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Annual Performance Evaluation Estimated time and cost of report: 424 hours of staff time, $2,155. Social and Community Services Administration TABLE OF CONTENTS
I. INTRODUCTION This report provides the annual performance evaluation of the City's contract for services with Narconon Palo Alto (NPA). As was the case with all human services contractors, the report was undertaken during the second quarter of the 1976-77 contract in order to be available for consideration during the early planning stages of the 1977-78 budget process. However, this report is unique because it is the final report on a terminated contract. The report uses as appropriate a standard format developed for annual evaluations. First, the methodology used in the construction of the report is noted. Background information on NPA and its relationship with the City is given. Next, NPA performance is assessed; first, its performance during the first quarter of the present contract; second, its performance during the third and fourth quarters of the 1975-76 contract. Some information for the second quarter of 1976-77 is included because the report is intended as a final report on NPA. Notes on community need, available resources and current trends in the field of anti-drug abuse are given, in order to provide a perspective on NPA's performance. At this point, utilizing the previous information including performance criteria specified in the contract, a staff analysis is possible. Finally, conclusions and recommendations are given as appropriate. II. METHODOLOGY In developing the report, the following tasks were accomplished: 1) The format was developed to conform to a standardized annual evaluation format used for contractor provided human services administered by the Department of Social and Community Services. 2) A contract history was obtained from City document files. 3) Information on anti-drug abuse services in Santa Clara County was obtained from the Santa Clara County Drug Abuse Coordinator's Office and from the May 1976 Human Services Study. 4) An evaluation of the performance of NPA in regard to the contract for services with the City was developed based on data-gathering procedures which included: utilizing the Human Services Study; interviewing selected NPA staff; visiting NPA premises; examining a limited number of NPA client files; obtaining some citizen input through ads placed in the Palo Alto Times (which related to all of the City's human services contractors undergoing annual evaluations); and interviewing professionals who have reason to relate to NPA including the PAUSD Special Problems Counselors, a PAPD officer, M.V. Methadone Clinic, Detour and The Center staff members, and several County Probation Officers and other County personnel. It in recognized that not all possible professionals were interviewed. 5) The need for anti-drug abuse services in Palo Alto was assessed by using information gathered for the Human Services Study, consulting the first draft of the County's drug abuse plan for fiscal year 1977-78, and interviewing a number of anti-drug abuse professionals. 6) Resources were evaluated by consulting information gathered for the Human Services Study and by consulting professionals. 7) Some trends in the field of anti-drug abuse were discussed. 8) An analysis of NPA performance was undertaken, utilizing available information, with the constraints indicated below. 9) Because the contract was terminated effective January 5,1977, the standard format was modified to provide for a final evaluation of NPA contract services. 10) Conclusions and a: summarization based upon-the findings in the report were developed, 11) Meetings were held with NPA representatives to review the report including findings, assumptions and recommendations. A member of the Church of Scientology asked to participate in the first evaluation review meeting because "Scientology was mentioned in the report", and was given permission at the request of Narconon. There were a number of methodological problems. NPA reports, statistics and -3- other data were often incomplete as submitted or in need of revision. Therefore, much effort was focused on review and reorganization of original data. In addition, during substantial periods of the evaluation study, NPA staff were not available for discussion of the data, nor did NPA provide access to client files as required by the contract. Therefore, final cheeks on the accuracy of some of the statistics and related statements in this report were not possible. Problems with any specific statistics are indicated in the body of the evaluation. However, staff concluded that the ranges of possible inaccuracies were not sufficient to be critical to the evaluation, analysis or conclusions. The principal analyst in the NPA evaluation was Kathleen Kells, Human Services Analyst, City of Palo Alto. During the evaluation review meetings, NPA identified general and specific disagreements with the evaluation document. Staff has inserted summaries of NPA comments on all appropriate pages of the document. At the conclusion of the evaluation review meetings, NPA requested the opportunity to insert two additional statements regarding the evaluation. The statements are included below and on page 36.
III. BACKGROUND The City had a contract with Narconon Palo Alto (No. 3748) relating to the period from July 1, 1976 through June 30, 1977. The annual allocation for NPA in the 1976-77 budget was $38,000. Funding in 1976-77 was based upon a minimum annual basic fee of $15,000, as the contract specified a basic monthly rate of $1,250. In addition, the contract authorized NPA to be paid $250 per person for treating drug addicts or users whose cases met certain criteria as specified in the contract. The number of cases meeting the criteria determined the exact amount of funding. NPA was reimbursed for two clients during the-first quarter (July-September) of 1976-77. NPA was reimbursed for two clients during the first two months of the second quarter (October-November). Because Council directed that the NPA contract be terminated January 5, 1977, total funding for 1976-77 will be $8,701. The City had one previous contract with NPA (No. 3717) during 1975-76. This was initially established for the period from February 1, 1976 through June 30, 1976. Funding in 1975-76 totalled $7,000 for the five months of the contract ending June 30, 1976: $6,250 for five months at the monthly rate of $1,250 and $750 for three case reimbursements at $250 a piece. This would be equivalent to $16,800 for a twelve month contract. The total cost for the NPA contracts in 1975-76 and 1976-77 was $15,701. -5- B. Anti-drug Abuse Services Provided by the County of Santa Clara The State of California's goals * in providing services for addicts and abusers is to insure that community-based programs, operated locally, by counties and private agencies, are provided in the areas of prevention, treatment and rehabilitation. Such a program is mandated under State law in providing social services to heroin and alcohol addicts. The State appropriated approximately one million dollars (including federal funds which it distributes) to Santa Clara County during fiscal year 1976-77, and an additional 850 thousand dollars in support of the County methadone maintenance program. The County Drug Abuse Coordinator indicated that the federal funds are being reduced at the rate of approximately 5% per year, not including the actual reduction caused by inflation. In addition, the anticipated cost of living increase in State funds for 1977-78 is only approximately 3-4%. Therefore, the County will be operating on an increasingly tight budget. In the past, the County has focused its resources in the San Jose area. The County's top priority now relates to sustaining the programs currently being funded at the