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Running Head: Los Lunas Community Program

Jill D. Marshall

The Los Lunas Community Program: Final Reflection Paper and Practicum Evaluation

New Mexico Department of Health, Los Lunas Community Program

445 Camino Del Rey, Suite A

Los Lunas, New Mexico 87031

Direct Supervisor: Jon Hellebust, Executive Director

Running Head: Los Lunas Community Program 1

Abstract

The Los Lunas Community Program (LLCP) operated by the New Mexico Department of Health

is a community based service provider for persons with intellectual and developmental

disabilities. While this organization has been operating in this capacity for approximately 17

years, as a state run organization they have operated most of those years without accreditation.

Given the importance of accreditation in demonstrating quality service delivery that assures

evidence based best practices above and beyond organizational compliance, the LLCP is seeking

accreditation in the early spring of calendar year 2016. In order to prepare for accreditation, the

LLCP was in need of a strategic plan for calendar year 2015 and stakeholder handbook that

included a revised mission statement and values statements, and a customer service training for

all managing staff within the organization. The development and implementation of these items

were assigned to the January 2015 intern. This report provides a background of the organization,

and summarizes the experiences developing these documents and training by the January 2015

intern. The report also includes recommendations from the intern for further implementation and

follow up with regard to implementing the objectives, mission, and values presented within each

of these documents and part of the customer service training.


Introduction and Background

The New Mexico Department of Health, Los Lunas Community Program (LLCP) has been

providing services and supports to individuals who receive Medicaid waiver services as part of

the New Mexico Developmental Disabilities (DD) Waiver since the Los Lunas Hospital and

Training School was deinstitutionalized in May of 1997 (LLCP Provider Agreement, 2012).

They also operate a four bed community based Intermediate Care Facility for individuals with

intellectual disabilities (ICF/IID). The LLCP has been serving persons with intellectual and

developmental disabilities in the community for approximately 17 years through the DD waiver

system. LLCP has been successful in serving persons with the most critical medical needs and

those with the most challenging behavioral issues (LLCP Provider Agreement, 2015). Many of

the individuals currently served by the LLCP, have been with the LLCP since 1997 and have

long standing relationships with the staff that support them (LLCP Provider Agreement,

2012).The LLCP takes pride in providing what they describe as “quality and enriching services

to the individuals they support” (LLCP Provider Agreement, 2015, p. 3).

The LLCP and its staff have many years of experience in the field. The average length of

employment is 11 years and supports an average of 55 individuals in supported living and 80 in

customized community supports and employment (LLCP Provider Agreement, 2015). LLCP

also serves as a statewide crisis response agency and safety net provider, offering services and

supports to those in need either through technical assistance, direct provision of services or at

the ICF/IID (LLCP Provider Agreement, 2012).

The LLCP is funded through state general funds as well as federal Medicaid funds. All

persons who are served by the LLCP are either allocated a Medicaid waiver slot from the New

Mexico Department of Health Developmental Disabilities Supports Division (DDSD) or are


offered institutional Medicaid for services when admitted to the ICF/IID. These funds are

provided to the LLCP for services delivered as allocated by the NM State Legislature and by

the state Medicaid office through the Medicaid billing and rate setting process (LLCP Provider

Agreement, 2012). Only individuals who are determined eligible by the New Mexico Human

Services Division (HSD) by meeting the criterion for admission to an ICF/IID and either be

admitted to an ICF/IID or be waived from institutional services and receive a Medicaid waiver

slot for the DD Medicaid waiver can receive Medicaid funds. Any other individual served by

the LLCP who has not been determined eligible by HSD is funded solely with state general

funds (LLCP Provider Agreement, 2012).

The LLLCP as a social service provider and as such, the public health issue I am addressing

with my practicum includes a) assisting the organization with the development of their new

stakeholder handbook, and strategic plan both of which will include a new mission statement

and set of organizational values, as well as the development and provision of a customer service

training that supports the new mission and values development. This will be done to assist the

LLCP to seek accreditation with the Commission on Accreditation of Rehabilitation Facilities

(CARF) International. This is important to the organization in that as they are necessary to be in

place for six months prior to having an onsite CARF review (CARF International, 2013).

