efforts were made to involve
family members on each of them, only the Evaluation committee is active and functional at this
time, according to program administrators. Key leaders in Ch’eghutsen’ recognize that the
limited input from a broad constituency could severely limit the potential sustainability of the
project as well as hamper ongoing services to the target population. Consequently, efforts
currently are underway to expand and reinvigorate the Ch’eghutsen’ Council. Yet, because the
FNA is fiscally responsible for the successful implementation of the grant, there also are

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pressures for it to exert greater control and influence over the project to ensure that it is
successful. A particular challenge for the initiative will be striking a balance between strong
central leadership by FNA and meaningful roles in governance by a broader constituency.

B.       Management and Operations

Project management and staff primarily are housed in Fairbanks. Exceptions to this are the
external evaluators, with offices at UAF, the interim project director, who works primarily from
the FNA office, and six care coordinators who work in the villages. Program staff are employed
by and responsible to the three primary partner organizations. For example, the project director
and the Fairbanks care coordinators are employed by the FNA. All coordinators report to the
clinical director, who, along with the village care coordinators, are employees of the Tanana
Chiefs Conferencel. Yet, the clinical director reports to the project director. This has led to
confusion about lines of authority and questions of equity since the different organizations have
different policies and procedures.

Staffing Structure

The deputy director of the FNA assumed the role of the interim project director after the prior
project director resigned effective July 9, 2004. A temporary project manager has been hired to
assist with ongoing operations during the search for a new project director.

The clinical director, clinical supervisor and lead care coordinator are all located in Fairbanks,
responsible for providing supervision and guidance to the care coordinators housed in Fairbanks
as well as those in the six villages served by Ch’eghutsen’. Supervision and coordination of
services in the villages is a major challenge, given that travel to the villages requires a plane ride,
an overnight stay (often on the floor of a central village building), and uncertain schedules due to
weather and landing strip conditions. Weekly telephonic clinical supervision takes place, but
telephone outages interfere with supervision as well as twice monthly clinical meetings where
care coordinators discuss cases and receive feedback from the clinical supervisors and one
another. All of the village coordinators now have office space.

Most direct clinical services are provided through referrals to Indian Health Services and local
mental health service providers, not by grant staff, although the care coordinators often do serve
as counselors for Ch’eghutsen’ clients, particularly in the villages. In addition to care
coordination, grant staff have focused their efforts on culturally-oriented group activities for
youth and families in an effort to build community and develop a presence in the target
population. Many interviewees pointed to the youth and family activities as an important service
provided by Ch’eghutsen’.

Grant funded staff include the following:

        interim project director
        clinical director
        interim project manager
        training coordinator (a position funded by SAMHSA set-aside funds only)

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        family advocate
        clinical supervisor
        internal evaluator
        social marketer
        lead care coordinator
        Fairbanks care coordinators (4)
        youth coordinator
        FNA administrative assistant
        TCC administrative assistant
        receptionist
        data specialist (vacant)
        village care coordinators (6)
        external evaluators (3)
        UAF administrative assistant (.5 funded by SAMHSA set-aside funds; .5 by CMHS
         grant)

Training

Training of Alaska Native care coordinators has been a major emphasis of Ch’eghutsen’. It is
hoped that, through training of care coordinators who have been recruited from their home
communities, the communities will develop a greater capacity to meet their specific needs, and
the care coordinators will be committed to serving their communities beyond the provision of
grant funding. The Psychology Department at UAF operates the Rural Human Services (RHS)
Certificate Program, and all personnel in the Ch’eghutsen’ teams, regardless of their degrees or
professional training, have attended the RHS training. The purpose of this training was to ensure
that all services staff developed a common core of competencies that would enable them to work
more effectively with the target population and with one another.

