BPS2009-12.doc



AMCHP Best Practice Submission 2009

1. What is the name of your practice or program?

Oregon CAre COOrdinatioN (CaCoon) Program

CaCoon is a program that encompasses many practices related to public health nursing, home visiting, access to care and care coordination for children and youth with special healthcare needs (CYSHN). It is offered as a promising practice for care coordination.

2. Please provide a description/abstract of the practice you are submitting in 200 words or less which address the following 1.) Project goals 2.) Activities undertaken to develop the practice 3.) How was project/practice success measured 4.) What makes this a remarkable practice, and 5.) How will others benefit from learning about this practice?

CaCoon is a community-based care coordination program for CYSHN administered by the Oregon Center for Children and Youth with Special Health Needs (OCCYSHN), Oregon’s Title V CYSHN program. OCCYSHN contracts with Oregon’s local public health departments (LHDs) to implement the CaCoon program statewide. Oregon’s care coordination program for children with special health care needs has a network of public health nurses who work with families to determine family needs and priorities and to develop a care plan. Public Health Nurses (PHNs) promote optimal child and family outcomes through the practice of care coordination and home visiting. Strengths of the CaCoon programs include its flexibility to meet the changing needs of families and its strong links to community systems. OCCYSHN maintains responsibility for ongoing program development, monitoring, teaching and technical assistance to support community-based CaCoon nurses.

The goals of the CaCoon Program are to assure:

• Access to health care services for CYSHN

• Increased family confidence/competence in caring for their CYSHN

• Coordinated care

• Knowledgeable and skilled PHNs to implement care coordination

Activities undertaken to develop the program were initiated in 1988 to move toward community-based systems of care and away from center-based direct care approaches. A thorough review of the literature available at the time on home visiting models and care coordination was conducted. The program was designed in partnership with LHDs and pediatric specialists. It began as a pilot project in 3 Oregon counties. Evaluation determined it to be a viable and effective program. By 1991, the program was implemented statewide, supported with curriculum, training and practice standards and OCCYSHN staff PHN consultants to provide ongoing technical assistance to local PHNs.

Early measures of program success included:

• Assessment of family satisfaction with the program services,

• Extent to which program met the child’s and family’s needs,

• Fidelity to program principles, standards, and design in implementation communities,

• Appropriate referrals for services.

The CaCoon program has spanned two decades of significant change in Oregon’s health care system and widely varying economic conditions. Primary factors in its longevity include:

• Consistent adherence to practices of community based, culturally competent, family-centered, comprehensive, and coordinated care

• Ongoing support and training provided to PHN’s

• Continuous quality improvement efforts over the life of the program

• LHDs’ commitment to the program and the target population

• Strong partnerships with agencies and organizations serving CYSHN

These factors have uniquely positioned CaCoon to fill a critical gap in services to CYSHN especially in the area of care coordination and access to care.

Indicators of Remarkable Practice

Continuous quality improvement is a hallmark of OCCYSHN. Significant adaptations and innovations include:

• Development of comprehensive nurse training modules

• Addition of Promotoras, lay health providers, to meet needs of culturally diverse and non-English speaking families

• Improvement in care coordination and data collection through use of a shared statewide data system: Oregon Child Health Information Data System (ORCHIDS)

• Sustained workforce of PHNs with ever increasing capacity to address needs of children with complex conditions

• Ongoing teaching and support in a variety of modalities. Current use of webinar training allows broad participation, low cost to program and less time lost to travel. Archived trainings are easily viewed at convenient times for local PHN’s.

Benefit to Others

Other states may benefit from learning about this program as an alternative method to assure care coordination for CYSHN on a statewide basis. The program provides accountability standards which are included in county contracts. Ongoing training and support, including expertise from OCCYSHN staff and OHSU specialty providers, contribute to practice quality and currency. CaCoon is a highly valued program at both the state and local levels. It greatly contributes to the assurance of access to health services that are community-based, culturally competent, family-centered and coordinated.

3. What is the primary population focus for your best practice? Check all that apply.

• Children with special health needs, age birth through 20 years

• Other: Families of children with special health care needs

4. Please provide information about the location of the practice - i.e., is the practice state-wide or in one area of the state/community? What is the approximate sample size?

