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					Nevada Mental Health Planning Advisory
   Council Rural Monitoring Report


        Pahrump Mental Health Clinic
                   January 7 and 8, 2009


Monitoring Team: Rene Norris, Alyce Thomas, Dave Caloiaro, Ann Polakowski

        Monitoring Team Staff and Report Writer: Roger Mowbray
             NEVADA MENTAL HEALTH PLANNING ADVISORY COUNCIL
       RURAL MONITORING REPORT FOR THE PAHRUMP MENTAL HEALTH CLINIC



                                                   Table of Contents
I.         Project Background .............................................................................................................. 3

II.        City of Pahrump Overview .................................................................................................. 4

III.       Pahrump Mental Health Clinic ............................................................................................ 5

IV.        Key Findings ........................................................................................................................ 7

V.         Monitoring Visit Detail ...................................................................................................... 10

      A.      Pre-visit preparation ....................................................................................................... 10
      B.      Environmental Scan ....................................................................................................... 10
      C.      Staff Feedback ................................................................................................................ 11
      D.      Consumer Feedback ....................................................................................................... 14
      E.      Community Stakeholder Feedback ................................................................................ 18
VI.        Response from Rural Clinics ............................................................................................. 22

VII.       Acknowledgements ............................................................................................................ 25

VIII. Appendix A – Focus Group Invitation............................................................................... 26

IX.        Appendix B – Focus Group Instrument ............................................................................. 27




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           NEVADA MENTAL HEALTH PLANNING ADVISORY COUNCIL
     RURAL MONITORING REPORT FOR THE PAHRUMP MENTAL HEALTH CLINIC




I.         Project Background
During State fiscal year (SFY) 2007, Nevada’s Mental Health Planning Advisory Council
(MHPAC) developed a structured, service provision monitoring project to help better meet the
federal mandate for Mental Health Planning Councils to “monitor, review and evaluate the
allocation and adequacy of mental health services within the state.” The Council formed a Rural
Monitoring Subcommittee that developed a plan and format for conducting quality assurance site
visits to selected Rural Clinics Centers, operated by the Nevada Division of Mental Health and
Developmental Services (MHDS), with a focus on consumer satisfaction with services. The
Rural Monitoring Project serves as an important collaboration between the Council, MHDS and
the Division of Child and Family Services (DCFS) in order to increase State partnership with
consumers and the Council toward improving the delivery of services.

The Subcommittee developed a set of specific questions, customized for adults, children, and
their families, to serve as a uniform, statewide instrument for conducting focus groups with
consumers and family members as part of the site visit. These questions were developed in
conjunction with program improvement staff from MHDS and DCFS in order to ensure that
effective, consistent monitoring is done throughout the rural areas. A copy of the focus group
instrument is included as Appendix B of this report.

Pre-visit study materials are requested from each site prior to the monitoring visit for review by
the monitoring team members, as follows:

        Informational materials provided at the clinic site for Rural Clinics services.
        Informational materials provided at the clinic site for related community-based services,
         including nonprofit and private agencies.
        Lists of local providers for related community-based services.
        Consumer survey format and outcome data from most recent survey, if available.
        Most recent performance improvement reviews, if available.
        Most recent MHDS monthly reports showing service and wait list statistics.
        Most recent Agency Director’s reports.

A 1.5 day format for site visits was established as follows:

Day:      Time:        Items:
ONE       Morning      •  Walk-through tour of clinic and environmental scan.
                       •  Introductory meeting with Clinic Director and staff to review
                          questions about pre-visit study materials.
                       •  Individual staff interviews to obtain direct feedback on service
                          successes and challenges.
          Afternoon    •  Formalized focus group with adult consumers, youth consumers, and
                          their families.

TWO       Morning      •   Individual interviews with local service providers, including agency,
                           nonprofit, and/or private staff to obtain feedback on service successes
                           and challenges.
                       •   Exit interview with Clinic Director.


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        RURAL MONITORING REPORT FOR THE PAHRUMP MENTAL HEALTH CLINIC


The first site visit was conducted June 14 and 15, 2007, at the Ely Mental Health Clinic. A
report of the key findings and recommendations from that visit is posted on the MHPAC website
at: http://mhds.nv.gov/dmdocuments/MHPACRuralMonitoring2007-Ely.pdf

The Council selected the Pahrump Mental Health Clinic to monitor and a visit was scheduled for
Wednesday, January 7 2009 and Thursday January 8, 2009.


II.          City of Pahrump Overview
Pahrump is located in the southwest corner of Nye County. Until the 1960s, Pahrump had no
telephone service and there were no paved roads in or out of the Pahrump Valley. However, as
Las Vegas grew, real estate speculation became more popular in the area, which led to increased
interest in Pahrump. This led to the introduction of telephone service and the construction of a
paved highway, from Las Vegas to Pahrump, during the late 1960s. Later, this road was
extended from Pahrump northward to US 95, near Amargosa Valley. A second paved road was
introduced that went from Pahrump to neighboring Shoshone, California, which provided a link
to the Death Valley area, as well as a shorter route to those wishing to travel to Los Angeles or
other areas in California. In 1974, Pahrump's first high school was constructed.1

Estimates of its population range from 33,000 to 39,000 with the former reflecting the effects of
the recent economic downturn and the latter posted on the Town of Pahrump website in April,
2008. It is 50 miles west of the south end of Las Vegas and 60 miles east of Death Valley. The
Pahrump Valley is 28 miles long and 8-12 miles wide. Surrounding the Valley are the Spring
Mountains to the East and the Nopah Mountains to the West. The Pahrump Valley is located in
Nye County, which covers 18,064 square miles and is the largest county in Nevada and the third
largest county in the nation. The county seat is located in Tonopah, 165 miles to the north on
U.S. Hwy 95. The county maintains offices in Pahrump for all its departments, and district court
is held in both Pahrump and Tonopah. Similar to many communities in Nevada, Pahrump has an
unincorporated town status, with a limited government that manages land use planning,
recreation, and fire, while leaving most services to Nye County.

Public education institutions include four local elementary schools, one middle school, and one
high school. There is also an alternative high school and middle school as well as two private
religious-based schools. Great Basin Community College, a member institution of the Nevada
System of Higher Education, offers associate and bachelor degrees in a variety of programs.