same level of service. The County has indicated a willingness to discuss establishing additional services in the north county area should funds become available. One possibility that has been tentatively explored is the establishment of an office of the Central Intake Unit in the north end of the county, perhaps utilizing unused hours and space in the Mountain View Methadone Clinic. Such a unit would provide screening, evaluation and referral for heroin addicts in need of services. However, such a plan is contingent on available resources. Even if such a facility were planned, implementation could require up to two years, according to the Drug Abuse Coordinator's office. * From the "Proposed Comprehensive Annual Services Program Plan" for 1976-77, published by the State Department of Health in California. IV. PERSPECTIVE ON PERFORMANCE While the major component of an evaluation of a contractor's performance is how well it has lived up to the contracted Scope of Services and the cost-effectiveness of services rendered (value received versus total costs), it is necessary to examine the contractor's external "environment" to fully assess the significance of the performance. Changes in the needs of the community, the resources available to the community, or trends in the field, may significantly reflect upon performance. B. Need for Anti-Drug Abuse Services The need for anti-drug abuse services in Palo Alto was reviewed in the Human Services Study Final Report of May, 1976, entitled "An Assessment of the Role of the City of Palo Alto in Anti-Drug Abuse Services including the contract with Narconon Palo Alto, Inc." As noted there, insufficient data is available for a full analysis of the need for drug-related services in Palo Alto. The report summarized information about need as follows:
-7- Needs data relating to drug abuse in Palo Alto continue to be limited. However, evidences such as clients of the methadone clinic, of PAUSD Special Problems Counselors and of other professionals who work with clients in "high risk" situations, appear to indicate that drug abuse is not decreasing in its impact upon the community. The first draft of the County's drug abuse plan for fiscal year 1977-78 supports this conclusion on a county-wide scale. One particularly interesting statistic is the increase in the average number of monthly referrals to the Juvenile Probation Department's Substance Abuse program, from 149.5 persons per month during Fiscal Year 1974-75 to 177 persons per month during Fiscal Year 1975-76. C. Anti-Drug Abuse Resources Available to Palo Alto Residents There is no indication that there have been any significant changes in the resources available to Palo Alto residents since the comprehensive review in the Final Report of the Human Services Study of May 1976. At that time, the study noted:
D. Trends in the Field of Anti-Drug Abuse 1. North County Drug Abuse Strategy The Council in June 1976, assigned staff and the Council representatives to the County Drug Abuse Coordination Commission to assist in facilitating discussions of governmental officials and agency representatives interested in preventing drug abuse in developing a coordinated North County anti-drug abuse strategy. Meetings have been held with County and other City officials and Mountain View Community Health Abuse Council (CHAC) to outline development of such a strategy. -8- A primary, if tentative, conclusion of these meetings is that municipal funding of anti-drug abuse services should focus upon primary prevention activities. This is for several reasons: a) The County has traditional responsibility for treatment of heavily involved drug abusers, especially those requiring institutional treatment such as heroin detoxification. It is unlikely that the County will expand such treatment for North County residents as long as the City of Palo Alto provides such services. The County has indicated that money is not available for such an expansion. b) A variety of resources exist for counseling and assistance of less heavily involved abusers. A coordinated area-wide strategy would concentrate upon identifying ways to assure these resources were effectively used. c) The activity with greatest potential is in primary prevention and in participating with other agencies in coordinating services. CHAC has demonstrated the effectiveness of the coordinating approach to primary prevention efforts in a community. It requires fewer financial resources than direct services programming but relies upon wide community involvement. The County Drug Abuse Commission has identified primary prevention as the most productive kind of anti-drug abuse activity and that it is receiving little attention. During the evaluation review meeting, NPA asked to include the note that it is ironic that during the contract, their services shifted away from primary prevention toward treatment services and that the shift had been dither dictated or encouraged by the contract. 2. Santa Clara County Drug Abuse Commission The County is developing its annual objectives as a basis for allocating funds earmarked for anti-drug abuse services. The City staff has participated in planning meetings of the Tertiary Treatment Committee relating to heavily involved abusers to encourage the County to provide adequate treatment to Palo Alto residents. Two letters were sent to detail the City's concern. The County has responded by seeking funding for detoxification services in the North County area. -9- 3. State of California Drug Abuse Plan The State solicited the City's comments regarding the 1976-77 California Plan for Drug Abuse Prevention. Staff provided extensive comments in June and, upon receipt of a response from the State Office of Narcotics and Drug Abuse, also in October. As a result of the information gathered in the human services study, staff was able to comment in an informed manner on the plan. The State indicated that comments such as the City's had demonstrated the usefulness and need for greater involvement of localities in the planning process. IV. PERFORMANCE ASSESSMENT A. Performance Assessment, 1st quarter 1976-77 The City's contract with NPA described services to be rendered in two ways: in the reimbursement section and in the Scope of Services section. The reimbursement section related to the "per client fee" which comprised only a portion of the contracted services. The Scope was a comprehensive description and included provision for treatment services to "reimburseable clients". It was developed through a series of meetings of City Staff and NPA representatives. In this section, NPA's performance will be measured against its contracted Scope of Services. (Items in the Scope of Services are in quotes.) However, before an item by item measurement is undertaken, a brief explanation of client categories may be useful. There were two major client categories: one was "hard drug" abusers ("hard drug" relates to long and consistent usage of drugs which cause severe dysfunction to the abuser. "Hard drug" includes heroin, barbituates, opiates, opium and its derivates, cocaine, amphetamines). Items 2-a-1 and 2-a-3 of the Scope refer to this category. The Scope also specifically refers to heroin addicts, who are a subset of the "hard drug" abusers category in item 2-a-2. The second category consisted of alcohol, marijuana, or hashish abusers and other users of other drugs. (While alcohol abusers experience severe dysfunction, treatment of alcohol abusers was a secondary objective in the contract because the County provides adequate treatment facilities in Palo Alto.) Item 2-b in the Scope referes to the second category. All clients fit into one of these two categories. Clients in either category were eligible for reimbursement, although any in the second category required prior review and approval by the City Manager and required documentation of "dysfunction".
