FALLING THROUGH THE CRACKS: Appendix 5
Survey Findings by Site Type
Community Health Centers/Clinics Summary
Fifteen of eighteen centers responded to the survey:
Pilot City Health Center
Model Cities Health Center
Southside and Green Central Community Clinics
Family Medical Center
Cedar Riverside Peoples Center
West Side Community Health Services
Fremont Community Health Services (includes Fremont, Sheridan, and Central Avenue Clinics)
North End Health Center
Hennepin County Womens and Childrens Health Program
Community University Health Care Center
Indian Health Board of Minneapolis
I. Mission, Philosophy, and Scope of Practice:
All of the responding community health centers have mission statements describing a commitment to serving low income populations in a defined geographic area. Most focus on serving people at risk of having poor access to health care and who may not be insured. Twelve of the fifteen have mission statements regarding perinatal services and recognize pregnant women and infants as particularly vulnerable populations. They are committed to early prenatal care, outreach and follow up activities, and mentioned the importance of coordinating with other community agencies. They provide primary health care and refer patients in need of high risk medical care to other clinics. They are committed to serving the diverse populations in their service areas. Some centers described themselves as a safety net for health care in the community. They are committed both to maintaining their capacity for integrated,wraparound services (all services the family needs) located under one roof (one-stop shopping) and in maintaining community connections with other service organizations.
II. Community and System-Level Activities:
The centers/clinics reported taking pride in providing a model of health care delivery in a variety of areas. The primary areas of competence were: care for a culturally diverse group of low-income patients and the use of advocacy services to improve patient access to medical care and supportive services. Nine of the centers provide outreach to the communities they serve. A few centers/clinics have outreach workers dedicated to visiting patients in their homes when they have missed perinatal appointments. Other outreach efforts include networking with other community-based organizations and participating in community events.
III. Client Level Activities:
The community health centers/clinics provide primary health care to women and their children, including medical care, prenatal and postpartum care, newborn and well child care, and family planning. The survey found that all fifteen centers/clinics also provide supportive services, including assistance in completing insurance applications, and assessment and/or treatment or referral for psycho-social issues, food resources, and drug/alcohol abuse. All of the centers/clinics also provide brief counseling on healthy lifestyle, coping skills, psychological support, and smoking cessation.
All of the community health centers/clinics provide services to women who are at risk for poor birth outcomes by virtue of being otherwise underserved, low income, and from diverse cultural and ethnic backgrounds. All of the centers/clinics have developed competencies in addressing the sociocultural needs of their specific communities. Most have experienced recent significant increases in the racial and ethnic diversity of the communities they serve, particularly for new immigrant and refugee populations.
IV. Financial and Capacity Issues:
Community health center respondents discussed decreases in traditional sources of federal funding impacting their capacity to provide wrap-around services on site. Centers are trying to work with other local health care providers and social service agencies to assure availability of and access to the services that they are lacking. However, centers acknowledged that referrals to other agencies may not be effective. Quoting a community health center administrator:
Twenty five years of experience working with our community indicates that often our patients do not keep referral appointments. The lives of our patients are often in enough chaos that even incentives such as child care, transportation, or food coupons are insufficient to get people to keep referrals. Thus, over the years we have learned that if we do not provide the counseling or service ourselves, it often is not done.
Nine centers/clinics reported an increased difficulty in securing sufficient levels of reimbursement to meet the costs of providing care. All of the centers/clinics report a large number of patients who are enrolled in a Prepaid Medical Assistance Program (PMAP). PMAP is Minnesotas managed care Medical Assistance (Title XIX) program administered by the State Department of Human Services (DHS). The centers/clinics financial analyses of payments from PMAP indicate that they do not cover the actual costs of providing the type of comprehensive care needed to improve outcomes in their low income, often high risk population.
Nine centers/clinics stated that low reimbursement rates for services they provide was one of their primary concerns. Specifically, some centers/clinics described the difficulty they face in providing continuous care for patients who are frequently taken on and off publicly funded insurance programs by their county financial worker due to changes in their financial status and eligibility. For example, a managed care organization reported that four months was the average length of time that PMAP participants were enrolled in their plan. In contrast, a center/clinic assumes the responsibility for continuous patient care, as determined by patient needs. In the context of this report, prenatal and infant care require a center/clinic commitment of one to two years. Most of the centers/clinics reported they are providing services that are not fully reimbursed or require reimbursement from multiple payors for one pregnancy, adding greatly to their administrative costs.