Accreditation is important to the organization as having accreditation will support the

organizations commitment to implement best practices and deliver quality services that exceed

general compliance measures (CARF International, 2013).


The mission of the organization upon starting my practicum was

The mission of the Los Lunas Community Program is to assure caring, high quality

support and services that assist New Mexicans with developmental disabilities to live a

life which is self-directed, and includes good health, a safe environment, meaningful

relationships and opportunities for personal growth in community-based settings

(LLCP Provider Agreement, 2012).

The Los Lunas Community Program (LLCP) provides an array of services including those

offered through the Developmental Disability Waiver Program (DD Waiver) and the

Intermediate Care Facility for Persons with Intellectual Disabilities (ICF/IID). Services include:

1. Community integrated employment: This is a service where the LLCP assists those

served to become employed in the community in jobs that increase economic

independence, self-reliance, social connections and career development (DD Waiver

Standards, 2012).

2. Customized Community Supports (CCS): This service provides supports to those served

by the LLCP to assist them in increasing their independence, strengthen their ability to

decrease needed paid supports, establish or strengthen interpersonal relationships, joining

social networks and participate in typical community life (DD Waiver Standards, 2012).

3. Living Supports: This service includes twenty-four hour, seven-day per week residential

community living supports designed to increase and promote independence and to assist

those served to live as independently as possible in the community of their choice (DD

Waiver Standards, 2012).


Discussion

My role during my internship/practicum with the LLCP was to initiate, facilitate, and

develop an organizational stakeholder handbook and strategic plan that included a revised

mission statement and organizational values. Additionally as part of my internship, I was

responsible for the development and facilitation of a customer service training that supported

the development and implementation of the new organizational mission statement and values.

Initial Planning and Preparation

The first step in the initial planning and preparation process was to meet with LLCP

administration and explain the process of strategic planning, mission statement and

organizational values development for the current calendar year, 2015. Given that I was already

employed with this organization as the Deputy Director prior to starting my internship, I was

able to plan my initial meetings before to starting my internship. This way, I was able to meet

with the LLCP administration to discuss the project planning and development on my first day

as an intern. My meeting with the LLCP administration consisted of meeting with the LLCP

Executive Director, Jon Hellebust, the LLCP Human Resources Director, Kathy Lucero, the

LLCP Finance Director, and Annamarie Gurule-Duran.

During this meeting we discussed the first section of the CARF International Accreditation

manual and what the organization had in place and what was needed. It was identified during

the meeting that prior to applying for the CARF accreditation survey LLCP would need to have

a 2015 Strategic plan, stakeholder handbook, and an updated mission statement and

organizational values (based on the required person-centered planning strategies already in

practice by the LLCP) in place for six months. During this meeting I explained that I would be

scheduling many meetings throughout the month of January to seek feedback and buy-in from


those served by the LLCP, staff, and other internal and external stakeholders in the

development of the plan, handbook, customer service training, mission statement, and

organizational values. I further explained that the mission statement and organizational values

would be developed with the input of those served and all staff. Additionally, managers

employed by the LLCP would participate in the development of the mission statement and

organizational values as part of the customer service training developed and presented during

the month of January 2015.

The second step in my initial planning and preparation was to meet with the LLCP quality

assurance and improvement committee and review current policies and materials in place and

those what would be needed for accreditation. This way they could concurrently be working on

any needed policy and procedural revisions. Doing this would allow for the presentation of

policy and procedural updates during the Governing Board meeting scheduled for March 2015.

This consisted of a review of all daily operations policies, training, medical records, finance,

nursing, and human resources policies. Policies were assigned to committee members within

their own department to meet and initiate any recommendations and bring back to the

committee for and overall review prior to being submitted to the LLCP Administration for

approval during the month of February 2015. Following the approval of the LLCP

Administration, these policies will be submitted to the LLCP Governing Board in March 2015.