In addition to the Pahrump Mental Health Clinic, social service governmental and non-profit
agencies include the following:
     Nevada Division of Welfare and Supportive Services: TANF, Food Stamps, Medicaid
     Nevada Health Division: Immunizations, family planning, STD testing and treatment.
     Nevada Division of Child and Family Services: Child abuse and neglect investigation,
        foster care services and child protective services.
     Nye County Health and Human Services: Food bank, medication, rent & utility
        assistance, transportation vouchers for medical appointments.
1
    Wikipedia (2009). Pahrump, Nevada. Retrieved February 4, 2009 from http://en.wikipedia.org/wiki/Pahrump,_Nevada




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       Nevada Outreach Training Organization
       Nye County Communities Coalition
       No To Abuse: Emergency shelter for victims of violence, support groups.
       Pahrump Family Resource Center: Temporary housing, referrals.
       Alcoholics Anonymous: Meetings, hot line.
       Al-Anon: Alcohol and substance abuse prevention meetings.
       Food Bank/Soup Kitchen of Nye County: Emergency food, clothing, furniture.
       Oasis Outreach: Food, emergency assistance, support groups.
       Salvation Army Social Services: Emergency food and utility assistance, counseling.
       Sunrise W.I.C. Supplemental Nutrition Program.
       NyE Communities Coalition: Drug, alcohol and tobacco prevention and collaboration

Medical service organizations include the following:
   Advanced Medical Center: Health care facility offering urgent care, primary care and
      family practice.
   Advanced Insight Behavioral Health: Counseling for individuals and groups.
   Choice to Change: Counseling and classes.
   Teen Care: Youth counseling.
   Healing Our Future: Drug & alcohol counseling.
   Positive Solutions Unlimited: Drug & alcohol counseling.
   West Care of Nevada: Drug & alcohol counseling.
   Nathan Adelson Hospice.
   Evergreen at Pahrump Health and Rehabilitation Center: Long term nursing care facility.

III. Pahrump Mental Health Clinic
Pahrump Mental Health Clinic staff members include the following:

•   Clinic Director: Manages the clinic and provides mental health counseling services.
•   Psychiatrist: Visits the clinic one day per week and provides seven client hours per day
    excepting vacations and sick leave. He is not board certified to treat children so he treats
    adults only.
•   Nurse: Reviews intake forms and performs the initial assessment, assists the psychiatrist on
    days he visits the clinic, coordinates a medication management group and educates clients on
    the effects of their medications, monitors medication supplies and dispenses medications as
    prescribed by the psychiatrist.
•   Psychologist: Provides mental health counseling services, conducts psychological tests,
    performs intake assessments and makes appropriate referrals.
•   Psychiatric Caseworker II: At the time of the visit, one caseworker position provides
    service coordination and psychosocial rehabilitation (PSR) while one position was being held
    vacant.
•   Mental Health Counselor II: Provides mental health counseling services, performs intake
    assessments and makes appropriate referrals.
•   Mental Health Counselor I: Provides mental health counseling services as an intern under
    the supervision of the Clinic Director.
•   Mental Health Tech II: Assists with service coordination and runs basic living skills groups


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•   Administrative Assistant III: Serves as the Office Manager, manages billing, pre-
    authorizations and provides administrative support to staff.
•   Administrative Assistant II: Greets clients, assists in completion of initial screenings, and
    provides administrative support to staff.
•   Consumer Services Assistant I: Provides client services such as transportation and other
    service coordination need. Also coordinates the peer-to-peer support group.

The Pahrump Mental Health Clinic (as of 1/2/09) has a caseload of 186 with a waiting list of 53.
From May, 2008 through December, 2008, the caseload has been relatively steady averaging
189. The number of clients on the waiting list has declined somewhat as illustrated in the next
chart but the number of days to the furthest appointment for service coordination and the
medication clinic has increased significantly as illustrated in the second chart.




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IV.    Key Findings
Successes
The following are service system strengths identified as a result of the site visit:

   1) The Pahrump Mental Health Clinic has generated cost savings of over $10,000 a month
      from medicinal samples and medication scholarships obtained from pharmaceutical
      companies.
   2) The Consumer Services Assistant position was recently filled and has provided much
      needed support to the service coordination efforts of the staff and assistance to the clients
      including the peer-to-peer counseling group.
   3) Both clients and staff strongly agreed that the Pahrump Mental Health Clinic has
      improved the quality of life for those who have received services there.
   4) More specifically, the staff who provide service coordination to clients have resolved
      many difficult situations and issues.
   5) Clients report experiencing many positive results from the various group therapy sessions
      offered by the Clinic.
   6) The staff at the Pahrump Mental Health Clinic is well respected by the clients and the
      other public and private non-profit organizations in the area.
   7) There is a strong collaborative effort among the various public and private non-profit
      social services organizations in the area.
   8) The Nye and Esmeralda Community Coalition has brought $1.75 million in funding to
      the area since 2002 and has added seven accredited prevention programs.

Challenges

The following are service system weaknesses identified as a result of the site visit:

   1) The overall State of Nevada general fund revenue shortfall is having a significant impact
      on the operations of the entire Rural Clinics.
   2) A particularly harsh impact is the planned closure of 11 of the agency’s smaller offices.
      The Pahrump Mental Health Clinic is not anticipated to be one of them; however the
      Tonopah satellite office is anticipated to close.
   3) The global/national economic downturn has increased the waiting list for the Pahrump
      Mental Health Clinic as well as the caseload at most other public social services agencies
      in the area.
   4) There are insufficient resources available to utilize Rural Clinic’s Telepsychiatric
      services in the Pahrump Mental Health Clinic.
   5) The substance abuse counselor contracted by the Substance Abuse Prevention Treatment
      Agency (SAPTA) to serve Pahrump recently relocated out of the Pahrump Mental Health
      Clinic to another location, making referrals to that counselor more cumbersome.
   6) There is limited number of mental health counselors and therapists in Pahrump. In
      particular, there are limited mental health resources for the support of children and
      adolescents in the area.



