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					Prince of Wales
Behavioral Health System
Needs Assessment Report
May 2010
Acknowledgments
The residents of Prince of Wales Island provided valuable input and guidance through
questionnaires and personal interviews to the Prince of Wales Behavioral Health System Needs
Assessment report. This report is the direct result of their time and knowledge of their communities,
and their desire for a healthy future for Prince of Wales Island.
The Project Team also provided valuable direction and input to guide the assessment process, acting
as a sounding board and review body. The Project Team also helped make connections with local
communities and helped gather background information for the report provided here.
Project Team members:
   •   Colleen Watson, (State of Alaska, Public Health)
   •   Esther Hammerschlag, (Prince of Wales Health Network)
   •   Bess Clark, (Community Connections)
   •   Carolyn Lemmon, (Southeast Alaska Regional Health Consortium)
   •   Mark Walker, (Alaska Island Community Services)




All photos by Agnew::Beck Consulting unless otherwise noted.

                           Prince of Wales Behavioral Health System :: Needs Assessment Report :: Acknowledgments
Prince of Wales Behavioral Health System
Needs Assessment Report
Table of Contents
1 :: BACKGROUND + PROJECT DESCRIPTION ............................................................................ 1
        1.1 Introduction ............................................................................................................................ 1
        1.2 Strategic Prevention Framework ....................................................................................... 1
        1.3 Planning Process .................................................................................................................... 2
        1.4 Report Format ....................................................................................................................... 3
        1.5 Project Organization ............................................................................................................ 4
        1.6 Methodology........................................................................................................................... 5
2 :: PRINCE OF WALES ISLAND COMMUNITIES .......................................................................... 8
        2.1 Community Demographics ................................................................................................. 8
        2.2 Trends impacting local population................................................................................... 10
3 :: POPULATION + HEALTH STATUS ........................................................................................... 12
        3.1 Health Indicators ................................................................................................................. 12
4 :: BEHAVIORAL HEALTH SERVICE DELIVERY SYSTEM DESCRIPTION............................. 24
        4.1 Definition of Behavioral Health and Service Definitions ............................................ 25
        4.2 Prince of Wales Island Communities .............................................................................. 27
        4.3 Current Utilization of Behavioral Health Services....................................................... 35
        4.4 Gaps in Service and Barriers to Service Delivery ........................................................ 37
5 :: SUBSTANCE RELATED CONSEQUENCE OR PROBLEM BEHAVIOR ............................ 41
        5.1 List of problems to be addressed through capacity building, strategic planning
            and priorities for action on POW ................................................................................... 42
        5.2 Intervening Variable ............................................................................................................ 43
6 :: COMMUNITY STRENGTHS + RESOURCES .......................................................................... 45
        6.1 Resources on Prince of Wales Island and Opportunities for Collaboration ......... 46
7 :: DISCUSSION OF FINDINGS ........................................................................................................ 49




                                         Prince of Wales Behavioral Health System :: Needs Assessment Report :: Table of Contents
Table of Figures + Maps
1.1 Strategic Prevention Framework..................................................................................................... 1
2.1 Community Locations ........................................................................................................................ 8
2.2 Community Demographics ............................................................................................................... 9
3.1 Serious Behavioral Health Disorders in Total Household by Region ................................... 13
3.2 Cause of Death Associated with Substance Abuse in Alaska, 2001-2005 ........................... 17
3.3 Prince of Wales Island Reported Assaults and Domestic Violence, 2004-2008 ................ 20
3.4 Juveniles, Referrals, and Charges for each Region and Office ................................................ 21
3.5 Number of Charges by Type for each Region and Office (Referrals) FY 2004-2008 ....... 21
3.6 Total Allegations Substantiated in CY 2008 ............................................................................... 22
3.7 Total Allegations Substantiated in CY 2007 ............................................................................... 23
3.8 Total Allegations Substantiated in CY 2006 ............................................................................... 23
4.1 Service Continuum Matrix .............................................................................................................. 34
4.2 COHO Census, 2008-2009 ............................................................................................................ 35
4.3 Client Utilization of Services, SEARHC and Community Connections ............................... 36
5.1 Community members rank Top 5 negative behaviors ............................................................. 42
5.2 Social Providers ranked Top 5 negative behaviors.................................................................... 42
5.3 Logic Model ........................................................................................................................................ 44



Appendix 1 :: Questionnaires
Response Summary for Questionnaires
Stakeholder + Community Member Questionnaire
Prevention + Behavioral Health Service Provider Questionnaire




                                           Prince of Wales Behavioral Health System :: Needs Assessment Report :: Table of Contents
1 :: BACKGROUND + PROJECT DESCRIPTION

1.1 Introduction
In 2009, the Prince of Wales (POW) Health Network 1 received funding from the State of Alaska,
Department of Health and Social Services to complete a planning process for behavioral health
service delivery for the Prince of Wales Island region. This project includes an assessment of the
current behavioral health system and planning for improved prevention and early intervention
services to serve Prince of Wales Island residents. The guiding priority of this project is to identify
actions that local communities can take to positively impact behavioral health.
When Communities Organized for Health Options (COHO), a primary provider of behavioral
health services on Prince of Wales Island, closed its doors in January 2009, the members of the
POW Health Network saw it as part of their mission to facilitate planning related to the behavioral
health needs of Prince of Wales residents. The Prince of Wales Health Network contracted with
Agnew::Beck Consulting, LLC, a community planning and development firm located in Anchorage,
to carry out a needs assessment, develop and facilitate a capacity building training and to conduct a
strategic planning process.
1.2 Strategic Prevention Framework
1.1 Strategic Prevention Framework
                                            This project uses Strategic Prevention Framework
                                            (SPF) to structure the planning. The Strategic
                                            Prevention Framework helps communities take a step-
                                            by-step approach to create an effective prevention
                                            program. Each step contains key milestones and
                                            products to encourage long term success, and ensure
                                            that the process is culturally relevant to the target
                                            population. The Strategic Prevention Framework (SPF)
                                            was developed to provide an effective prevention
                                            process and common set of goals to be adopted and
                                            integrated at all levels (Federal, State/tribal and
                                            community). It is built on a community-based risk and
                                            protective factors prevention approach.
                                            The purpose of the SPF is to build capacity in
                                            communities to decrease substance use and abuse,
                                            promote mental health, and reduce disability related to
                                            behavioral health conditions. It utilizes a five-step
process, with cultural competency and sustainability overlaying all five: 1) Assessment; 2) Capacity;
3) Planning; 4) Implementation; and 5) Evaluation.

1
  The Prince of Wales Health Network is a collaborative effort between the City of Craig, PeaceHealth –
Ketchikan General Hospital, Southeast Alaska Regional Health Consortium (SEARHC), State of Alaska – Craig
Public Health Center, and Alaska Island Community Services. The Health Network’s mission is to build a strong
and sustainable network of healthcare organizations collaborating to strengthen quality healthcare on Prince of
Wales Island and increase access to quality healthcare for all island residents far into the future. The Network is
funded by a three year grant from the Health Resources and Services Administration Office of Rural Health Policy.


Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                              1
1.3 Planning Process
This planning process completes steps1-3 of the Strategic Prevention Framework. The following is a
brief explanation of these steps:
SPF Step 1 Assessment: In this step, communities use data to accurately assess their behavioral health-
related problems. This phase also assesses community assets, resources, and gaps in services as well
as the readiness to act.
SPF Step 2 Capacity: Step 2 engages key community stakeholders who are critical to planning and
implementing successful activities that can be sustained over time. Key tasks during this phase
include convening stakeholders and community leaders; building coalitions; training stakeholders in
coalition-building; and engaging stakeholders to help sustain activities over time.
SPF Step 3 Planning: During Step 3, stakeholders work together to develop a strategic plan that is
based on documented needs, builds on identified resources and strengths in the community, sets
measureable objectives and includes performance measures to monitor progress. Strategic plans can
be adjusted as new information is learned through ongoing assessment and monitoring activities.
One of the critical elements of this step is to develop a logic model that identifies the key
components of the strategic plan. Key components should include the project goal, prioritized
factors the community wishes to change, available resources, activities planned for implementation
and desired outcomes.




Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                  2
Section 1.4 Report Format
This needs assessment report is organized in the following sections:
Chapter 1: Background + Project Description
Includes a description of the Prince of Wales Behavioral Health Planning project; a description of
the Strategic Prevention Framework and the project approach and methodology.
Chapter 2: Prince of Wales Island Communities
Includes a description of the communities located on Prince of Wales and a brief discussion of
trends affecting the location population.
Chapter 3: Population + Health Status
Provides population estimates and projections as well as a description of local health status and a
discussion of various data sources to help define behavioral health issues on Prince of Wales Island.
Chapter 4: Behavioral Health Service Delivery System Description
Outlines the services currently available in the Prince of Wales Island service area and identifies the
gaps in the behavioral health service continuum. Current utilization of behavioral health services are
also provided in this chapter.
Chapter 5: Problem Behavior + Substance Abuse Related Consequence
Includes the list of problems that community members identified related to substance abuse as well
as priorities to address through capacity-building and future prevention and early intervention
planning efforts.
Chapter 6: Community Strengths + Resources
This section will be the foundation for the capacity building step which will rely on community
members and stakeholders to take actions related to the problems identified in the assessment
process.
Chapter 7: Summary of Results
Provides a discussion of the key findings from the needs assessment process, capacity building and
strategic planning.




 Photo courtesy of DCCED
Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                    3
1.5 Project Organization
Project Team
A Project Team was created to help guide the process and give input as project milestones are
achieved. The overall goal of the Project Team was to help guide the assessment and planning
process and work with the Consulting Team as sounding board and review body. The Project Team
provided connection on the local level and background information for the Consulting Team.
Membership included representation from: the Prince of Wales Health Network; State of Alaska
Public Health; Southeast Alaska Regional Health Consortium (SEARHC); Community Connections;
and Alaska Island Community Services (AICS).
Stakeholder Work Group
The success of this planning process will depend on the engagement of stakeholders on the local
level. A stakeholder work group made up of stakeholders from communities throughout the island
as well as representatives from service provider agencies, schools, law enforcement and community
members will be convened to help identify prioritized problems and mobilize the community on
issues identified through the needs assessment.
This work group will help ensure that stakeholders are active participants in all phases of the project.
This will also ensure that a stakeholder work group is in place to begin the process of coalition
building which is a key element to ensuring the successful implementation of activities identified
through this process. It also is a critical piece to ensuring that initiatives are sustained over time.




Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                   4
1.6 Methodology
The approach to collecting data to inform the needs assessment report was based on guidance from
the Center for Substance Abuse Prevention’s (CSAP) Western and Southwestern Centers for
Applied Prevention Technologies. 2 CSAP has identified sources of data that are available that states
and local communities can use to better understand the scope of problems pertaining to substance
consumption and consequence. Once data is collected, the next step in the process is to review and
analyze the data to begin to understand consumption rates, the consequences of behaviors related to
substance abuse consumption, and to help prioritize and target the prevention and early intervention
activities that will be most effective in dealing with those behaviors.
The key questions that guide this needs assessment include: What services are already available?
Who is providing those services? Which services are needed based on a profile of the population?
Where are the gaps? What is the most pressing problem that should be addressed?
Data Collection efforts sought to identify needs and inventory existing resources; present
preliminary health status data; identify the problem behaviors related to substance abuse that should
be a priority for action on an island-wide level. Through identification of the problem to be
addressed, the needs assessment process will inform the capacity-building (SPF Step 2) efforts, and
help the community to identify what will be addressed.
A preliminary list of available services was compiled using information from key stakeholders in the
community including members of the Project Team and service providers in the area. Structured
interviews were conducted with key stakeholders who provide behavioral health services on Prince
of Wales Island. Document reviews were conducted and previously published needs assessments
and health profiles were utilized. Demographic data was gathered through the U.S. Census Bureau as
well as State of Alaska Department of Labor and Workforce Development. Service utilization data
from the State Medicaid office and data reports from individual service providers were also analyzed.
The data collection process for the project included both primary and secondary data sources and is
discussed in more detail below.
Primary sources of data
Key Informant Interviews
Qualitative data was collected through structured interviews with area service providers and those
involved in the delivery of social services. A standardized list of questions was developed and used
to guide interviews that took place in person and by telephone. The goals of the interviews were to
identify the services currently being provided; whether the level of services being provided met the
demand; identify gaps and any workforce challenges; and to identify priorities for new service
development. The interviews also provided an opportunity for those on the island to identify the
best way to solicit input from community members and to help with making sure the questionnaires
were fielded to as many people as possible. A total of nine (9) preliminary interviews were conducted
and results were complied identifying overarching themes. Agencies who participated included: State
of Alaska, Public Health; State of Alaska, Division of Juvenile Justice; Craig City School District;
City of Craig; Hydaburg Cooperative Association; Alaska Island Community Services; Southeast
Alaska Regional Health Consortium, Alicia Roberts Medical Center and Behavioral Health Program


2
 http://captus.samhsa.gov/western/resources/bp/spf.cfm
http://captus.samhsa.gov/southwest/southwest.cfm



Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description               5
staff. A number of follow up interviews with local stakeholders were also conducted to gain
feedback on the DRAFT assessment report’s conclusions.
Service Provider + Stakeholder and Community Questionnaires
Primary data was collected through a self-administered questionnaire that was posted on an online
portal. Information about the questionnaire was circulated throughout the community via flyer and
by members on the Project Team. Overall, 60 questionnaires were completed. The intent of the
questionnaire was to measure the awareness, satisfaction, access to behavioral health services
currently being provided, as well as the needs for new service development. A copy of the
questionnaire and a response summary is included in Appendix A.
Secondary sources of data
Secondary sources of data include demographic and health status data. Secondary data sources used
for this assessment report are described below.
U.S Census Bureau
The U.S. Census Bureau conducts a survey on the American population every ten years. Census data
collected in 2000 was utilized for the Prince of Wales—Outer Ketchikan census area. 3
The Alaska Department of Labor and Workforce Development
The State of Alaska Department of Labor and Workforce Development compiles economic data for
the state. The Department typically publishes studies related economic trend analysis including
population, workforce, employment and unemployment statistics, industry profiles, and cost of
living estimates.
Alaska Native Tribal Health Consortium (ANTHC) Rural Behavioral Health Needs Assessment
This report, published in 2005 was a collaborative effort between the State of Alaska Department of
Health and Social Services (DHSS), Division of Behavioral Health (DBH), Division of Public Health
(DPH), the Denali Commission, Alaska Mental Health Trust Authority, the University of Alaska and
the Alaska Native Tribal Health Consortium (ANTHC). The study addressed behavioral health
service and facility needs for residents of rural Alaska.
2006 Behavioral Health Prevalence Estimates in Alaska: Serious Behavioral Health Disorders by
Household
The State of Alaska Division of Behavioral Health and the Alaska Mental Health Trust Authority
funded a prevalence study designed to estimate the rate of serious behavioral health disorders in
Alaskan households. The report is intended to be used to provide a basis for defining the needs for
services of the population. Prevalence estimates were provided for the total household population in
Alaska, as well as for individuals who were in low-income households.