The training provided by the RHS program was widely viewed by interviewees as important and
successful. Nine care coordinators recently completed the Rural Human Services Certificate
program. All direct service staff are working on their associates, bachelors or masters degrees.
Although there is great agreement about the success of the training program, as Ch’eghutsen’ has
moved from planning to service provision, there are different opinions about whether the training
component should continue to be as time-intensive and supported by the program. Considerable
“work” time is taken by the training, and the Ch’eghutsen’ Council has recommended that all
staff earn a minimum of an associates degree. Concerns have been raised about the feasibility of
continuing to provide work time for the additional training, given the needs to provide services to
clients.

In addition to the training provided through the RHS program, a variety of workshops has been
made available to grant staff and partner agencies, including mental health, juvenile justice,
education, child welfare, private providers, family members, substance abuse treatment
professionals, and faith-based groups. Included in the 16 different trainings between August,
2003 and the site visit were such topics as cultural competence, Alaska Native healing in human
services, community readiness, introduction to recovery and mental illness, children’s mental

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health services, ethics, fetal alcohol spectrum disorders, sexual abuse, grief and healing, and
addictions interventions.

C.       Service Array

All grant-required services1 are present in the Ch’eghutsen’ service array. Additional services
include community-based youth groups, cultural activities and community capacity building
activities; significant efforts have been devoted to the development of culturally-based activities
allowing children in the community to connect or reconnect with their cultural heritage. A key
event is the annual Ch’eghutsen’ “Sharing Times” held at a traditional camp, with staff, children
and families attending the 5-day event and engaging in such cultural activities as beadwork,
birch bark basket making, and story telling. A family advocate, working with families primarily
in the Fairbanks area, also is part of the grant staff.

All children and families in Ch’eghutsen’ receive services from one of the care coordinators,
who provide case management, care coordination and basic counseling services and help
participants gain access to service providers. While all required services are available for
participants who live in the Fairbanks area, it is still viewed by some as quite common for
children to be seen outside their home communities, either in Anchorage or in residential
facilities in the lower 48 States. Ch’eghutsen’ has been involved with statewide efforts to
minimize out-of-community residential placements, but these efforts are only in beginning
stages. Care coordinators and other community stakeholders expressed some disagreement about
the availability of services.

A significant expansion of services in the rural villages has occurred with the hiring and training
of care coordinators, since there had been only limited mental health services of note in these
remote locations previously. These village care coordinators only recently had begun to provide
service at the time of the site visit, and as they become more involved in service provision in
their communities, it is expected that they will identify additional needs for collaborative service
provision there. In both the villages and in the Fairbanks office, there are some efforts to provide
services in expanded evening hours, but this seems to be much more common in the villages.

D.       Quality Monitoring

A partnership with the University of Alaska Fairbanks (UAF) has provided a great deal of
assistance with the development of culturally specific measures, including the Athabascan
Global Assessment of Functioning (GAF), and other measures of process and outcome in
coordination with Native members of the community. The UAF team had developed a process
evaluation for Ch’eghutsen’ in 2003; a draft report of the second year dated July 2004 was
available for review.


         1
            Services required in the grant’s guidance for applicants include diagnosis and evaluation; case
management; outpatient individual, group, and family counseling; medication management; professional
consultation; 24-hour emergency; intensive home-based; intensive day treatment; respite; therapeutic foster care;
and transition-to-adult.


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Ch’eghutsen’ had contracted with a company to provide a management information system
(MIS) to support service provision, management and the evaluation efforts. At the time of the
site visit, the MIS was not yet functioning and it was unclear how long it would take for it to go
on line. In the meantime, efforts were being made to lay the groundwork for collecting child and
family data that would be useful for monitoring child and family outcomes. An evaluation
committee had been formed, but it did not appear to be meeting regularly or functioning well.
Meetings were being held with the village elders to gain their approval of the evaluation efforts,
and family members’ input had been sought regarding measures. At the point of the evaluation,
however, given that Ch’eghutsen’ had only begun to provide services and the sense that any data
being gathered would not be recorded or analyzed until the MIS is functional, no useful
information about the quality of the services or the outcomes of those services was available.


III.     Description of the System of Care at the Service Delivery Level

A.       Entry into the Service System

Children enter Ch’eghutsen’ through referrals from child protective services, the schools,
juvenile justice, Tanana Chiefs Conference Counseling, and Head Start as well as from mental
health providers, private practitioners, and self-referral by families.