Additionally, nine of the centers/clinics report seeing more uninsured patients than in previous years with incomes insufficient to pay the sliding fees. They reported that this is a problem particularly for the growing Latino population. Many Latina women are reluctant to pursue insurance coverage due to uncertain immigration status either for themselves or members of their family.
Despite the fact that PMAP reimburses for interpreters, some centers/clinics mentioned increasing need for and cost of interpreters as being a financial drain on resources. At the time of the survey (1999), centers/clinics covered the cost of interpreters for fee-for-service Medical Assistance and for their uninsured patients. Several centers/clinics have been serving the Latino and Hmong populations for many years and have good systems in place for doing so efficiently. Providing interpretation for newer immigrant groups such as African immigrants has been an additional challenge of cost and capacity for the centers/clinics.
The issue of failed appointments was listed by five centers/clinics as a major source of lost revenue. Some overbook appointments to compensate. However, when all the patients do show up, the results are longer waiting times for patients and increased stress for rushed providers.
V. Community Health Centers/Clinics Recommendations:
1. Increase the technological capacity of centers especially in terms of
automating functions and in recording data that can be used across systems.
2. Create a system for the centers to be able to learn best practices from each other.
3. Create a list of resources (especially culturally specific and appropriate resources) that would be available to all clinics.
4. Disallow global billing for high risk patients; assure presumptive eligibility for insurance for these cases.
5. Expand funding for outreach and supportive services.
6. Develop more consistent prenatal assessment and documentation forms and procedures for providers.
7. Provide better access to and reimbursement for interpreters.
8. Devise solutions for failed appointments and long patient waiting times.
9. Assure stable funding for community health centers in order to keep basic programs afloat. Coordinate and educate payors that community health centers need infrastructure support.
10. Devise ways for centers to maintain more direct contact with the services to which they refer patients.
PUBLIC HEALTH NURSING SERVICES SUMMARY
The three agencies providing public health nursing in Hennepin and Ramsey Counties completed the survey:
Minnesota Visiting Nurse Agency (MVNA)
St. Paul - Ramsey County Department of Public Health
Bloomington Division of Public Health
I. Mission, Philosophy, and Scope of Practice:
All three agencies reported that their mission is to serve low income, disadvantaged families. All report having strong formal and informal connections and collaborations with other community organizations and have large networks of potential referrals for families in need of additional services. Services to individual families appeared to be based on a shared professional model of comprehensive public health nursing practice, using assessment, plan development, intervention, health education, referral and follow up. The following quotes from the survey further illuminate how the agencies perceive their mission:
Our public health staff build on family-focused, community-based principles in delivering services to perinatal clients. Staff are skilled in working with families who have complex social needs and use multiple resources in the community to help meet those needs. Staff are also able to address sensitive family issues such as chemical use, violence, and other complex situations. The focus is on prevention and early intervention.
Our agency serves primarily a high risk population, ie, increased perinatal risk factors due to socioeconomic status, age, race, etc. We have attempted to maintain the mission of serving families regardless of financial means or payment source.
II. Community and System Level Activities:
All three agencies provided many examples of coalition building around a common health-related purpose. Most coalitions involved other public health organizations; some were with health care and managed care organizations.
The agencies listed examples of internal and external collaborations to share information and resources and to develop policy and advocacy for health-related community issues. Examples are lead poisoning prevention, violence-free families and communities, child abuse prevention, chemical health programs, child injury prevention, and follow up for graduates of neonatal intensive care. Family Services Collaboratives were mentioned as partners, as were schools, health care organizations, and social service providers. Additional collaboration among the public health nursing agencies takes place through the Maternal and Child Health (MCH) Coordinators meeting.
Differences in Referral Services
There are differences in referral sources between the three agencies. Most of Bloomingtons referrals are postpartum and are initiated from information on birth certificates sent by MDH several weeks after the delivery. Additionally, large numbers of referrals come from Bloomingtons Women, Infants, and Children Program (WIC) and WIC clinics which work closely with the county public health nurses. MVNAs referrals primarily come from a single hospitalHennepin County Medical Centeras postpartum newborns. Only a few, as confirmed by the community health centers/clinics themselves, come directly from the centers/clinics. In Ramsey County, the largest number of referrals come from Regions Hospital, but a significant number also come from the community health centers/clinics and from the countys WIC clinics.