3
 The Prince of Wales—Outer Ketchikan census area includes the following communities: Coffman Cove, Craig,
Edna Bay, Hollis, Hydaburg, Hyder, Kasaan, Klawock, Metlakatla, Naukati Bay, Point Baker, Port Protection,
Thorne Bay, Waterfall, Whale Pass. In 2008, the name of the Prince of Wales—Outer Ketchikan Census Area was
changed to Prince of Wales-Hyder Census Area.


Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                      6
State Epidemiological Profile on Substance Use, Abuse, and Dependency
In April 2008, the State of Alaska Department of Health and Social Services Division of Behavioral
Health Prevention and Early Intervention Services Section published a report that included major
indicators of Alaska’s substance consumption and consequences related to use and dependency.
Indicators include measure of alcohol and tobacco sales; self-reported substance abuse consumption
behavior; and outcomes including morbidity, mortality, treatment, and criminal activity associated
with substance abuse and dependency.
State of Alaska, Division of Juvenile Justice (DJJ)
DJJ collects and reports data related to: “Juveniles, Referrals, and Charges for each Region and
Office;” “Number of Charges by Type for each Region and Office (Referrals);” “Race % as reported
at Referral, for each Region and Office;” “Age at Referral for each Region and Office.” All data is
reported on an annual basis. For purposes of this project, data sets were reviewed from 2004-2008.
State of Alaska, Division of Public Safety
The Division of Public Safety provided information from their data system by year on the number
of criminal offenses that involved drugs or alcohol. Data from a 5-year period are reported.
Offenses such as assaults, domestic violence, DUI, and minor consumption were included. This
information was also broken down by community.
State of Alaska Department of Transportation and Public Facilities
The Department of Transportation and Public Facilities collects data on Alaska Traffic Crashes and
provides annual reports on a variety of data related to crashes. The following reports were reviewed:
“2006-2008 Alaska Court Outcomes for DUI cases;” “2008 DUI Arrests Violations in Alaska;” and
“Alaska Traffic Crashes – Crash Data” for years 2003-2007.
Youth Risk and Behavior Survey
The Youth Risk Behavior Survey (YRBS) is part of an epidemiological surveillance system that was
established in 1990 by the Centers for Disease Control and Prevention (CDC). It was developed to
monitor health risk behaviors that contribute markedly to the leading causes of death, disability, and
social problems among youth and adults in the United States. The YRBS high school survey was
first implemented at the national level in 1990. Alaska first participated in the YRBS in 1995 and
obtained representative statewide data. However, a number of factors have made annual reporting
on YRBS a challenge. The last survey administered that achieved an adequate response rate, yielding
survey results was in 2009.
State of Alaska Behavioral Risk Factor Survey 2007 Annual Report
The Centers for Disease Control and Prevention (CDC) developed the Behavioral Risk Factor
Surveillance System (BRFSS) to monitor state level prevalence of the major behavioral risks among
adults associated with premature morbidity and mortality. The State of Alaska began the BRFSS in
1991 as a point-in-time study and has continued yearly since. The Alaska Behavioral Risk Factor
Surveillance System is a collaborative project with the CDC and Alaska Division of Public Health.




Prince of Wales BHS:: Needs Assessment Report :: 1. Background + Project Description                 7
2 :: PRINCE OF WALES ISLAND COMMUNITIES

2.1 Community Demographics
Prince of Wales Island is considered one of seven sub-geographic areas in the state of Alaska. There
are twelve (12) communities on Prince of Wales Island (POW). Two are considered hub
communities:
      •   Craig (pop. est. 1,117)
      •   Klawock (pop.est. 785)4


2.1 Community Locations




4
    2008 estimates. Alaska DCCED, US Census Bureau


Prince of Wales BHS:: Needs Assessment Report :: 2. Prince of Wales Island Communities             8
2.2 Community Demographics
                     2008       2000 Population+
Community            Population
                     Estimate++ Population Race                      Unemployment+++      Median Age

                                                    174 White        10.5%
Coffman Cove         141             199                                                  40.3
                                                    5 Native         33.5%

                                                    937 White        9.0%
Craig*               1,117           1,397                                                33.8
                                                    303 Native       29.7%

                                                    47 White         0.0%
Edna Bay             40              49                                                   36.8
                                                    0 Native         48.6%

                                                    125 White        3.1%
Hollis               172             139                                                  40.9
                                                    7 Native         34.4%

                                                    36 White         31.3%
Hydaburg             341             382                                                  31.8
                                                    325 Native       66.3%

                                                    20 White         20.0%
Kasaan               54              39                                                   44.8
                                                    15 Native        52.9%

                                                    350 White        15.7%
Klawock*             785             854                                                  34.5
                                                    435 Native       39.6%

                                                    117 White        29.1%
Naukati Bay          124             135                                                  36.6
                                                    13 Native        60.2%

                                                    32 White         0.0%
Point Baker          27              35                                                   42.8
                                                    1 Native         58.3%

                                                    55 White         0.0%
Port Protection      66              63                                                   42.4
                                                    0 Native         44.3%

                                                    515 White        14.6%
Thorne Bay           440             557                                                  38.8
                                                    16 Native        41.4%

                                                    56 White         0.0%
Whale Pass           48              58                                                   37.0
                                                    1 Native         62.2%

TOTAL                                               2,464 White
                     3,355           3,907                           N/A                  N/A
++++                                                1,121 Native
* Indicates hub communities.
+ Population estimates for the year 2000 are gathered from the US Census.
++Population estimates for the year 2008 are gathered from estimates certified by the State of Alaska,
Department of Commerce, Community and Economic Development.
+++
    For “Employment,” the percent unemployment is the first reported number. The percent of all individuals
aged16+ not working (unemployment + not seeking) is the second.
++++
    Please note that this total only includes organized and unorganized communities on Prince of Wales Island. In
addition to the populations noted for these communities, Prince of Wales Island has residents living in subdivisions
such as Port St. Nicholas and in other outlying areas. The population of these areas combined was, according to
the 2000 US Census and calculations by Agnew::Beck, approximately 767 people. In 2008, personal communication
with the State of Alaska DCCED estimated this number at about 551 people.



Prince of Wales BHS:: Needs Assessment Report :: 2. Prince of Wales Island Communities                             9
 According to the U.S. Census, the Prince of Wales – Outer Ketchikan Census Area population has
decreased over the last ten years. The 2000 population for the Census Area was 6,146 persons, a
decrease of 132 from 1990. The 2008 Population Estimates from the US Census Bureau estimate
the population was 5,533, approximately a 10 percent decrease from 2000. 5
The population in Southeast region of Alaska on average is 26 percent Alaska Native, however that
proportion varies for sub-geographic regions such as Prince of Wales Island. 6 Prince of Wales –
Outer Ketchikan Census Area’s Alaska Native population is 45 percent of the total population as
reported in the 2000 U.S Census. 7 Although the overall population is estimated to continue to
decrease, it is estimated that by 2015 the percentage of Alaska Native residents will increase. 8
2.2 Trends impacting local population
Population shifts can be attributed to the shift in economy on POW over the last twenty years.
Historically, logging has played an important role in the economy with at least twenty (20%) percent
of all wages earned on POW coming from the timber industry. 9 The POW economy included a large
number of timber related jobs until the mid-1990s, when local mills began closing.
Commercial fishing also plays a large role, with fishing being the foundation of the economy for
many towns on the island, including Craig, Klawock, Hydaburg, Port Protection and Point Baker.
During the summer of 2009, Silver Bay Seafoods began operating a newly constructed seafood
processing facility, located in Craig. This facility offers additional opportunity for local employment
during the summer months and the capacity to process commercial catches on Prince of Wales
Island. Silver Bay employs approximately 150 seasonal workers during the fishing season.
Local sources report an increase in the POW population during the summer months due to hunting,
fishing, fish processing and visitor services positions associated with seasonal employment at
hunting and fishing lodges. City of Craig staff estimate that the island population increases by 10-
20% during the summer months due to summer employment and seasonal residents. This number is
an estimate only and is not based on hard data.
Government sector employment also contributes heavily to the local economy. The Tongass
National Forest covers much of the island, with two ranger districts providing employment
opportunities. Due to heavy logging activity on the island, POW has an extensive network of roads
that were built by the U.S. Forest service and that are maintained by grant from the Federal Highway
Administration. Unlike a number of communities in Southeast Alaska, most communities on POW
are connected by roads. This is a potential asset for future economic development activities.
Due to a number of variables the POW island population, as previously mentioned, has continued
to decline. Though local sources do report an increase in the POW population during the summer
months due to hunting, fishing, fish processing and positions associated with hunting and fishing
lodges, population decline is projected to continue. Tourist related businesses such as lodges and
charter operators that contribute to population increase during the summer season bring their own
clientele, workers and supplies from off island, so little revenue is retained in the local economy.


5
  US Census Bureau, US Census and 2008 Population Estimates, www.census.gov.
6
  Alaska Native Tribal Health Consortium “2004 Rural Behavioral Health Needs Assessment.” Final Report.
7
  This percentage is the percentage of the population reporting Alaska Native alone or in combination with one or
more races. U.S. Census Bureau 2000. www.census.gov.
8   Alaska Native Tribal Health Consortium’s “2004 Rural Behavioral Health Needs Assessment.”
9
    Alaska Economic Trends, November 2001.


Prince of Wales BHS:: Needs Assessment Report :: 2. Prince of Wales Island Communities                         10
There is a local push towards developing the local capacity to offer tourist services and related
opportunities and thus capture more tourist dollars locally, but this effort is still developing.
With a declining manufacturing sector and fewer jobs in recent years, POW is in a transition period.
Trends in local economies certainly have an impact on the population and the health and wellbeing
of community members. Delivery of healthcare services, particularly behavioral health services in
rural Alaska communities is inherently challenging. This is most certainly the case for POW due to
geographic isolation, terrain, extreme weather, and a smaller population base.




Prince of Wales BHS:: Needs Assessment Report :: 2. Prince of Wales Island Communities            11
3 :: POPULATION + HEALTH STATUS

Data related to behavior and lifestyles choices can be used to assess the current health status of a
population and to provide a baseline of information to monitor and evaluate future changes. Health
indicators show individual behaviors, physical and social environmental factors, and health system
issues that affect the health of individuals and communities. Health indicators can be used to plan
education and prevention efforts. Data sources such the Behavioral Risk Factor Surveillance System
(BRFSS) and the Youth Risk Behavior Survey (YRBS) along with mortality, morbidity, public safety,
and criminal justice data provide a better understanding of substance use, abuse, dependence and the
consequences of these behaviors. The following section describes the various data collected for
POW Island and provides a summary of information to inform decision-making for policymakers,
program administrators, stakeholders and community members.


3.1 Health Indicators
Serious Behavioral Health Disorders Prevalence Estimates
In 2008, the State of Alaska, Division of Behavioral Health and the Alaska Mental Health Trust
Authority sponsored a study conducted by WICHE Mental Health program that provided
prevalence estimates of serious behavioral health disorders in Alaskan households. This report was
entitled, Behavioral Health Prevalence Estimates in Alaska: Serious Behavioral Health Disorders by
Household. Alaska’s 27 Boroughs and Census Areas were divided into 4 regions for this report.
These included:
     •   The Northern Region (19% of the total state household population)
     •   The South Central Region (27% of the total state household population)
     •   The Anchorage Region (42% of the total state household population)
     • The Southeast Region (12% of the total state household population)
The Behavioral Health Prevalence Estimates in Alaska report defined serious disorders for four
target groups, the sum of which is a total estimate of individuals with serious behavioral health
disorders in Alaska. Those groups include: youth with serious emotional disturbance (SED); adults
with serious mental illness only (SMI only); adults with substance use disorders only (SUD only);
and adults with co-occurring disorders mental health and substance abuse (COD). 10
Estimates compiled in this report were considered conservative because, as was noted in the
findings, data was collected by household and did not include those who are not currently residing in
households including homeless, seasonal workers, or who live in institutions such as prisons and
jails. Research and collateral information indicates that a high proportion of chronically homeless
and individuals who are incarcerated have mental health and/or substance abuse issues. A study
funded by the Alaska Mental Health Trust Authority (AMHTA) found that during a point in time
count conducted on June 2006, of the 3,628 people who were in the custody of one of Alaska’s



10
  Definitions of Serious Behavioral Health Disorders can be found on page 33 of the report.
http://www.hss.state.ak.us/DBH/perform_measure/PDF/200804_rept_prevalence.pdf



Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                    12
thirteen correctional institutions, 1,524 people (42 percent) constituted AMHTA Beneficiaries. 11
AMHTA beneficiaries include:
     •     People with Mental Illness
     •     People with Developmental Disabilities
     •     People with Chronic Alcoholism
    • People with Alzheimer’s Disease and Related Disorders
This count did not include those who were in custody and in community residential facilities or a
contract facility located in Arizona. As a result, it is reasonable to assume that the prevalence
estimates highlighted in the 2006 study are much lower than actual rates.
Data specific to the Prince of Wales- Outer Ketchikan Census area was not provided in the
Behavioral Health Prevalence Estimates in Alaska report, which focused instead on statewide totals
and the Southeast region as a whole.
The total household population in the State of Alaska is 647,901 with 69,295 households reported in
Southeast (12% of the state population). The study estimated that there are 51,430 households
statewide with serious behavioral health disorders (this includes all four categories mentioned
earlier). This equates to a 7.9% prevalence rate statewide. There are an estimated 5,192 households
in Southeast with serious behavioral health disorders. This equates to a 7.5% prevalence rate, slightly
lower than the statewide rate. The southeast region had the lowest prevalence numbers and
prevalence rate statewide (69,296 and 7.5% respectively). The following chart illustrates the
diagnostic group, prevalence estimate, household population and prevalence rate for the Southeast
region: 12

3.1 Serious Behavioral Health Disorders in Total Household by Region (Southeast region)
                                                           Household            Prevalence
 Diagnostic Group            Prevalence Estimate
                                                           Population           Rate

 Youth with SED              1,186                         16,506               7.2%

 Adults with:

         SMI Only            1,844                                              3.5%

         SUD Only            1,708                                              3.2%

         COD                 454                                                0.9%

         Adult Total         4,006                         52,789               7.6%

 Southeast Total             9,198                         69,295               7.5%




11
   “A Study of Trust Beneficiaries in the Alaska Department of Corrections” Hornby Zeller Associates, Inc.
December 2007.
12
   Census areas included in the Southeast region: Haines Borough; Juneau City and Borough; Ketchikan Gateway
Borough; Prince of Wales Island- Outer Ketchikan Census; Sitka City and Borough; Skagway-Hoonah-Angoon
Census Area; Wrangell-Petersburg Census Area; and Yakutat City and Borough.