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During the first quarter of 1976-77, NPA reported that they held eleven seminars which were attended by a total of 123 people. In its first quarterly report for 1976-77, NPA noted that "The drug information seminars presented to the public were aimed at select target groups. The first was parents of children who use drugs." NPA held weekly seminars for this group in the NPA offices on Emerson street. The format was part lecture and part question and answer. NPA reported that the average attendance per seminar was eight, with the total for the quarter being 83. However, NPA also noted that "the participants are encouraged to return, and often do, bringing their friends." It is not clear how many different people attended the seminars as there may have been double-counting. The seminars were directed at an important target group because parents are initial participants in assisting to resolve drug abuse-related problems of their children. A second target group reported by NPA was the Palo Alto Police Department NPA noted that they gave a series of three seminars to the PAPD. The PAPD reported that a total of 35 officers attended the seminars. The PAPD seminars probably belong under the Coordination and Community Involvement objectives of the Scope of Services and, consequently, are not included in the assessment of this objective. It is however acknowledged that PAPD is a resource for furthering preventative goals in drug abuse. Revising the statistics appropriately, NPA has held eight seminars to a maximum of 83 different people. Using these numbers, NPA would easily have met the numerical aspects of the goal, as the equivalent annualized figure is 32 seminars to a total of 332 people. -12- The seminars represented a useful beginning in preventive efforts. However, other target populations should also have been addressed especially young people. Involvement of community organizations and individuals in planning NPA preventative services would have helped in meeting this objective.
In NPA's first quarterly report for 1976-77, it is reported that:
In the first Narconon Quarterly Report Supplement, NPA noted:
NPA primarily distributes NPA materials. That is, they provide ready access to pamphlets and books relating to their treatment approach and concepts. They do not distribute, in as accessible a manner, general drug information. Some information which NPA has distributed is highly controversial. This can be expected in drug-related programs as the City experienced with the previous contractor. A specific document (a newspaper article discussing the results of a Berkeley research regarding marijuana) provides an interesting case at point. Acceptance of the research could probably be fairly summarized as rejected by a majority of researchers because of methodological problems. -13- However, during the evaluation meetings, NPA noted that they distributed the specific article because of their feelings that marijuana is severely destructive and because the article reinforces the conclusions drawn from their experience. Because the contract requires NPA to provide information regarding drugs to the community as the official City representative, greater discretion should probably have been exercized in regard to the article because of its extreme nature. NPA did not provide a balanced spectrum of "current, factual, and accurate information" about drugs both in terms of accessibility and content. NPA should have reached out more actively to target populations and provided more balanced information. They generally assisted people who sought NPA's help.
NPA reported having treated eight clients in this category during the first quarter of 1976-77. Staff experienced substantial difficulty with regard to NPA's recordkeeping and documentation. Therefore, close scrutiny was given to these statistics. Two of the eight (8) clients were not Palo Alto residents. Of the remaining six (6), three were primarily alcohol abusers, and therefore, belong in the second treatment category (see "2.b"). Of the remaining three, an examination of the client file of -14- one "heroin abuser" showed that in the enrollment form which he filled out, he had stopped using heroin and all other drugs two years previously. Therefore, NPA treated two Palo Alto residents in this category during the first quarter of 1976-77, July through September (one for heroin and one for cocaine). NPA applied for and received two reimbursements during the first quarter, one of which was for a client who was abusing alcohol and therefore does not enter into this category, and the other of whom was the heroin case. NPA was reimbursed for the cocaine case during the second quarter of 1976-77. As mentioned above, reimbursements refer to the financial mechanism in the contract and may include clients in Section 2(a) or 2(b). Therefore, the number of clients treated under Section 2(a) can be expected to differ with clients meeting the minimum reimbursement criteria. All Section 2(a) clients should be reimbursable, however. NPA was reimbursed for two clients during the first two months of the second quarter, one of which was the cocaine case mentioned above. The other case was a heroin abuser. This additional case was the only case of treatment of a hard drug abuser during the second quarter about which NPA submitted information.
a. Detoxification This objective in the contract describes two kinds of services to heroin abusers: a) detoxification either on-site or by referral to other detoxification programs; and b) a full range of treatment, including detoxification and rehabilitation services to the target or 15 clients. -15- NPA reported that it had done no "drug-free" detoxifications (i.e., NPA supervised, on NPA premises) during the first quarter. NPA reported that it referred three heroin addicts to the Good Samaritan Hospital in San Jose for hospital detoxification. Only two (Palo Alto) heroin addicts are listed in the comprehensive client listing (see Appendix A). Of these two, one was not an addict, as discussed in regard to Section 2-a-1 above. NPA policy was to provide only minimal support services to addicts whom it had referred for hospital detoxification. NPA staff did not accompany the addicts to or from the hospital, and did not visit them daily while they were in the hospital. Because these are requirements at Stanford and El Camino hospitals, the two local hospitals who do detoxifications, for the acceptance of referred addicts, NPA clients have had a limited choice of alternatives. NPA had indicated that it would normally refer clients needing a hospital detoxification to Detour, in Mountain View. Detour was aware of NPA's intent and had anticipated such referrals. However, according to a November interview with a Detour staff member, NPA had not yet referred any clients to Detour, nor has NPA established a working relationship with Detour. Currently, Stanford and El Camino hospitals primarily accept detoxification referrals from Detour. As Detour requires an addict to participate in Detour's own counseling program, any addict who might be referred by NPA to Detour in order to be referred for hospital detoxification would not necessarily have any further contact with NPA. Good Samaritan Hospital's detoxification program did its own evaluation/screening, daily counseling, and follow-up counseling services. It should be mentioned that as Good Samaritan provided its own services, any addict could go there to request a detoxification, without an official referral from another -16- agency. It is important to note that Good Samaritan stopped its program in September/October 1976, due to the passage of legislation which stopped Medical funding of detoxifications. Therefore, that referral source is no longer available for NPA to utilize. In any case, the County operates the Central Intake Unit which can competently screen and refer any heroin abusers who will travel to San Jose. Unless NPA were to start providing the necessary services for hospital referrals, it would have to refer heroin abusers to another agency for hospital detoxification purposes, notably, Detour. Treatment of heroin abusers NPA reported having provided the treatment services specified (in 2.a.2) to three heroin addicts. However, as noted above, the comprehensive client list shows only two Palo Alto residents characterized as heroin addicts, and one of these two was not an addict. Revising the statistics appropriately, NPA has apparently provided the services specified in the contract to the one heroin addict mentioned earlier (under 2.a.1) during the first quarter of 1976-77; assuming the same rate of clients, this is equivalent to an annual figure of four addicts treated, which is only 27% of the target figure of 15 addicts. This low level of performance in reaching heroin addicts is a significant problem since it relates to an identified service gap which has been given priority in previous City policy regarding drug services. Of course, the appropriateness of the target figure of 15 could be questioned. However, the target seems conservative in light of the 37 heroin abusers, Palo Alto residents, who were served by the CIU in San Jose and in light of the experience of the previous contractor. NPA indicated during the evaluation review meeting that it had not found an alternate method of detoxification that was satisfactory. NPA tried several alternatives including on-site detoxification at the agency offices. However, NPA -17- determined that a residential center was needed. Therefore, several actions were taken including sponsoring a golf tourney to raise funds and attempting to locate a facility for residential care. NPA also indicated during the evaluation review meeting, that it had practical differences with hospital detoxification and with this objective and therefore, decided at some time during the contract, that efforts in regard to this objective were not useful.