This third step in the initial planning and preparation was to meet with the NM Department

of Health, Office of Facilities Management Governing Board to obtain approval to move

forward with the strategic planning process. The Governing Board has membership from the

LLCP Executive Director, as well as directors from all other state operated facilities to include

Fort Bayard Medical Center, New Mexico Veterans Home, Turquoise Lodge Hospital, Sequoia


Adolescent Treatment Center, Roswell Rehabilitation Center, and the New Mexico Behavioral

Health Institute. Other membership includes the Department of Health Secretary, Chief Deputy

Secretary, Deputy Secretary, Chief Medical Officer, Chief Nurse Executive, Chief Financial

Officer, Chief Communications Officer, and Chief Counsel. Governing board was scheduled at

LLCP the first week of my internship, and as such I was able to speak to the board during

LLCP’s allotted agenda time during the meeting. It was at this meeting I obtained approval to

move forward with the strategic planning process to include the development of a revised

mission statement, organizational values, and stakeholder handbook for the LLCP.

Information Gathering

Information gathering was a critical part of the development of my internship project. The

first step in the information gathering process was to develop the customer and employee

satisfaction surveys and organizational mission survey. This way, those served by LLCP

including guardians, LLCP staff, and those that interact with the LLCP regularly would have

the opportunity to answer questions about the mission of the LLCP and what they believe the

mission should be, LLCP’s customer service, and the LLCP experience in general.

The second step in the information gathering process was to meet with HR Director to

discuss dissemination of survey and to actually disseminate survey. This was done to assure

that staff at all levels would be able to read and review the survey and have a way to return the

survey anonymously if they preferred. It was decided that surveys would be sent out to those

served by LLCP and their guardians, LLCP staff, community members who interact with the

LLCP regularly (e.g., the county, local police, major business general managers, WIC, etc.) in

two formats: 1) electronic through the use of survey monkey for those who prefer to use their

computer to complete the survey and 2) paper for those who do not prefer to use or have access


to a computer. Additionally, the electronic and paper copies were be available in both English

and Spanish with accompanying pictures for those who may have an intellectual or

developmental disability. All recipients of the survey were given a week to review and return

the survey, and a number to contact if they required assistance reading and/or completing the

survey. Surveys were distributed via email, in person, or with paychecks. Arrangements were

made to pick up completed surveys, have a drop box on site, in addition to their return through

the use of Survey Monkey or U.S. Mail.

The third step in the information gathering process was to conduct community site visits and

meet with staff at all levels of organization, meet with guardians and case managers, new

employees attending new employee orientation, and the human rights committee to obtain

feedback from the surveys and the survey process. These meetings were carried out separately

as follows. Site visits were made throughout the county and questions from the survey were

asked of those at each site. This same process was used to meet with staff in all locations,

during all shifts, and at all levels of the organization. I met with guardians, case managers, and

the Human Rights Committee (HRC) during their regularly scheduled meetings. I met with the

HRC at LLCP just before the start of the committee meeting, I met with guardians from the Arc

of New Mexico (who serve as approximately 45 percent of the LLCPs corporate guardians) and

with multiple independent case managers during an arranged meeting at the LLCP that was

scheduled solely to obtain feedback for this project. Finally, I met with the new employee

orientation class scheduled for the month of January to ask the class questions and obtain

feedback about what would be helpful with regard to a stakeholder handbook provided as part

of new employee orientation.


Materials Preparation

Following the informational gathering process, I reviewed all surveys returned to the LLCP.

From the information returned in those surveys, I was able to prepare outlines to guide me and

the stakeholders through the development of each of the projects. As suspected, it was found

that customer service was an important part of the responses from those completing the survey.

Following the survey analysis, the first part of materials preparation was the development of the

customer service training as this training was to serve two purposes. The first was to train all

managers on customer services as it relates to the LLCP and the person-centered philosophy

required by CARF International. The second was to use the training to identify and seek buy-in

from the managers regarding the LLCP mission statement and organizational values s. Once the

outline was prepared, I met with the technical assistance and regional training personnel from

the NMDOH, Developmental Disabilities Supports Division (DDSD) to talk through my

outline and ideas and to solicit their support in providing the training. They agreed to attend the

training to serve as additional support, as well as actors for the roll playing activities.

The second materials that needed to be prepared was the outline of the strategic plan and

stakeholder handbook. These outlines had placeholders for the mission statement and

organizational values so that they could be discussed during the meeting and further developed

through the customer service training.