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                 13
According to the Serious Behavioral Health Estimates report, prevalence rates for serious behavioral
health disorders are relatively constant between the four Alaskan regions described at the beginning
of this section.
General Mental Health Status
There are four school districts on POW: Craig City Schools; Hydaburg City Schools; Klawock City
Schools; Southeast Island Schools. Craig High School provided 2009 YRBS data and key findings
are provided below. Statewide YRBS data is used as comparison. The nationwide data set is not yet
available, so no comparisons can be made between responses from Craig High School and statewide
data. YRBS information was not available for the Hydaburg, Klawock or Southeast Island School
District. Both Southeast Island Schools and Klawock City Schools did not participate in the 2009
survey. The Hydaburg School District participated in the survey as part of a sample regional survey
conducted by SEARHC but does not have access to localized survey results.
YRBS Policy states that school districts that do not return more than 30 completed surveys will not
receive localized survey results (to ensure student confidentiality). Since Hydaburg does not have
greater than 30 students enrolled currently (of age to participate in th e YRBS), they do not receive
local survey results. Because of this, the results here represent one school and not all schools on
Prince of Wales Island. The following are statistics on general mental health status for youth
participating in YRBS survey. Data was collected and reported from Craig High School students and
is compared to statewide data.
     •   Nineteen (19.3%) percent of students reported feeling sad or hopeless almost every day for
         two weeks or more in a row that they stopped doing some usual activities during the past 12
         months; compared to twenty-five (25.2%) of Alaska youth statewide
     •   Eight (8.5%) percent of students seriously considered attempting suicide during the past 12
         months; compared to thirteen (13.9%) percent of Alaska youth statewide
     •
     Six (6.3%) percent of students attempted suicide one or more times during the past 12
     months; compared to eight (8.5%) of Alaska youth statewide
Consumption Patterns
Alcohol use, heavy drinking, and binge drinking among adults and youth have been historically
higher in Alaska when compared with the national average. 13 Youth Risk Behavior Survey (YRBS)
data shows that over the past twelve years, initial and episodic heavy drinking among Alaska youth
has been on a steady decline. 14 Although YBRS data is collected from a number of school districts
throughout the state, data is aggregated on a statewide basis and reported accordingly. Information
on illicit drug use is also included here. The following is a summary of findings based on 2007 YRBS
statewide data for students in grades 9-12:
     •   Seventy-three percent (73%) of students reported they had at least one drink of alcohol on
         one or more days during their life
     •   Twenty percent (20%) of students reported they had their first drink of alcohol other than a
         few sips before age 13 years


13
   “State Epidemiological Profile on Substance Use, Abuse, and Dependency.” Hull-Jilly DMC, Casto LD. Juneau,
Alaska: Section of Prevention and Early Intervention Services, Division of Behavioral Health, Alaska Department of
Health and Social Services, April 2008.
14
   Ibid. p 4.


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                  14
    •    Thirty-nine percent (39%) of students reported they had at least one drink of alcohol on one
         or more of the past 30 days
    •    Twenty-five percent (25%) of students reported they had five or more drinks of alcohol in a
         row, that is, within a couple of hours, on one or more of the past 30 days
    •    Twenty-three percent (23%) of students who reported they rode one or more times during
         the past 30 days in a car or other vehicle driven by someone who had been drinking
    •   Sixteen percent (16.5%) of high school seniors who drive, drove when they had been
        drinking alcohol.
The following is a summary of key findings from the 2009 YRBS data collected from Craig High
School with statewide comparison data included:
    •    Thirty percent (30%) of students has at least one drink of alcohol on one or more of the past
         30 days; compared to thirty-three (33.2%) of Alaska youth statewide
    •    Sixty-seven percent (67.9%) of students had at least one drink of alcohol on one or more
         days during their life; compared to sixty-six (66.6%) percent of Alaska youth statewide
    •    Thirty-six percent (36.8%) of students who used marijuana one or more times during their
         life; compared to forty-four (44.5% percent) of Alaska youth statewide.
    •    Seven percent (7%) of students who used any form of cocaine one or more times during
         their life; compared to (7.4%) of Alaska youth statewide
    •    Nine percent (9.6%) of students who sniffed glue, breathed the contents of aerosol spray
         cans, or inhaled any paints or sprays to get high one or more times during their life;
         compared to (9.8%) of Alaska youth statewide
    •    Five (5.5%) percent of students who used methamphetamines one or more times during
         their life; compared to (3.6%) of Alaska youth statewide
    •    Eight (8.2%) percent of students who used ecstasy one or more times during their life;
         compared to (7.1%) percent of Alaska youth statewide
    •    Twenty-two percent (22.1%) of students who have taken a prescription drug without a
         doctor’s prescription one or more times during their life; compared to (20.9%) of Alaska
         youth statewide




Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                      15
Adult consumption rates are captured through the Alaska Behavioral Risk Factor Survey. Risk
factors such as heavy drinking and binge drinking are reported for adults statewide. 15 Binge drinking
in Alaska had remained higher than the national rate for all ages over 18 years of age. 16 However, in
2008, BRFS data showed the prevalence of binge drinking was the same in Alaska as the U.S. In
2005, binge alcohol use was reported by 18% of Alaskan adults. 2008 BRFSS data is highlighted
below:
     •   Sixteen percent (16%) of Alaskan adults reported binge drinking in the past 30 days
     •   Over six percent (6.5%) of Alaskan adults reported heavy drinking in the past 30 days
     •   The prevalence of heavy drinking was slightly higher in Alaska than the U.S.
     •   Since 1991, overall prevalence of binge drinking appears to have decreased, but has remained
         relatively flat after 2003
Consequences of Substance Abuse
The following section offers a statistically based consideration of the negative impacts of substance
abuse in the following categories:
     •   Substance abuse and its relationship to leading causes of death
     •   Drinking and driving crashes
     •   Driving under the influence offenses
    • Assaults, Sexual Assault, and Domestic Violence
Data for this section was drawn from several State of Alaska sources (footnoted below). Where
possible, data reported in this section is specific to Prince of Wales Island with statewide data
provided for comparison. Where data specific to Prince of Wales Island is not available, data for the
Prince of Wales – Outer Ketchikan Census area is provided.
Leading Causes of Death
Alcohol abuse alone is associated with motor vehicle crashes, homicides, suicides, and drowning, all
leading causes of death among youth. Long-term heavy drinking can lead to heart disease, cancer,
alcohol-related liver disease, and pancreatitis. Of the ten leading causes of death in Alaska, all except
Alzheimer’s disease can be associated with substance abuse as a potential contributing cause of
death. Chronic liver disease and cirrhosis can be strongly associated with alcohol abuse. Chronic
lower respiratory disease (chronic obstructive pulmonary disease-COPD) and many cancers also
have strong association with tobacco use. Until recently, unintentional injury has been the third
leading cause of death in Alaska and has been identified as a major contributing factor for
recreational, home, and occupational injuries. 17 The following table shows the ten leading causes of
death in Alaska from 2001-2005.


15
    Heavy drinking is defined as: males having more than 2 drinks per day and females having more than 1 drink per
day in the past 30 days. Binge drinking is defined as: males having 5 or more drinks and females having 4 or more
drinks on at least one occasions in the past 30 days.
16
    “State Epidemiological Profile on Substance Use, Abuse, and Dependency.” Hull-Jilly DMC, Casto LD. Juneau,
Alaska: Section of Prevention and Early Intervention Services, Division of Behavioral Health, Alaska Department of
Health and Social Services, April 2008.
17
   “ Alaska Violent Death Reporting System 2003-2005” State of Alaska Department of Health and Social Services,
Division of Public Health. August 2008.


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                  16
3.2 Cause of Death Associated with Substance Abuse in Alaska, 2001-2005

                                                  POW-Outer                             Alaska
Cause of Death                                                          Percentage                    Percentage
                                                  Ketchikan                             Total

All Causes of Death                               142                   100%            15,409        100%

Alcohol Induced                                   9                     6%              586           4%

Drug Induced                                      1                     1%              420           3%

Unintentional Injury                              12                    8%              1,642         11%

Suicide                                           5                     4%              639           4%

Homicide                                          1                     1%              207           1%

Chronic Liver Disease + Cirrhosis                 5                     4%              285           2%



As the table above shows, from 2001-2005 in the Prince of Wales-Outer Ketchikan census area
there were a total of 142 deaths reported. The causes of death reported in the table below are all
classified by the State of Alaska, Division of Behavioral Health as being associated with substance
abuse including:
     •    Alcohol induced
     •    Drug induced
     •    Unintentional injury
     •    Suicide
     •    Homicide
    • Chronic Liver Disease and Cirrhosis
For deaths reported in this time period for the Prince of Wales – Outer Ketchikan census area,
twenty-three (23%) of all deaths were associated with substance abuse, slightly lower than the
statewide total (24%). 18
The highest rates of alcohol-induced death are found in rural Alaska. 19Causes of alcohol-induced
death included alcohol psychoses, alcohol dependence syndrome, non-dependent abuse of alcohol,
alcohol induced chronic liver disease and cirrhosis, and alcohol poisoning. From 2001-2005, the
Prince of Wales – Outer Ketchikan census area had nine (9) reported alcohol induced deaths (1.54%
of statewide total) and ranked 5th out of 27 Borough/census areas in Alaska, preceded by (1) Lake
and Peninsula; (2) Yukon-Koyukuk; (3) Nome; and (4) Southeast Fairbanks. 20 For the same period,
there was only one (1) drug induced death reported for the census area.



18
   “State Epidemiological Profile on Substance Use, Abuse, and Dependency.” Hull-Jilly DMC, Casto LD. Juneau,
Alaska: Section of Prevention and Early Intervention Services, Division of Behavioral Health, Alaska Department of
Health and Social Services, April 2008.
19
   Ibid pg. 28
20
   Ibid pg. 29. Rates are per 100,000 population, age adjusted to the year 2000 US standard population. Disclaimer:
rates based on fewer than 20 events are statistically unreliable and should be used with caution.


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                   17
In addition to death, alcohol and illicit drug use are associated with child and spousal abuse; sexually
transmitted diseases, including HIV infection; teen pregnancy; school failure; motor vehicle crashes;
escalation of health care costs; low worker productivity; and homelessness. Alcohol and illicit drug
use also can result in substantial disruptions in family, work, and personal life. Data to illustrate the
consequences of substance abuse on POW are included in the sections below.
Drinking and Driving Crashes
Data reported for this section is specific to Prince of Wales Island and is drawn from data collected
by the State of Alaska, Department of Transportation and Public Facilities (ADOT/PF).
ADOT/PF data shows that during a 5-year period, from 2003-2007; there were 130 automobile
crashes on POW. Of those 130 crashes, there were 13 (or 10%) that involved alcohol. This is slightly
higher than the statewide rate which varied between 6-7% per year from 2003-2008. 21 There may
have been additional crashes involving alcohol, however, only those where law enforcement became
involved are reported.
Driving Under the Influence – Offenses
According to the State of Alaska, Department of Public Safety, the number of Driving Under the
Influence (DUI) offenses on POW have remained relatively consistent from 2004-2008, with 8-10
cases per year. The exception was in 2006 with three (3) DUI cases. There were a total of 39 DUI
cases from 2004-2008.
Assaults, Sexual Assault and Domestic Violence
Binge drinking is associated with many intentional injuries including assault, sexual assault, and
domestic violence. 22 The U.S. Department of Justice, Bureau of Justice Statistics found that “two-
thirds of victims who suffered violence by an intimate (a current or former spouse, boyfriend, or
girlfriend) partner reported that alcohol had been a factor. Among spouse victims, 3 out of 4
incidents were reported to have involved an offender who had been drinking. By contrast, an
estimated 31% of stranger victimizations where the victim could determine the absence or presence
of alcohol were perceived to be alcohol-related.” 23
State data included here is limited to reported assaults and domestic violence incidences where drugs
and alcohol were shown to be involved. According to a survey conducted by the National Institute
of Justice, most intimate partner victimizations are not reported to the police. Approximately one-
fifth of all rapes, one quarter of all physical assaults, and one-half of all stalkings perpetrated against
female respondents were reported to the police. The majority of victims who did not report their
victimization to the police thought that the police could not or would not do anything on their
behalf. These findings suggested that most victims of intimate partner violence do not consider the
justice system an appropriate vehicle for resolving conflicts with intimates. 24 Thus, data provided
here is meant to provide an estimate of the prevalence of intimate partner violence and assaults, with
the acknowledgement that many cases go unreported each year.

21
  2003-2008 Statewide Crash Data; Total crashes and Alcohol-involved crashes: State of Alaska, Department of
Transportation and Public Facilities.
22
   Centers for Disease Control and Prevention. “Alcohol and Public Health—Binge
Drinking.”http://www.cdc.gov/alcohol/quickstats/binge_drinking.htm
23
   U.S. Department of Justice, Bureau of Justice Statistics. “Crime Characteristics—Summary Findings.”
http://www.ojp.gov/bjs/cvict_c.htm#findings
24
   US Department of Justice, Office of Justice Programs, National Institute of Justice. Extent, Nature, and
Consequences of Intimate Partner Violence. Findings from the National Violence Against Women Survey.