It is not apparent that NPA was meeting this objective. Generally, NPA only obtained one urinalysis after 25 hours of program treatment, not one per week. (Only one urinalysis during treatment was required for reimbursement as written in the contract.) This objective provides a non-subjective test of the effect of treatment upon clients. This objective is probably most important in relation to heroin abusers.
NPA reported treating seven Palo Alto residents in this category during the first quarter of 1976-77. Of the seven Palo Alto residents in the comprehensive client list, (which lists all treated clients during the quarter) three fall under the first ("hard drug") treatment category, and have been discussed previously (under "2.a.1"). Of the remaining four clients, two were treated for alcohol, one for alcohol and PCP, and one was listed as being, treated for prescribed medications. It should be noted that the client who had been on prescribed medications was -18- "routed-off", (reflecting an NPA policy to drop a Person from the program when he/ she persistently causes trouble or disrupts the NPA course). NPA also noted that the client was a "Type III", a term used by NPA to describe "an individual so completely overwhelmed by the past as to have lost contact with the present ("psychotic")." Research into the case revealed that the person was being medically treated for chronic schizophrenia. Neither the person (on intake forms) nor the person's psychiatrist indicated that the person was taking the course for a drug problem. Therefore, it does not seem that this person should be included in the statistics. Revising the statistics accordingly, it appears that NPA has treated three people in this category during the first quarter. Assuming the same rate of clients, this is equivalent to an annual figure of 12 clients in this category. This is far below the target figure of 75 clients - only 16% of the target. During the evaluation re view meeting, the NPA representative stated that NPA had interpreted this objective as relating to both non-Palo Alto as well as Palo Alto residents. He also reported that NPA felt the objective related to non-Palo Alto clients who were abusing the dangerous drugs listed in 2a. While staff did not agree with this interpretation as consistent with contract discussions with NPA, Council policy or the regular monthly contract review meetings, question remains regarding the interpretation of this objective. Based upon NPA's interpretation, NPA projected that they would have met this objective. Using their interpretation and the information submitted by NPA (the comprehensive client list prepared by NPA attached as Appendix A), a maximum of 32 clients could be considered to have been served under Section 2(b) in the first quarter. Of these six clients were "routed off" and two were "AWOL", leaving a maximum of 24. Of these 10 were non-Palo Alto clients who were reported to have primarily abused heroin, cocaine, or amphetamines and who, -19- therefore, would have been included under category 2a had they been Palo Alto residents.
NPA had not submitted follow-up reports as of December 30, 1976, although several clients had completed the basic course of treatment 6 to 9 months previously. Staff feel that such follow-up information is very important. This is because the "units" of contract-specified services, necessary for reimbursement or meeting the numerical target, are artificial to a certain extent. This is because, while having received the specified services and thus reaching specified objectives is an important first step in the rehabilitation of drug abusers, this cannot really be considered evidence of a "cure" or successful treatment. For example, drug abuse professionals generally think that 2-5 years are necessary for the complete rehabilitation of a heroin addict. This being the case, follow-up information on treated clients is necessary to monitor the long-term efficacy of the services provided. Even if the targets were being met, if the follow-up information indicated little long-term efficacy of the services, a change in NPA's program and/or in the City's drug abuse policies would be indicated.
During the first quarter of 1976-77, youths under 18 were not represented in the total NPA client population in terms of both the client categories (described in "2.a." and "2.b.") One major reason for this situation was that -20- a working relationship with the PAUSD Special Problems Counselors was not established. (See discussion under Objective 4.b.) The lack of involvement of youth is disappointing because of the documentation of need for youth services as demonstrated in the recent PAUSD studies of youth-related drug use. Outreach to this target population would seem to be important to meet this contract requirement.
During the first quarter of 1976-77, women were not represented in the total client population under category "2.a.". Women were not represented in the client population described in category "2.b.". (The client population referred to here is the revised figure of "3" arrived at in the discussion of "2.b.".) NPA did have female clients from other cities, and it seems reasonable to assume that NPA may have female clients from Palo Alto in the future. Outreach to address this problem would seem to be important to meet this contract requirement.