Scheduling

The customer service training was scheduled by the human resources administrative

assistant and would take place over a two-day period in order to ensure that all those invited

would be able to attend one of the two day, four-hour trainings. Each class was limited to 35

participants. Meetings were scheduled the community living administrative assistant for the


LLCP. The stakeholder meeting was scheduled as an event serving a meal to include posole,

ham, vegan dolmas, tortillas, and chocolate chip cookies. A meal was planned so that all those

invited would be motivated to attend and participate throughout the meeting. The menu was

chosen with a traditional New Mexican lunch serving Valencia County, New Mexico Red Chile

Posole to foster the New Mexican culture and promote one of the largest New Mexican and

Valencia County crops. Finally, a follow-up strategic plan and stakeholder question and answer

meeting was scheduled for later in the month, following the first meeting and the customer

service training) in order to present the finalized mission statement, organizational values, the

strategic plan, and the stakeholder handbook. A meal was planned for this meeting as well. The

meal for this meeting would be traditional Valencia County New Mexico Green Chile Stew,

tortillas, vegan tamales, and biscochitos (the state cookie).

Training, Presentations, and Project Development

The Stakeholder Meeting

The first presentation and meeting held was the stakeholder and strategic planning meeting

where we discussed the and overview of the services and service delivery; brainstormed the

mission statement and organizational values, discussed the future direction of the organization;

reviewed the organization’s financial status; conducted an environmental scan of the

organization and analysis of the organization’s strengths, weaknesses, opportunities, and threats

(SWOT analysis); developed organizational objectives based on the socio-ecological model;

and developed of measurable organizational outcomes.

The meeting involved many activities and started with the overview of service delivery to

include LLCP’s provision of services including community integrated employment, customized

community supports, and living supports. Next, the purpose of the organization was discussed


as well as a directed brainstorming of the mission statement and organizational values. This was

done using flip charts and sticky notes. The overall operating budget of $16.4 million was

reviewed, as well as a high level overview of current and projected revenue and expenditures.

Flip charts and facilitated small groups were used to conduct the environmental scan and

SWOT analysis that were later combined in a large group activity.

The SWOT analysis process revealed that the LLCP had strengths in its application of

strong values and person-centered service delivery, are in compliance, have active leadership,

and a positive working relationship with advocacy organizations. Weaknesses were identified

as needing more support for evidence-based best practices, need for more full time equivalent

(FTE) positions to accommodate growing census, there is a long screening time of applicants at

the state office level, no flexibility with compensation, and a need to develop a cultural

competency plan and program. Opportunities were identified as the LLCP continues to

demonstrate substantial compliance with the State of NM Jackson Class Action Lawsuit (filed

in 1987 to deinstitutionalize those with developmental disabilities in New Mexico), serve as a

model program for community services, promote a public image, and offer gainful employment

for persons served. The threats to the organization include the organizations relationships with

other community organizations (e.g., county operated senior centers), the lack of understanding

and acceptance by the community of person with disabilities specifically those with intellectual

and developmental disabilities, and access to a qualified and competent workforce.

Following the discussion and review of the SWOT analysis an overarching framework for

the development of objectives was presented using the socio-ecological model. Objective

categories were placed within the socio-ecological framework using a large poster of concentric

circles and sticky notes handed out to each participant. Discussion regarding each suggestion or


recommendation and its importance for inclusion in the strategic plan was processed with the

group and an outline was prepared and used to support each objective category selected by the

committee (by vote). The categories chosen were as follows:

1. Individual – Focus on quality of services delivered not just compliance.

2. Community – Improve relationships with sister agencies and community organizations.

3. Organizational –

a. Improve recruitment efforts to solicit a more qualified and competent workforce.

b. Update organizational policies and procedures

c. Train and promote the new philosophy, mission, vision, and values.

4. Policy – Become CARF Accredited.

Following the identification of each objective measurable outcomes were written including

timeframes for completion.

Upon the completion of this exercise, the need for a stakeholder handbook was discussed

and items and sections to be included in the handbook were identified by the group. Sections

determined by the committee to be included in the new stakeholder handbook were: an

introduction to the LLCP, an overview of the purpose, mission, vision, and values of the

organization, an introduction to leadership, and organizational chart, discussion of cultural

competence, a description of services, and where a stakeholder can obtain a copy of the LLCP

policy and procedural manual.