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                 18
The State of Alaska, Department of Public Safety’s data shows that between the years of 2004-2008
there were a total of 95 assaults reported on POW, which include sexual assaults that were alcohol
or drug related. The total offenses reported have remained somewhat consistent between years, with
the exception of 2005 and 2006 where there were an increased number of offenses (25 and 22
respectively). The number of reported offenses decreased in 2007 and 2008 (16 and 17 respectively).
Domestic Violence where drugs or alcohol were involved has increased over the years, from 7
offenses to 10 in 2008. Similar to the number of assault offenses, domestic violence offenses, where
drugs or alcohol was related, were highest in 2005. Please note that data reported by the Department
of Public Safety does not include information for the following Prince of Wales Island communities:
     • Edna Bay
     • Point Baker
     • Port Protection
     • Whale Pass




Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                    19
3.3 Prince of Wales Island Reported Assaults and Domestic Violence, 2004-2008

                  2008                                                          Case Year
                                                                                                                           Grand
Community         Pop.       Crime Type
                                                                                2004   2005      2006   2007   2008        Total
                  Est.*

                             Assaults (includes sexual assaults) drug or
Coffman                                                                            2        2       3                          7
                      141    alcohol related
Cove
                             Domestic violence with drugs and alcohol              1        2                                  3
Total (Coffman Cove)                                                               3        4       3      0      0           10
                             Assaults (includes sexual assaults) drug or
                                                                                                    1      1      2            4
Craig              1,117     alcohol related
                             Domestic violence with drugs and alcohol                               1      1      1            3
Total (Craig)                                                                      0        0       2      2      3            7
                             Assaults (includes sexual assaults) drug or
                                                                                                    2      1                   3
Hollis               172     alcohol related
                             Domestic violence with drugs and alcohol                               1      2                   3
Total (Hollis)                                                                     0        0       3      3      0            6
                             Assaults (includes sexual assaults) drug or
                                                                                   8        15      8      8      8           47
Hydaburg              341    alcohol related
                             Domestic violence with drugs and alcohol              4        6       6      4      6           26
Total (Hydaburg)                                                                  12        21     14     12     14           73
                             Assaults (includes sexual assaults) drug or
                                                                                            1       1                          2
Kasaan                 54    alcohol related
                             Domestic violence with drugs and alcohol                       1       1                          2
Total (Kasaan)                                                                     0        2       2      0      0            4
                             Assaults (includes sexual assaults) drug or
                                                                                   2        1       1             1            5
Klawock              785     alcohol related
                             Domestic violence with drugs and alcohol              1        1                                  2
Total (Klawock)                                                                    3        2       1      0      1            7
                             Assaults (includes sexual assaults) drug or
                                                                                                    2      3      2            7
Naukati              124     alcohol related
                             Domestic violence with drugs and alcohol                                      1                   1
Total (Naukati)                                                                    0        0       2      4      2            8
                             Assaults (includes sexual assaults) drug or
                                                                                   3        6       4      3      4           20
Thorne Bay           440     alcohol related
                             Domestic violence with drugs and alcohol              1        3       1      1      3            9
Total (Thorne Bay)                                                                 4        9       5      4      7           29
*State of Alaska, Department of Commerce Community and Economic Development



Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                        20
Juvenile Involvement with Criminal Justice System
The Division of Juvenile Justice (DJJ) reports on the number of youth who are involved with DJJ,
the number of referrals from other law enforcement agencies, 25 charge types for each region and
office in the state. The following data are collected and reported from 2004-2008 for the Division of
Juvenile Justice Prince of Wales Island Office:

3.4 Juveniles, Referrals, and Charges for each Region and Office
 Year         Juveniles       Referrals        Charges

 2008                  23                31             67

 2007                  18                26             51

 2006                  30                36             62

 2005                  24                33             50

 2004                  34                53             82


Juveniles refer to the number of unique juveniles who were referred to DJJ during the fiscal year.
Some juveniles were referred multiple times within the year. All arrests, investigations, or violation
of court orders involving juveniles (defined as under 18 years of age) are required to go through the
DJ J office. Referrals refer to the number of referrals (or requests) that came to DJJ from law
enforcement agencies. The number of charges refers to the general category of the offense. The
referral is considered a single event but may include multiple charges. Each juvenile should not be
viewed as a single unduplicated count as some juveniles may have been referred more than once
within a year or over multiple years.
3.5 Number of Charges by Type for each Region and Office (Referrals) FY 2004-2008
                                                        Against
                 Against             Against                           Drug +
 Year                                                   Public                       Weapon       Misc.          Total
                 Persons            Property                           Alcohol
                                                        Order

 2008                        8                  13                 3             2            0           5             31

 2007                        6                  29                 4             2            0           10            51

 2006                       12                  16                 1             2            0           5             36

 2005                       16                  34                 1             8            0           2             61

 2004                       19                  37                 4             5            1           16            82

In 2002, the State of Alaska reported that during a one-day count of Alaska’s juvenile justice
population completed during 2002, 40% of youth served by the Division of Juvenile Justice had at
least one diagnosis of a mental disorder classified by the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). Within this group 42% had a co-occurring substance abuse disorder. 26

25
   A request by a law enforcement agency for a DJJ response following the arrest of a juvenile or as a result of the
submission of a police investigation report alleging the commission of a crime or violation of a court order.
26
   State of Alaska, DHHS Women’s Children’s and Family Health “Title V Needs Assessment: Special Series Fact


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                                     21
Child Abuse and Neglect
The relationship between parental alcohol or other drug problems and child maltreatment is
becoming increasingly evident. In a national study, among confirmed cases of child maltreatment,
40% involve the use of alcohol or other drugs. 27 The State of Alaska, Office of Children’s Services
(OCS) collects data on children and families referred for child protective services and on providers
for out-of-home placements. The “Southeast not Juneau” region encompasses communities around
four “hubs” which include Craig, Ketchikan, Petersburg, and Sitka. Due to confidentiality and small
community size, OCS would not provide data specific to POW. In addition, they do not currently
track whether alcohol and/or other drugs were a factor in the referral or substantiated claim. Data
from 2006-2008 seem to indicate that the number of total victims of one or more substantiated
allegation of abuse and/or neglect is increasing.
3.6 Total Allegations Substantiated in CY 2008
                                              Physical          Sexual           Mental     Total
 Area                         Neglect          Abuse            Abuse            Injury    Victims

 Anchorage                        1,402                232              61           129     2,640

 Fairbanks                         231                   50             25            66      372

 Northern                          251                   35             25           128      439

 Kenai Peninsula                   178                   42              6           146      372

 South Central                     269                   40             36           131      476

 South West                        376                   48             11           217      652

 Juneau                              99                  28              5            14      146

 South East not Juneau               98                  14              3            53      168

 Total Allegations                2868                 488            172            878     5265




Sheet.” April 2005.
27
   Prevent Child Abuse America. “The Relationship between Parental Alcohol, Drug Abuse and Child Maltreatment
Study Number: 14.”


Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                            22
3.7 Total Allegations Substantiated in CY 2007
                                                 Physical        Sexual          Mental     Total
 Area                            Neglect          Abuse          Abuse           Injury    Victims

 Anchorage                             648              112             34           112      906

 Fairbanks                             207                  42            9          125      383

 Northern                              252                  51          19            78      400

 Kenai Peninsula                       164                  30          16            96      306

 South Central                         243                  32          31           129      435

 South West                            366                  49          12           163      590

 Juneau                                107                  14            4           66      191

 South East not Juneau                  88                  13            2           56      159

 Total Allegations                  2,047               342           126            823     3,370



3.8 Total Allegations Substantiated in CY 2006
                                                 Physical        Sexual          Mental     Total
 Area                            Neglect          Abuse          Abuse           Injury    Victims

 Anchorage                             718              178             60           360     1,316

 Fairbanks                             255                  69          17           199      540

 Northern                              249                  30          17            94      390

 Kenai Peninsula                       227                  42          25           110      404

 South Central                         250                  63          21           173      507

 South West                            307                  55          16           154      532

 Juneau                                 78                  6             4           28      116

 South East not Juneau                  63                  24            7           42      136

 Total Allegations                  2,126               466           167          1,156     3,941




Prince of Wales BHS:: Needs Assessment Report :: 3. Population + Health Status                       23
4 :: BEHAVIORAL HEALTH SERVICE DELIVERY
SYSTEM DESCRIPTION

Primary care facilities on Prince of Wales Island are located in Hydaburg, Klawock, Craig, Kasaan
and Thorne Bay. The Peace Health Medical Group operates the Peace Health Medical Group –
Prince of Wales clinic with one physician. There are visiting specialists on an itinerant basis.
Construction on this facility was completed in 2010.
Southeast Alaska Regional Health Consortium (SEARHC), a non-profit tribal health organization,
provides both medical and behavioral health care services to residents on POW. SEARHC operates
the Alicia Roberts Medical Center (ARMC) located in Klawock which is designated as a federally
qualified health center (FQHC) and receives grants under Section 330 of the Public Health Service
Act to provide care to underserved populations. According to the Indian Health Service’s
population report, in 2008 there were 1,355 active users of the Tribal healthcare facilities on POW.
There was a 257 person increase in users from 2007. In addition to Alaska Native users, there are
2,285 non-native active users. 28
Additional primary care facilities/services on the island include: the Thorne Bay Health Center, the
Hydaburg Clinic, the Kasaan Health Center, which are all operated by SEARHC; and Craig Public
Health, operated by the State of Alaska. Alaska Island Community Service’s health center, located in
Wrangell, also serves the communities located on the North side of the island (Coffman Cove,
Naukati, Whale Pass, Port Protection, Point Baker, and Edna Bay) on an itinerant basis.
Behavioral health services available on POW are limited. Currently, three agencies provide
behavioral health services. A more detailed discussion of the services available and the organizations
serving those with behavioral health issues is included below.




28
 Alaska 2008 Native “IHS Active User Population Report” 12/10/08. (Active users are described as those who’ve
made at least one visit between 10/1/05-9/30/08).


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   24
4.1 Definition of Behavioral Health + Service Definitions
Behavioral health services are defined as health care services provided for the prevention or
treatment of mental health or substance abuse disorders and that are delivered along a continuum of
care from least intensive to most intensive, with services such as community prevention and
education on the “least intensive” side of the continuum and inpatient services being the “most
intensive.”
The State of Alaska Department of Health and Social Services (DHSS) and the Divisions of
Behavioral Health (DBH) and Public Health (DPH) have drafted a description of the continuum of
care related to behavioral health services. Services along the continuum range from programs and
services at the community level (least intensive) to those more appropriately provided in the regional
“hub” community (more intensive or needing a minimum number of clients to make a viable
program) to those concentrated in the urban centers (most intensive). Working definitions of the
eight major program definitions are shown below. 29

1. Community Prevention/Education: Community interventions and education that ward off the
initial onset of a mental disorder or emotional or behavioral problem. Community
prevention/education examples include: peer/consumer and client support services; community
education; advocacy/self-help; and prevention.

2. Outreach: Facilitates entry into treatment or meets the individual within their community, job,
home or school setting to engage in treatment or support services.

3. Assessment: A face-to-face, computer-assisted, or telephone interview with the person served to
collect information related to his or her history and needs, preferences, strengths, and abilities in
order to determine the diagnosis, appropriate services, and/or referral. The type of assessment that
is performed is determined by the level of entry into services and the qualification of staff delivering
the service. Assessment types include:
       •   Intake Assessment
       •   Psychiatric Assessment
       •   Psychological Assessment
       •   Neuro-psychological Testing
       •   Evaluation

4. Outpatient (Clinic-Based) Services: Refers to a range of facility-based behavioral health services
that can include assessment, individual, family, and group therapy.

5. Rehabilitation and Recovery Services: Refers to a range of services that are available to clients
who meet criteria based on levels of functioning in multiple spheres. Services can include a
functional assessment, case management, individual/family/group skill development, and recipient
support services. Recovery is a treatment philosophy that provides the framework of service
delivery. A recovery model offers hope that the restoration of a meaningful life is possible and
achievable.

29
     Comprehensive Integrated Mental Health Plan


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   25
6. Residential Services: Refers to a licensed 24 hour facility (not licensed as a hospital) which offers
behavioral health services; settings ranges from highly structured, resembling psychiatric treatment
centers, to those that are more like group homes or halfway houses; therapeutic foster care and
foster care. Respite, foster homes, emergency foster care, semi-independent living, therapeutic foster
care, family teaching homes, crisis beds, board and care homes, therapeutic group homes, staff-
secure crisis/respite group homes, residential case management specialized drug/alcohol,
evaluation/treatment, nursing homes, pioneer homes, specialized vocational rehabilitation.

7. Medical Services: Refers to a range of behavioral health services that are delivered by trained
medical staff, and can include psychiatric assessment and pharmacological management.

8. Detoxification Services: Detoxification is a process involving multiple procedures for alleviating
the short-term symptoms of withdrawal from drug dependence. There are three detox models:

    1.    Social Detox: This is a model of detoxification that may or may not require medication, and
          allows the client to withdraw from abused chemicals in a safe environment.
    2.    Outpatient Detox: The client is at minimal risk of severe withdrawal that requires moderate
          levels of medication and monitoring.
    3.    Inpatient Medical Detox: This level of detoxification provides the highest level of monitoring.
          Placement criteria are defined by the presence of high risk factors for complicated
          withdrawal: high risk biomedical complications, psychiatric or behavioral complications.

9. Emergency Services: are provided in a crisis situation during an acute episode of a mental,
emotional or behavioral disorder. Emergency services are intended to reduce the symptoms of the
disorder; prevent harm to the recipient or others; prevent further relapse or deterioration of the
recipient’s condition; or stabilize the recipient.

10. Inpatient Services: Inpatient hospitalization is the most restrictive type of care in the continuum
of behavioral health services; it focuses on ameliorating the risk of danger to self or others in those
circumstances in which dangerous behavior is associated with mental disorder. Examples include
facility-based crisis respite, community hospitals, Detox beds, Alaska Psychiatric Institute, geriatric
mental health, and assessment/treatment facility.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   26
4.2 Inventory of existing programs and services
Prince of Wales Island services are most concentrated in the hub communities of Craig and
Klawock, with lower levels of care and/or itinerant services available in most of the smaller
communities on the island. According to questionnaire responses given by local providers, service
types provided on the island include:
    •    Community prevention/education
    •    Outreach
    •    Assessment
    •    Outpatient services including:
            o Early intervention services
            o Outpatient services
    •    Medical services
    •    Emergency services

The following behavioral health related services were reported by respondents as not currently
delivered on Prince of Wales Island:
    •    Outpatient services including:
            o Intensive outpatient
    •    Residential substance abuse treatment (adult)
    •    Residential substance abuse treatment (under 17)
    •    Detoxification services including:
            o Social detox
            o Outpatient detox
            o Inpatient medical detox




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   27
Primary behavioral health service providers
There are three primary behavioral health service providers operating on Prince of Wales Island:
    •    Southeast Alaska Regional Health Consortium (SEARHC)
    •    Community Connections; and
    •    Alaska Island Community Services (AICS).

Southeast Alaska Regional Health Consortium (SEARHC)
SEARHC provides mental health counseling and substance abuse treatment to the Alaska Native
population residing on Prince of Wales Island and also mental health counseling and substance
abuse treatment services to the adult population residing in the communities of Thorne Bay, Kasaan,
Hollis, Hydaburg, Craig and Klawock.

