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Strategic Plan 2007-2012
Promoting the health and wellness of ND citizens with disabilities
ND Disability Health Project Staff Dr. Brent Askvig, Principal Investigator
Kari Arrayan, Program Director Kylene Kraft, Project Assistant
Nicole Flink, Administrative Assistant
For alternative formats or additional copies please contact: ND Disability Health Project
ND Center for Persons with Disabilities Minot State University
500 University Avenue West Minot, ND 58707 1-800-233-1737
www.ndcpd.org/health
September 2008
This plan is supported by a grant (1 u59 DD000278-01) to the North Dakota Center for Persons with Disabilities at Minot State University from the Centers for Disease
Control and Prevention (CDC). Opinions expressed are those of the authors and do not necessarily reflect the official policy of the CDC.
1
The ND Disability Health Project is a partnership between:
• The ND Center for Persons with Disabilities at Minot State University • The Center for Rural Health at the University of North Dakota • The ND Department of Health, Office for the Elimination of Health Disparities
Special thanks to the members of the ND Disability Health Project Advisory Council for their time and contributions to the project.
John Baird Pat Conway
Tammy Gallup-Millner Brad Gibbens
Phyllis Howard Jim Moench Kyle Muus Sue Offutt
Bonnie Olheiser Melissa Parsons
Sherri Paxon Revel Sapa
Judith Schlak Suzanne Schlak
Judy Siegle Bob Syverson Becky Telin Bobby Vogel
2
ND Disability Health Project
Mission Statement The North Dakota Disability Health Project will promote the health and
wellness of ND citizens with disabilities, and prevent or lessen the effects
of secondary conditions* associated with disabilities. *Secondary Conditions refers to conditions directly related to the primary disability, such as
contractures in a person who has cerebral palsy, and the impact on a person’s functioning.
Vision Statement All people in ND have access to information and the services they need
to maintain good health and wellness. There are no health disparities
between people with and without disabilities that are based solely on the
presence of a disability.
3
I
Nearly one in five Americans, 49.7 million people, has some type of long lasting condition
or disability. -U.S. Census 2000
ntroduction ately 54 million Americans live with at least one disability (2005 Surgeon
iated
t
akotans age five and older have a disability (U.S. Census, 2008)
and ma
s
alth
health
no specific plan that addresses health
and e
ea of
Approxim
General’s Call to Action). Achieving and maintaining good health and wellness can be
complicated for people with disabilities who are challenged by access to transportation,
attitudinal barriers, inadequate insurance
coverage, and secondary conditions assoc
with their disability. Health and wellness are no
the same as the presence or absence of disability,
they are broader concepts that can directly affect
the quality of a person’s life.
About 15% of North D
ny have health issues associated with their disability. Many of these citizens do not have
access to care and information that makes good health possible. As a rural state, ND has many
challenges to face in providing quality health care to all citizens. Unfortunately, ND health and
disability service agencies have made few coordinated efforts to provide North Dakotans with
disabilities access to health and wellness activities and education. In July 2007 the Centers for
Disease Control and Prevention (CDC) awarded funding to the North Dakota Center for Person
with Disabilities (NDCPD) to launch the ND Disability Health Project. In addition to the
development of this strategic plan, the project has established a state office on disability he
on the campus of Minot State University; provides a system of statewide data collection, analysis
and reporting on the health and wellness of ND citizens with disabilities; develops and
implements collaborative activities in health promotion; and works to improve access to
care and wellness programs for persons with disabilities.
While ND has a Healthy People 2010 plan, there is
w llness issues for people with disabilities. This strategic plan will coordinate with the
efforts of the Healthy North Dakota Initiative and build on the Healthy People 2010 focus ar
Disability and Secondary Conditions; the Surgeon General’s Call to Action to Improve the
Health and Wellness of Persons with Disabilities, and the CDC’s Health Protection Goals
Related to Adults, Older Adults, and Healthy Places.
4
ND Center for Persons
with Disabilites
ND DOH‐Division of Chronic Disease
ND Disability Health Project
Center for Rural Health‐UND
ollaboration sability Health Project is funded by the Centers for Disease Control and
to
the lead agency for promoting the health
isparities, and
h as the
ng and Physical
l, and
A continuous planning model was used in the strategic planning and development
lanning model diagramed below shows the process for
ability
wellness of ND citizens with disabilities, and
keholders were identified and prioritized for inclusion in
the plan. Collaborations were established with key partners to better access information and for
integration of disability issues throughout the state.