The Customer Service Training

The second part of training, presentations, and project development included the customer

service training. Following the planning phase, the training was prepared in a PowerPoint


format (Appendix A) and planned so that a variety of training techniques were used to engage

the audience. The training consisted of and ice breaker and introduction, group discussion, two

videos from TEDTalks.com (one that inspired me so much during one of my CUNE Classes,

that I borrowed it for this training), one self-actualization activity, and a role playing. I

facilitated this training with the assistance from the DOH DDSD training and technical

assistance department Juan Carlos Martinez, Regional Trainer, David Espinoza, Statewide

Trainer, and Doug Wooldridge, Technical Assistance Specialist. The training was scheduled to

begin at 10:00 a.m. each of the two mornings run until noon, have an hour for lunch, and start

up again at 1:00 p.m. for another two hours of training.

The training included an introduction that explained to all in attendance that this class was

being offered in response to the information received from the surveys completed by both

internal and external stakeholders and would be the first in a series of courses to follow. Future

courses will include professionalism, leadership, teambuilding, and quality. The rest of the

morning went as follows a review of the DOH Mission; an icebreaker activity and group

introduction; the first video; group discussion regarding why LLCP provides exceptional

customer service, how exceptional customer service is provided, a definition of exceptional

customer service, and identification of the LLCP customers; a self-actualization exercise and

group sharing and processing; discussion of barriers to quality customer service; discussion

regarding the qualities of those who deliver exceptional customer service (the writing of the

LLCP values list); and overview of the DOH Secretary’s Speed of Trust Action Items.

Following the lunch break, the second half of the afternoon focused on practical application

and the development of the mission statement. The afternoon training consisted of a recap of

the morning’s activities; presentation and discussion of a formula for success; another TED


Talk video; role play of three actual LLCP scenarios including the concerned citizen, the team,

and the guardian; role play debrief regarding how customer service is relative to LLCP and why

we are all here; review of the why we are here and why we provide exceptional customer

service and see if we all agree to the reason we are all here; writing of the draft mission based

on why we are all here; review draft; ask for questions and obtain feedback; and close.

Final Question and Answer Meeting

The third part of the training presentations, and project development was a final question

and answer meeting. This included inviting all internal and external stakeholders to attend a

presentation of the final strategic plan (Appendix B) and stakeholder handbook (Appendix C),

both of which included LLCP’s the new mission statement and organizational values. Prior to

this meeting both the strategic plan and stakeholder handbook were revised to a final draft that

included the mission and values as consolidated from the first stakeholder meeting and the

customer service training and reviewed and approved by the LLCP executive administration for

stakeholder review. Both documents were printed and prepared for the stakeholder meeting and

presented as final drafts. During the meeting both internal and external stakeholders able to

review and comment on the documents during a facilitated question and answer session. The

meeting went well and both documents were endorsed by the committee. The final drafts and

will be presented to the OFM Governing Board at the beginning of March for final approval.

Applicability and Appropriateness of Project to the Organization

In my opinion, the project including the proposed goals and objectives were appropriate in

addressing the problems within the organization in that each objective identified by the

stakeholder committee was directly related to organization’s improvement. This was evident

through use of the SWOT analysis process, as well as needed to meet the requirements for


CARF accreditation. The barriers I struggled with during this project was adhering to the set

and scheduled timeframes while also preparing for the NM Legislative Session. Had my

internship not been limited to approximately 80 hours, I may have pushed back some of the

initiatives in order to address the pressing issues related to the legislative session preparation.

The barriers the organization will face in the completion of this project will be with adhering to

the timeframes set in the strategic plan as well as working with the community to promote the

acceptance of persons with disabilities.

Personal Assessment

This practicum has contributed to an understanding of public health practice in that my

practicum period revolved around the legislative session and the strategic planning process.

This experience helped me to better understand all of the various facets involved in state

government from funding through service delivery. The things I learned during my practicum

period included having a more in-depth understanding of how different stakeholders and groups

with differing perspectives can offer valuable input that pulls the organization together in ways

that will ultimately make it more successful. I also gained more knowledge about the New

Mexico legislative process and about how the funding allocations and successful organizational

finances can drive the provision of services in New Mexico.

The public health competencies that were applied during my internship included two

domains of public health (i.e., social and behavioral sciences and health policy and

management); the design, implementation, and evaluation of a public health program and its

policies; implementing a public health program that reflected communication, leadership, and

advocacy skills; and a demonstration of principles of ethical reasoning and professional

practice. These were met as described below.