Upon entry, an intake form is filled out by the intake worker. Lead care coordinators serve as
intake staff, coordinating the process and, along with other staff members, deciding whether or
not applicants fit entry criteria. If the applicant meets criteria for participation, they are accepted
and services begin. The length of time between referral and the first service contact by grant
program staff typically is within approximately 8–14 days.

Eligibility for participation includes a family member between the ages of 0 and 22; residency in
the service area, which includes Fairbanks and six villages throughout the interior of Alaska; and
meeting any of the six indicators for serious emotional disturbance, which are: suicide attempt,
substance abuse, violence, sexual abuse, fetal alcohol syndrome disorder (FASD), and trauma.

A care coordinator is assigned to each child and family. During the first meeting, the care
coordinator provides information about the wraparound process and assesses the family’s needs.
In addition, the family strengths and risks are identified at this time.

Intake is conducted in English. Although the situation has not occurred, an Athabascan translator
can be provided upon request.

Outreach

Community outreach is directed by a social marketer employed by Ch’eghutsen’. Outreach
activities conducted since grant funds were received include a general media campaign,
preparing and distributing print materials, conducting community activities, workshops, and
participating in community meetings to provide information to city and tribal councils and
school boards. According to the program’s Second Quarter Report to CMHS, production of an

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educational digital video and the development of a Web site are underway. A social marketing
committee, which will include family members, is being formed.

B.       Service Planning

Following intake, the care coordinators and family members work together on service planning.
Families and children (when deemed appropriate) are part of the service planning process 100
percent of the time, and the process emphasizes family involvement.

Service planning meetings are held at times and locations convenient to families, with
accommodations for special requests. Families reported being satisfied with the process. The
service planning process includes needs assessment, prioritizing problems or concerns,
development of goals and objectives, identification and selection of service options, examination
of life domains and discussion of cultural issues.

Service plans have been developed for 100 percent of clients. Care coordinators have an average
of 6 clients.

C.       Service Provision and Monitoring

Ch’eghutsen’ identified three levels of mental health service provision in its grant (2004 Second
Quarter Report), which are community development, prevention and treatment. Community
wellness teams either are in place or are being developed in the six villages within the service
area.

Services are provided in locations and at times convenient to families and children. The majority
is spent within an office setting, according to interview sources, but staff can accommodate all
requests.

The services provided by Ch’eghutsen’ include mental health counseling, finding housing for
homeless families, helping families obtain clothing and furniture, helping parents get into college
and obtaining financial aid, assisting with FASD diagnosis, alternative school, providing
recreational, cultural and educational activities, and offering youth services.

Mental health services are provided by partners from Indian Health Services, Hope Counseling
Center and Tanana Chief Counseling. These services include individual and family therapy.

Monitoring is accomplished by verbal communication, telephone calls and home visits. These
occur “weekly, at least,” according to interviews.

D.       Case Review

There is no formal case monitoring and review process at Ch’eghutsen’ beyond weekly contact
with children and families served.



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IV.      System of Care Strengths and Challenges

The following section outlines Ch’eghutsen’s strengths and challenges as related to program
infrastructure and service delivery. The term challenges is used in a broad sense to identify areas
in which the program has not yet made any efforts, or is still in the early stages of development,
as well as areas that have been difficult to implement, or in which system-of-care principles have
not been successfully achieved.

A.       Family Focused

Strengths at the Infrastructure Level

        Care coordinators and other staff members have been provided with extensive training,
         including specific training in family systems, through the Rural Human Services (RHS)
         program established at the University of Alaska Fairbanks.

        In most instances, care coordinators are paraprofessionals who have been trained to serve
         in their roles. The care coordinators in the villages were specifically recruited from those
         villages to serve in those roles. A family liaison is a part of the Ch’eghutsen’ staff,
         helping provide support to family members.

Strengths at the Service Delivery Level

        Entry into the Ch’eghutsen’ program was reported to be easy, with families feeling very
         respected and comfortable.