C The ND Di
Prevention for a five year period (2007-2012). ND is one of 16 states to receive this funding
work on various health initiatives and to build overall capacity within the state. The project will
promote the health and wellness of ND citizens with disabilities, and prevent or lessen the effects
of secondary conditions associated with disabilities.
The ND Center for Persons with Disabilities is
and wellness of people with disabilities. Key partnerships have been established with
the ND Department of Health, Office for the Elimination of Health D
the Center for Rural Health at the University of North Dakota. Connections have
also been established with existing health-related state committees suc
Office for the Elimination of Health Disparities, Healthy Eati
Activity committee, Flu Workgroup, Tobacco Prevention and Contro
the ND Diabetes Coalition.
Strategic Planning Model process. The components of the p
development of the strategic plan (see Figure 1).
The mission reflects the purpose and population that will be served by the ND Dis
Health Project, which is to promote the health and
prevent or lessen the effects of secondary conditions associated with disabilities. The vision
specifies where ND wants to be in five years in their work to prevent secondary conditions and
promote the health of people with disabilities. The vision specifies that all people in ND will
have access to information and the services they need to maintain good health and wellness.
There will be no health disparities between people with and without disabilities that are based
solely on the presence of a disability.
The system readiness assessment was completed through the gathering and analysis of
multiple data sources. The needs of sta
5
The goals identify the anticipated results in achieving the vision, while the strategies
identify the steps that will be used to accomplish the goals. The implementation plan describes
the timeline and assigns accountability. The evaluation plan and system improvement
components will determine progress and allow feedback for improvement. Procedures for
reportin s,
Figure 1. ND’s Proposed Strategic Planning Process
g and documentation will identify documents that will be used for conveying the goal
progress and results of the project work to stakeholders and others.
6
7
Health is
physical,
a state of complete
mental and social
w
~W
ell-being, and not merely the
absence of disease or
infirmity.
orld Health Organization, 1948
The Advisory Council members of the ND Disability Health Project reviewed all
elements of the plan and provided feedback for all
aspects
o
ed to
The ND Disability Health Project has adopted the definition of disability as
y the United States Healthy People 2010 plan. This definition is also used by the
efined as a
ane, a wheelchair, a special bed, or a special telephone?
nication
or other impairments that affect their ability to answer the telephone or telephone survey
p
ancy
of access to and the quality of health care that is
person’s functioning.
of the strategic planning process. In an effort to
gain support for the plan, a draft of the plan was als
sent to individuals and agencies. Suggestions that
required only minor adjustments were integrated into
the plan. More substantive suggestions were referr
the Advisory Council members for discussion.
Definitions
recommended b
Behavioral Risk Factor Surveillance Survey (BRFSS) and the CDC. A disability is d
“Yes” response to either or both of the following questions:
Question 1: Are you limited in any way in any activities because of physical, mental, or
emotional problems?
Question 2: Do you now have any health problem that requires you to use special
equipment, such as a c
It should be noted that this methodology (1) does not include adults with commu
questions, and (2) does not include adults who live in institutions in the survey sample, such as
nursing home or other long term care facilities, state facilities, prisons, or residential grou
homes.
The term health disparity addresses the discrep
provided between various populations. Secondary
Conditions refers to conditions directly related to
the primary disability, such as contractures in a
person who has cerebral palsy, and the impact on a
People with
Disabilities17%People
without Disabilities
83%
Disability Prevalence among North Dakota Adults
Combined Years 2001‐2006
Impact of Disabilities in ND
In preparation for development of thi
and without disabilities have been analyzed u ive data sources including
nce Survey (BRFSS), Children with Special Health Care
n
ilities
impact the quality of life for people with disabilities in
services and information, health discrepancies, affordable health
sportation, and prevention. Highlights from the data analysis are
-
s strategic plan, health related issues for people with
sing multiple quantitat
the Behavioral Risk Factor Surveilla
Needs (CSHCN), Kids Count ND,
U.S. Census Data, Youth Risk
Behavior Survey (YRBS), and the
Behavioral Health Workforce in ND
status report. In addition, new
qualitative data were gathered
through focus groups and surveys to
obtain more specific informatio
directly from people with disab
and their families. Both the
qualitative and quantitative data
indicate several issues that negatively
ND. These include access to
care, transition, quality care, tran
outlined below. For a complete review of the data analysis, refer to the Impact of Disability in
North Dakota, Health Status and Disparities report (Arrayan & Askvig, 2008), and the Health
Related Attributes of North Dakota Adults with Disabilities: Analysis of 2001-2006 BRFSS Data
(Muus, 2008). Both reports can be found on the ND Disability Health Project website at
www.ndcpd.org/health.