Community Connections
This agency provides mental health counseling services to youth residing on Prince of Wales Island.
Community Connections has four distinct programs that contribute to the health and wellness of
island residents. Community Connections Programs include:
Early Learning Program: Services for families of children aged birth to three years with developmental
delays or who are “at risk” of developing delays. Services are designed to assist families in
supporting their child’s development. Services may include: speech, physical and occupational
therapy, specialized instruction and service coordination. Individualized speech therapy is also
available for children ages three and older.
Children’s Mental Health Services: Comprehensive mental health services for children and their families.
These services provide a broad range of interventions and supports to children and families in the
home and community. Available services include; psychological assessments, individual, family or
group counseling and intensive experiential skill building in group, individual and family settings.
Developmental Disabilities Services: Services are designed to assist people with developmental disabilities
and their families to achieve their life goals. Through partnerships with the individuals and families
served, a customized plan for services is developed that is aimed at supporting each individual’s
ability to live, work, and learn to their fullest potential. Services are provided wherever the person
chooses to reside, socialize, recreate, or work.
Older Alaskans and Adult Resource Services (O.A.R.S.): This program provides individualized services for
adults and seniors who require assistance to remain at home or in their community of choice.
Individualized plans are designed to meet goals for living with dignity. Services may include; respite
care, chore services, care coordination, transportation and personal care services.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   28
Alaska Island Community Services (AICS)
AICS offers a number of different programs to Prince of Wales residents:
Behavioral Health Services: The behavioral health program is composed of five components: 1)
Emergency mental health services, 2) Services to Adults with Severe and persistent Mental
Disorders, 3) Services to Severely Emotionally Disturbed Youth, 4) Substance Abuse Services which
involve individual and group counseling, Substance Abuse Education School, and Case
Management, and 5) All other adult, youth, and family problems that can be treated with prevention,
therapeutic techniques, and education.
Project CHOICE and Senior In Home Services: CHOICE (Community and Home Options to
Institutional Care for Everyone) offers alternatives to people who otherwise would have to be in a
nursing home. Various programs enable seniors and people with disabilities to remain in their own
homes. CHOICE is based on the philosophy that older citizens are entitled to enjoy their later years
in health, honor and dignity and that disabled citizens are entitled to live lives of maximum freedom
and independence. Senior In-home Services is a grant based program that provides these same
CHOICES services to individuals who may not qualify for Medicaid assistance.
FLOAT Project: (Float Learning Opportunity + Academic Triumph) is a collaborative effort with
five school districts (Wrangell, Klawock, Craig, Metlakatla, and Southeast Island), funded by a
federal grant, that aims to offer:
    •    Extended Learning Opportunities for Native students through individual and group
         remediation for academically at-risk students. A certified teacher is dedicated to this project
         in each school district;
    •    Drop-out Prevention and Parenting Education. AICS hires a support worker in each
         community that coordinates with the FLOAT teacher to provide services within the school,
         community and home environments; and
    •    A ten-day intensive multi-disciplinary learning experience based on a floating marine
         research station in the wilderness.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   29
Following is a description of the services that are available on the island, organized into the “service
type” categories described above.
Community Prevention/Education Services
Many organizations on Prince of Wales Island provide programs and services that fall within the
spectrum of community prevention/education services related to behavioral health. Programs that
fall within this category encourage and reinforce healthy lifestyles, inform good decision making,
help connect individuals to community and culture.
    •    The Klawock Cooperative Association (federally recognized Tribe) currently operates a Tribal
         Youth program where local youth particpate in cultural activities as a way of increasing
         cultural connectivity, community and family connectivity and increasing protective factors.
         The program is funded through a grant from the Office of Juvenile Justice and Delinquency
         Prevention. Tribal Youth program participants learn the following:
             o Clan history and genealogy through an on-going dialogue with local elders and
                 immediate family members; mother, father, aunts, and uncles
             o Heenya Kwan clans (clans specific to Klawock)
             o Tlingit words and phrases
             o Traditional drumming, song, and dance
             o Identifying, gathering, and preparing local traditional subsistence foods and
                 traditional medicinal plants
             o Making a variety of traditional Native regalia: dance blankets, drums, moccasins,
                 dance aprons, deer antler rattles, devils club beads, gather and prepare cedar bark for
                 weaving
             o Paddle a thirty seven foot traditional canoe
             o How to create and run a Tribal Youth Council
             As of Spring 2010, the Klawock Tribal Youth program had a total of forty participants
             and had expanded services to include evening classes at the Prince of Peace Church in
             Klawock two nights a week for a total of six hours of instruction. Participants in this
             group are primarily made up of families. Two elders have joined the evening class and
             offer their expertise in regalia making.
    •    Helping Ourselves Prevent Emergencies (HOPE) is a local organization that offers domestic
         violence and sexual assault advocacy and education. HOPE provides education, training and
         referral services. Since its establishment in 2008, HOPE has provided training to increase
         awareness of law enforcement staff, service providers and the local court system staff on
         issues related to domestic violence and sexual assault. HOPE volunteers regualarly take part
         in community events to raise awareness, talk with community members about HOPE’s
         services and mission, and help sponsor healthy family events.
    •    Craig Police Department offers Drug Abuse Resistance Education (D.A.R.E) classes to local
         schools. D.A.R.E. is a police officer-led series of classroom lessons that teaches children
         from kindergarten through 12th grade how to resist peer pressure and live productive drug
         and violence-free lives.
    •     Craig Public Health provides general information to primary care patients on behavioral
         health awareness, resources available to treat behavioral health related issues and provides
         referrals to local behavioral health service providers.
    •    Southeast Alaska Regional Health Consortium (SEARHC) provides behavioral health
         education to local schools upon request and convenes a variety of support groups.


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   30
    •  Alaska Island Community Services(AICS) is developing a comprehensive evidence-based
       tobacco control program to address tobacco use in Wrangell and Northern Prince of Wales
       Island. AICS is working to develop this program to further the State of Alaska Tobacco
       Cessation Interventions (TCI) objective to “Develop and implement a comprehensive
       cessation intervention for addressing tobacco use within the health care system.” The long-
       term goal of AICS TCI is to reduce the prevalence of tobacco use in health care center
       populations throughout our communities.
   • The Prince of Wales Interagency Group is a coalition of service providers and community
       members from around the island that meet on a monthly basis to discuss issues related to
       community health and wellness, increase connectivity between providers and community
       members, help to organize informational events, and help to dissemanate information.
   • The Klawock Coalition was established by concerned community members to address
       underage drinking in Klawock in 2006. Through group process, the coalition decides on
       priority issues to work on in the community. The coalition acts as an advisory board to the
       Tribal Youth Program director (program described above).
   • Prince of Wales Emergency Resources (POWER) is a local non-profit organization provides
       fuel assistance applications for households in need, a food bank and second hand clothing
       and household items.
   • Alcoholics Anonymous/Narcotics Anonymous AA is currently available two nights per
       week in Craig. NA is currently available one night per week in Craig. Additionally, AA/NA
       is available one night per week in Naukati.
Fewer organizations offer services under the remaining service categories, as “higher” levels of
behavioral health care offer more behavioral health treatment and support.

Outreach
    • Community Connections conducts outreach for its programs in a variety of ways – through radio
      and newspaper, also through referral from community members; community service
      providers such as medical providers and schools; and through participating in community
      organizations such as the Interagnecy Group and in community events such as health fairs
      and other wellness related events.
   • Southeast Alaska Regional Health Consortium (SEARHC) outreach efforts rely on much the
      same methods as reported for Community Connections – through media such as radio and
      newspaper; also through referral from community members; community service providers
      such as medical providers and schools; and through participating in community
      organizations such as the Interagnecy Group and in community events such as health fairs
      and other wellness related events.
   • Alaska Island Community Services (AICS) outreach efforts include media such as the local
      newspaper, through referrals from primary health care providers and through taking part in
      events such as health fairs and other wellness related events.
Assessment
    Each of the behavioral health providers currently operating on the island, SEARHC,
      Community Connections, and AICS provide assessment services for their clients.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   31
Outpatient Services
Outpatient mental health and substance abuse services are provided by all three behavioral health
service providers currently operating on Prince of Wales Island.
       • SEARHC services are offered in several locations, with staff available for treatment at the
         Alicia Roberts Medical Center in Klawock and with a second office newly opened in Craig.
         Itinerant staff also provide services through the Hydaburg clinic with visits to the
         community one day per week. SEARHC offers substance abuse treatment to individuals
         who have been mandated by the court system to complete treatment due to a sustance abuse
         related legal issue and to self-referrals.
         Patients on Prince of Wales Island who need behavioral health services can also access
         SEARHC psychiatrists, psychologists and mental health therapists based at Sitka’s Haa
         Toowóo Náakw Hít outpatient behavioral health clinic in Sitka through SEARHC’s nationally
         recognized tele-behavioral health program. This is a secure videoconferencing connection
         that connects the patient on Prince of Wales Island to a behavioral health provider in Sitka,
         allowing a private face-to-face visit. SEARHC offers the tele-behavioral health service to its
         patients on Prince of Wales, but they may need to travel to Klawock, Hydaburg or one of
         our other clinics in order to access the videoconferencing equipment.
     • Community Connections offers children’s mental health services including assessment,
         individual, and family counseling. For at risk children, community/school mental health
         associates provide individual, group, and family skill building activities. A psychiatrist is
         available and provides tele-psychiatry in cases requiring a pharmacological intervention.
     • AICS provides mental health counseling, substance abuse treatment, and psychiatric
         emergency services to Prince of Wales Island residents living in the following communities:
         Coffman Cove, Edna Bay, Naukati Bay, Point Baker, Port Protection, Whale Pass. Though
         still in the development stages, these services will be offered via tele-behavioral health
         technology and through itinerant service.
     • Southeast Island School District (SISD) has a newly hired counselor to serve the school
         population in the communities they serve including Hollis, Coffman Cove, Kasaan, Thorne
         Bay, Naukati Bay.
As mentioned above, no local provider currently provides intensive outpatient services. Intensive
outpatient services are defined as intermediate level of behavioral health care where individuals are
seen as a group 2 to 5 times a week (depending on the structure of the program) for two to three
hours at a time. The clinical work is primarily done in a group setting, with individual sessions
scheduled periodically outside group hours. Groups are led by a least one clinician. These programs
tend to focus on a target group such as addictions, borderline personality disorders, eating disorders,
self-injury, chronic mental illness, as well as others. This can be “step-down treatment” from a
higher or more restrictive level of care, or can be an appropriate level of care to provide intensive
intervention. 30
Rehabilitation and Recovery Services
No recovery support services are currently offered on Prince of Wales Island.




30
     Source: Erin Johnston, L.C.S.W.


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   32
Residential Services
At this time, Community Connections offers therapeutic foster care as part of the individualized
services created for at-risk children. Foster parents who are licensed by the State of Alaska are
provided with clinical direction from the licensed clinicians of Community Connections. Children
with co-occurring disorders are provided early intervention services and psycho-educational
materials and counseling related to substance abuse. Community Connections currently has seven
beds established on Prince of Wales for youth needing therapeutic foster care.
Residential services are not provided by other agencies on-site on Prince of Wales Island. In
addition, residential substance abuse treatment is not available on Prince of Wales Island. However,
SEARHC and AICS offer residential programs based in other communities that Prince of Wales
Island residents can be referred to for treatment. SEARHC’s Sitka campus has three residential
substance abuse treatment programs: Bill Brady Healing Center for adults, Déilee Hít – Safe Harbor
program for women with children, and Raven’s Way, an adolescent residential treatment program.
Additionally, AICS offers the Crossings Wilderness Expeditions for Youth program, which is a 49
day experiential program for children dealing with mental health issues. The program is based in
Wrangell.
Medical Services
    •  Community Connections offers psychiatric assessment and on-going medication management
       through tele-psychiatry.
   • SEARHC offers psychiatric and counseling services are available via its tele-behavioral
       health network.
   • AICS plans to offer psychiatric assessment and on-going medication management through
       tele-psychiatry. As of spring 2010, they were testing connectivity with their psychiatrist and
       working towards offering this service.
Detoxification Services
No detoxification services are currently offered on Prince of Wales Island. The island has no safe
place to hold individuals who are in need of detoxification services. The responsibility of providing
detox services usually upon primary care providers who do not have the training or resources to
adequately respond to the demand for this service.
Emergency Services
    •    AICS plans to provide behavioral health emergency services to Prince of Wales Island
         residents living in communities located on the Northern side of the island. As of spring
         2010, AICS has provided telephone support in crisis situations. When tele-medicine services
         are established in each community, they hope to be able to do assessments. In greater
         emergencies, AICS staff will make a special trip to stabilize the situation.
    •    The SEARHC Behavioral Health Division has contracted with a crisis call center to provide
         help for Southeast Alaska residents. The SEARHC Help Line is available 24 hours a day,
         seven days a week, and it will be staffed with a team of master’s-degree-level mental health
         therapists. The counselors will assess the situation and provide appropriate intervention
         using protocols developed with SEARHC Behavioral Health. Follow-up calls from
         SEARHC Behavioral Health or partner agencies will be made the next business day.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   33
Since there is no organization providing emergency behavioral health services other than those
services described above, emergency services in cases of behavioral health crisis are often provided
by primary care providers such as Alicia Roberts Medical Center, Craig Medical Clinic and clinic
facilities/EMS providers in smaller communities. On-island primary care staff have reported that
this places a heavy burden on medical staff who are not trained in providing psychiatric emergency
care and do not have adequate facilities to provide this service. See Section 4.4 Gaps + Barriers to
Service Delivery for more discussion of behavioral health emergency services on Prince of Wales
Island.
Inpatient Services
No inpatient services are currently offered on Prince of Wales Island.
The following matrix provides information about services provided by the three behavioral health
providers serving Prince of Wales Island including: Community Connections, SEARHC, and Alaska
Island Community Services.
4.1 Service Continuum Matrix
                                            *Community                    SEARHC                      Alaska Island
                                            Connections:             (Coffman Cove, Craig,        Community Services
                                         (Coffman Cove, Craig,          Edna Bay, Hollis,          (Coffman Cove, Edna
                                           Hollis, Hydaburg,           Hydaburg, Kasaan,          Bay, Naukati Bay, Point
                                         Klawock, Naukati Bay,       Klawock, Naukati Bay,        Baker, Port Protection,
 Services Matrix                              Thorne Bay)           Thorne Bay, Whale Pass)            Whale Pass)
 Community
                                                    X                            X                          X
 Prevention/Education
 Outreach                                           X                            X                          X
 Assessment                                         X                            X                          X
 Outpatient Mental Health
                                                    X                            X                          X
 Services
 Outpatient Services –
 Substance Abuse
        Level .5 (Early Intervention)               X                            X                          X
                Level 1 (Outpatient)                                             X                          X
   Level 11.1 (Intensive Outpatient)        Not Available
 Residential Substance Abuse
                                            Not Available
 Treatment Services
 Medical Services                           Not Available
 Rehabilitation and Recovery
                                            Not Available
 Services
 Detoxification Services -                  Not Available
                        Social Detox
                   Outpatient Detox
            Inpatient Medical Detox
 Emergency Services                                                                                         X
 * Community Connections provides services to youth.



Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description              34
Future Programs
Service providers who responded to the community questionnaire circulated on Prince of Wales
Island described the following behavioral health programs currently in development:
       •   Tele-medicine and tele-behavioral health – AICS is currently developing a tele-medicine
           system that will be used to provide behavioral health services to clients in communities
           located on the northern part of Prince of Wales Island including: Coffman Cove, Edna Bay,
           Naukati Bay, Point Baker, Port Protection, Whale Pass
       •   The Southeast Island School District has a newly hired counselor to serve the school
           population in the communities they serve including Hollis, Coffman Cove, Kasaan, Thorne
           Bay, Naukati.
       •   HOPE has started to provide advocacy for domestic violence and sexual assault, including a
           paid advocate 20 hours per week with volunteer advocates to supplement this service. More
           paid advocates are needed. HOPE works in collaboration with WISH in Ketchikan, which
           provides training to volunteer advocates and provides a 24 hour emergency hotline. HOPE
           requires funding for staff and operations. Safe housing options are currently available for 1-2
           nights on-island. For individuals who need housing of longer durations, they must go off-
           island to receive services and housing supports.


4.3 Current Utilization of Behavioral Health Services
As previously mentioned there are three main providers of behavioral health services for POW –
Community Connections (serving youth); SEARHC (serving adults); and Alaska Island Community
Services (providing services to residents located in northern communities on the island). Previously,
COHO reported providing services to between 20-57 individuals annually. As mentioned earlier in
this report, COHO is no longer offering services to Prince of Wales Island.
The chart below highlights COHO’s census during Fiscal Years 2008 and 2009. 31 Numbers reported
here are drawn from data reported to the State of Alaska, Behavioral Health as part of grant
reporting required for State of Alaska, Substance Abuse Treatment grant. Information on whether
these numbers represent the total number of clients served by COHO or represent only the clients
served under the Treatment grant is not available.