MVNA serves approximately 500 pregnant women annually and 1700 post partum women. About 1900 newborns and infants up to the age of one year are provided services.
Bloomington serves about 200 pregnant women annually but specified they provide case management/care coordination to 76 women annually. Approximately 100 of their 200 pregnant women are served by public health nurses working with them in the WIC clinics. They serve 130 postpartum women and infants plus about 500 infants are identified as high risk annually from birth certificates and receive some additional follow up activity.
St. Paul Ramsey County serves 380 pregnant women and 960 newborns and infants to age one through home visiting annually.
In total, approximately 1,000 pregnant women are served by public health nursing in Hennepin and Ramsey Counties annually. Comparing this to the estimated 8,000 to 9,000 low income births occurring annually in the two counties , it may be that a large number of pregnant women at risk for a poor birth outcome may not be reached and offered coordinated care by a public health nurse. Although many more infants are served by public health nursesabout 2600 annuallythe opportunity for preventive activities and education by public health nurses during pregnancy are missed in over two thirds of these births.
III. Client Level Activities:
Public health nurses in the three agencies use written care plans and goals developed with input from families. Two of the agencies have a quality assurance method of determining whether preset goals were met, based on random chart audits of a percentage of cases that have been closed by the nurse. Beyond these audits by the quality assurance staff, the ability to report outcome data was limited to reports to agency funders on how their money was used in particular programs.
The agencies provided all of the components of health teaching, brief counseling, and care coordination/case management in the survey instrument. All three agencies at the time of the survey (May-June, 1999) were using paper records.
IV. Financial and Capacity Issues:
Public health nurses perform case management/care coordination based on risks they assess with patients who are referred to them. Except for Bloomington, which does outreach through its WIC clinics, they appear to have limited internal capacity for outreach and have difficulty serving the number of patients referred to them. (See Community Update in the Discussion section for increases in home visiting capacity since the survey was administered.) The agencies report that 15 to 20 percent of attempted home visits are not completed because the client was not at home when the nurse arrived. These visits are not reimbursable. Other problems identified include much administrative time spent on securing reimbursement, providing their own interpreters, and using antiquated data and technology systems that hamper their ability to manage cases and report on the effectiveness of what they do.
Reporting of overall service levels and outcomes in the entire population served
was not possible. Agencies described data systems that are inadequate for population-based
reporting needs. Only one of the three agencies was able to track where referrals
to the agency originate, the number of referrals coming from a particular source,
and referrals out of the agency to other resources. Another agency could report
referrals in and out but could not specify type of client receiving the referral.
Public health nursing respondents identified the following financial and reimbursement problems:
Medical Assistance reimbursement rates have not kept up with escalating costs of providing professional services. Factors such as the increasing acuity of families needs, the complexity of the health care delivery system, the high rate of violence and chemical use, and high numbers of residents who are illiterate or non English speaking; these factors require staff to spend much time coordinating care with no reimbursement.
Reimbursement for service coordination to pregnant women who are mentally ill was discussed as a serious challenge to one agencys resources.
Public health nurse agencies face high staff turnover and the high costs of orienting, training, and certifying staff.
Obtaining authorization for third party reimbursement continues to be complex and time consuming. Turnover at managed care companies means public health nurses must often orient new managed care staff on the public health nurses processes and procedures.
Care coordination by public health nurses during pregnancy or for infants and children is not reimbursed either by PMAPs administered by health plans or by fee-for-service Medical Assistance administered by DHS.
New home visiting and parent support research demonstrated the effectiveness of public health nursing home visiting services. However, third party payers are not authorizing payment for these types of services. Limited grant money is available for pilot projects of this type.
V. Public Health Nursing Agencies Recommendations:
The three public health nursing agencies recommended the following to improve perinatal services:
1. Pay for care coordination, especially during pregnancy, even if there
is no medical necessityas required by payors.
2. Improve access to consistent health care throughout the perinatal period by maintaining the same medical insurance and clinic.
3. Use prompt and family-friendly transportation services, not metro buses.
4. Use public health nursing services for coordination of perinatal services. Fully fund public health nursing services without excessive paperwork and phone calls.
5. Address disparities in health outcomes through community-based partnerships of state and local public health, service providers, and community members.
6. Improve cultural competence and responsiveness to individual situations within systems of care.
7. Promote policy changes at state and local levels to acknowledge and support public health nursing services financially to coordinate care for at-risk pregnant women, families, and infants.