        Families are involved in the service planning process and service provision. They are
         asked about their concerns, and encouraged to help develop goals and objectives. It was
         reported that in general the involvement in service planning was sufficient.

        Examples of services planned and provided to families include discussing their concerns,
         identifying and prioritizing their problems, having family meetings and encouraging
         families to become involved in their children’s activities.

        In some cases, family needs are assessed and services are planned to meet family needs.
         Care coordinators reported meeting with families, assessing needs, performing a GAF
         (Global Assessment of Functioning) evaluation. Examples of services planned and
         provided include Fetal Alcohol Syndrome Disorder (FASD) diagnosis, Big Brother/Big
         Sister help, respite care, referrals for counseling, vouchers for clothing and furniture, help
         with parents entering college, provision of support groups, housing, food and
         encouragement for children.

        Strengths are assessed for families served during the wraparound process. Examples of
         strengths identified include practicing traditional culture, speaking traditional languages,
         using traditional foods, qualities of independence among family members, good
         communication within a family, and sobriety. Examples of how strengths were used to

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         guide service planning include starting a family drum group, using the family’s strong
         existing value system to stabilize the family and using a family’s enjoyment of playing
         basketball together to strengthen the family.

Remaining Challenges

        The governing body, the Steering Committee, currently does not have any family
         member participants. Although the Ch’eghutsen’ Council currently is being revitalized,
         and it has had a tradition of active family involvement, it has served only an advisory role
         in the development of the Ch’eghutsen’.

        Since family members have not been included on the steering committee, it is unclear if
         the meeting times and locations would be convenient for families to attend. The
         Ch’eghutsen’ Council had not met sufficiently recently to determine if meeting times and
         locations were convenient for families.

        There are no apparent mechanisms in place to help make it easy for families to attend the
         steering committee or the Ch’eghutsen’ council.

        Family members are not actively involved in the grant operations. In fact, some staff
         members are clear that the family members have been “left out” of the process of
         developing and implementing the program.

        Family outcome data have not yet been systematically collected nor used to improve
         services.

        Family satisfaction data have not yet been systematically collected nor used to improve
         services.

        Although family members are included on the evaluation committee and family members
         have provided input in the development of culturally sensitive measures (e.g., the
         Athabascan GAF), the opportunities for family members to take part in a range of quality
         monitoring and improvement roles have been quite limited thus far.

        Several respondents indicated that they were not given a choice of services or the
         opportunity to turn down services, and were not asked whether there were individuals
         they did not want to be present at wraparound planning meetings.

        Evaluators found inconsistencies in reports regarding assessing family needs and the
         planning and provision of services. While some respondents reported 100 percent of
         families’ needs were assessed, others disagreed. For example, one respondent reported
         the family wished to receive counseling but it was not provided. Another indicated that
         family needs were not considered during service planning or provision at all.

        While Ch’eghutsen’ identifies family strengths and uses these strengths for service
         planning, this is not always documented in case records.

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        Families currently are not involved in the case review process.

B.       Individualized Care

Strengths at the Infrastructure Level

        Ch’eghutsen’ has fully embraced wraparound as a policy and practice for all children and
         families served. In addition, flexible funds have been made available to teams to help
         meet the individual needs of children and families.

        Substantial resources have been provided to train staff to utilize the wraparound process
         and to tailor services to meet the specific needs of children and families.

        A wide array of services is available to children and families to help ensure that their
         multiple needs can be met.

Strengths at the Service Delivery Level

        Individualized service plans are developed for all children and families and available as
         requested.

        Children are involved in the service planning process. They are included in meetings,
         asked for their opinions, encouraged to bring or exclude participants as they choose,
         discuss their concerns, goals and objectives, and asked for input regarding service
         options.

        Children’s strengths are identified and incorporated into service planning and delivery.
         Examples include helping a child understand his own strengths, which were caring for
         others and looking after siblings, helped the child achieve better balance in his life. In
         another case, a child’s love of the outdoors was used to get him involved in outdoor trips
         that strengthened his cultural identity. Another child who liked to hunt and fish began
         helping other children learn to hunt and fish, allowing him to achieve a sense of mastery
         and maturity. An artistically gifted child became involved in art classes and competitions
         in order to strengthen self-esteem and confidence. Children’s strengths were well
         documented in case records, as well.