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   7) There is a significant lack of professional development opportunities for social service
       agency staff.
   8) Because of the geographic location of Pahrump and its lack of a reliable public
       transportation system, citizens in the area seeking mental health services face many
       challenges getting to and from scheduled appointments.
   9) There is a lack of data for social services indicators specific to Pahrump.
   10) Although it has improved somewhat compared to previous years, some social services
       agencies are still experiencing difficulty retaining qualified staff in rural Nevada.

Unmet Needs

The following are unmet needs identified as a result of the site visit:

   1) Because the Pahrump Mental Health Clinic is open from 8:00 a.m. to 5:00 p.m.,
       appointment times for school age children and adolescents are limited to a narrow time
       frame between 3:00 p.m. to 5:00 p.m. making it difficult for these clients to schedule
       appointments without missing school.
   2) The number of days to the furthest appointment for clients of the Medication Clinic and
       those needing Service Coordination has steadily increased over the last year as illustrated
       in the second chart on page 6.
   3) Funding for one-time emergency assistance and special needs has virtually been
       eliminated. For example, if a client needed a minor car repair in order to fulfill part of
       their treatment plan, the Service Coordinate previously was able to fund it.
   4) The clinic does not have adequate resources to treat children. Clinics in other areas have
       an art room, play room and other interpretive resources but not in Pahrump.
   5) The psychologist has several testing tools on hand but they are not compatible with the
       existing computers in the Clinic rendering them useless.
   6) Based on comments from staff, clients and community stakeholders, Pahrump does not
       have a sufficient number of day treatment facilities for mental health services nor are
       there a sufficient number of drug and alcohol residential treatment facilities.
   7) The drug court refers participants to the Pahrump Mental Health Clinic but there are no
       enforceable consequences if they do not complete a treatment program.
   8) There are few if any licensed group homes for mental health clients or homeless people.
   9) There are no re-entry programs for veterans or prisoners.
   10) There is little if any bereavement counseling available in the community.
   11) Emergency response to mental health crises is limited in scope and slow to occur
       presenting a danger to clients and clinic staff as well.

Recommendations
   1) Explore one-time funding opportunities to purchase supplies, equipment and other
      interpretive resources necessary to enhance the clinic staff’s ability to treat children.
      Possible sources of funding include reallocating some of the Community Mental Health
      Services (CMHS) Block Grant or by including a request in the MHDS application for the
      Transformation Transfer Initiative grant offered by National Association of State Mental
      Health Program Directors (NASMHPD).


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   2) Review the available staffing resources necessary to utilize the existing Telepsychiatric
      services in Pahrump.
   3) Consider allowing staff to work flexible hours in order to provide a greater window of
      opportunity for children to schedule appointments at the Pahrump Mental Health Clinic
      without having to miss school.
   4) Agency administration should consider allowing the Pahrump Mental Health Clinic to fill
      the vacant Psychiatric Caseworker II position in order to reduce the significant wait time
      for clients to receive service coordination.
   5) Explore funding opportunities for one-time emergency assistance requests that had
      previously been budgeted. Possible sources of funding include reallocating some of the
      CMHS Block Grant or through the Transformation Transfer Initiative grant offered by
      NASMHPD.
   6) Reconsider the decision made by Rural Clinics administration to relocate the SAPTA
      contracted counselor from the Pahrump Mental Health Clinic to another location.
   7) Research and consider appropriate psychological testing software that is compatible with
      the existing computers and that does not require on-going analysis fees.
   8) Research the State of Nevada and Department of Health and Human Service as well as
      Mental Health and Developmental Services Division rules and guidelines regarding
      transportation of clients to identify opportunities to expand the use of agency vehicles for
      the transportation of clients without putting the State at risk.
   9) Explore opportunities to utilize video conferencing equipment located at the DCFS office
      in Pahrump to provide Telepsychiatric services so that child and adolescent clients can
      receive treatment remotely from DCFS staff in Las Vegas or Reno.

A response from Marcia Bennett Ph.D, Acting Director of Rural Clinics, to these
recommendations is in Section VI of this report.




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V.      Monitoring Visit Detail
     A. Pre-visit preparation
     Prior to their visit, the monitoring team requested the following information from the Clinic
     and the Division:
        Informational materials provided at the clinic site for Rural Clinics services.
        Informational materials provided at the clinic site for related community-based services,
         including nonprofit and private agencies.
        Lists of local providers for related community-based services.
        Consumer survey format and outcome data from most recent survey, if available.
        Most recent performance improvement reviews, if available.
        Most recent MHDS monthly reports showing service and wait list statistics.
        Most recent Agency Director’s reports.

     The material provided by the Division was thorough and well organized and gave the
     monitoring team a good basis to formulate questions prior to their visit.

     B. Environmental Scan
     The monitoring team arrived at the Pahrump Mental Health Clinic on Wednesday, January 7
     2009 and initially met with Clinic Director Theresa Lambrecht, and Rural Clinics Regional
     Director Susan Haut. Built in 1998, the clinic is located at 240 S. Humahuaca in Pahrump
     was built specifically for Rural Clinics with input from the staff on various layout and design
     issues. The lobby was comfortable with a television and numerous brochures and
     informational pamphlets available for clients.




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RURAL MONITORING REPORT FOR THE PAHRUMP MENTAL HEALTH CLINIC


Overall, the clinic was clean, well organized and included a Peer-to-Peer room available for
support group meetings among clients. It was well stocked with books, jig saw puzzles,
video tapes and games.




C. Staff Feedback
The monitoring team met with the Pahrump Mental Health Clinic staff in two sessions
(half the staff in one and half in the other for the sake of continuity of service to clients)
and asked a series of questions intended to help determine the impact of recent budget
reductions, identify services provided, successes, challenges and unmet needs.



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How have the budget cuts affected the services provided by the Pahrump Mental
Health Clinic?
The Tonopah satellite office closed. It had been open twice a month for two days at a time.
The caseload had dwindled but it’s still an active area with a lot of unemployment that
usually results in the need for mental health services. Clients there now have to drive to
Pahrump or Hawthorne.

It’s hard to schedule children within the normal 8:00 a.m. to 5:00 p.m. business hours. If
hours are changed to 4 ten hour shifts, it will provide more time for children after school.
The psychiatrist is not board certified to treat children so 75% of the clients seen by the
Nurse in the last six months are children and teenagers.