8
Data Highlights
Approximately 18% of adults in ND report limitations from a physical, mental, or
motional problem. Approximately 38% of these respondents described their health as being fair
with just 7% of the general population. The data indicate adults with
,
ut
ch
e
or poor compared
8
%
Prevalence of Fair/Poor Health among North Dakota Adults,by Disability Status and Age, Combined Years 2001-2006
Source: ND BRFSS*Ages 18 and older Age
disabilities are more likely than people without disabilities to have chronic joint symptoms
arthritis, high blood pressure, high cholesterol, cardiovascular disease, a recent fall-related
injury, asthma, and diabetes. ND adults with disabilities are more likely than those witho
disabilities to be overweight/obese and smoke cigarettes, and are less likely to be physically
active. People with a disability are more likely to have one or more days each month in whi
their mental health is not good (42%), than people without disabilities (31%). People with
disabilities are more likely to be unemployed, not see a physician due to financial limitations,
and have lower income than people without disabilities (Muus, 2008).
9
Health conditions among North Dakota adults with and without disabilities, by age group, BRFSS ombined years 2001-2006.
Total Age 18-64 Age 65 or Older N (%) N (%) N (%)
21 (84.65) 112,125 (83.08) 71,015 (87.07) Without disability 9.3 ) .73)
is ** 8 (56.41) 91,029 (47.48) 84,510 (70.30)
1H
lity 131,584 (48.74) 59,257 (36.71) 71,071 (66.66) 1 1
H 6,353 (44.48) 58,134 (39.15) 57,350 (51.60)
2 1C as
64,985 (24.87) 12,394 (23.27) 45,246 (39.15)
Fell and was Injured *8 (18.63) 5,728 (21.25) 5,006 (16.30)
A82,846 (17.39) 56,157 (19.26) 26,561 (14.59)
2 18 2D
isability 69,473 (14.56) 29,304 (10.03) 39,579 (21.69) 1
N regnancy s.
**
y 1 ,500 ch ren, ages 0-17 years, with special health care needs in
have conditions that affect their activities
usually, alw
c Chronic Joint Symptoms **
With Disability 184,4313,423 (5 0 237,655 (56.52) 74,741 (70
ArthritWith Disability 177,00Without disability 302,134 (19.41) 191,365 (14.66) 08,950 (44.93) igh Blood Pressure ** With DisabiWithout disability 296,909 (24.02) 79,447 (17.64) 15,198 (54.49) igh Cholesterol **With Disability 11Without disability 341,607 (30.33) 32,611 (26.08) 06,482 (47.10) ardiovascular Dise e *** With Disability Without disability 65,325 (6.45) 13,815 (7.70) 39,241 (16.10)
With Disability 10,90Without disability 21,402 (11.83) 15,219 (13.15) 6,122 (9.72) sthma With Disability Without disability 11,611 (8.92) 5,584 (9.33) 4,853 (6.74) iabetes With DWithout disability 05,219 (4.43) 60,925 (3.06) 43,571 (11.81) ote: Diabetes defined as type I or II only, not p diabetes or pre-diabete
* 2003 * 2001-2003, 2005 ** 2001, 2003, 2005, 2006 Source: Muus, 2008
There are approximatel 6 ild
ND (CSHCN, 2008). Twenty percent of these children
ays, or a great deal; this is slightly less than the national average of 24%. Thirteen
percent of children with special health care needs have 11 or more days of school absences due
to illness. In 2006, 26% of children with special health care needs had insurance although it was
considered inadequate, compared to 33% at the national level. Eleven percent of these children
had unmet needs for specific health care services, below the national level of 16%. Nearly 6% of
ND babies were born to mothers receiving inadequate prenatal care in 2005, and this increased
from 4.2% in 1995 (Fassinger, 2007).