4.2 COHO Census, 2007-2008
                                                        July 1, 2007-June 30, 2008           July 1, 2008-Dec. 31, 2008
Target population served
                                                         number of clients served             number of clients served

Substance Abuse clients served                                                      42                              57

Substance Abuse new admissions                                                      16                              40

Seriously Emotionally Disturbed youth (SED)                                         12                              23

Seriously Mentally Ill adults (SMI)                                                 13                              21




31
     Please note that the State’s Fiscal Year begins July 1st each year and ends June 30th


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description             35
The Division of Behavioral Health collects data on numbers of clients currently using behavioral
health services per behavioral health provider that have received grants from the State to offer
behavioral health services. In FY 2007, data collected by the State showed that SEARHC had a total
unduplicated client count on Prince of Wales Island of 124 clients receiving mental health and
substance abuse services. In FY 2008, utilization data shows the unduplicated client count receiving
mental health and substance abuse services on POW increased to 169 clients.
Utilization data from the Division of Behavioral Health shows that from July 1, 2007-June 30, 2008
there was a total of eighteen (18) youth receiving Children’s Mental Health services (SED youth
outpatient mental health) through Community Connections. 32 Clients were mostly located in the hub
communities on POW. This unduplicated client count remained the same in the following year (July
1, 2008-June 20, 2009), although clients living outside the hub communities sought services during
this period.
According to the State of Alaska, AICS has been developing a program offer services on the north
side of POW, which has been their primary goal during the 1st and 2nd quarters of 2009. Currently
they have 4 clients enrolled and have provided 13 services to these 4 clients. According to AICS,
they have been working with additional clients, but these have not been documented to the State as
these clients have elected not to fill out the State’s required intake forms, which allow an individual’s
data to be collected.




32
  To protect confidentiality due to small census numbers, the home community of those receiving services are not
reported here—instead the total number island-wide is reported.


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description     36
4.4 Gaps in Services and Barriers to Service Delivery
When asked if they were satisfied with the array of services currently offered in their home
community, 24.4% of Prince of Wales Island community members reported that they were satisfied
with the service system as it currently exists, and 75.6% of respondents reported being dissatisfied
with the array of services that are currently available. When asked if they were satisfied with the array
of services provided island-wide, 21.1% of survey respondents reported being satisfied with services,
78.9% of respondents reported dissatisfaction.
When asked to explain the ways in which the service array is not satisfactory, responses fell into the
following general categories:
    •    Type of care needed locally is not currently available.
    •    Services are centered in Craig and Klawock, which makes it hard for residents from remote
         communities and less mobile populations such as Elders and youth to travel to receive
         services.
    •    Providers are spread too thin to deal with the depth of issues that exist island-wide – there is
         a recognition that existing providers are doing the best they can with limited resources.
    •    Respondents not well informed about what exists.

The following section describes gaps within the service continuum and barriers to providing and
accessing services, based on feedback from community members, stakeholders and service
providers. As previously mentioned, information reported here is based on service provider
questionnaires, stakeholder/community member questionnaires and interviews.
Transportation + small, remote communities
Questionnaire respondents reported that the lack of an island-wide transportation system, distances
between communities, and inclement weather make it difficult to access services located in hub
communities and add to the difficulty for itinerant providers to provide regular service in remote
locations.
Residents have difficulty travelling between communities on the island and to larger communities
such as Ketchikan, Sitka, Juneau or Anchorage to receive higher levels of care. Remoteness and
isolation add to the difficulty of accessing services, especially during winter weather, when roads can
be treacherous and air travel unreliable. In the words of one respondent “it’s too challenging to get
treatment.”
Respondents in three small communities on the island, Coffman Cove, Thorne Bay and Hydaburg,
mentioned the need for behavioral health support such as counseling services offered locally by a
provider based in the community as opposed to an itinerant.
Several responses also pointed to the challenge of providing/receiving confidential behavioral health
related services in a small community as a barrier to people feeling comfortable accessing services.
Limited workforce and staff turnover
Questionnaire respondents reported that high employee turnover in behavioral health positions
makes it difficult to establish ongoing trust relationships between providers and clients and that
clients who have been in treatment in the past are hesitant to pursue treatment after experiencing
turnover of several consecutive providers. Respondents reported that they would like to have greater
transparency in recruiting and retaining staff by health service organizations. Are exit interviews


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   37
being conducted and if so, what lessons have been learned? Are organizations with high staff
turnover working to improve working conditions for their employees?
Small communities outside of Craig and Klawock noted that they would like to have local behavioral
health support, and have vacant positions in their home communities but that service organizations
have been unable to fill positions. Respondents also indicated that the severity of some issues is
beyond local workforce expertise.
Some residents have suggested that tele-behavioral health is one way to deal with workforce issues.
In communities where there is a lack of qualified behavioral health staff and also concerns about
confidentiality or stigma related to seeking behavioral health care, tele-behavioral health can be a
good way to augment in-person care.
Some residents also reported that since the much of the administration of behavioral health services
is located off-island (SEARHC; Community Connections; Alaska Island Community Services), that
there is not enough local voice/control over how services are provided on the island. Respondents
suggested increasing representation on boards, advisory boards etc. to represent the local voice in
decision making that has direct impacts on the local population.
Residents also would like more Alaska Native practitioners delivering services on POW. Some
respondents expressed that they would feel more comfortable talking to an Alaska Native provider.
Finally, several respondents reported a lack of women-specific care and a lack of female providers.
Service specific gaps
Service providers and community members gave input on services that are not currently available or
should be further developed on Prince of Wales Island as a way of enhancing the continuum of care.
Prevention and Education
    •    Prevention programs: suicide prevention, peer helpers or student assistant program,
         substance abuse prevention for teens.
    •    Educational programs including: teaching people how to parent; working with people who
         batter their partners, anger management, teaching teens about healthy relationships, anti-
         bullying for middle school students, New Generation: Value, Directions, Goals, Self Esteem
Substance Abuse Related

    •  Detox facility is needed to offer an array of detox services
            o Outpatient detox
            o Inpatient medical detox
            o Social detox
With no detox services and little in the way of Behavioral Health Emergency Services, the burden of
providing detox and psychiatric emergency services often falls to primary care providers who do not
have the training or resources to adequately respond.
    •    Substance abuse treatment and rehabilitation are desperately needed to augment services
         currently offered on Prince of Wales Island for adults and for youth.
    •    Aftercare services – currently there is a lack of support for individuals returning to Prince of
         Wales communities who have left the island to receive substance abuse treatment. There is a
         need for local support focused on both youth and adults who are returning to the island and
         are in need of continuing support to stay sober and meet treatment goals.


Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   38
    •  Locally based residential substance abuse treatment facility/program for adult clients and
       youth: Providers and stakeholders report that a local residential treatment option would
       increase the number of community members who can receive treatment. Leaving the island
       to seek residential treatment often requires an individual to leave family, employment and
       local supports.
   • Prescription drug abuse: Providers and stakeholders report that prescription drug abuse is
       prevalent on Prince of Wales and the problem seems to be getting worse. Diversion of
       medications (with one person obtaining medication through prescription and another person
       using the prescription) is common. As clinics, pharmacies and dispensaries are working
       together to prevent misuse, providers are often pressured by patients to provide
       medications. As a group, Elders are often targeted for medication diversion by family
       members and others. Parents, teachers and community members need education on
       identifying signs of abuse and ways to take action.
Psychiatric Emergency Service

A number of behavioral health service providers, primary care providers and community members
reported that the lack of psychiatric emergency services including assessment, support and a secure
facility in which to hold individuals needing stabilization is a huge gap in the service continuum.
Since there is no organization providing emergency behavioral health services other than those
services described above, emergency services in cases of behavioral health crisis are often provided
by primary care providers such as the Alicia Roberts Medical Center, the Craig Medical Clinic and
clinic facilities/EMS providers in smaller communities. On-island primary care staff have reported
that this places a heavy burden on medical staff who are not trained in providing psychiatric
emergency care and do not have adequate facilities to provide this service.
Additional challenges exist around transporting patients off of the island to receive higher levels of
care. Currently, State Troopers (if available) can escort individuals to Ketchikan General Hospital,
which does have a stabilization room but does not have the resources to care for emergency
behavioral health crisis patients. Patients can be held at KGH temporarily to wait for escorts to take
them to Anchorage or Juneau. Should a local Trooper not be able to provide this service, an escort
must be sent from Anchorage to Prince of Wales, which can take a day or longer to arrange. During
this time, crisis patients can held in an Emergency Room, a locked room in a hospital or clinic, or
jail. Crisis patients who are held at Alicia Roberts Medical Center are held in the Emergency Room.
As the facility has only two Emergency Room bays, the need to hold crisis patients affects the ability
to treat emergency patients.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   39
Other
    •    Community shelters/safe homes/temporary housing
    •    Wilderness and culturally based programs for substance abuse treatment and general mental
         health treatment
    •    Group home
    •    Assisted living
    •    Lack of home health care
    •    FAS assessment services
    •    Family counseling
Law enforcement
Many communities on Prince of Wales Island have no locally based law enforcement personnel.
Craig is served by the Craig Police Department. Law enforcement for all other communities is
provided by the State Troopers out of Klawock. Due to the distance between Klawock and other
communities on the island, the response in times of emergency is often slow. Emergency and crisis
situations are especially difficult to respond to, due to a limited workforce. Troopers have advised
local residents that they are only able to respond to emergency situations or must prioritze these
over less severe complaints. Additionally, with no established local law enforcement presense in
most communities on the island, problem behaviors often go unreported and undetected.
Stigma associated with seeking and receiving care
Questionnaire respondents reported stigma associated with seeking and receiving behavioral health
care, and that there is a culture of undervaluing behavioral health in the midst of great social
problems. Also reported is a feeling that substance abuse treatment is a punishment, especially in
regard to court mandated substance abuse treatment. Respondents suggested that there is a need to
connect a sense of well being, healing and positive mental health with treatment.
Lack of “healthy activity” options
Many questionnaire respondents agreed that having healthy activity options that offer alternatives to
substance abuse and offer increased opportunities for community connection and personal health
and wellness are lacking on Prince of Wales Island.
Lack of understanding of what is available
Several respondents reported either a lack of knowledge about what is available or that no services
are available in communities where some form of counseling or treatment is actually currently
offered.




Prince of Wales BHS:: Needs Assessment Report :: 4. Behavioral Health System Delivery System Description   40
5 :: SUBSTANCE RELATED CONSEQUENCE OR
PROBLEM BEHAVIOR

Consequences of substance use are the social, economic, and health problems associated with the
use of alcohol, tobacco, and illicit drugs. Any social, economic, or health problem can be defined as
a substance use problem if the use of alcohol, tobacco, or drugs increases the likelihood of the
problem occurring. For example, consequences of substance use could be the risk of a traffic crash,
which increases when the driver has been drinking; or the risk of lung cancer increases through
long-term smoking. 33
The SPF SIG process requires a data-driven and systemic approach to address the most critical
needs in a community. The intent of this needs assessment process is to collect information to help
communities on POW identify the substance related consequence or “problem behavior” to address
through prevention and early intervention efforts. The substance related consequence is the
indicator by which community-level change can be measured. By identifying the substance related
consequence, communities can then identify the substance use patterns that contribute to the
substance related consequence. For instance, if the substance related consequence is the high rate of
alcohol-related crash mortality among 15-24 year olds, the substance use patterns of this age group
should be identified to better understand how to impact this problem. An example of substance use
pattern in this case could be underage binge drinking or underage drinking and driving. By
identifying the substance related consequence and examining the substance use patterns that
contribute to that consequence, the community can then examine the intervening variables that
contribute to the substance abuse pattern and begin to identify strategies to address those
contributing factors. This is described in more detail in the sections that follow.




33
  Feathers, Paula, Southwest Center for Applied Prevention Technology. New Mexico Strategic Prevention
Framework – “Assessment Training.”


Prince of Wales BHS:: Needs Assessment Report :: 5. Substance Related Consequence or Problem Behavior    41
5.1 List of problems to be addressed through capacity building,
strategic planning and priorities for action on POW
To begin the process of identifying the substance use consequence and substance use pattern, both
community members (n=42) and service providers (n=18) were asked to choose from a list of
negative social behaviors and rank in order of magnitude (i.e. problems of greatest to least
importance) in the questionnaire circulated to community members. A number of respondents
noted that they saw problems listed as related to each other and that ranking problems as more or
less severe than others is difficult, because they are often closely connected.
Community members reported the following as the top five negative social behaviors affecting the
POW population:
5.1 Community members rank Top 5 negative behaviors
      Underage Drinking + Binge drinking
 1
      (Adult 21+) Tied as top negative social behavior

 2    Illicit drug use (Adult 21+)

 3    Illicit drug use (Underage)

 4    Alcohol related crashes

 5    Underage binge drinking



Service providers reported the top five negative social behaviors affecting the POW population as:
5.2 Social Providers ranked Top 5 negative behaviors

1    Binge Drinking (Adult 21+)

2    Illicit Drug Use (Adult 21+)

3    Domestic Violence

4    Underage Drinking

5    Illicit Drug use (Underage)



Of these responses from both respondent groups, two can be identified as “substance use
consequences” (Alcohol related crashes and Domestic Violence) and the others are “substance use
patterns”:
     •   Underage Drinking
     •   Binge Drinking (Adult 21+)
     •   Illicit Drug Use (Adult 21+)
     •   Illicit Drug Use (underage)
     •   Underage Binge Drinking



Prince of Wales BHS:: Needs Assessment Report :: 5. Substance Related Consequence or Problem Behavior   42
Questionnaire respondents identified Alcohol Related Crashes and Domestic Violence as the
priority substance use consequences. It is important to analyze the data collected from other sources
to gauge whether questionnaire responses support other primary sources of data such as automobile
crash data collected by the Department of Transportation and the State Division of Public Safety.
Although there is a perception that Alcohol related crashes is one of the biggest social problems on
POW, the data on incidence of assault and domestic violence are higher than that of alcohol-related
crashes. In order to effectively address the substance use consequence, consumption patterns that
contribute to the consequence must be identified.


5.2 Intervening Variable
The intervening variable is the “link” between the factors that influence substance use patterns to
substance related consequences, or those variables that can be changed to produce a desired
response. Once the substance use consequence has been identified and the substance use patterns
that contribute to the consequence, the next step is to define the factors strongly related to and that
influence the occurrence and magnitude of the substance use (patterns) and related consequence.
For example, research has shown that in order to have an effect on the substance use patterns of
underage drinkers, a number of intervening variables that contribute to underage drinking must be
addressed. Those could include: retail access; enforcement; perceived risk; social access; social
norms; promotion; price. Developing a logic model can help communities effectively create
evidence-based strategies that will address the intervening variables.
The following page shows an example of a logic model developed for the State of New Mexico. This
model focuses on the prioritized indicator, the high rate of alcohol-related crash mortality among
15-24 year olds. Next, usage patterns related to the indicator are identified. Third, an identification
of a broad range of behaviors, circumstances, times and locations, norms, policies, risk and
protective factors, etc., that are intervening variables are identified. Lastly, strategies to address these
intervening variables are listed.