While not all five of the domains were addressed during my internship the two that were

addressed included social and behavioral sciences and health policy and management. These

were addressed in that the LLCP is a social services organization and the services delivered as

part of their daily operations are grounded in providing people with the supports and services

they need in order to make behavioral changes that help them to become healthier and more

independent. My internship project and most of my work during my internship period centered

heavily on health policy and management as during this time period the LLCP was preparing

for the legislative session. As part of this preparation, I met with the legislative finance

committee, the senate finance committee, and the house appropriations committee, as well as

interviewing with the legislative finance committee review team to discuss the provision of

LLCP’s services and how it relates to the FY16 appropriations request. My internship projects

involved the development of my management skills and abilities in order to design documents

that will drive the future of the organization in its mission and values, in their objectives and

outcome measurement, and when working with those served and community at large.

As part of my internship, evaluating the program and its status was conducted through the

surveying of internal and external stakeholders. Once the evaluation was conducted and

analyzed I developed documents to assist me with the development of the strategic plan.

Additionally, I met with the quality assurance team to review current agency policies and made

assignments for a comprehensive policy review and revision to address the service delivery of

the LLCP for all served by the organization. As part of this process, it was critical to ensure that

there was a strong advocacy for those served by the organization. This included the

development of the internship materials making sure that all focus was person centered and was

to improve the lives of those served by the organization.


The demonstration of ethical reasoning was at the forefront throughout my internship, not

only in the delivery of services and the advocacy of individuals, but in the responsibility to the

public as a state operated organization. As such, it is imperative to ensure financial

responsibility that uses resources efficiently and effectively and does not waste the tax payer’s

money. As a public entity, it is the responsibility of the LLCP to assure evidence based best

practices are implemented while doing so in a way that does not compromise service deliver or

create wasteful spending. Through the strategic planning process this was very tedious, as there

is fine line to tread when discussing quality of services and financial responsibility. The

strategic planning process served to balance both of these issues.

Conclusions and Recommendations

As part of the strategic planning development, the plan itself has sections to evaluate the

ongoing progress toward the completion of the plan. This is critical, as the development of

objectives without measurement of the outcomes for this organization could result in the

organization failing to put into place the steps necessary for accreditation, as well as a loss of

credibility from all of the stakeholders that put in time and effort to assist in the development of

the plan. To assure that this does not occur, strategic planning follow up meetings have been

scheduled for each quarter throughout the year to discuss the ongoing progress toward the

completion of the plan. This also includes a final evaluation of the plan to determine how

effective the implementation was to the organization.

Additionally, the plan has been assigned to the Director of Quality Assurance who will put

together a project management plan for each of the items that includes responsible parties and

deadlines for each action step required to successfully complete each outcome. This is

necessary as it breaks down the overarching plan into manageable sections and tasks that can be


carried out by different staff within the organization.

Finally, it is important that the LLCP continue with management training as this was

something identified as part of the survey process, but due to time constraints could not be

addressed during the time of internship. Due to its importance and due to the need for

validation of the staff’s response to the survey, the need for additional classes was discussed

with the staff during the customer service training and with LLCP administration following the

initial survey analysis. The trainings should focus providing mid-level managers with more

leadership skills and abilities relative to the mission of the LLCP. Fortunately, my employment

with the organization will continue beyond my internship (my evaluation included as Appendix

D) and I will be able to assure the recommendations presented as part of this report will be

carried out.


REFERENCES

Developmental Disability (DD) Waiver Standards (2012). Developmental Disability Supports

Division. New Mexico Department of Health. Retrieved from

http://actnewmexico.org/downloads/2012%20DD%20Waiver%20Service%20Standards.pdf

Los Lunas Community Program (LLCP) Provider Agreement. (2012). Los Lunas Community

Program. New Mexico Department of Health.

Los Lunas Community Program (LLCP) Provider Agreement. (2015). Los Lunas Community

Program. New Mexico Department of Health.

Los Lunas Community Program (LLCP) 2015 Strategic Plan (2015). Los Lunas Community

Program. New Mexico Department of Health

TedTalks.com (n.d.). TED Conferences, LLC. Retrieved from https://www.ted.com/talks

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