        According to respondents, service plans meet the needs of children and to date have been
         provided as planned.

        Children’s strengths are used in the provision of services to children. Strengths are
         identified, behaviors praised, and reframing is done to help children recognize their
         strengths and build upon them.

        The care of all children is monitored by telephone and through home visits on a weekly
         basis. The process includes talking with children and parents to see if they are receiving


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         the services they need. Respondents reported that they monitor suicide ideation, home
         lifestyle, academic success, attendance at programs and sports, progress of children with
         FASD, counseling progress, and whether families need help with transportation.

Remaining Challenges

        While a number of services have been developed that help strengthen children’s
         competencies and enhance their skills, there is little emphasis on advocacy to ensure that
         children’s rights and preferences are defended.

        Since service delivery had just started at the time of the site visit, it was too early to have
         data on child outcomes that could improve service delivery. Continuing delays in the
         implementation of the MIS could interfere with the ability to effectively use data to
         monitor quality of service provision.

        Data on individualization of care are not yet being recorded.

        Respondents reported that barriers to regular follow up for case monitoring include the
         family not being responsive or not following through, difficulty in contacting families
         due to distance or lack of telephones, and care coordinators having limited time to give to
         the process. Some respondents mentioned that the time needed to attend the required
         training for care coordinators and staff limits the time that is available to follow up with
         families.

        Children are not involved in case review.

C.       Culturally Competent

Strengths at the Infrastructure Level

        Training of staff, primarily through the RHS program, has emphasized the provision of
         services that address the specific needs of the Native populations targeted by
         Ch’eghutsen’, including Alaska Native cultural traditions and Alaska Native healing.

        Most of the key care-providing staff, and all the care coordinators have been recruited
         from the Native population being served, helping to ensure that the services provided by
         Ch’eghutsen’ are culturally competent and accepted by the target population.

        While the vast majority of families targeted by Ch’eghutsen’ speak English, and every
         family served speaks English, Athabascan interpreters could be obtained if needed.

        Services are planned with the needs of the Alaskan Native population in mind. Family
         members have been involved in planning such events as the Sharing Time camp, and
         Native elders have been actively involved in providing training and support for youth.
         Alaskan Native culture is infused throughout the services provided by Ch’eghutsen’.


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        Clear efforts have been made to ensure that measures of functioning of children (e.g., the
         Athabascan GAF) are culturally sensitive, and that other measures are sensitive to the
         needs of the Alaskan Native population. Family members serve on the evaluation
         committee, and their input has been solicited.

Strengths at the Service Delivery Level

        Outreach is targeted to the Native population of the service area—which is the only
         cultural group served by Ch’eghutsen. These efforts have been very effective.

        Intake is conducted in English. Ch’eghutsen’ can provide interpreters for the Native
         languages as needed.

        The cultures of the children and families are assessed and utilized in the service planning
         process. Culture is discussed and incorporated into the service plan according to the
         family’s interest and preferences. Examples include assessment of the Alaskan Native
         nation they belong to, and whether or not families are traditional, speak their Native
         language, and eat Native foods. Examples of service planning incorporating culture
         include providing cultural activities, such as singing, dancing, fishing, and hunting.
         Cultural activities such as beading, hunting and fishing are used to bring families
         together. Members of extended families may be invited to participate.

        Cultural assessment and understanding is an important part of the services provided at
         Ch’eghutsen, because many services are intended to be culturally based. Service
         providers routinely assess child and family cultural tribal background, the extent to which
         culture influences parenting, practices of tradition, religion, family values, and ethnicity.
         These are documented in case records.

        Service planning and provision accommodate language preferences. When Native
         translators are needed, they are available.