The CaCoon program is delivered statewide at the local level in all 36 Oregon counties. Data from the National Survey of CSHN 2005-6, estimates approximately 117,000 children (0 to 17 years of age) in Oregon have special needs. In FY09, 1,858 Oregon children received 7,773 visits from CaCoon nurses.

5. Describe the audience or practitioner who would benefit from learning about this practice.

Title V programs in states with large rural areas and limited provider access as well as provider resources may find this model to be particularly helpful. Physicians and Nurse Practitioners challenged to provide care coordination may also benefit by partnering with Title V and County Public Health Departments to develop similar programs. Families of CYSHN may be interested in CaCoon, a care coordination program that provides home visiting, parent support and teaching, as an alternative to a practice-based model.

6. What is the primary issue focus(es) for your best practice? Check all that apply.

• Access to care

• Other: Care Coordination for CYSHN

7. Please describe the specific need for this practice, i.e., what data or evidence do you have regarding your target population that shows this is a problem? Cite specific literature and local or state data as appropriate.

National initiatives around developing comprehensive care and coordination in a medical home, including Maternal and Child Health performance and outcome measures for all Title V programs, highlight the continued need for better coordination for CYSHN. Data from the 2005-06 National Survey for CYSHCN confirms that Oregon families do not receive needed care coordination even though most do have a regular source of care:

• 32% of Oregon families reported receiving help arranging and coordinating care even though almost 93% reported having a regular source of care – a personal doctor or nurse

• Only 47% of CYSHN (age 0-17) met all criteria for a medical home

A Family Voices and Brandeis University national survey of 2200 families of CYSHN in 20 states, including Oregon, pointed to similar issues with care coordination, including frustration of parents who had multiple case managers but still had to coordinate care (or case managers) and that trying to coordinate care on their own was often difficult.

8. What are the overall goals and key objectives of your practice?

The overall goal of the program is to assure access to timely and appropriate care for children with special health care needs and their families through the practice of care coordination delivered by a public health nurse at the local level. The CaCoon Program responds to the needs of children requiring a higher level of specialized service due to complex conditions involving multiple providers across multiple systems of care. The program is delivered through a home visiting program by highly skilled public health nurses knowledgeable of the systems of care and the barriers that often exist for children with complex needs and their families.

The key objectives of the practice include the provision of the following services to the child and family:

• Child health and family assessment, including family strengths

• Tier assessment identifying priority of issues, areas of focus, and parental need

• Monitoring of CYSHN health and development

• Linking families to specialty health care and community resources

• Support and counseling

• Advocacy

• Service coordination

• Consultation with other agencies/providers about CYSHN

DESIGN

9. What is the theoretical foundation (e.g., Social Change Theory) for your practice? List any theories used, and explain how they were applied. If multiple theories were used, explain how they fit together to form the basis of your practice.

The Nursing Process provided the theoretical foundation for the CaCoon Program with a model of assessment, diagnosis, outcomes/planning, documentation and evaluation. This model of continuous assessment with a focus on outcomes and evaluation of interventions provided the foundation for public health nurse interactions with families and their children with special health needs within the community through home visiting.

Family-centered care and care coordination as an emerging theoretical and practice models also informed the development of the CaCoon program practices. These practices delivered through public health nursing are the foundations of the CaCoon program.[i]

David Olds contributed to this thinking through his studies of outcomes resulting from public health nurse home visiting to intervene in the outcomes of families and children’s health. This informed much of the development discussion of the CaCoon program[ii].

Within Oregon, work around The Oregon Benchmarks began to frame the discussion and thinking in Oregon toward how to systematically move indicators of health and wellbeing on Oregon citizens, most especially its children through systems change. This was supported by the work of Healthy People 2000 (and subsequently 2010, and now 2020 toward Achieving Better Health Outcomes.

Public health nursing, as framework for implementing for care coordination, supports the potential to serve all families with CYSHN who live in the community. Since the program early development 20 years ago, additional studies and literature reviews have addressed the benefits of various models of care coordination which continue to reinforce the original goals, principles, and practices of the CaCoon program.

The well-developed theoretical framework for public health nursing is the Nurse Family Partnership, stemming from David Olds’ work, and is based on a social ecology model. Nursing process contains all the components necessary to develop appropriate relationships and plans of care with families, including care coordination. The strength of the public health nursing model lies in the demonstrated ability of PHNs to build relationships. These relationships increase families’ ability to develop enhanced skills.