The number of clients for the Medication Clinic is more than the staff can handle. They have
stopped taking new clients and have had to send them to Rawson Neal Psychiatric Hospital
in Las Vegas which takes a whole day. The waiting list is over a year and would be higher
but for the efforts of the clinic staff to get clients into private practitioners.

The number of Supported Living Arrangements (SLAs) has been reduced significantly.
They are only available to homeless or those on the brink of homelessness. There are very
few housing options in the rural areas compared to the urban areas. It is estimated that half
the patients live with their parents.

Interagency cooperation is still working well but is limited by resource constraints. Rural
Clinics provides services to children in the rural areas so transitioning from child to adult
services is not a particular challenge. A Stakeholders meeting is held quarterly and some
clients are starting to attend.

A Consumer Services Assistant position was recently filled and has already been a valuable
addition to the clinic. She helps with transportation and medicinal scholarships and some
service coordination issues.

The area use to have staff on-call 24/7 but it stopped several years ago due to budget cuts.
The only phone numbers provided by the clinic for after hours crisis help are the Nye County
sheriff and the suicide hotline.

How have the budget cuts affected the number and types of clients served?
Adults – Counseling is the most accessible service. Requests for one-time funding for
special needs or emergencies have not been met this year.

Children – The clinic does not have the resources to treat children. Only 13 children are
currently being served by Pahrump. Mesquite has a separate room for children services.
Staff is expected to provide resources. Supplies were requested 8 months ago but not
fulfilled. The psychiatrist is not certified to serve children under 18 so any children younger
than 18 are referred to private practitioners for medications. When asked what the youngest
age a child would be served, staff responded that it depends on the experience and expertise
of the clinician. At the younger ages, much of the counseling work includes the parents.
The Service Coordinator has not served any children in the time he has been at the Pahrump


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Mental Health Clinic. Requests for service for children with Autism are usually referred to
private practitioners or the DCFS in Las Vegas.

Dual Diagnosis or Co-occurring Disorders – The Substance Abuse Prevention and Treatment
Agency (SAPTA) contracted counselor relocated out of the building to another office which
has made it more difficult to make referrals and it is taking longer. Transportation to the
other location is one of the challenges. Generally, clients with chemical dependencies have
relatively low compliance rates so moving the SAPTA contracted counselor has made it
more difficult. Many of the co-occurring disorder clients participate in group sessions.

Subsequent to the rural monitoring visit, conversations with Rural Clinics and SAPTA staff
clarified that the SAPTA contracted counselor was relocated at the request of the Rural
Clinics administration.

What efforts are being made to recruit and retain staff?
The 2007 session of the Nevada Legislature provided for a two step increase for nurses,
mental health counselors, psychologists and clinical social workers by passing Senate Bill
(SB) 575. These increases became effective on July 1, 2007. Prior to that, turnover had been
a constant problem. However, with the economy downturn and the budget cuts, it appears
that some of the turnover has slowed.

How are Telepsychiatric services for children and adolescents used?
The staff indicated that the Pahrump Mental Health Clinic is not equipped to utilize
telepsychiatric services.

Subsequent to the rural monitoring visit, conversations with the Rural Clinic’s management
and Information Systems staff clarified that the Pahrump Mental Health Clinic does in fact
have the necessary equipment for Telepsychiatric services but that there are not sufficient
psychiatric staff available to provide the service.

What services are provided by the Nurse?
The Nurse conducts an assessment and screening of each client before they see the
psychiatrist. She assists the psychiatrist on the days he visits the Pahrump office and
conducts a medication management support group for the clients. She also manages and
dispenses medications in accordance with prescriptions written by the psychiatrist.

What services does the Psychologist provide?
The Psychologist provides a mix of counseling, consultation and education. Very limited
testing is done because the equipment is so old, it doesn’t support the tests. They need an
upgraded computer to utilize the existing supply of testing materials.

What services does the Mental Health Counselor provide?
The Mental Health Counselors conduct an intake assessment, provide individual therapy and
counseling as need and make appropriate referrals to other staff or service providers in the
area.




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What services do the Administrative Assistants provide?
The Administrative Assistants answer phone calls, determine what services are being sought,
perform initial screening, refer clients to the Nurse, provide and review information packets,
schedule initial appointments, follow up on missed appointments and post and verify contacts
in AVATAR.

In addition, the AA III secures prior authorization for treatment and contacts Managed Care
Organizations (MCO’s) proactively.

Is the design and layout of the office conducive to servicing clients?
The staff was able to provide input into the design of the clinic before it was built so they
generally are pleased with it. They did mention that parking has been a problem in the past
and they have to be conscious of when group meetings are held to ensure the clients have
sufficient room to park. They also indicated that the acoustical insulation in some of the
private offices is minimal making privacy and confidentiality difficult to ensure.

Successes
Staff reported they believe they have kept people alive a lot longer and given them hope.
They also believe the quality of their clients’ lives have been improved. They have generated
$10,000 a month in cost savings from samples obtained from pharmaceutical companies and
medication scholarships from pharmaceutical companies. The Service Coordinator has
solved numerous problems by trouble shooting and identifying options.

Challenges
Legal 2000 holds are not being done because it takes the Sheriff’s office at least 3 hours to
get to Las Vegas. It’s a resource issue with the Sheriff’s office.

Unmet needs
   Additional facilities for day treatment for adults and children.
   Drug and alcohol residential treatment and counseling.
   Children’s resources.
   Transportation for all clients.
   Funding for one-time crisis situations.
   Drug court will send people to the Pahrump clinic for a psychiatric evaluation but it’s
     not something that is done there and the client ends up having to go to a private
     practitioner to get it done.
   Boarding care, group homes and a homeless shelter are needed.

D. Consumer Feedback
The rural monitoring team scheduled a meeting at the Bob Ruud Community Center in
Pahrump and invited adult consumers of mental health services in the area to participate in a
focus group. The invitation that was posted in the Clinic and circulated in the community is
in Appendix A. A second session for children and their families was scheduled following the
adult session but, unfortunately, no children or families attended it. In the adult session a
series of questions were asked that led to open and candid conversation regarding mental
health services in Pahrump.