Prince of Wales BHS:: Needs Assessment Report :: 5. Substance Related Consequence or Problem Behavior    43
5.3 Logic Model




Prince of Wales BHS:: Needs Assessment Report :: 5. Substance Related Consequence or Problem Behavior   44
6 :: Community Strengths + Resources

Responses to an open-ended question to explore the values of Prince of Wales community members
were grouped into three general categories. These responses demonstrate that Prince of Wales
residents share some significant common values about their homes and communities.
    •    Nature and the environment: Prince of Wales residents value the natural beauty of the island they
         live on and the surrounding area as well as the access to clean air, abundant fish and wildlife,
         outdoor recreation and the remote, quiet quality of their home. The ability to practice a
         subsistence lifestyle is highly valued by a number of respondents.
    •    Population and community: The greatest number responses in this category showed that Prince
         of Wales residents value living in small, interesting communities, the sense of community
         and closeness of community members. Respondents value the friendliness of people who
         live on the island. Questionnaire respondents also mentioned the feeling of being safe in
         their community, feeling that their children are safe, and the connectivity of local groups and
         organizations serving the island. The school system and the road system were also
         mentioned as positive aspects of life on Prince of Wales.
    •    Culture and lifestyle: A number of respondents value Native culture, and reported the
         importance of local culture in maintaining physical, spiritual and emotional wellness, as well
         as their connection to their community and history. Respondents also value the simple, rural
         lifestyle, the quality of life, the privacy and freedom of life on Prince of Wales. Respondents
         noted positively that there are fewer outside influences affecting the local lifestyle than in
         more urban settings.




Prince of Wales BHS:: Needs Assessment Report :: 6. Community Strengths + Resources                    45
6.1 Resources on Prince of Wales Island and Opportunities for
Collaboration
As the responses above indicate, Prince of Wales Island residents share common values that
contribute to community health and wellness. Local organizations offer a wide array of support
services and opportunities for collaboration. Enhancing the behavioral health system serving the
island will depend on using existing resources on the local level to strengthen the behavioral health
system.
    •    Cultural projects and programs: A number of
         communities on Prince of Wales Island have cultural
         projects and programs that support and increase
         wellness. Examples include annual culture camps that
         take place each summer in Hydaburg and Kasaan, the
         totem carving project that is currently underway in
         Klawock, the Klawock Cooperative Associations’s Tribal
         Youth program, the Heenya Kwaan Native dance group,
         and the Taanta Kwaan Native Dance Group.
         Respondents report that perpetuating these activities will
         foster wellness and prevent negative social behaviors.
    •    Prince of Wales Interagency Group: The Prince of
         Wales Interagency Group is a coalition of service
         providers and community members that meet on a
         monthly basis to discuss issues related to community
         health and wellness, increase connectivity between
         providers and community members, organize
         informational and educational events, and to
         dissemanate information. The Interagency Group
         provides a venue for service providers to support one
         another.
    •    Regularly convened support groups: Support groups
         offered on the island include the Grandparents Raising
         Children Support Group which meets at the SEARHC
         office in Craig, as well as Alcoholics Anonymous and
         Narcotics Anonymous.
    •    Service oriented volunteer groups: Prince of Wales Island is home to a number of service
         oriented volunteer groups such as the Prince of Wales Emergency Resources Food Bank
         (POWER) which provides food assistance, second hand clothing and household items for
         sale out of its thrift store; and applications for fuel assistance. The non-profit organization
         HOPE advocates for victims of domestic abuse and provides education largely through
         volunteer efforts. The Alaska Native Brotherhood + Alaska Native Sisterhood are non-
         profit social service agencies that have in in existence since 1912. Each year, ANB and ANS
         provide volunteer support services at local events such as: memorials/funerals, Elizabeth
         Peratrovich Day celebrations, Easter, Mother’s Day, Father’s Day, Halloween, and
         Chirstmas.




Prince of Wales BHS:: Needs Assessment Report :: 6. Community Strengths + Resources                     46
    •    State of Alaska services: State agencies that impact behavioral health with a presence on
         Prince of Wales Island include the State Troopers, who provide law enforcement to
         communities island-wide; the Office of Children’s Services whose mission is to work in
         partnership with families and communities to support the well-being of Alaska’s children
         and youth; the Division of Juvenile Justice, which works with juvenile offenders involved in
         the court system to: promote the safety and restoration of victims and communities and
         assist offenders and their families in developing skills to prevent crime; Public Health who
         offer resources and referrals for health and social services, community resources, STD
         screening and treatment, and prevention programs, community, group and individual
         treatment plans, DV and sexual assault screeing and counseling and resource referring,
         developmental screening and referral, family planning services for teens and adult women
         with priority on people who have limited resources – school and community education,
         immunization, preventable disease vaccination, community preparedness (for emergency or
         other situations).
    •    Elder-related services: Elder-related services provided on Prince of Wales Island include
         the Craig/Klawock Senior Center which offers senior meals and a number of wellness
         programs; the Community Connections Older Alaskans Respite; and, senior meal programs
         available in small communities around Prince of Wales Island
    •    Community events: Prince of Wales Island residents benefit from community events such
         as the Sobriety Walk and Basketball tournament that took place in September 2009; the
         Island Grind event; coalition building events such as the White Bison training that took
         place in Klawock in October 2009; health fairs; monthly movie nights at Craig High School;
         Prince of Wales Island International Marathon; and, monthly Out in the Rain events; the
         Gathering of Native Americans training (offered in 2009) offered an opportunity for Native
         community members who want to become change agents, community developers and
         leaders; several school districts, including SEISD, Craig and Klawock take part in red ribbon
         week. Elizabeth Peratrovich Day includes a parade, potluck dinner and native dancing. The
         schools celebrate the holdiay by performing skits, delivering speeches in Tlingit, having
         luncheons for community members and Elders with traditional food menus. This is day
         when Alaska Native people stand strong and prideful and remember a woman who paved
         the way for civil rights.
    •    School based programs, youth and early learning opportunities: Head Start programs are
         currently available in Craig and Klawock; for youth involved in Craig High School, the
         following activities are available:
             o Sports
             o Clubs
             o Parks and recreation activities
             o Volunteer opportunities
             o Parent Teacher Student Association
             o Career and technical training (connecting youth with individuals working in technical
                  fields)
             o Service group (work on service projects as defined by youth)
             o National honor society
             o Student government
             o Work study
             o Alaska Tour



Prince of Wales BHS:: Needs Assessment Report :: 6. Community Strengths + Resources                 47
    The Klawock Boys and Girls Club and the Salvation Army Timberals youth group also offer
    activities for local youth.
    •    Community facilities: A variety of community facilities offer Prince of Wales residents
         opportunities for health, wellness or recreation. These include: community health clinics;
         school libraries and school gym facilities; the Craig Pool and Recreation Center; community
         gardens.
    •    Island-wide Emergency Medical Services: Prince of Wales Island has an island-wide
         network of Emergency Medical Services volunteers with a volunteer located in each
         community on the island. The EMS staff person based in Klawock is a paid position.




Prince of Wales BHS:: Needs Assessment Report :: 6. Community Strengths + Resources                48
7 :: DISCUSSION OF FINDINGS

(Insert Coalition building + Strategic Planning meeting results, when completed)




Prince of Wales BHS:: Needs Assessment Report :: 7. Discussion of Findings         49
APPENDIX 1 :: QUESTIONNAIRES
•   Response Summary for Questionnaires
•   Stakeholder & Community Member Questionnaire
•   Prevention and Behavioral Health Service Provider Questionnaire
Response Summary for Questionnaires
A total of 43 community member/stakeholder questionnaires were returned by Prince of Wales Island
residents. A total of 18 service provider questionnaires were returned by organizations providing services on
Prince of Wales Island. Questionnaires were returned by mail, through an online survey tool and by email.
Following is a summary of survey responses. Community member and service provider responses are
compiled in this document.
    •    CMS responses are those that Community Member/Stakeholders provided
    •    SP responses are those that Service Providers provided

1. In what community do you currently live? (CMS)
    Of the communities located on Prince of Wales Island, residents from 8 communities submitted
    questionnaire responses. These included:
         •   Coffman Cove: 2 responses received
         •   Craig: 15 responses received
         •   Hollis: 1 response received
         •   Hydaburg: 4 responses received
         •   Klawock: 7 responses received
         •   Naukati Bay: 3 responses received
         •   Thorne Bay: 13 responses
         •   One respondent reported residing in more than one community
    Reponses were not received from four communities on the island. These included:
         •   Kasaan
         •   Edna Bay
         •   Point Baker
         •   Whale Pass
         •   Port Protection
    The greatest number of responses came from the communities with the largest populations including
    Craig, Klawock and Thorne Bay.

2. Which three things do you value most about living on Prince of Wales Island? (CMS)
    Based on response frequency, the top 3 things questionnaire respondents listed as things they valued
    about living on Prince of Wales Island included:
         1. Surroundings and scenery
         2. Small, interesting communities and rural lifestyle
         3. The people who live on the island – their friendliness, the connectedness and closeness of
            community members




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary        1
    Responses to this open-ended question were grouped into three general categories and demonstrated that
    Prince of Wales residents share some distinct similarity in the types of things they value about their home
    and the things that are important to them as community members. These included:
         •   Nature and the environment: Prince of Wales residents value the natural beauty of the island
             they live on and the surrounding area as well as the access to clean air, abundant fish and wildlife,
             outdoor recreation and the remote, quiet quality of their home. The ability to practice a
             subsistence lifestyle was mentioned by a number of respondents as something they hugely valued
             about their home.
         •   Population and community: The greatest number of similar responses in this category showed
             that Prince of Wales residents value living in small, interesting communities and the sense of
             community/closeness of community members. Respondents also valued the friendliness of
             people who live on the island and their connectedness. Questionnaire respondents also
             mentioned the lack of traffic, the feeling of being safe in their community and feeling that their
             children are safe, the connectivity of local groups and organizations serving the island and the
             excellent road and school system.
         •   Culture and lifestyle: A number of questionnaire respondents reported valuing the Native
             culture, the simple, rural lifestyle, the quality of life, the privacy and freedom of life on Prince of
             Wales with fewer outside influences impacting the local lifestyle than in more urban settings.

3. What are the three greatest challenges? (CMS)
    Based on number of responses, the top 3 things questionnaire respondents listed as the greatest
    challenges in living on Prince of Wales Island included:
         1. Lack of services and access to amenities
         2. Difficulty and expense related to travel
         3. Cost of living, stagnant economy and lack of economic opportunity
    Responses to this open-ended question were more diverse than the previous question however,
    responses still showed a high degree of similarity. Reponses are grouped into 5 general categories.
    Opinions about the greatest challenges facing island residents included:
         •   Nature and the environment: the highest number of questionnaire responses under this
             category had to do with the difficulties related to travel – both between communities to receive
             important services and to larger community such as Ketchikan, Sitka, Juneau or Anchorage.
             Travel related issues are listed in this category due to travel difficulty being related to several
             other factors that respondents listed as challenges: isolation and inclement weather (though it is
             recognized that other factors impact travel as well). Darkness was also listed as a challenge of
             living on Prince of Wales Island.
         •   Population and community: under this category, questionnaire respondents noted challenges
             related to a lack of cooperation/coordination between communities located on Prince of Wales
             Island; lack of things for youth and adults to do recreationally; a declining population and a lack
             of higher education.
         •   Economy: the majority of questionnaire respondents indicated challenges associated with the
             local economy – a stagnant economy with a lack of economic opportunities and a high cost of
             living including the cost of goods, food, freight, and energy.
         •   Social Problems: a large number of questionnaire respondents reported substance abuse – both
             alcohol and illicit drugs are an extremely serious local problem that lead to challenges for the
             service system and community health. Both youth and adults were listed as groups struggling
             with substance abuse issues. Other social problems listed as local challenges (and acknowledged
             as being intimately connected with substance abuse) were domestic violence and Elder abuse.



Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary          2
         •   Services: the highest number of questionnaire responses under this category had to do with the
             challenges inherent to the lack of services island wide: emergency services (both for primary care
             and behavioral health) and 24 hour care opportunities for behavioral health services; the lack of
             mental health and substance abuse treatment service (especially in smaller communities outside
             of Craig and Klawock service centers) and for small communities, the lack of on-site behavioral
             health support (as opposed to itinerant support); law enforcement (also a larger issue in
             communities located outside of Craig and Klawock), specialty medical services, programs for
             youth, and structured recreational and cultural events. Several responses also pointed to the
             challenge of providing confidential behavioral health related services in a small community as a
             barrier to people feeling comfortable accessing services in the first place.

4. Are you aware of behavioral health services provided in your community? (CMS)
    The majority of questionnaire respondents reported an awareness of behavioral health services being
    provided on Prince of Wales Island, with 72.5% affirmative responses and 27.5% negative responses.
    When asked to list the services they were aware of, respondents overwhelming reported an awareness of
    services provided by:
         1. Community Connections
         2. Southeast Alaska Regional Health Consortium
    Other responses to this question indicated an awareness of services offered through: Helping Ourselves
    Prevent Emergencies (HOPE), a local domestic violence advocacy and education organization; Public
    Health; Alcoholics and Narcotics Anonymous; Women in Safe Homes (WISH), a domestic violence
    shelter and associated advocacy and education program located in Ketchikan; Head Start; Peace Health;
    Craig Clinic; Tribal Programs; Police Department; COHO; Women, Children’s and Infants program;
    school based special education programs.
    Respondents in three small communities on the island, Coffman Cove, Thorne Bay and Hydaburg,
    mentioned the need for behavioral health support such as counseling services offered locally by a
    provider based in the community as opposed to an itinerant. In the case of Coffman Cove, it was
    reported that no behavioral health support is currently available in the community. In the case of Thorne
    Bay, services are offered on an itinerant basis to youth through Community Connections. For Hydaburg,
    itinerant services for youth are offered through Community Connections and behavioral health services
    for adults are offered through SEARHC. Respondents in all communities underscored the desire for
    locally based behavioral health support.
    The following organizations had staff members that answered BH project questionnaires. Their answers
    to questions about the service spectrum and particular needs of the POW population are included in this
    document:
         •   Community Connections
         •   Craig Community Schools
         •   Craig Public Health Center
         •   Helping Ourselves Prevent Emergencies (HOPE)
         •   Klawock Cooperative Association
         •   Southeast Alaska Regional Health Consortium (SEARHC)
         •   Southeast Island School District
         •   Alaska Community Island Services
         •   State of Alaska, Office of Children’s Services
         •   Klawock City School District
         •   Craig Emergency Medical Services



Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary      3
    It should be noted that this does not represent the entire service continuum for Prince of Wales Island,
    and that answers provided by service providers to this questionnaire are representative only and not
    intended to be illustrative of the entire service continuum.