The CaCoon program model and its practices is the result of the intersection of the public health nursing model and framework and theories of care coordination and family-centered care.

10. Did you base your practice on existing tools (guidelines, protocols, models or standards such as Bright Futures guidelines)? If so, please specify which ones and explain how they were used in the practice.

Yes, the CaCoon program and the many practices within the program was and continues to be based upon existing tools at the time and throughout its 20 years of implementation.

The original CaCoon Program, as piloted, drew upon a curriculum designed specifically for CaCoon in collaboration with OHSU School of Nursing faculty. This curriculum which included evidence-based practice for nurse training became the basis for the CaCoon program manual and its recommendations and guidelines for practice. The model of nursing education and training which demands a consistent curriculum with standards provided a basis for this work. Additionally, the guidelines around assessment of CSHN intensity of needs were used to develop the CaCoon Tier Level Assessment Tool.  The Nursing Process model was applied to the development of all the assessment tools.

Other tools, as noted below, have also informed and shaped the CaCoon program practices. Over the years, CaCoon has produced many of it own program standards, guidelines, and program-specific tools have emerged over the years to support fidelity of implementation of CaCoon (see item #27). 

1. Region X Nursing Assessment Protocols are based on Gordon’s 11 functional categories. They contain a series of questions and a template to guide the nurse assessment process. CaCoon PHN practices were based upon these protocols as the standard of nurse practice[iii].

2. NCAST Feeding Scale and NCAST Teaching Scale - informed practice of public health nurses.

3. Standardized developmental screening tools have been included in the “tool box” for PHNs to assess children and then refer them to appropriate services. Training in the implementation of the tools is included in the CaCoon program. Standard tools recommended for use by CaCoon Nurses include:

a. Ages and Stages Screening

b. Infant Motor Screen

c. Revised Developmental Screening Inventory (RDSI)

d. The CAT/CLAMS Screening Tool

e. MCHAT

4. Bright Futures – published by American Academy of Pediatrics provided foundational practices for serving children with special health care needs

5. Safety Tips for Children with Special Needs, (Toledo Children’s Hospital, ed Fall2007). This tool was incorporated into the set of tools for use by PHNs with families of CYSHN.

6. AAP Emergency Form – This tool was incorporated into the recommended set of tools for all CaCoon Coordinators and Nurses to use in serving CYSHN. No adaptations were made.

11. How did you adapt these tools to your practice? Be specific about changes to the model that were made, portions that were not used, and why adaptations were made.

• The Region X Nursing Assessment Protocols were adapted for use within the CaCoon program by the addition of questions related to serving CYSHN to the Region X cards. Guidelines were formatted onto a set of 4” by 6” cards for ease of reference for PHNs during home visits.

• Safety Tips for CSN, Fall 2007 edition from Toledo Children’s Hospital –Wyoming Department of Health Care Coordination Manual_Chart Review Tool. This tool was adapted to the CaCoon program resulting in the CaCoon Chart Review Tool for use within the local county.

• CaCoon utilizes the Hearing History Questionnaire and the Vision Screening Guideline developed by the Oregon Babies First! Program

• We used the Chapter on care coordination from the Wyoming Department of Health’s Care Coordination Manual[iv] as well as material from the BaBies First! Chart Review Tool to design the care coordination section of CaCoon’s Chart Review Too.

12. What was your process to incorporate peer/ stakeholder input and lessons learned throughout implementation?

Through the development and early implementation of the program, evaluative feedback was collected through surveys, meetings, and focus group studies from Local County Health Department Public Health Nurse Supervisors, CaCoon Nurses implementing the program at the local level, and families receiving services from the CaCoon program. This feedback and input was utilized to continue to strengthen the program and respond to the needs of the CaCoon nurses as they implemented the program activities.

13. Describe your evaluation process, including short term and long term outcomes that were measured. Explain the methods of evaluation such as whether you used a control group, how people were selected to participate in the practice, and the potential biases of this process.