HOSPITAL AND HEALTH SYSTEM SUMMARY
Four of the five metro health plans responded to the initial survey:
Blue Cross/Blue Shield
Metropolitan Health Plan
U Care Minnesota
Medica provided information for the report in the summer of 2001, following the meetings arranged by the Minnesota Council of Health Plans. All five health plans provided information to clarify their activities, and to give updates, upon reading an initial draft of the report in Spring, 2001. Their clarifications are included at the end of this section.
Nine of the twelve hospitals located in Hennepin and Ramsey Counties responded:
Abbott Northwestern Hospital
Minneapolis and St. Paul Childrens Hospitals
Fairview Southdale Hospital
Fairview University Medical Center
Hennepin County Medical Center and OB Clinic
St. Johns and St. Josephs Hospitals (HealthEast)
I. Mission, Philosophy, and Scope of Practice:
Four of the five health plans responded to this question. One health plan noted that they do not have a formal mission statement specifically for prenatal care. The companys overall vision and mission statements are:
We will be the health system of choice in the communities we serve. It is our mission to ensure access to quality services which are valued by the customer.
(Health plan) will improve the health of our members through innovative services and partnerships across communities.
To improve the health of our members and our community.
Vision:To be the recognized leader in improving the health of the communities we serve.
Mission:To provide an excellent health care experience for our customers.
The hospital survey did not ask for information about their mission statement.
II. Community and System-Level Activities:
Perinatal care coordination is performed by case managers at the health plan or at the hospitals. The case managers duties,manner and scope of interventions vary widely across the different hospitals, plans and systems. Except for one plan, case managers reported seeing their role as interacting and coordinating among providers, as opposed to having regular contact with patients. The reason noted for this is to minimize confusion for the patients. When care coordinators reported contacting patients, it was always done by phone.
Three hospitals have case managers who have spent significant time building relationships with the physicians who attend the majority of the deliveries at those hospitals. These relationships have led to better coordination of information between the case managers and the physicians during prenatal care, and increased the followup case managers do during pregnancy based on assessed risks.
All health plans and hospitals reported offering some level of referral to social services. Coordination of follow-up for social issues addressed in prenatal assessment varied widely. For one plan and one hospital, these referral links appeared to be much more comprehensive in scope, and there was evidence of significant administrative capacity for this type of role. Overall, the hospital and health plans reported using care coordination standards and processes that are primarily designed to identify and respond to medical risk factors. Given this, great variation exists between different hospitals and health plans regarding the degree to which system capabilities to address social risk factors are integrated into their processes. When social risk factors are addressed by care coordinators, this is done by telephone as opposed to in-person.
One hospital and one health plan serving specifically high-risk, low-income and/or Medicaid populations reported having more extensive organizational structures and processes in place for providing perinatal care coordination. The other four responding health plans reported having somewhat different system capabilities for PMAP populations.
One health plan stands out among others for the extent to which it reported providing a significantly expanded capacity for provision of perinatal care coordination services. This plan reported reimbursing providers for both the initial and follow-up completion of the MPAF, and regularly uses public health nursing visits to address and coordinate the care of prenatal patients. Another plan stated that care coordination services are widely available within its provider network, and that the plan provides additional coordination services only to fill in the gaps. A third plan reported that case managers contact all pregnant patients deemed at risk, and that all State Public Program members are included in the at risk category.
All hospitals reported receiving prenatal clinical records via fax at regular points in prenatal care. Faxes are also used to receive the current record if a woman presents at the hospital and current records have not been received from the clinic.
Although under DHS guidelines plans could reimburse public health nurses for visits done prenatally, only one plan reported doing so. Hospitals reported that, when used, public health nurses generally take over home visitation after a health plan no longer covers the visits. Except for one hospital and one health plan, staff working on perinatal care coordination did not have consistent or extensive knowledge of how and when to access public health nursing services. One health plan noted that despite continuing problems or issues for the mother or family, care often drops off dramatically after the babys birth.
III. Client Level Activities:
Four health plans reported having developed patient incentive systems for patients to begin prenatal care early, continue care throughout pregnancy, attend prenatal classes, and keep their post partum appointment. Financial incentives are usually in the form of gift certificates.
Three health plans reported providing written materials to their prenatal patients in the form of a pregnancy information and resource packet. These packets provide information about medical expectations during pregnancy, list offerings of prenatal classes, and sometimes contain informational brochures about additional resources such as smoking cessation classes.