1. PAUSD NPA has not established any sort of working relationship with PAUSD Special Problems Counselors, as the contract required, and is not currently making any efforts to do so. During an interview, the Special Problems -21- Counselors indicated that they were and had been prepared to discuss the possibility of such a relationship. According to the counselors, during the first quarter, NPA arranged two one-hour meetings with them. A NPA representative arrived 55 minutes late to the first meeting NPA cancelled the second meeting by telephone 40 minutes after it was to have commenced. In addition to this experience, the very brief interaction the counselors did have with the NPA representative, as well as their second-hand knowledge of NPA, led them to state that they had serious doubts about the competency of NPA. They emphasized that they were still willing to discuss these questions with NPA in an attempt to resolve them. During the evaluation review meetings, the NPA representative reported that NPA felt that NPA had made an effort to establish a relationship with PAUSD but were not well received. Besides the situations noted above, which were characterized as unfortunate, NPA noted one meeting with a Special Problems Counselor early in the previous contract and a meeting with the PAUSD Drug Task Force as evidences of NPA's efforts. Neither achieved results. Responsibility for initiative rested in large measure on NPA. Staff feels that this section of the objective was not fulfilled. 2. PAPD and County Probation Departments As discussed under Primary Prevention, NPA gave three seminars to the PAPD concerning its program, philosophy, etc. These were given to the street officers of each watch. PAPD officers and NPA staff rewrote the PAPD General Order (No. 5.01) which discusses general policy and the relationship between the PAPD and the Palo Alto drug abuse program (standard procedure, since the General Order refers to the specific contractor). Since this was done, there has been little interaction between them, apparently because few relevant cases or situations have arisen. NPA had laid the proper groundwork should such cases occur. NPA has apparently established a good relationship with a number of the staff -22- of the North County Adult Probation Department:, and has received referrals from the over the years. During an interview with the juvenile probation officer in charge of the Palo 1 area, lie indicated that the North County Juvenile Probation Department runs its own drug diversion program, which does not interact with NPA although it does interact with other local drug abuse agencies. He also noted that he has met with NPA, but has chosen not to make referrals to them. In summary, NPA has made efforts to fulfill this section of the objective. Satisfactory results have been achieved in regard to the PAPD and some individuals in the Adult Authority. NPA has not been successful regarding other probation office in the Adult Authority or regarding the Juvenile Probation Department. 3. County Drug Abuse Coordinator's Office In regard to the county drug abuse coordinator's office, in NPA's second (11/4) supplement to its first quarterly report for 1976/77, it notes,
The county recently completed its planning research for the services to be provided by county-funded agencies in 1977-78. The county is completing final review of its program planning. NPA input was not provided. Missing this opportunity to affect county drug abuse program priorities was a serious oversight, particularly, in light of the effective participation of many private drug abuse agencies in the county, including several from Palo Alto. NPA was informed, however, that the City staff did communicate to the county's Drug Abuse Commission regarding needs In North County. "5. Self-Evaluation Process
No information was submitted to -23- City staff except in the first supplement to the First Quarterly Report in which NPA noted that it intended to re-evaluate "the promotional aspects of the program."
NPA has not provided information relating to this objective. NPA relies upon primarily a single course of treatment. In general, NPA trains its staff in its own counseling techniques. It should be noted that NPA follows the protocol of involving clients early in the process where warranted in their opinion. NPA involves clients as staff members when NPA directors feel they have sufficiently progressed. Some become responsible for substantial portions of the course work. In one case, a client who was reportedly a heavy cocaine abuser, became a supervising counselor after less than three months in the program. While client involvement is commendable, the evaluation staff question the advisability of placing a former addict or heavy abuser in a responsible supervisory position within such a short time. B. Performance Assessment, 3rd and 4th Quarters 1975-76 Since NPA's performance criteria for 1975-76 are similar to the 1976-77 criteria which were previously assessed in Section IV-A of this report, only relevant statistics for the third and fourth quarters of last year will be highlighted. For a more extended 1975-76 performance evaluation, the reader is referred to the May, 1976 Human Services Study entitled "An Assessment of the Role of the City of Palo Alto in Anti-Drug Abuse Services including the contract with Narconon Palo Alto, Inc." NPA's contract with the City did not begin until February 1, 1976. Therefore, in the following discussion, "the third quarter" refers to Februay and March 1976, -24- a two month period. In its final report for 1975-76, NPA reported that it treated and was reimbursed for two heroin addicts in the third quarter. They reported treating no other "hard drug" abusers ("hard drug" category includes heroin, barbiturates, opiates, opium and its derivatives, cocaine, amphetamines). NPA reported treating eight clients in this category in the fourth quarter of 1975-76, April through June. This number included three alcohol abusers, who belong in the other treatment category. (The one client for which NPA was reimbursed in the fourth quarter was one of these three alcohol abusers.) Revising the statistics, NPA treated five hard drug users: four heroin users and one cocaine user. This gives a total of seven hard drug users for both quarters in 1975-76. NPA was reimbursed for one of the heroin users in the first quarter of 1976-77 - therefore, this person is counted in the statistics for both the 4th quarter, of 75-76 and the 1st quarter of 76-77. According to an NPA report regarding these clients, apparently NPA did not apply for reimbursement for the other four because: one left the program before completion and still uses some drugs, though at a reduced level; one completed the program but dropped all contact with NPA; one reverted back to heroin and has not re-enrolled; and one left the program when ordered by court to a residential program. In the second category of users (primarily alcohol, marijuana, hashish abusers, or "lighter" users of other drugs), NPA reported treating a total. of six Palo Alto residents during the third and fourth quarters of 1975-76. Adding the three alcohol abusers mistakenly put in the first category, NPA reported actually treating nine Palo Alto residents. This is subtantially below the target figure in the contract's scope of services of thirty clients for 1975-76 - only 30% of the target. During the third and fourth quarters, NPA: increased their number of hours of operation per week; added a R.N. to the staff to supervise urinalyses; reported -25- participating in twelve crisis interventions; and, in conjunction with, the University of Santa Cruz Extension, provided a course on Narconon communications techniques, and counseling skills to 25 counselors, drug abuse personnel, etc. It should be noted that this is not a comprehensive summary of NPA's activities, but merely a note of several points of interest. In reviewing the performance in the third and fourth quarters, NPA reported some success in treating from 3 to 6 heroin or cocaine abusers. NPA also reported treating 9 Palo Alto residents who abused other drugs. While below contract targets, this represented moderately good performance during start-up of the contract. It is puzzling that NPA was not able to sustain or expand that level of activity in its program during the first quarter of 1976-77. C. Summary Assessment of Services Provided This section reviews some implications of the statistics and other information about NPA performance during the evaluated period and discusses possible conclusions which may be reached regarding the performance level. The basic question of the evaluation is whether NPA was