OCCYSHN conducts ongoing program monitoring and program evaluation with a focus on program improvement of the CaCoon Program. Evaluation efforts focus on the fidelity of practice to program standards. Family satisfaction is assessed every few years to maintain an ongoing measure of family response to the program. Short term and long term outcomes that are assessed through the program evaluation include:

• Implementation of program standards

• Referrals to services

• Successful completion of the referral process

• Access to needed health care services

• Increased family competency in caring for their CYSHN

Program Monitoring and Evaluation and Quality Assurance. OCCYSHN uses data submitted by counties to monitor and evaluate program services. In 2007, Oregon implemented a database, “ORCHIDS” (Oregon Child Health Information Data System) that allows PHNs to document encounters with children and families. This database was developed by the Oregon Office of Family Health in collaboration with the OCCYSHN program. ORCHIDS supports the collection of key demographic data as well as outcome data on issues addressed by PHNs including nutrition, child development, parenting, injury, and family knowledge of their child’s condition. ORCHIDS data reports support activities of quality assurance as in setting targets for increasing the percentage of children who have a nutrition screening.

Program Standards. OCCYSHN’s state nurse consultants conduct minimally one site visit per year to each county to review program standards, discuss additional training needs, and to consult with the nurses on individual children. Local health department capacity and community issues are also addressed.

14. Does your best practice relate to any of the 18 National Title V/MCH Block Grant Performance Measures? Check all that apply

The CaCoon program addresses MCHB Performance Measures 2, 3, 5 and 6 (limited)

15. What was the time frame for your practice (e.g., time from implementation to completion or is it ongoing)?

This program is ongoing. It began in 1988.

16. What did your practice cost in terms of resources (e.g, type/amount of personnel, funds, supplies/materials, etc.)? Include a calculation of cost per client.

Local implementation costs of the CaCoon program varies county by county. This variation depends on variables such as population, density, level of need, and county capacity to contribute financial and/or personnel resources to the CaCoon program.

OCCYSHN contracts with the local counties at a total annual cost of $939,801 in FY09 in which 1,669 children and families were served through 7,763 visits.

• At the local level, cost per client averages out to be: $563 per client.

• Per visit per client, the average cost is $121 per visit

State costs associated with the administration, management and evaluation and monitoring of the program include:

• $53,371 - a shared integrated data system (ORCHIDS)

• $193,000 - state administrative and professional support including evaluation support

• $10,00 (high) – to support training, technical assistance delivery with supplies and materials included

Costs have varied year to year in relation to training and materials depending on initiatives and priorities identified at the time.

17. If this practice involved collaboration, who were your partners?

• Local public health departments and the Maternal and Child Health Committee of the Conference of Local Health Officials (MCH-CLHO) an organization of local health county department nursing supervisors focused on maternal and child health.

• Early Intervention and Early Childhood Education (Part C), Department of Education, through participation on state and local Interagency coordinating councils (SICC, LICC)

• Oregon Title V Maternal and Child Health Program, Oregon Department of Human Services, Division of Public Health, Office of Family Health to assure a coordinated effort around integrated data collection systems as well as maintaining shared communications regarding home visiting programs that complement one another.

18. Were there other factors in your state or community that influenced the launch of this practice- e.g., legislation, new leadership, release of data, etc.? Please describe how these contributed.

In 1987 the Surgeon General of the United States, C. Everett Koop, M.D., called for a shift in the Maternal and Child Health Block Grant (MCHB) funds from a focus on identification and treatment in tertiary centers to establishing community-based, family–centered services for children with special health needs at the local level. 1989 legislation strengthened this effort by redefining the mission of the Title V Maternal Child Health Programs to also provide care coordination services to children with special needs and their families. The CaCoon program was designed and implemented to reflect this change in focus.

19. Was the practice implemented as intended? What challenges did you face in implementing your practice?

The program was implemented as intended throughout Oregon.

Challenges faced included:

• Consistency of implementation while allowing flexibility to accommodate to the unique setting and issues within a local community.

• Geography of the state of Oregon

20. How did you overcome the challenges you faced in implementing your practice?

• Consistency of implementation statewide

Local public health nurses are encouraged to respond to their communities’ unique needs. The support of the state nurse consultants to assist in information finding, resource linkage and general support the program allows local programs to adapt to their populations’ needs. The CaCoon program standards and standards of care have universal support at the county level. OCCYSHN developed an Annual Onsite Monitoring Guide to assess the fidelity of implementation with program design and standards. Additionally, the development of a statewide data system has supported improved monitoring of program implementation throughout the year.