10
Issues that arose consistently during focus group discussions and through surveys
included concerns surrounding insurance in general but specifically Medicaid and Medicare
cov rag
for
sabilities. The
aviors is higher among people with
disa il
f
d
all of these issues cannot be addressed within this
stra
ss
After analyzing existing ND disability-related data, gathering and reviewing new data,
from the ND Disability Health Project Advisory Council, three goals were
rmula
e e; lack of transportation in rural areas and limited access in urban areas; need for
training/education for doctors and other health providers; assistance with coordination of care
people with disabilities and their families; caregiver issues such as turnover, low pay, and
shortage of workers; the need for more health care providers such as dentists,
psychiatrists/mental health workers, and other specialists.
Clearly there are health disparities between people with and without di
prevalence of specific health conditions and certain risk beh
b ities. In general it is also more difficult for people with disabilities to obtain care due to
difficulties with transportation, insurance, lower income, and service coordination. The quality o
care is sometimes deficient due to lack of knowledge on the part of health service providers
regarding disability issues and sensitivity issues. Quality of life for people with disabilities can
be negatively impacted by health issues which may prevent involvement in usual activities an
problems finding good quality caregivers.
These findings are presented fully within the 2008 Data Impact Report and provide a
baseline to measure future progress. While
tegic plan due to time and resource constraints, these data will help to determine priority
areas and guide the ND Disability Health Project in its efforts to promote the health and wellne
of people with disabilities.
Priority Areas
and soliciting input
fo ted to focus the direction of the strategic plan and address the health and wellness of
people with disabilities.
11
Rationale: ND data indicate people with disabilities are more
,
re is evidence to support that a healthy diet and
e
ng.
ot
h the
te
Annual review of ND data will indicate changes in the disparities between people with
likely than people without disabilities to be overweight or obese
have diabetes, experience mental health issues, and to use
tobacco.
The
exercise can reduce the risk of a variety of health conditions
including obesity, heart disease, diabetes, high blood pressur
and cholesterol. It is also recognized that regular exercise can
help to alleviate depression and anxiety and improve mental
health. Health promotion programs can help people develop
lifestyles or behaviors to maintain and enhance their well-bei
There is often an assumption that people with disabilities or
chronic poor health conditions cannot benefit from health
promotion or preventive practices. As a result preventive
screenings or other health promotion activities are often n
offered or accessible to people with disabilities. People with
disabilities need to have the same access and opportunities to
health promotion information and services as people without
disabilities. These four areas of health and wellness were
targeted because it is believed they can be impacted throug
activities of the ND Disability Health Project. They are also
areas being focused on in the Healthy ND state plan. Project
staff have developed collaborations with groups within the sta
health department that are addressing these issues.
Goal #1
Improve health and wellness for
people with disabilities,
specifically in the targeted
areas of obesity, diabetes,
tobacco use, and mental health.
and without disabilities regarding the health conditions specifically targeted in this goal.
12
Strategies for all targeted areas
th and disability professionals regarding the
ilities,
te
e with disabilities. This may
r all people to recreation programs,
es to ensure disability issues
s
Strategies for Obesity
• Increase awareness among heal
importance of quality health and wellness opportunities for people with disab
accessibility, and/or prevention strategies. Distribute monthly fact sheets featuring
specific wellness topics and offering tips and guidelines to health care providers,
people with disabilities, schools, advocates, community service providers, and sta
and local agencies via electronic and postal mailings.
• Promote advertising venues that are accessible to peopl
include large print, adjusted reading levels, etc.
• Enhance statewide awareness regarding access fo
fitness centers, community health initiatives, and screening facilities by providing
information and/or technical assistance upon request.
• Collaborate with existing state committees or task forc
are addressed and included in state plans. Promote an understanding of what it mean
to really include people with disabilities to be active participants.
onstration projects in targeted communities to promote
robics
Do It! program. This
ing Well with a Disability or the Healthy Lifestyles curricula in a
Implement model dem•
preventive health and wellness activities. Include activities such as adaptive ae
and gamercize activities that include people with disabilities.
• Request funding for and, if approved, implement the ND I Can
program will match adult mentors, with or without disabilities, with youth who have
disabilities to teach the youth about making good nutritional choices and increasing
physical activity.