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Have you encountered barriers that have hindered you or your family from receiving
the mental health care you need? After your initial intake phone call or visit, were you
put on a waiting list? If so, how long before you began receiving services?
One client said she has been waiting over 10 months to see a psychiatrist for medications.
The wait list is over a year and a half because the psychiatrist is only there once a week. She
has been treated by a general practice physician and got some basic medications but needs to
see a psychiatrist for psychiatric medications. She was told that she could go off her basic
medication and go to a hospital to get psychiatric medications but did not think that was
right.

Another client said she has been going to the clinic for six years and the psychiatrist for three
of those years. She was asked to find another psychiatrist to take care of her medications for
schizophrenia and paranoia.

One client said he was one step from “going to the nut house” when they brought him to the
clinic and has been going there for about two years and has been helped tremendously.

Another client said she has been going to the clinic for 5 years and has been served very well.
The staff is wonderful but, unfortunately, the service coordinator has not been available
much of the time for personal reasons. He does the job very well when he is there but there
is a void when he is not there although the Mental Health Tech has been very helpful.

It was also expressed that, in general, there are not enough counselors, doctors and
coordinators and that more groups are needed. A depression group had been provided but
was recently stopped.

What kind of services do you receive? What types of services are available in
Pahrump?
The most valuable services provided by the Pahrump Mental Health Clinic are group therapy
sessions, service coordination, basic living skills and psycho social relations education
(PSRs).

Most of the participants agreed that the Pahrump Mental Health Clinic is just about all there
is in Pahrump unless you have money or Medicaid or insurance although it was mentioned
that the Westcare outpatient clinic does provide group counseling for clients who have gotten
out of rehab and they do serve some clients without insurance. Most of the group in
attendance had either Medicaid or Medicare. One client said that he was able to be served
quickly but he acknowledged that he may have been considered “pretty scary” to them. The
clinic has been very good to him.

Are treatments available in Pahrump for adults with co-occurring substance abuse and
mental health disorders?
The relocation of the SAPTA contracted counselor from the Pahrump Mental Health Clinic
to another location has made it much more difficult to coordinate treatment for co-occurring
disorders.



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When receiving treatment, do you feel that it is private, confidential and respectful to
you as an individual? If you feel uncomfortable with your therapist, do you feel
comfortable that you can ask to change to a different one?
The consensus among the clients was that they did feel the treatment was private,
confidential and respectful. The only situation mentioned where a change in therapist was
requested involved a therapist that had left the Pahrump Mental Health Clinic to seek
additional education and credentials. When that therapist returned, one of the clients
requested she be switched to the returning therapist, not because of problems with the
treating therapist, but rather because of the previous relationship the client had had with the
returning therapist.

What does wellness mean?
One response was “what is normal?” The group agreed that, in general, wellness means
being able to function in society on society’s terms.

How did you hear about Rural Clinics?
A variety of sources were credited for the clients hearing about the rural clinics ranging from
the police, to clinics and hospitals in Las Vegas to disability attorneys. It was mentioned that
there is a resource guide for the area but that it was outdated. Subsequent to the visit, the
director of the NyE Communities Coalition indicated that an updated resource guide is in the
final stages of development.

Do you feel you have been stigmatized in your community because you are coming here
for services, or may have a mental health need? Did any specific event happen and what
could be done to remove this stigma?
No one reported having felt stigmatized.

Would you like to see more informational material or classes on recovery from mental
illness and substance abuse made available? Is there particular information you would
like to see made available?
They would like to see more classes with homework assignments and movies. The lobby has
all kinds of books but they would like to see more on depression, schizophrenia, anxiety, and
Post Traumatic Stress Disorder (PTSD).

What is the best way for you to get information in your area? Radio, television,
newspaper, website, or other?
The clients observed that the yellow pages are a frequently used tool and sometimes there are
ads on TV in the wee hours of the morning. One of the clients in particular is well versed in
the internet and researches conditions and medications for others in the group.

If you come from a different background than other people in your area, do you feel
that your cultural needs were met? Was information provided to you in your native
language? Did you have any special needs in order to receive services?
In general, their culture and ethnic needs are being met and accommodated.



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Are there any needs not being met?
More Psychosocial Rehabilitation (PSR) classes were requested. In some situations, it is a
challenge for clients to get “appointment cards” which are used to get gas vouchers from Nye
County. They are being restricted because there have been abuses in the past.
Transportation services have been reduced and there are confusing rules and restrictions on
the when the clinic van can and cannot be used to transport clients.

What has impeded you from getting services in your community?
As mentioned above, some of the clients felt that the rules regarding transportation were
confusing and restrictive. Several others cited the lack of insurance coverage for some and
limitations in what services are covered for others. It was mentioned that the requirements to
complete paperwork for homeless clients are daunting and that being homeless often carried
a stigma. Another impediment to getting services was the loss of the 24/7 crisis call line.
Placement on the waiting list depends on the need and condition. The most needy are usually
able to get help fairly soon but it takes a few months for the “normal nuts.”

If you could change three things about the existing services you receive, what would
you like to be different?
    1) The clients all agreed that they would like to be able to see a therapist more often.

   2) They felt that the need to fill out the same paperwork at every appointment takes an
      inordinate amount of time and reduces the amount of time that they actually spend
      with a therapist.

   3) The clients would like to see more group sessions and/or longer sessions with fewer
      people. Additional groups they would like to see offered include basic living skills,
      depression and Psychosocial Rehabilitation (PSR).

What additional services would you like to see offered?
It was suggested that a call line for non-crisis situations that would be available after hours or
between sessions would be helpful. The need for bereavement support was also mentioned.

Successes
The groups have been very rewarding and many friendships have been formed. Some of the
group activities have included field trips to museums in Las Vegas in the Clinic’s van. In the
basic living skills groups, they each have a job. When they got together with other groups
for a Thanksgiving gathering, they were given aprons by the clinic staff paid for out of their
own pocket which made the clients feel like a very cohesive group.