reasonably effective and efficient in providing service addressing the community's drug, abuse problem is described in the contracts with the City. This question may be addressed in several ways; e.g., 1) comparing the service level and performance to the objectives of the contract and to need, and 2) comparing the service level and performance in relation to the cost of the contract. The first relates to the overall community need which the contract services were meant to address. The objectives were developed using information provided in Council, staff and contractor discussion and research with regard to need. 1. Service level and performance in relation to the objectives of the contract and to need. The scope of services for the two contracts were developed by NPA representatives and staff utilizing information available about needs and City priorities. Because of the Council approval process for contracts, they represent the most current statements about City priorities with respect to need in drug abuse. Therefore, a method of answering the basic question in the evaluation is to compare performance against objectives and targets in the contract's scope and to compare with experience of other drug abuse programs. The contract's scope of services contains standards relating to two principal areas: preventative activities and treatment services. Preventive Activities. NPA has held "parents' seminars" weekly, on NPA premises. These seminars represented a good beginning in reaching an important target population NPA did not utilize some available resource, in order to achieve the objective to reach a wider variety of people, particularly potential drug -27- abusers such as youth. NPA has not met the objective of establishing a working relationship with the PAUSD, which would have facilitated provision of preventative services to youth. These were important objectives in the scope of services. In its first quarterly report for 1976-77, NPA reported that it was in the process of compiling information on all of the drug abuse programs and related resources in the Greater Bay Area for a booklet to be printed in early January. NPA did not provide a library or resource room for information on drugs and drug abuse programs, although it reported having a folder for such information. A book case with Narconon materials was provided. They reported disseminating information on a "as needed" basis, when requested by someone "coming in the door". To sum up NPA's performance in the area of primary prevention, NPA assisted people who sought them out. However, NPA did not actively reach out to and with persons, organizations and most target populations in the community to work on primary prevention. Staff does not feel that performance in preventative activities satisfied the intent of the scope of services. Treatment Services. During the period that the City contracted with NPA, February 1976 through January 5, 1977, NPA was reimbursed for seven clients. Of these seven, three were alcohol abusers, three were heroin abusers, and one was a cocaine abuser. Treatment of heavy abusers is felt by staff to be a key indicator of effectiveness. NPA did not respond to staff requests for client information for the second quarter except in connection with client reimbursements. NPA did not provide access to client files during the evaluation study, as required by the contract. Therefore, the following Summary statistics relate primarily to the first eight months of the contract, February through September 1976. During this period, from a City staff analysis of various NPA reports, it appears that NPA has -28- treated a total of 20 Palo Alto residents. Eight of these were categorized by the contract as "hard drug" abusers, while twelve were categorized as "lighter" users, including alcohol abusers. (Not all of the eight "hard drug', abusers were successful "graduates" of the program. As noted in section IV-B, this number includes one client who left the program before completion and still uses some drugs, though at a reduced level, one client who reverted back to heroin and has not reenrolled, and one client who left the program when ordered by a court to a residential program) NPA has been reimbursed for four of the eight hard users, and for three of the twelve "soft users". (The three were all alcohol abusers.) Comparing the statistics given above with the target in the contract and with the experience of the previous contractor, NPA has not been able to reach the larger part of the target population of Palo Alto residents who need or could benefit from anti-drug abuse services. It is not possible to state definitively why this is so. However, several possible conclusions are discussed below. First, one could conclude that the target figures in the Scope of Services were too high. However, they were established jointly by NPA representatives and City staff, and, according to NPA, sent to the National Narconon office for approval. In City staff's opinion, the targets are not high, when compared to caseloads of other drug abuse agencies and the previous City drug abuse contractor. As noted in Section IV, it does not appear that the need for drug abuse services has decreased. Other agencies are filling some of this need in Palo Alto. The first draft of the County's drug abuse plan for fiscal year 1977-78 notes that 4.3% or 37 of the 851 cases processed through the Central Intake Unit in San Jose were Palo Alto residents. The County notes that, again in reference to the 851 cases processed, the primary drug abused upon admission was heroin in 94.6% of the cases. Assuming Palo Alto clients are similar to those of the -29- county as a whole, approximately 35 Palo Alto heroin addicts went through the Central Intake Unit. Detour, in Mountain View, has provided hospital detoxification services to 41 heroin addicts since it opened in October, 1975. A Detour staff member estimated that 12 of these addicts were Palo Alto residents. A counselor from The Center, in Redwood City, estimated that it receives 8-10 calls per week from Palo Alto residents, about 50% of which are from concerned parents. Most calls are concern with heroin detoxification, and about 50% of the calls "lead to something". The counselor noted that The Center receives more detoxification and counseling requests than it can fill, and stated that in general, the demand for anti-drug abuse services is greater than the supply. In summary, the need for anti-drug abuse services did not apparently decrease during the contract period. Some Palo Alto residents went to agencies other than NPA for services. Apparently, some residents were not receiving treatment at all. Therefore, some other explanation than the need for services must be found to explain NPA's low performance level. It is possible that the publicity associated with selection of NPA as contractor, with contract renewals, and during the implementation of the two contracts had a negative impact on NPA's client intake. During the evaluation review meetings, NPA reported that their assessment was that negative press had reduced their outreach and intake effectiveness There is little objective data on how well NPA is known in the community. It is possible that NPA has had such a low level of clients because it is not well known. If this were the case, possible explanations are: NPA is relatively small; NPA has not treated a high level of clinets in the past and therefore, is not well known in the drug-using community; or NPA publicity and outreach is not sufficient to make NPA well known to the community in general. The latter -30- possibility should be thoroughly assessed by NPA staff. Another possible explanation is due to the fact
that NPA provides a single, standardized course of treatment. Because
of this, NPA may have a more limited appeal for drug abusers and addicts,
as compared to more eclectic drug abuse agencies. This could affect both
the number of people who go to NPA in the first place, and the number
of people who stay with NPA long enough to complete the program. The Human
Services Study notes that, according to statistics provided by NPA, "NPA's
files for 7/1/75 to 2/1/76 show that 43% of those entering the treatment
program left, before completing the basic course." While further
data on this topic is not available, the percentage appears to support