• Implement the Liv
targeted community to teach people with disabilities strategies for the best possible
lifestyle to promote good health and wellness.
13
0
5
10
15
20
25
Age 18-64 Age 65 or Older Total
Perc
enta
ge
Age
Diabetes among North Dakota adults with and without disabilities, by age group, BRFSS combined
years 2001-2006.
With Disabilities
Without Disabilities
0
10
20
30
40
50
With Disabilities Without Disabilities
Perc
enta
ge
Engagement in moderate physical activity among North Dakota adults with and without disabilities,
BRFSS combined years 2001-2006.
With Disabilities
Without Disabilities
Strategies for Diabetes
• Collaborate with the ND Diabetes Coalition to ensure people with disabilities are
included in diabetes prevention and treatment activities.
14
Strategies for Tobacco Use
• Collaborate with the Department of Health, Division of Tobacco Prevention and
Control to include people with disabilities in their strategic plan.
• Provide information regarding cessation programs for people with cognitive
disabilities, and other information, upon request.
0
5
10
15
20
Age 18-64 Age 65 or Older Total
Perc
enta
ge
Age
% of persons having 15-30 days of poor mental health in the past month, status among North Dakota adults with and without disabilities, by age group, BRFSS combined
years 2001-2006.
With DisabilitiesWithout Disabilities
0
5
10
15
20
25
30
35
With Disabilities Without Disabilities
Perc
enta
ge
Tobacco Use among North Dakota adults with and without disabilities, BRFSS combined years
2001-2006.
With Disabilities
Without Disabilities
Strategies for Mental Health
• Provide technical assistance and/or resources as requested from individuals or groups.
15
Strategies for other related areas:
• Provide people with disabilities information to make informed choices about their
health care.
• Promote specific health promotion information and activities and prevention topics
such as flu vaccinations, breast cancer screening, blood pressure and cholesterol
screenings, and nutritional awareness.
Rationale: Misconceptions and gaps in information lead to
insensitivity and poor quality of care. Some professionals, and
some people in the general public, are not aware of issues
important to people with disabilities, such as people first
language and general disability etiquette. There is also a lack of
understanding about how to adapt educational material and the
physical environment to accommodate various needs.
Provision of information and technical assistance will
help to bridge gaps surrounding disability issues for
professionals and others. Knowledge and understanding will be
enhanced and the quality of information and service provision
will be improved. Health service providers and ND communities
in general need to demonstrate awareness of disability issues and
disability etiquette through words and actions.
Progress toward this goal can be evaluated through input
from people with disabilities and their families via focus groups
and satisfaction surveys.
Goal #2
ND citizens will have accurate
information on disability and health issues.
Strategies:
• Develop and implement a technical assistance request process that will provide state-
wide assistance to be provided to health service providers on-site or through the
provision of informational materials.
16
• Support the inclusion of disability and health related issues at workshops,
conferences, and through speakers at organized events.
• Promote public awareness using television, radio, and/or newspaper announcements
to convey personal stories and disseminate educational materials specific to health
and disability issues.
• Educate health care professionals via fact sheets and information booklets regarding
specific disability issues.
“Every human being is the author of his own health or disease.”
~ Hindu Prince Gautama Siddharta, the founder of Buddhism, 563-483 B.C.
• Utilize resource centers, such as the National Center on Physical Activity and
Disability, Amputee Coalition of America and the Christopher Reeve Paralysis
Resource Center, for resources on disability and health issues, and to assist them with
identifying peer visitors/trainers
for ND. Also utilize resources
among other Disability and
Health state grantees.
17
Goal #3
ND citizens with
disabilities will
have improved
health care
through cross
system
communication,
planning, and
implementation
for health and
disability related
services.
Rationale: People with disabilities and their families often
struggle with finding, keeping, and effectively utilizing existing
services. The process of paperwork can be overwhelming and
confusing, resulting in the loss of services or disqualification from
other services. Assistance from a central person or agency to
oversee all individual and/or family services, and to act as a
referral source, would provide a continuum of services that would
benefit many people with disabilities and their families.
Many stories were told during focus groups and one-on-
one conversations with people who have disabilities and their
families. People expressed great discontent in being sent from one
person to another for assistance, sometimes getting incorrect or
incomplete information. Many people also do not know about
existing services unless they hear about them inadvertently.