The Clinic Director’s Office door is always open for anyone who needs to speak to her about
anything. She also makes herself available to the group in situations where family members
are ill or have passed away. There is a Resource Room available for peer-to-peer services
without the need for clinic staff to be present. It feels much like a family because of the size
of the clinic. The clients feel like they can depend upon each other for support through the
groups. They also credit the clinic and the groups for the progress they have made.



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E. Community Stakeholder Feedback
On Thursday, January 8, 2009, the monitoring team conducted a focus group for mental
health service providers in and around Pahrump. Each of the participants was asked to
describe the nature and scope of the services their organization provides and to identify
successes, challenges and unmet needs in the area. The participating organizations were as
follows:

Nevada Outreach Training Organization
This organization operates several programs in the area. The Family to Family Connection
program has three staff members providing services to families in Pahrump and Amargosa.
They receive a grant from the Office of Traffic Safety to provide car seats for families.

Family Resource Center is a case management for life crisis situations. It includes a very
well stocked food pantry funded by FEMA. It is open weekdays 9:00 to 5:00. Clients are
limited to one visit per month which is closely monitored and there is no income test. The
program also gets food commodities from the State of Nevada for distribution every other
month. The food pantry serves 1,200 people per month and 900 people are provide
commodities every other month.

The organization provides life skills training as well as parenting classes on an ongoing basis
and a “No to Abuse” program which focuses on domestic violence and has a 24/7 crisis
hotline associated with it. Many women they see are cyclical domestic violence victims.
They have a contract with Nye County juvenile probation with separate groups for male and
females on anger management.

There are many clients with mental health problems that include situational depression as
well as many children who are troubled with violence in their homes and depravation but are
not to the point of requiring intervention by Child Protective Services. Virtually all the
children and adolescents they see say that they have no one they can go to for help, including
family members.

The Pahrump Mental Health Clinic has been a good resource to the Nevada Outreach
Training Organization and referrals are made back and forth between the two.

Successes include a reorganization that clarified the organization’s purpose. Challenges
include staffing the No to Abuse program and limited professional development and
credentialing opportunities for staff. They agree that mental health services are needed in the
area but have found that medical care is even worse, particularly for uninsured.

Nevada Division of Health, Rural Public Health Services
Most of their focus is on prevention. The state’s immunization rate is the third worst in the
country. They operate the Vaccines for Children Program targeting uninsured and
underinsured children under 18.

They are concerned that there are many adolescents on medications for anxiety and
depression without a clear understanding of why and that the root causes are not being



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addressed. They make frequent referrals to the Pahrump Mental Health Clinic but not many
clients follow through. A contributing factor is the fact that the Health Division can provide
services to adolescents without parental approval but the Pahrump Mental Health Clinic
cannot. In addition, the Pahrump Mental Health Clinic cannot transport children in agency
vehicles due to insurance restrictions.

Sometimes referrals are made to “No to Abuse” so the clients can interact with peers. A
significant challenge is that domestic violence victims have very limited transportation
options in and out of Pahrump if they have to get away from their situation.

The distance from Pahrump to Las Vegas is a major barrier as well as the cultural differences
between Las Vegas and Pahrump. The trip is virtually a full day due to the drive time, wait
time and actual service time.

Many changes have taken place within the Health Division recently and many more are
anticipated in the future while they sort out revised priorities. They have combined their
Community Health Program with Environmental Health and Early Intervention Services.
Services to Amargosa and Beatty have been cut due to budget issues but Nevada Health
Centers have clinics there so it was viewed as duplicative. Home visits are limited because
two staff members are required on each visit for safety reasons.

Forty percent of their clients are adolescents and most of the service providers attending
agreed that teenagers in the area are isolated and/or abandoned and many are living
nomadically at friends, which is known as “couch surfing.” Parental consent is a huge
barrier to adolescents seeking mental health services.

It is their opinion that early intervention services are non-existent in Pahrump. The school
district only has one registered nurse for five thousand kids in Pahrump.

Nevada Division of Welfare and Supportive Services (DWSS)
DWSS makes numerous referrals to the Pahrump Mental Health Clinic, usually through the
New Employees of Nevada (NEON) program which is basically a work program. Clients
must work 30-35 hours a week depending upon the family type. If a client comes in with a
crisis, the DWSS Social Worker identifies mental health or related issues, and refers them to
an appropriate agency such as the Pahrump Mental Health Clinic. When DWSS makes
referrals to the Pahrump Mental Health Clinic, they are usually given a high priority and seen
within 5 days.

A challenge is the growing caseload per staff at DWSS and providing services to a new class
of applicants, particularly owners and employees of small business that have closed down.

DWSS sees mental health clients that need medications but the response can be slow because
they have to be approved for Medicaid. Nye County Social Services has a one-time
medication support based on income.




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Specialty Courts in the Fifth Judicial District
There are three types of specialty courts in the Fifth Judicial District.
   1) Adult Drug Court – There are 40 to 50 participants who have extensive requirements
       including substance abuse counseling, self help meetings, completion of their GED
       and getting employment. It takes one to three years to complete. The majority of the
       participants have some kind of co-occurring disorder. They may be going to
       substance abuse counseling but, for the most part, not getting treatment for the mental
       health component even though they are referred to the Pahrump Mental Health Clinic.
       The Court can’t make the participants go to mental health counseling and there’s a
       possible stigma attached to seeking mental health services. They have a 40%
       graduation rate. Some graduates are mentoring other clients.
   2) Juvenile Drug Court – This is a shortened program for the juveniles. They have
       found that there is little or no support from the families to follow up on requirements.
       Parents are often sent to the Pahrump Mental Health Clinic but they do not
       acknowledge there is a problem with the child so Clinic has difficulty treating them.
       The graduation rate is much less, close to 1 in 100.
   3) Family Specialty Court – This court was initiated to fill a gap to get more parental
       involvement. However, the Court lacks tools to enforce recommended steps.

A major barrier to success in all three courts is the lack of a residential treatment facility in
Pahrump.

Nye and Esmeralda (NyE) Community Coalitions
They are a private, not for profit organization that serves other social services organizations
in Nye and Esmeralda counties. They generally don’t provide services directly to
individuals. They are the glue that holds the social services network together in the Pahrump
area by assessing the needs of the community and addressing them. Listening to the other
organizations has been their key to success.