this hypothesis. Another possible reason for NPA's inability to attract and retain clients is the cost of treatment services. The previous City contractor, which experienced a higher number of Palo Alto resident clients, charged no fee for treatment except for hospital charges for detoxification. NPA requires clients to pay for their own treatment. This is in some ways useful because it indicates client commitment. However, the cost of the complete series of courses is probably prohibitive to the majority of the target population. An interview with the NPA executive director indicated that NPA had found a sliding fee schedule unworkable, and has had standard fees since January 1976. All fees are paid in advance. The fee is $55 for the basic communications course, which NPA estimates takes a client at least 60 hour's to complete. It should be noted that, this -31- being the case, when a client has completed the communications course, he/she has completed the required number of hours for reimbursement by the City. However, it would be unrealistic to feel that he/she has been successfully treated after one short course. NPA encourages clients to take further courses. The next course is a comparatively brief study course which costs $25. It is followed by a longer "objective exercises" course which costs $350. These two are usually taken as a pair. Finally, there is the "drug rundown", which is extensive one-to-one counseling for which NPA charges $50/hour. NPA indicated to staff that the counseling is broken into blocks of 25 hours and that the client pays in advance for one block at a time. The NPA executive director estimated that usually, a person requires 75-125 hours to complete the whole "drug run-down" process. Palo Alto residents also pay $15 per urinalysis. NPA charges $300 for a "drug-free" detoxification, which takes 3-4 complete days on NPA premises: $255 for services and $45 for vitamins. During the evaluation review meetings, the NPA representative stated that the issue of the cost of treatment was not of substantial importance. The NPA representative stated that NPA staff generally discussed only the cost of the first or basic course at intake and that clients would not be deterred by the $55 fee. NPA stated the opinion that the fee is inexpensive and necessary to encourage and develop client commitment. It should be noted that NPA requires a complicated and detailed procedure for the refund or repayment of money. ("A refund is a return of money after service. A repayment is a return of money without the service being taken." See page three of NPA's "Refund/Repayment Application Form".) This procedure includes copies of all invoices, cancelled checks and receipts, a notarized statement by the claimant, signed statements from three different Narconon officers which must be obtained by the claimant, and application to the -32- Claims Verification Board (C.V.B.). The claimant must also sign the statements: "I (the claimant) understand that I cannot, by reason of my applying for and receiving a refund or repayment, obtain further service from this or any NARCONON"; and "I, the claimant, understand that there is an administrative charge in making the claim for a refund or repayment. The charge is set after my request has been reviewed by the C.V.B. as the full expenses incurred for processing this claim must be accounted for in the billing." The NPA refund/repayment policy is relevant because of the substantial amount of fees required for a client to complete the NPA course of treatment. As can be seen if a client required detoxification and stayed on through the complete "drug run-down," of a minimum of 75 hours, the total client fee would be $4,495. This high fee level is likely a deterrent to potential participants. During the evaluation review meeting, the NPA representative stated that he did not think that the refund or repayment procedure was an intake deterrent. He said NPA had few people who had requested refund or repayment. Another possible explanation for the low level of client participants NPA has served is that, broadly stated, NPA does not have the trust and support of some relevant portions of the community. This involves a number of more specific issues. First, NPA provided very little opportunity to general community discussions regarding NPA policy in a formal way. NPA did not develop any sort of broad-based community input process. It did initiate an Advisory Board concept which had potential of serving this objective. The Advisory Board, however, did not meet during the contract period. A second issue relates to the question of linkages with the Church of Scientology. The evaluation is not concerned as to whether or to what extent Narconon is linked to the Church of Scientology. The practical impact of the issue does affect the evaluation. This is because, whatever the facts of the situation, the concerns and opinions of some members of the community about the issue, whether or not justified, may have acted as a barrier to NPA's ability to reach potential clients. -33- During the first evaluation review meeting, the representative of the Church of Scientology stated the observation that the press had been largely responsible for creating the issue of the alleged link between NPA and the Church of Scientology. She emphasized that this was not a valid issue. It should be noted that the practical impact of this issue extends not only to potential NPA clients, but also to other anti-drug abuse professionals. Several of the agency employees that City staff interviewed in connection with the needs section of this study and the interagency objective in NPA's scope of services indicated that one of the reasons they did not refer clients to NPA was that they were concerned about the relationship between NPA and the Church of Scientology. Whether or not this concern was justified, the issue itself served as a barrier to the effectiveness of NPA in providing anti-drug abuse services. Unfortunately, ETA was not able to resolve this issue merely by declaring that it was not a relevant issue or that they had proof that the allegations of an inappropriate connection were unfounded. As long as members of the target population which NPA attempted to serve felt it to be an issue, it remained an issue and had a practical impact. The issue was thorny and could only be resolved by specific and effective activity to convince persons in the community that it was not a relevant issue. NPA was not apparently able to do that. Another possible explanation for NPA's low client caseload was that the organization was impaired by NPA administrative problems. NPA had three different executive directors in six months, from June to November 1976. During much of this time, City staff bad problems contacting the executive director. NPA had difficulty with City reporting requirements. This could have related to the difficulty of interacting with the City bureaucracy and bureaucratic process. It appeared, however, to be a symptom of internal administrative problems. -34- For example, NPA submitted inadequate documentation of treatment in client cases. This way have been a reporting (paperwork) problem or have related to inadequate organization of services. NPA did not collect intake urinalyses when required in the contract. This could have provided empirical data about the client's drug problem. NPA did not draw up individual client achievement plans at the time of client enrollment, as required in the contract. Such plans would seem to be a vital part of the treatment process, in order to set clear goals for the person's treatment in NPA programs. The NPA administrative situation was not objectively tested by City staff because NPA refused City staff access to its files, although access is required under the terms of the contract and chose not to provide additional information. Problems associated with monitoring the NPA contract resulted in a large expenditure of City staff time and far beyond that required in connection with other human services contractors. One reason for the low service level in regard to non-treatment objectives (primary preventing coordination, planning, etc.) may have been because of NPA's need to shift available resources into treatment activities. NPA INSERT (discussed on page 3)
2. Service level and performance in relation to the cost of the contract. The total direct cost of the contracts with NPA was $15,701. This included $13,951 in monthly basic contract fees of $1,250 per month and $1,750 in reimbursement for treatment services rendered to seven clients in accordance with -35- section 6 of the contract. The contract provided payment to NPA in two ways: a) reimbursement at a set fee of $250 each, for treatment of clients with relatively severe dysfunctions resulting from drug abuse; and b) for all other services specified in the contract at a basic rate of $1,250 per month. The monthly fee included administrative overhead and other costs associated with services rendered to "reimbursable" clients.