Remaining Challenges

        The process evaluation findings have not yet been acted upon to improve service
         delivery, and measurement of outcomes has not yet begun. Thus it is not yet possible to
         determine the degree to which the cultural competence of service delivery is having an
         impact on outcomes.

        Because no case review process exists, no cultural diversity is represented there.

D.       Interagency

Strengths at the Infrastructure Level

        There is strong commitment and a good working relationship among the three key
         partners of Ch’eghutsen’, the Fairbanks Native Association, Tanana Chiefs Conference,
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         and the University of Alaska Fairbanks. Staff from these three organizations are actively
         engaged in the Steering Committee, providing governance to Ch’eghutsen’.

        Staff from different organizations, including education, mental health, child welfare,
         substance abuse and juvenile justice agencies, have been trained together on a number of
         occasions, and one respondent indicated that agencies have had joint staff meetings and
         joint performance reviews.

Strengths at the Service Delivery Level

        Referrals are made from mental health, education, child welfare, juvenile justice and self-
         referral, with the largest proportion coming from mental health, juvenile justice and self-
         referral.

        The intake process can be initiated by child protection, mental health, juvenile justice and
         Head Start. A referral form is filled out, and a call is made. A lead care coordinator staffs
         the referral, and two or three other staff from Ch’eghutsen’ are involved. The child must
         meet the criteria selection, and is then admitted or put on a waiting list. If necessary, a
         referral is made to another agency.

        Services are planned by the care coordinator and family advocate, along with the family
         and child. Respondents reported participation by education, mental health, child welfare,
         public assistance, public health and others. Agencies participate only when they are
         involved with the child or family. All agencies are willing to participate.

        Agencies involved could request a case review but have not, as there is no case review
         structure.

Remaining Challenges

        While there are formal agreements among the three key organizations involved in the
         steering committee, no other organizations play an active role in the governance of
         Ch’eghutsen’, potentially limiting its sustainability and effectiveness.

        Although the University of Alaska Fairbanks has facilitated the training of staff, key
         child-serving agencies have not developed shared administrative procedures that could
         facilitate service provision. While the MIS could provide an opportunity for sharing
         information, there were no plans at the time of the visit to ensure that the MIS was shared
         across agencies.

        There are no mechanisms in place to pool funds from different agencies.

        While some respondents suggested that their agencies have changed to focus more on
         strengths, few tangible examples were provided to demonstrate ways that actual practice
         has changed.


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        Quality monitoring activities have not involved a range of child-serving agencies.
         Agencies other than the three primary partners have not been actively represented on the
         evaluation committee.

        At the time of the site visit no information had been collected and used regarding the
         extent of interagency involvement.

        One respondent said it is difficult at times to get participation from other agencies; others
         said all agencies routinely participate. Receiving referrals from schools is a struggle, one
         respondent reported; however, other respondents said education was involved heavily in
         service planning.

E.       Collaborative/Coordinated

Strengths at the Infrastructure Level

        Ch’eghutsen’ has recently become involved in a community coalition (Partnership for
         Children) designed to help different agencies collaborate to address the needs of youth.
         The Ch’eghutsen’ Council is being reconstituted to facilitate a greater level of
         involvement among different agencies.

        Case management is provided to every family to help them negotiate the system. While
         multiple agencies provide case management, it is not clear to what extent the different
         agencies collaborate on their care coordination functions.

Strengths at the Service Delivery Level

        Ch’eghutsen’ has a number of efforts in place to inform other community organizations,
         providers and family organizations about the grant and services provided. Tactics used
         include pamphlets, weekly meetings, strategic planning for a statewide conference on
         systems of care.

        Organizations in the community, direct service providers or private providers who
         provide support or services to families participate in service planning. Examples of
         participants include Big Brothers/Big Sisters, mental health, private therapists,
         community health and tribal social workers. Such organizations are frequently involved
         when invited.

        Most family members reported that services are coordinated among agencies,
         organizations and providers, and that these efforts are highly effective. Another family
         member respondent said there was no coordination. Staff reports that no formal structure
         for coordination exists but that coordination does occur during the wraparound process.