Much of their focus is on alcohol, tobacco and drug abuse prevention. Originally, they
started working with the school districts. They are funded through federal and state grants as
well as by the other organizations they support. If there is an organization that can address a
need, the coalition will sub-grant money to them. They receive a significant amount of their
funding from SAPTA. The best way they have found to reach parents is by working through
the school district.

Challenges include the lack of data on many social services indicators, particularly on
suicide. In addition, since many of the births for Pahrump actually take place in Clark
County, statistics on birth problems such as drug addiction are not properly categorized. The
lack of adequate, regular professional development opportunities for social services
professionals in the area is another challenge. Transportation and access to activities are also
challenging. In addition, school counselors are overwhelmed. There are few, if any, reentry
programs for prisoners and veterans. Bereavement issues and anger management aren’t
being addressed for younger mental health patients.




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Successes include the fact that since 2002, $1.75 million in funds have been acquired. Also,
when they started, there were no accredited prevention programs in the area and now 7 of
them are certified with 5 of them actively providing prevention services.

They also funded prevention programming on school buses traveling between remote areas
of Esmeralda County and Tonopah. In general they have enhanced collaboration among their
various partners.

Nevada Division of Child and Family Services (DCFS)
The Pahrump office of DCFS deals with families where there are reports of abuse or neglect
so it is initially somewhat confrontational. Often there is no actual abuse or neglect but the
clients have needs for which the DCFS Social Workers refer them to other social services
providers in the community.

DCFS has a significant barrier to its success due to staff turnover and shortages which limits
its institutional knowledge. Maintaining consistency and continuity with providers is
difficult due to turnover. It takes some time for new staff to learn about the available
services in the community.

They sponsor a foster care Christmas party every year and this last year’s party in particular
was very well supported by the community partners.

When they take a child into custody, they become involved with the entire family, most of
whom need other social services. They could use more support with in-home services and
training on individualized parenting skills.

DCFS staff usually has to go to Las Vegas or Carson City for professional development
which is becoming more difficult with budget limitations on travel. Training needs include
ethics for continuing education certification, evidenced based practices for clinicians,
communication facilitation and suicide awareness. Opportunities for internships are limited
and it would be good have more.

Open Discussion Among All Participants
Statewide, Rural Clinics’ turnover for clinicians was 42% but it has slowed since the
elimination of the after-hours emergency crisis call line which caused staff burn-out. During
budget development for SFY 2010 and SFY 2011, Rural Clinics responded to budget cut
targets by changing their service model – closing 11 smaller clinics and moving to a “hub
and spoke” model whereby communities without clinics would be served from the larger
“hub” clinics by traveling staff. Rural Clinics would collaborate with other community
providers in the “spoke” communities and contract with providers as well.

Subsequent to the Rural Monitoring visit, the 2009 Legislature has indicated its interest in
keeping as many rural clinic locations open as possible. It requested an alternative budget
plan from Rural Clinics administration. Administrative staff collaborated with Clinic
Directors and has presented an alternative budget plan that will re-open the clinic in Tonopah
and keep a mental health services presence in the communities previously scheduled to have



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  their clinic closed. The outcome for the agency will be determined by the legislative process
  for the next biennium.

  The monitoring team heard that there is limited response to mental health issues by the Nye
  County Sheriff’s office. It was said a client just about has to have a gun to their head before
  the Sheriff’s office responds. Transportation issues are the greatest challenge. If a client
  shows up at the Pahrump Rural Clinic that needs immediate attention beyond the clinic’s
  capability, it can take 4-5 hours for the Sheriff’s Office to show up to transport them to a
  higher level service facility. It’s a safety issue for the Rural Clinics staff that stresses them
  because they can’t transport them, can’t restrain them and they are free to leave at any time.
  There are ethical and professional standards facing the staff. If the Sheriff’s office has to
  transport them to Las Vegas, it takes two officers most of the day and usually some overtime
  which is a budget issue. It also reduces the police coverage to the community. The
  Emergency Responders are not trained to transport seriously ill mental health clients.


VI.   Response from Rural Clinics
  In the following section, the recommendations of the Monitoring Team are restated in italics
  followed by a response from Rural Clinics Acting Director, Marcia Bennett Ph.D, in bold.

  1) Explore one-time funding opportunities to purchase supplies, equipment and other
     interpretive resources necessary to enhance the clinic staff’s ability to treat children.
     Possible sources of funding include reallocating some of the Community Mental Health
     Services (CMHS) Block Grant or by including a request in the MHDS application for the
     Transformation Transfer Initiative grant offered by National Association of State Mental
     Health Program Directors (NASMHPD).

      Rural Clinics has an administrative position who is currently responsible for
      coordination of Special Projects. This position is working on identification of grant
      opportunities, development of shared office space and other collaborations with
      human services and public health providers in rural communities, and developing
      opportunities for social work and mental health professional internships at Rural
      Clinics sites. The acquisition of appropriate tools and equipment for the treatment
      of youths and families will also be addressed as a Special Project.

      In addition, Clinic Directors are exploring ways to partner with local school
      districts, particularly in the high schools, to provide prevention and individual and
      group treatment services for at risk youth, as well as community education for
      teachers and parents. Rural Clinics is partnering with DHHS Office of Suicide
      Prevention to provide suicide risk identification and intervention training for rural
      Nevada communities.

  2) Review the available staffing resources necessary to utilize the existing Telepsychiatric
     services in Pahrump.




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   Rural Clinics is working to increase opportunities for Nevada Psychiatrists to
   contract with the agency, as well utilizing Locum Tenens Psychiatrists, to provide
   additional telemedicine and consultation resources. Both adult and child/adolescent
   psychiatrists are needed. Currently Rural Clinics is exploring ways to partner with
   community physicians and universities to provide practicum placements for
   residents. The agency has included development of a position for a staff
   psychiatrist to provide continuity and back-up psychiatric services in its 5-year
   quality improvement plan for 2015.

3) Consider allowing staff to work flexible hours in order to provide a greater window of
   opportunity for children to schedule appointments at the Pahrump Mental Health Clinic
   without having to miss school.