• Oregon geography

Care Coordination, including access to specialty care and therapies, is challenged by geography and demographics. Oregon is a rural state where most tertiary services are located on the western side of the state. This program supports access to care coordination services for CYSHN regardless of where they live in the state. Multnomah County, location of state’s largest city – Portland, is the only county which is classified by the Oregon Office of Rural Health as “urban”. The other 35 counties are classified as rural or frontier. The frontier counties are all located in eastern and central Oregon. They are sparsely populated and families often have to travel long distances to receive care. There are 13 counties in Oregon that do not have a pediatrician.[v] To address this challenge CaCoon has worked toward increased web-enhanced training and technical assistance, and the Center works to contribute to the development of effective models of telemedicine.

The success of the CaCoon program is dependent on several key assets:

• Collaboration among state agencies and local health departments

• PHNs and/or Promatoras receive a comprehensive orientation to public health, including the core functions of public health, working with maternal child populations, and working with CYSHN and families.

• Annual site visits and frequent email and phone contact support the confidence and knowledge of new PHNs. Regular contact with PHN supervisors, and prompt responses to their requests for information is necessary to maintain program credibility.

• OCCYSHN designed and supported trainings are an integral part of the CaCoon program that continues to maintain high quality practice.

OUTCOMES

21. What data did you collect to measure the outcomes of your practice?

The CaCoon program collects data about every visit. The encounter data is entered into an electronic database and is updated daily and made available to the program for tracking and evaluation purposes. CaCoon providers have direct access to computer generated reports at a county and statewide level. Data element descriptions follow:

Demographic data: Age, county of residence, insurance, income status, billing information, diagnosis and level of acuity.

Assessment data: Access to health care services, nutrition, parenting, safety, family knowledge of child’s condition, development, immunizations, second hand smoke, insurance, housing, food, and utilities.

Intervention data: Education, training, direct care, and coordination of care.

Referral source: source of referral into CaCoon program and referrals from CaCoon to other programs and services.

Outcome data: Follow-up data about services received, health assessment, and issues summary.

22. What were the results of your practice? Be specific, including both short-term and long term outcomes. If available, please provide data (e.g., through use of control group, etc) demonstrating that outcomes were achieved by your practice and not due to outside factors.

The CaCoon program was implemented statewide in 1991 and continues to serve children with special needs. In 1991 CaCoon nurses provided services for approximately 1,000 children. The strengths of the program are face-to-face contact with families and assistance with coordinating care tailored to the needs of the child and family circumstances. Providers are from the community and have expertise about the unique issues and challenges about accessing services in the local community. CaCoon providers help families navigate barriers and link them with supporting services.

| |FY2008 |FY2009 |

|Number of Children Served |1,363 |1,669 |

|Number of visits |5,864 |7,763 |

|Children aged 0-3 |67% |67% |

|Children aged 3-5 |15% |18% |

|Children aged 5-12 |13% |12% |

|Children 13+ |3% |3% |

|Medicaid/other |* |84% |

|*Missing data due to data system issues makes estimates unreliable |

The extent to which nurses address priority outcomes through assessment and intervention is monitored. Improvement efforts have resulted in an increase in the outcomes being assessed on a regular basis for children with special health needs.

|Assessment-Coordination-Outcome |FY2008 |FY2009 |

|Access to medical care |89% |95% |

|Child Development |87% |93% |

|Community resources |89% |95% |

|Family knowledge of chronic condition |87% |91% |

|Injury |68% |75% |

|Insurance |87% |94% |

|Nutrition |82% |89% |

|Oral health |73% |77% |

|Parenting |77% |86% |

|Tobacco (2nd hand smoke exposure) |79% |83% |

|Well child care |90% |96% |

In addition to regular data collection activities, the program conducts focused program evaluation and needs assessment for process improvement. For example, in 2009 CaCoon providers were interviewed about their adolescent transition practices and approaches. The program identified that families need greater assistance with the transition from the child system of health care and financing to the adult system. Adolescents historically are a small percent of the CaCoon caseload, but have very complex health issues and needs.

23. Was there an expert/peer review process that determined your practice to have significant evidence of effectiveness (e.g., peer-reviewed journal, conference presentations, etc)? If YES, please describe process:

The CaCoon program has been presented at various state and national conferences. The three CaCoon modules on specific conditions were reviewed by a national group of nursing experts. The CaCoon manual was reviewed by nurses and family members at CDRC.