        Providers, organizations and agencies work together at Ch’eghutsen’ to coordinate the
         delivery of services. Family members reported that coordination was sufficient, that
         agencies shared information, and worked well together. Care coordinators reported
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         working together efficiently and productively with other organizations through telephone
         conversations, progress reports and wraparound meetings. Information shared includes
         client participation, evaluation reports, assessments, educational progress, status and
         progress reports, scheduling information and diagnoses. Direct service providers reported
         mixed participation and results.

        In cases where there are transitions, Ch’eghutsen’ helps insure that they are handled
         smoothly and that families do not experience disruption. Care Coordinators are
         responsible for notifying families. Efforts are reported to have been sufficient in this area.

        No formal case review process exists. Reports from respondents conflicted regarding case
         review.

Remaining Challenges

        Very little active collaboration among multiple agencies occurs, with the exception of the
         connections between FNA, TCC, and UAF. Other agencies generally are not involved in
         the operations of Ch’eghutsen’.

        No information is yet collected and analyzed in the quality monitoring process regarding
         coordination of services.

        Service planning across agencies, organizations, and providers is not formally
         coordinated.

        In service provision, release of information is not coordinated, and more information
         could be shared. One direct service delivery staff reported that some agencies do not
         share information well at all, particularly schools.

        Questions on case review were answered with a high degree of inconsistency. While
         there is no formal case review process, some respondents seemed to believe there was a
         process in place. This may be an issue of terminology—mixing up case monitoring and
         case review—or something that Ch’eghutsen’ could clarify in training.

F.       Accessible

Strengths at the Infrastructure Level

        Flexible funds have been made available, and have been used for such needs as car
         repairs and taking families on outings to the State fair. It is reported that services are
         provided regardless of the ability to pay.

Strengths at the Service Delivery Level

        Outreach activities at Ch’eghutsen’ include television spots, brochures, community
         activities, having youth on the board, having staff attend meetings to provide information
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         to city and tribal councils, providing workshops, attending regional Tanana Chiefs
         Counseling meetings, and meeting with the school board. The program holds four large
         events each year. Efforts, except for brochures, have been very effective and positive; the
         program has a waiting list.

        According to respondents, the service delivery process includes intake, after which the
         care coordinator is assigned. Next, wraparound information is provided, needs are
         assessed, and strengths and risks are identified. The entry process is described as simple
         and easy for families.

        The average length of time between referral and receipt of services is reported to be 8
         days. The shortest amount of time was 1 day; the longest was 21 days. Families reported
         being very satisfied with the time frame.

        Service planning usually takes place during afternoons, which is convenient for families.
         Special requests can be accommodated, however, if families desire. Meetings are held in
         the office, at schools, over the telephone and in homes, and again, special requests can be
         accommodated.

        Respondents were not in agreement on whether the services provided by Ch’eghutsen’
         have sufficient capacity to serve all families and children in need.

        Services are provided at times and locations that generally are convenient to children and
         families, with some exceptions. Special requests can be accommodated, although staff
         respondents reported this has not been an issue. Service provision usually occurs during
         business hours; some staff may be accessible during evenings and weekends, however.

        Locations of service provision are convenient, according to families. Other respondents
         reported that most services are provided in the office (85–95 percent), but can be
         provided in homes, and that staff are flexible enough to accommodate special requests.

        Transportation to services offered by Ch’eghutsen’ is available. Families reported that
         they are always able to receive transportation easily if they need it.

        Services are financially accessible; families reported that they do not have to pay out-of-
         pocket for anything. Other respondents agreed that there are no financial barriers to
         receiving services.

Remaining Challenges

        Although the wraparound process had begun to identify needs for those being served, it
         was too soon, at the time of the site visit, to adequately determine whether the service
         array had developed the capacity to meet the needs of the target population. Increased
         engagement with a range of service providers could help Ch’eghutsen’ identify additional
         service needs.


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        Quality monitoring has not yet begun to examine the degree to which services are
         accessible or barriers to services.

        While respondents claimed that times and locations of service planning and provision are
         convenient and flexible, almost all are provided during business hours and in the office.