   Rural Clinics has recently instituted a Variable Work Schedule for staff. This
   allows clinicians and staff to better address community needs by working later in
   the evening or even on weekends. The Clinic offices continue to be open from 8:00
   to 5:00 Monday through Friday. Clinic Directors are able to approve variable
   hours based on local needs for services.

4) Agency administration should consider allowing the Pahrump Mental Health Clinic to
   fill the vacant Psychiatric Caseworker II position in order to reduce the significant wait
   time for clients to receive service coordination.

   The vacant Psychiatric Caseworker II position has recently been approved for
   hiring and is in recruitment. In addition, the second service coordinator position at
   Pahrump Mental Health Clinic has become vacant and the agency is working
   through the State of Nevada hiring procedure to be able to recruit for this position
   as well. These positions, once filled, will provide two full-time service coordinator
   positions for the community to increase service coordination and PSR services and
   address the waiting list for these services.

5) Explore funding opportunities for one-time emergency assistance requests that had
   previously been budgeted. Possible sources of funding include reallocating some of the
   CMHS Block Grant or through the Transformation Initiative grant offered by
   NASMHPD.

   While resources in the budget have been severely limited in current proposal before
   the legislature, Rural Clinics continues to explore grant opportunities and develop
   partnerships with other community based service providers and consortiums to
   address local needs of people in services.

6) Reconsider the decision made by Rural Clinics administration to relocate the SAPTA
   contracted counselor from the Pahrump Mental Health Clinic to another location.

   The Acting Director is working with the Director of SAPTA to identify ways to
   reinstate co-location of SAPTA counselors with the clinic in Pahrump as well as



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   other Rural Clinic locations. Both are committed to making treatment for co-
   occurring disorders a priority for mental health programs in rural Nevada.

7) Research and consider appropriate psychological testing software that is compatible with
   the existing computers and that does not require on-going analysis fees.

   Psychologists at the various clinics have been asked to develop a list of testing
   materials they need. Rural Clinics Coordinator of Special Projects is researching
   grants to upgrade the agency’s ability to do psychological testing. Rural Clinics
   Information Technology staff have been tasked to upgrade computer technology in
   the clinics to provide the capability to use current software programs. Dedicated
   computers for testing software with appropriate licenses are being set up in clinic
   offices.

8) Research the State of Nevada and Department of Human Services as well as Mental
   Health and Developmental Services Division rules and guidelines regarding the
   transportation of clients to identify opportunities to expand the use of agency vehicles for
   the transportation of clients without putting the State at risk.

   The policies and procedures of Rural Clinics are being reviewed at the present time
   to identify unnecessary restrictions (not required by law or regulation) to enhance
   services to people, reduce paperwork requirements, and make business processes
   more efficient and effective.

   Lack of transportation is a barrier for many people in rural communities, including
   seniors, people with disabilities, and low income families and individuals. Medicaid
   will not reimburse service coordinators for providing direct services, including
   transportation. The administration has submitted a budget plan to the legislature
   that includes Mental Health Technician positions in the clinics. These positions can
   be used to provide direct support, including transportation, for people in need of
   these services. The administration is also looking into the use of contracted private
   providers who can assist individuals by teaching skills, coaching for independent
   living, and helping people to access their communities.

9) Explore opportunities to utilize video conferencing equipment located at the DCFS office
   in Pahrump to provide Telepsychiatric services so that child and adolescent clients can
   receive treatment remotely from DCFS staff in Las Vegas or Reno.

   The Acting Director has requested DCFS to participate in regularly scheduled
   meetings to increase communication, collaboration, and improve services for
   children and adolescents and their families in rural Nevada. The use of the
   telemedicine system to increase availability of clinical services will be addressed by
   Rural Clinics staff with DCFS partners, including those in Washoe and Clark
   counties. Rural Clinics has identified the provision of appropriate services for
   children and adolescents, including psychiatric services, as a priority goal in its
   quality improvement plan for 2015.



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VII. Acknowledgements

Monitoring Team: Rene Norris, Dave Caloiaro, Ann Polakowski

Monitoring Team staff and report writer: Roger Mowbray

Rural Monitoring Subcommittee members: Kathy Hughes, Rene Norris, and Alyce Thomas

Pahrump Mental Health Clinic Director: Theresa Lambrecht, LCSW

MHDS staff: Dave Caloiaro

DCFS staff: Ann Polakowski and Patricia Merrifield




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VIII. Appendix A – Focus Group Invitation




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IX.   Appendix B – Focus Group Instrument

                           ADULT Focus Group Questions

  1. The President’s New Freedom Commission recognizes that sometimes barriers can
     impede individuals from receiving mental health care. Have you encountered any
     barriers that have hindered you or your family from receiving the mental health care
     you need?

  2. After your initial intake phone call or visit, were you put on a waiting list? If so, how
     long before you began receiving services?

  3. What kinds of services do you or did you receive?
      What types of mental health services are available in your area?
      Do you feel that you have adequate choices for mental health treatment in your
       area?
      Are treatments available in your community for adults with co-occurring substance
       abuse and mental health disorders? What do you need in your community to
       address this?
      When receiving treatment, do you feel that your therapist is effective?
      Do you feel your symptoms have lessened? Why?
      When receiving treatment, do you feel that it is private, confidential, and respectful
       to you as an individual?
      If you feel uncomfortable with your therapist, do you feel comfortable that you can
       ask to change to a different one?
      What does wellness mean to you?

  4. How did you hear about Rural Clinics?

  5. Do you feel you have been stigmatized in your community because you are coming here
     for services, or may have a mental health need? Did any specific event happen and
     what could be done to remove this stigma?

  6. Would you like to see more informational material or classes on recovery from mental
     illness and substance abuse made available?

  7. Is there particular information you would like to see made available?




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8. What is the best way for you to get information in your area? Radio, television,
   newspaper, internet, or other?

9. If you come from a different background than other people in your area, do you feel
   that your cultural needs were met? Was information provided to you in your native
   language? Did you have any special need in order to receive services?

10. What needs do you have that are not being met?

11. What has impeded you from getting services in your community?

12. What do you see as the role of the clinic you are going to?

13. If you could change three things about the existing services you receive, what would you
    like to be different?

14. What additional services would you like to see offered?

15. Is your input being considered? If so, how?




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