24. Has your practice been replicated (e.g., in other settings and/or with other populations)?

The CaCoon program was visited and/or reviewed early on by several states that have gone on to develop a state care coordination program.

25. What would you keep and what would you change if you were creating this practice now?

If creating the program at this time, the practices and features that would be maintained include:

• Ongoing training and technical assistance to the local PHNs

• Capacity to continue to develop innovative public health nurse training and support tools

• CaCoon Annual Onsite Monitoring Protocol

• CaCoon Tier Level Assessment

• ORCHIDS Data System

Aspects of the program that might require some revision or changes include:

• A more highly refined and articulated training curriculum based on nationally standardized protocols for working with CYSHN and their families.

• Increase in the timely access to data reports for county supervisors

• Greater funding support for program expansion

FOLLOW-UP

26. Is there a sustainability plan in place? Do you know the next steps for your practice? If YES, please describe:

CaCoon is sustained through the continued funding of the OCCYSHN program. Sustainability is always a challenge especially during difficult budget periods. Special development projects of the CaCoon program have been funded through grants from private or governmental sources. Ongoing diligence is required to sustain the program.

27. What products/resources resulted from your practice (e.g. website, published?

CaCoon developed its own unique tools to support ongoing implementation. Most significant are:

• CaCoon Program Manual, which includes sections on:

o Family-centered care

o Family Assessment of Needs

o Child Health Assessment

o Instructions and Recommendations for use of standardized screening tools

o Information to increase cultural competency relative to disability

o Community Resources

o Tertiary Care center services around the state

• CaCoon Tier Level Assessment Tool – assessing extent and urgency of care needs for the child and family. The Tier Level Assessment addresses thirteen areas of evaluation including medical needs and management, parent/child interaction, coping, and housing.

• Nursing care of children with special needs in the community: cerebral palsy, cleft lip and palate, and congenital heart disease, (nursing modules) each including public health nurse interventions, anticipatory guidance, and transition planning.

• CaCoon Eligibility Criteria - All CYSHN from 0-20 years who meet the guidelines on the CaCoon eligibility list are eligible for care coordination by a public health nurse. The CaCoon Eligibility Guidelines have been updated to include strategic data related to newborn screening, fetal alcohol spectrum disorders and autism spectrum disorders. This is commonly known as the “B” list. A category of B90 allows inclusion of any child with a chronic condition.

• CaCoon Program Contract Attachments regarding Program Standards and Roles and Responsibilities specify minimum caseload expectation, number of contacts per family, and assurances that families receive minimum assessments and services that are included in the contract with the county health department.

• CaCoon Program Brochure

• CaCoon Program Chart Review Tool - A chart review tool was developed to support local supervisor oversight and monitoring of the implementation of CaCoon. The CaCoon Chart Review includes care coordination as an item for documentation.

• Pain Cards - CaCoon developed a set of 4 x 6 “pain cards” that briefly outline screening assessment and interventions related to pain in children at different ages, including CYSHN. These cards were developed as a handout for a conference on pain management in CYSHN. In 2005, the Oregon legislature mandated that health professionals complete seven hours of continuing education in pain management.

• Children with Special Health Needs Nutrition Screening Forms were developed in collaboration with feeding teams and nutritionists at the Child Development and Rehabilitation Center at OHSU and Oregon WIC nutrition consultants. These forms are based upon a screening form originally designed by an Oregon county health department.

• PHN Specialty Clinic Information Form was developed to enhance information exchange and family satisfaction with tertiary center clinic visits

• CaCoon Website

• Webinar trainings

• Annual Onsite Review Protocol

• CaCoon Listserv - allows for rapid communication with all local CaCoon Coordinators and Nurses statewide

28. How would you tell other people about this practice, i.e., what is your "take away" message?

Community-based care coordination is an effective means of assuring children with special health care needs, and their families, receive the services they require for optimal health outcomes. It serves to increase the confidence and competence of families in caring for their children within the local community. The program requires a sustained commitment in terms of staffing, orientation, training, and program monitoring and evaluation and quality assurance. It is possible to provide family-centered care coordination services in frontier, rural, and urban areas through local health departments. Public health nurses are uniquely qualified to provide care coordination to families with CYSHN with complex health conditions. Financial support and contractual standards of care, coupled with technical assistance and consultation are vital to success.

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