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On December 6, 1976, the City Council voted to give NPA 30 days notice of contract termination, in accordance with Section 5(b) of the contract between the City of Palo Alto and Narconon Palo Alto (contract #3753). The contract was terminated effective January 5, 1977. VI. SUMMARY AND CONCLUSIONS The basic question of the evaluation is whether NPA was reasonably effective and efficient in providing services addressing the community's drug abuse problems. This question may be addressed in several ways; e.g., 1) comparing the service level and performance to the objectives of the contract and to need, and 2) comparing the service level and performance in relation to the cost of the contract 1. Service level and performance in relation to the objectives of the contract and to need. The contract required NPA to provide both treatment and preventative services to the Palo Alto community. Preventative and coordination services. NPA provided preventative services to participants in parents' seminars held at NPA offices. The seminars assisted parents in responding to family drug abuse related problems. NPA provided information to other persons seeking, assistance. This generally took the form of distributing materials relating to NPA services. NPA did not develop a broad range outreach program nor did it effectively involve or reach young persons in preventative (or treatment) activities. NPA established working relationships with some agencies and professionals dealing with drug abuse problems in the community such as the PAPD and the Adult Probation Authority. NPA did not establish effective working relationships as required in the contract with several important agencies which are involved in anti-drug abuse work including the Santa Clara County Drug Abuse Coordination Commission, Palo Alto Unified School District, and others. NPA's experience with these agencies prior to the City contracts was limited. NPA did not establish effective outreach to youth or to women and consequently -38- did not provide a satisfactory level of either treatment or preventative services to these target populations. NPA attempted to develop a community input mechanism of an Advisory Board. The Board was never fully implemented and NPA did not provide other substantial opportunity for community input into the organization's policy-making process. This direction from Council represented a different way of doing business for NPA and was difficult for them. Treatment Services to Drug Abusers. During the contract period from February 1, 1976 to January 5, 1977, NPA provided treatment services which qualified for reimbursement (under Section 2(a) of the Scope of Services) to seven (7) Palo Alto residents. From February 1st to September 30, 1976, NPA provided other treatment services, as described in Section 2(b) of the contract's scope of services, to 14 other Palo Alto residents for a total of 21. This figure does not include clients NPA may have treated after October 1st who were not reimbursable cases because NPA has not submitted information for this period. Nine of the 21 were characterized by the contract as "hard-drug" abusers, while 12 were "light" users, including alcohol abusers. This level of treatment services is low when compared to needs information, the experience of other drug abuse related agencies in the County or the experience of the previous City contractor and with target figures in the contract's scope of services. During the evaluation review meetings, NPA stated that they had interpreted Section 2(b) of the scope of services to include any clients whether Palo Alto or non-Palo Alto residents, who were not qualified for reimbursement. Staff felt this to be inconsistent with previous City-NPA discussions. Under NPA's interpretation, NPA provided services to between 24 and 32 clients during the first quarter. NPA did not provide any verifying documentation such as client files on these persons. Furthermore, 10 of the 24 were non-residents reported to have abused heroin, cocaine or amphetamines and would have been included under Section 2(a) had they -39- been Palo Alto residents. On balance, the performance described above characterizes a level of service and effectiveness which is acceptable neither in relationship to the scope of services incorporated in the City contract nor in light of the needs for services existing in the community. 2. Service level and performance in relation to the cost of the program. The evaluation of NPA relates also to the cost-effectiveness of the services rendered. The total cost entailed to the City by the contract with NPA was relatively low when compared with previous drug abuse contracts. Because of the client fee mechanism in the contract, the low number of reimbursable clients resulted in the bulk of the allocated funds reverting to the City's general fund. 3. Other conclusions The staff evaluation was not conducted under optimal circumstances. Throughout most of the evaluation period, NPA refused access by City staff to client files and records. For much of the time no communications were acknowledged. Much information was not stated until the evaluation review meetings. Documentation was extremely limited. Staff, however, was obliged to complete the evaluation based upon available information to meet the Council assignment. The evaluation review meetings were used to integrate NPA input into the report and to take the place, within obvious constraints, of independent verification of data. It is the opinion of the evaluation office that this level of performance was not satisfactory and that NPA's performance did not warrant a future contract for service unless substantial improvements were to be made in community involvement in decision making; in outreach capabilities to attract and involve participants from such priority target populations as youth, women, and others; in relationships with other agencies or referral sources such as PAUSD, Juvenile Probation, and area hospitals; and in other aspects noted in the body of the evaluation report. -40- No further action by the City with regard to NPA is indicated as a result of this evaluation in light of Council action of December 7, 1976. It is felt to be appropriate that any future role for the City in anti-drug abuse activity be reviewed in connection with the two current outstanding assignments to staff which will be reviewed by the City Council's Policy and Procedures Committee during February 1977. APPENDIX A APPENDIX B Introduction The following two pages were submitted by NPA as its first Women and Minority Employment Program Report. (Staff have included the instructions for section B on the second page, for the reader's convenience.) NPA reports having done no hiring during the first quarter of 1976-77. -43- -44- Progress Report Complete the progress report on a separate sheet(s) of paper.
Narconon Palo Alto Jul-Sept 1976 Minority Employment Program Progress Report 1. There has been no hiring other than of volunteers during the quarter. Equal staff training tine has been afforded to all staff in-house as a matter of policy. There have not been time or resources to send staff for external training activities in this quarter. The few promotions made internally have been geared to maintain a balance of minority staff in executive positions. 2. As above. 3. Satisfactory except as regards Spanish surname, which is a recruitment target area. Priority at present is toward a volume increase of staff. 4. a) Number of staff (currently too few); b) Part-time semi volunteer youth on staff; c) Maintain a good MRP balance and include Spanish surname representation. VOTE: NPA is operating at a level of such limited resources that its priority is in seeking and attracting staff rather than choosing amongst applicants. APPENDIX C SCOPE OF SERVICES A. GOALS AND OBJECTIVES 1. Primary Prevention GOAL: To prevent destructive experimentation and abuse of drugs by providing interventions and printed materials about drugs and their effects.
2. Secondary Prevention/Treatment and Tertiary Treatment GOAL: To reduce drug abuse in Palo Alto by facilitating changes in the social, personal and material environment of the drug abuser in order that he/she may establish a more productive, fulfilling and stable lifestyle.
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3. Outreach GOAL: To involve as many of the drug using/experimenting population as possible in either NPA or in other programs.
4. Coordination and community involvement GOAL: To establish liaison with other agencies and individuals interested in anti-drug abuse services and to coordinate treatment and prevention activities.
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5. Self-Evaluation Process GOAL: To identify more effective and efficient procedures to improve Narconon's ability to attract and assist clients with drug abuse problems.
-48- SUPPORT SERVICES - BEHAVIORAL CHANGES Each client will complete an achievement plan with contractor, including specific objectives and targets for appropriate categories.
-49- C. REIMBURSEMENTS - required documentation
-50- D. FOLLOW-UP CRITERIA AND INDICATORS FOR SUCCESSFUL REHABILITATION
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