        Although some of the village care coordinators had been able to increase access to
         facilities and services after hours, this did not appear to be common in Fairbanks.
         Additional attention to expanded service hours could improve access.

        If the program does offer case review, which cannot be determined, it does not include
         families.

G.       Community Based and Least Restrictive

Strengths at the Infrastructure Level

        The lack of residential services locally and the need to reduce placements outside of the
         community has been examined as part of the planning effort for developing
         Ch’eghutsen’, and can serve as baseline data for monitoring the impact of the program.
         Initial assessment of the use of out-of-community and out-of-State residential services
         has been made. Updates of these data will help determine if desired changes occur.

Strengths at the Service Delivery Level

        Most children and families are able to receive services in their own communities. It was
         mentioned that one child had to travel 350 miles for services. Efforts are being made to
         work with other agencies to insure that all services are readily available.

        Some children are placed in restrictive settings. Respondents reported that attempts are
         made to move children to less restrictive settings as appropriate.

Remaining Challenges

        Some training for agency staff has been provided to help minimize overly restrictive care,
         but respondents indicated a lack of understanding of mechanisms and resources in place
         to help ensure that children are provided with the least restrictive care.

        While there is agreement that the full array of required services is available to
         participants, there is much disagreement about what services are available locally versus
         which ones require extensive travel to Anchorage or the lower 48 states.

        Some information about placements in restrictive settings was collected while planning
         for the grant, but these data have not been updated. As additional services are provided,
         these data will be helpful in determining if Ch’eghutsen’ is meeting desired goals.


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        Although there have been initial efforts to work with other organizations to minimize the
         need for children to be placed outside their local communities, it was viewed as too early
         to see any direct impact of these efforts. For the villages, there is an expectation that the
         new care coordinators will make a difference, but at the time of the site visit, it was
         judged to be too early to see any impact on the need for services outside the community.

        To date, Ch’eghutsen’ has limited experience with transitioning children into less
         restrictive settings; a process for this does not yet exist.

        Some efforts have been made to put structures in place to review care and help ensure
         that children are provided with preventive and outpatient services rather than residential
         or restrictive services. While there is general consensus on the need to keep children from
         being placed in locked facilities, some respondents see this as a continuing problem that
         needs additional attention.


V.       Sustainability and Lessons Learned

Ch’eghutsen’ is currently in its second year of funding. As a result, provision of services is now
underway but the program does not yet have a great deal of history.

Successes mentioned included staff training, prevention activities in rural tribal communities,
working with families, more coordination of services within the Fairbanks area, healthy activities
for children, embedding Native values—from five different Indigenous cultures—in the program
and helping bring together these world views, helping providers become more culturally
competent, and providing a different, more family-centered type of care.

The training of care coordinators was mentioned by several respondents as a particular
achievement. Several noted that the program is helping the child-serving agencies within
communities focus more on strengths and become more family-driven. One respondent said the
program was helping the University of Alaska at Fairbanks become more flexible in meeting the
needs of the community. Another noted that the System of Care model has been adopted
successfully. Overall, respondents indicate that Ch’eghutsen’ is having a positive effect on the
people and communities served.

Lessons learned include the importance of staying true to plans and involving rural sites in all
phases of the program. Obstacles to expanding system-of-care principles and philosophies
include the lack of knowledge; lack of follow-through by core agencies; lack of formal
Memoranda of Agreement or Memoranda of Understanding; lack of understanding of Systems of
Care; issues of protecting turf and categorized resources; politics among staff; and conflicts
between Native versus non-Native, urban versus rural communities.

The program has not begun significant efforts to create sustainability, because it is early in the
grant funding cycle.


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Areas that could be sustained after the grant expires were identified as the concept of
wraparound and pooling informal resources to address problems; family activities; cultural
competence; improved training; “wellness” teams; educated staff; healthy families and children;
and the Systems of Care approach.
Barriers to sustainability foreseen include funding, resources, lack of adequate services for
children and families, and lack of understanding of how to use Medicaid for sustainability.




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