People with disabilities and their families need to be aware of
available services that address their individual needs, and need to
be able to access those services without significant difficulty.
Subsequent information gathered through focus groups or surveys
will indicate changes in the perception of the coordination of
health care.
People with disabilities and their families often experience
a sense of displacement during periods of transition between
services (i.e. child moving from pediatric to adult health care
services). A change in services can also be detrimental financially
for those not familiar with requirements for eligibility of services.
For example, a family can be referred for a support service only
to find that after they apply and are approved, they have
inadvertently become ineligible for another service they were
receiving.
Many service entities in ND work in a compartmentalized
manner, but are willing to collaborate when approached by
18
another service provider. This collaboration is especially critical during periods of change for
people with disabilities and their families. Disability and health service providers need to
engage in intra-agency collaboration to provide comprehensive services to people with
disabilities and their families. Review of the strategic plan activities will indicate collaboration
between entities though cross-agency meetings, facilitation of information exchange, and
provision of technical assistance.
Strategies:
• Provide referral assistance through the Technical Assistance request process.
• Support the efforts of state agencies to achieve a medical home model of care in ND.
• Disseminate information on the availability of services and resources within the state
as requested.
• Promote familiarity and networking between disability and health providers through
participation in state-wide conferences, community health fairs, and other venues.
• Facilitate collaboration between disability and health entities by partnering with
existing state or local committees such as the Office for the Elimination of Health
Disparities, Flu work group, Physical Activity and Healthy Eating committee,
Division of Tobacco Prevention and Control, the ND Diabetes Coalition, and others
as appropriate to ensure disability and health related issues are addressed through
joint efforts and included in applicable state plans.
• Request funding for and, if approved, implement the ND I Can Do It! program.
Through this program, provide leadership for cross collaboration with faculty and
students from various departments/programs at Minot State University including
teacher education, special education, physical education, the MSU campus fitness
center, as well as students and special education directors and teachers from the
Minot Public Schools system.
• Document the need for Health Care Benefits Planners/Coordinators throughout the
state to assist families in
planning for services. Unity is strength... when there is
teamwork and collaboration, wonderful things can be achieved.
~Mattie Stepanek
19
Monitor and update the plan To accomplish the goals of the strategic plan, the ND Disability Health Project will
closely monitor progress, activity, and feedback from people with disabilities, their families, and
disability and health service providers. The structure of the plan allows for continuous
evaluation, reporting, and assessment to determine if modifications are needed. An Executive
Management team has been formed to review progress, identify barriers, and delineate solutions
on a monthly basis. In addition, the Advisory Council will convene quarterly to review progress
and make recommendations as necessary. Collaboration with other grantee states will be
beneficial to exchange ideas and share information between states; conference calls and annual
grantee conferences will provide opportunities to network with other states who have disability
health plans. A project evaluator will monitor activity, meeting with key project staff quarterly,
and will prepare annual reports. Data analysis will be updated on an annual basis to ensure
critical issues are being addressed as identified by constituents within the state.
Stakeholder involvement and collaborations with other state entities are critical to the
success of the strategic plan. The ND Disability Health Project will continue to collaborate with
key partners, build new partnerships, and maintain an active Advisory Council to receive input
and recommendations on activities and new ventures.
20
21
References
Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved 2/6/08 from www.cshcndata.org Fassinger, P. (2007). 2007 Overview of children’s well-being in North Dakota; Our children, our state. North Dakota Kids Count: North Dakota State University. Muus, Kyle. (2008). Health-related attributes of North Dakota adults with disabilities: Analysis
of 2001-2006 BRFSS data. Grand Forks, North Dakota: Center for Rural Health, University of North Dakota.
U.S. Census Bureau. (2008). State and County Quick Facts. Retrieved February 28, 2008 from http://quickfacts.census.gov/qfd/states/38000.html.
U.S. Department of Health and Human Services. The Surgeon General’s Call To Action To Improve the Health and Wellness of Persons with Disabilities. US Department of Health and Human Services, Office of the Surgeon General, 2005.
U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2008). The national survey of children with special health care needs chartbook 2005–2006. Rockville, Maryland: U.S. Department of Health and Human Services. Western Interstate Commission for Higher Education. (2007). The behavioral health workforce in North Dakota: A status report. ND Mental health Program: Division of Mental Health and Substance Abuse Services.
.
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