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary       4
    Are you satisfied with services currently being offered in your home community? (CMS)
    The majority of survey respondents reported not being satisfied with services currently offered in their
    home community, with 75.6% of respondents reporting dissatisfaction and 24.4% of responses
    reporting satisfaction.
    Responses explaining dissatisfaction with services fell into the following 5 general categories.
         1. Recognition that financial resources allocated to offer programs is not sufficient to
            address the local need: a number of questionnaire respondents noted that although the local
            need for services related to behavior health is great, the amount of funding available to offer
            programs such as substance abuse treatment, behavioral health, and domestic violence support is
            limited. A few respondents offered the perception that the suite of services offered locally seem
            to be decreasing (perhaps in relation to the amount of funding available to offer services).
         2. Limited workforce and staff turnover: several questionnaire respondents reported a lack of
            female health care providers for both primary care and counseling services. Small communities
            outside of Craig and Klawock also noted that they would like to have local behavioral health
            support, and even have positions available for this purpose, but that service organizations have
            been unable to fill positions. Respondents also indicated a severity of some issues beyond the
            expertise of some of the workforce to deal with.
            It was also reported that high employee turnover in behavioral health positions sometimes makes
            it difficult to establish ongoing trust relationships between providers and clients and that clients
            who have been in treatment in the past are hesitant to pursue treatment since experiencing
            turnover of several providers.
         3. Limited services: several respondents noted the lack of core services such as emergency
            services for behavioral health emergencies and lack of 24 hours a day, 7 day a week behavioral
            health support.
         4. Remote communities: questionnaire respondents reported that it is hard to access services
            from more remote communities and that fewer services are offered in smaller communities.
            Remoteness and isolation add to the difficulty of accessing services, especially during winter
            weather when roads can be treacherous and air travel unreliable. In the words of one respondent
            “it’s too challenging to get treatment.”
         5. Stigma around seeking and receiving care: questionnaire respondents reported that there is
            stigma around behavioral health on Prince of Wales Island, that there is a culture of undervaluing
            behavioral health in the midst of great social problems, and a feeling that substance abuse
            treatment is a punishment, especially in regard to court mandated substance abuse treatment.
            Respondents suggested that there is a need to connect a sense of well being, healing and positive
            mental health with treatment.
         6. Lack of understanding of what is available: several respondents reported either a lack of
            knowledge about what is available or that no services are available in communities where some
            form of counseling or treatment is actually currently offered.

5. Do you receive services in a community other than the community you are living in? (CMS)
    43.6% of respondents reported that they do receive services in a community other than the one in which
    they live, 56.4% responded they do not. Since the greater number of responses came from the service
    hubs of Craig and Klawock, it is difficult to gage the true breakdown of how many island residents go to
    other communities for services, especially as residents from smaller communities are more likely to travel
    to service hubs for care not available in their home community.
    When asked for additional explanation of why they seek services outside of their home communities, the
    responses fell into four general categories:




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary       5
         1. Higher level of care: respondents reported seeking higher levels of care at Alicia Roberts Medical
            Center such as dental, medical and mental health; in Ketchikan, Juneau and Anchorage; needing
            to see a psychotherapist; needing optometrist’s care
         2. Feeling that there is a lack of confidentiality in small community setting
         3. Not comfortable with the quality of local care
         4. Receiving care in hub community of Craig because it fits with commute for employment
    When service providers were asked if they had clients who received services in a community other than
    the community that they were living in, 93.3% responded in the affirmative and only 6.7% responded
    that they did not.

6. Are you satisfied with the array of services provided island-wide?
    The majority of questionnaire respondents reported dissatisfaction with the array of services provided
    island-wide. 78.9% of respondents reported being dissatisfied with services; 21.1% of respondents
    reported being satisfied with services as they are currently offered.
    When asked for additional explanation of why the service array is not satisfactory, responses fell into the
    following general categories:
         1. Particular type of care is needed locally that is currently not available:
                o Group home is needed
                o Assisted living is needed
                o Detox facility is needed
                o Lack of women-specific care or care provided by a female provider
                o Lack of home health care
                o Residential substance abuse treatment
         2. Services are centered in Craig and Klawock which makes it hard for residents from remote
            communities and certain populations such as elders and youth to travel to receive. Several
            respondents noted that they would like to see increases in itinerant services, of community based
            providers and a larger number of service locations.
         3. Not sure what is provided.
         4. Providers are spread too thin to deal with the depth of issues island-wide – recognition that
            providers are doing the best they can with limited resources.

7. How do you get information about services offered on Prince of Wales Island? (CMS + SP)
    Respondents were provided a list of options for ways they get information about services offered locally
    and the option to supply independent responses. The following responses are ranked in order of most
    commonly reported method for gaining information to least. Independent responses are listed following
    the ranked list.
         1.   Word of mouth (75.6%)
         2.   Newspaper (56.1%)
         3.   Health care provider (56.1%)
         4.   Radio (19.5%)
         5.   Internet (2.4%)
    “Other” responses included:
         •    The non-profit organization, HOPE
         •    Alicia Roberts Medical Center
         •    Community bulletins
         •    Professional contacts
         •    Police

Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary          6
    When service providers were asked if they conduct outreach for their programs, 71.4% said they did
    conduct outreach and 28.6% said that they do not. The following responses are ranked in order of most
    commonly reported method for providing outreach to the community on services available information
    to least commonly reported. Independent responses are listed following the ranked list.
         1.   Word of mouth (90%)
         2.   Community events (70%)
         3.   Primary health providers (60%)
         4.   Newspaper (50%)
         5.   Radio (20%)
    “Other” responses included:
         •    Police
         •    Letters
         •    Meeting with court, schools, OCS, referral sources, treating agencies
         •    Interagency group
         •    Consultation with Community Connections
         •    Health fair

8. Do you have a waitlist for services? (SP)
    Service provider respondents were asked whether they had a waitlist for services. Of those that
    responded to the questionnaire, 23.1% reported having a waitlist, 76.9% reported no wait list for services.
    Of those that did report having a waitlist for services, the following was reported:
         •    HOPE – one person on waitlist for emergency and long term housing
         •    SEARHC – 3-5 people on waitlist for substance abuse services
         •    Community Connections – 38 people on waitlist for in-home care and chore services

9. How are clients referred to your program? (SP)
    For the providers that responded, referrals are made in the following ways:
         •    Schools, students refer themselves, teacher referrals (III)
         •    OCS (IIII)
         •    Court mandated (III)
         •    Self-referral (III)
         •    Clinic, medical provider, health aide (IIII)
         •    Family referral, parents(IIIII)
         •    Word of mouth (IIIII)
         •    Treating agencies
         •    Dispatcher

10. Are there services not currently being provided that are needed? (CMS + SP)
    Respondents were provided a list of options for services not currently provided but needed and the
    option to supply independent responses. The Top 5 responses provided by community members are:
         1.   Mentoring program (such as Big Brothers, Big Sisters): (51.2%)
         2.   Residential substance abuse treatment (adult): (58.5%)
         3.   Vocational services: (58.5%)
         4.   Residential substance abuse treatment (under 17): (53.7%)
         5.   Detoxification services: (46.3%)

Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary      7
    “Other” responses included:
         •   Recreation center, where the whole island can go to recreate
         •   Educational events that inspire wellness and advertise local programs
         •   Marriage counseling
         •   Psychotherapist
         •   Crisis counseling
         •   Home health
         •   Hospice
         •   After hours behavioral health services
         •   Crisis intervention
    100% of providers said there are services that are currently needed that are not being provided. These
    include:
         •   Substance abuse related:
                 o Emergency substance abuse housing for people under influence of alcohol not
                      associated with clinic or police, rehab and recovery services, rehabilitation programs
                      after coming back from treatment
                 o Detoxification, outpatient detox, inpatient medical detox, social detox
                 o Alcohol related
                 o Tobacco related
         •   More comprehensive guidance & counseling program
         •   Medical services
         •   Prevention/education (parenting & boltore’s),
         •   Mental health & FAS assessments
         •   More localized mental health services
         •   Emergency Psychiatric Services
         •   Pediatric therapies; motor and language
         •   Mental Health for non-Native population
         •   Temporary housing
         •   Behavioral counseling, anger, special needs
         •   Family counseling


11. Are there people in the community who need services but are not receiving them? (SP)
    84.6% of providers feel that there are people in the community who need services but are not receiving
    them, 15.4% of providers responded that there were not. When asked to elaborate, the following
    responses were given:
         •   People experiencing dual diagnosis: DD and Mental Illness
         •   Workforce limitations: COHO closed, SEARHC used to only serve Natives, they have 2
             clinicians & 1 is retiring
         •   Services being offered are just beginning (this could be related to either ACIS or SEARHC, who
             has just opened new service location for adults in Craig)
         •   Family counseling for a variety of problems such as domestic violence, depression, parenting
             skills
         •   Alcohol Services, suicide prevention for adults & teens




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary       8
         •   Stigma on mental intervention. I think prevention and community awareness would help more.
             We also have some special needs folks that could use housing. Chemical dependency, anger
             management, life skills; by choice, many people do not seek out services.
         •   They were families receiving services at COHO. Also, in place of suspension, students opted to
             take classes at COHO for using tobacco. Parents had their child drug tested at COHO.
         •   Lack of education on what is available.


12. In terms of developing new programs, what do you think is most important that should be
    planned for? (SP)
    Service providers offered the following responses on which programs should be priority for development
    on Prince of Wales Island.
         •   Adult mental health services
         •   Substance abuse treatment and rehabilitation (IIII)
         •   Prevention programs
         •   Educational programs: teaching people how to parent, working with people who batter their
             partners, anger management, teaching teens what healthy relationships are, anti-bullying for
             middle school students, suicide prevention, peer helpers or student assistant program, substance
             abuse prevention for teens, aftercare, Building up Values and Morals of Healthy Living in the
             community, New Generation: Values, Directions, Goals, Self-Esteem
         •   Tele-behavioral health (for remote communities)
         •   Community shelters, safe homes
         •   Wilderness programs
         •   Social detox
         •   Programs that support the family unit, counseling families


13. Are there new programs being planned? (SP)
    Service providers offered the following responses on which programs are currently being
    planned/developed on Prince of Wales Island.
         •   Telemedicine and tele-behavioral health (north side of island served by ACIS)
         •   As a part of my work I am planning to make prevention education in middle school with focus
             on prevention/substance abuse and drugs problems; communications and respect (this may be
             SEARHC?)
         •   District wide school counselor was just hired by SE Island School District
         •   HOPE is starting to provide advocacy for DV/sexual assault but are in need of support
             (financial) and safe housing options

14. Are there barriers to accessing services? If so, what are they?
    Service providers offered the following responses on the barriers to POW residents accessing services on
    the island.
         •   Travel difficulties, no public transportation on the island either in the communities or between
             the communities, winter weather, distance, consistency of access/delivery (IIIIIII)
         •   Financial (both to limit programs and the limitations of the average family) (III)
         •   treatment that accepts couples and children (since it is a family illness)
         •   a person’s interest in following through with projects


Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary        9
         •   Stigma (II)
         •   Not enough law enforcement in rural areas
         •   Family violence and control issues
         •   No services available for certain issues, such as a batterer’s class
         •   Workforce limitations, facility limitations
         •   Native preference at the clinic level


15. Are there barriers to delivering services you or other organizations currently provide? If so, what
    are they? (SP)
    Service providers offered the following responses on barriers to delivering services on the island.
         •   Not enough time in schedule for guidance & counseling services. Counselor has other
             educational responsibilities.
         •   Substance use is socially acceptable; penalties and consequences are not deterrents
         •   Weather, distance, transportation for counseling, poor road conditions, we are located in
             Klawock and person’s who don’t drive need someone to provide transportation. We have one
             taxi service on the Island, no bus service. (III)
         •   Staff limitations of credentials, not enough staff, lack of appropriate supervision
         •   Letting people know what services are available
         •   Funding (II)
         •   No safe housing
         •   Logistics


16. What is the most pressing need in your community in regard to behavioral health service
    delivery? (SP)
    Responses to this open-ended question were grouped into 5 general categories. Service providers showed
    similarity in their feelings about the most pressing needs faced by the island in relation to behavioral
    health service delivery.
         •   Substance Abuse: Drug and alcohol counseling, issues, abuse, prevention (IIII)
         •   Education: Letting people know what services are available (III)
         •   Transportation/access: Helping people access services, weather, poor road conditions
         •   Workforce: lack of Master’s Level Social Work clinicians; lack of clinicians that will stay on long
             term, enough qualified staff to meet treatment needs (IIII)
         •   Domestic Violence related: support for the survivor and the batterer; help for the children who
             are observing and/or directly involved with the violence


17. What is the most pressing need in your community as it relates to prevention and behavioral
    health support? (CMS)
    Responses to this open-ended question were grouped into 5 general categories. Once again, questionnaire
    respondents showed similarity in their feelings about the most pressing needs faced by the island in
    relation to prevention and behavioral health support. Ideas about the types of things needed on the island
    fall along the service spectrum – from increased options for healthy activities, to increased treatment
    options such as detox and residential treatment facility.




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary       10
         1. Educational services:
                o life skills,
                o budgeting,
                o bill paying,
                o parenting classes
                o career counseling
                o school prevention curriculum
                o education on what services are available on the island
         2. Healthy activities such as:
                o Community recreation center
                o Mentoring for youth
                o Youth discussion group
                o Discussion group focused on prevention and that offers counseling element
         3. Improved facilities such as:
                o Community recreation center
                o Behavioral health center
         4. More law enforcement
         5. Services that deal with substance abuse/drug and alcohol treatment
                o Detox services:
                o Residential treatment facility
                o More trained professionals who know how to deal with substance abuse treatment
                o Emergency services for behavioral health emergencies available island-wide
                o Prevention services


18. What would you say is the biggest problem in your community? (CMS + SP)
    Questionnaire respondents were asked to choose from a list of negative social behaviors and rank in
    order of magnitude problems of greatest to least importance. A number of respondents noted that they
    saw problems listed as related to each other and that it is difficult to rank problems as more or less severe
    than others, because they are often co-occurring. With that said, the top 5 problems selected were:
     1     Underage Drinking + Binge drinking (Adult 21+) These were tied for first place
     2     Illicit drug use (Adult 21+)
     3     Illicit drug use (Underage)
     4     Depression or alcohol related crashes
     5     Underage binge drinking

    Service providers were ranked the Top 5 most severe problems in communities they serve as:
     1    Binge Drinking (Adult 21+)
     2    Illicit Drug Use (Adult 21+)
     3    Domestic Violence
     4    Underage Drinking
     5    Illicit Drug use (Underage)




Prince of Wales Behavioral Health System :: Needs Assessment Report :: Appendix 1. Questionnaire Summary       11
Prince of Wales
Behavioral Health System
Needs Assessment Report
   prepared with assistance from
   Agnew::Beck
   resources for community

				
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