One health plan and two hospitals noted they face an increasing challenge to provide services to a growing population of patients who do not speak English. Six hospitals stated that interpreters are available throughout care, and that AT&T interpreter services are used as a back-up. They also commented on the additional time required to serve non-English speaking patients.
All hospitals reported that discharge planning includes informing new mothers of conditions needing immediate medical attention, and providing a phone number for the mothers to call.
Five hospitals reported offering some form of follow-up after discharge regarding breastfeeding issues. The type of follow-up ranged from phone contact to offering breastfeeding clinics.
Four hospitals reported that social workers are sometimes used for post-discharge follow-up on families with complex social and behavioral issues.
Four hospitals reported that new mothers in the hospital are told when they need to see their doctor and their pediatrician for follow-up, but the appointment is not made at the time of discharge and hospitals do not do follow-up on postpartum or newborn appointments. One hospital does make the newborn and postpartum visit appointments.
Six hospitals reported that they offer new mothers one postpartum home visit. These visits are most often provided by hospital home visiting programs or by home visiting agencies approved by the womens insurance. Less frequently, these visits are done by public health nurses. The determination of who does the home visit is almost always dependent upon the payer.
IV. Financial and Capacity Issues:
Health plan respondents to the survey did not report data on the financial status of the health plans. The staff responding to the survey presumably did not have knowledge of their plans financial status. (The survey staff made no additional efforts to obtain financial information from the plans, but some health plan financial information from other sources is included in the Discussion section of this report.) The hospital survey did not ask for financial information.
V. Hospital and Health Plan Recommendations
One hospital and one health plan submitted recommendations to improve perinatal services. The hospital recommended a need for more space. The health plan respondent recommendations were:
Provide consistent and comprehensive health care coverage early and throughout pregnancy.
More effective and timely communication among care team members, especially between prenatal care staff and infant care staff, would promote family health, especially for at-risk families.
Develop a centralized information resource for prenatal/infant health education tools designed for clients whose primary language is not English.
In summer, 2001, a draft of this report was discussed with health plan representatives at the Minnesota Council of Health Plans. Some of their comments have been integrated throughout the report. One overall comment was that some of the surveys were completed by people who did not have the full picture of the plans care coordination/case management activities. Below are comments from each health plan to provide clarification in their own words about the services they provide.
Blue Cross / Blue Shield
Blue Plus provides Healthy Start, a prenatal program for MinnesotaCare and PMAP members. Healthy Start is a telephonic case management program designed to educate and support pregnant women and their health care providers. Healthy Start nurses, trained in obstetrics, work with expectant mothers and their doctors to detect and reduce risks. The program is designed to be consumer friendly with easy access. Two fifty-dollar gift certificate incentives are utilized to encourage expectant mothers to enroll early in the program and continue participation in the program through childbirth and the six-week post-natal examination. MinnesotaCare members must also submit a completed Pregnancy Verification form to receive both gift certificates. Healthy Start is completely confidential and voluntary.
The program includes a comprehensive initial assessment of medical and psychosocial risk factors, incorporating the MPAF risk assessment. Risk factors are reassessed monthly and an individualized care plan is developed. Telephonic counseling, support and education is supplemented with additional personalized education materials. The case managers provide linkage between primary care providers and the completion of referrals to community resources including public health nursing, WIC, support groups, and specific education programs. Members are also referred to the Blue Cross smoking cessation program, health promotion services, and car seat program. Additional case management services are provided to women with complex perinatal needs, including benefit management services.
Finally, Blue Plus has implemented protocols to streamline public health/home health agency referrals and submission of MPAF records to DHS for participating health providers.
Minnesota Pregnancy Assessments Forms (MPAF): Health Partners requires providers to complete the MPAF form for all women. Forms for women on state public programs are then sent to Health Partners where the information is data entered and electronically submitted to DHS. Health Partners currently uses this information to identify high-risk pregnancies and pregnant women who smoke.
Prenatal Tobacco Cessation Project: When pregnant women are identified as a tobacco user, they become part of HealthPartners prenatal tobacco cessation project. A Health Educator for the Partners for Better Health (PBH) Phone Line calls the identified members. The Health Educator will make three attempts to reach the member. If they are unable to reach the member, a letter and PBH Phone Lines Programs brochure will be mailed. The letter contains information about the health benefits of smoking cessation and related HealthPartners resources. If they are able to reach the member and the member declines tobacco cessation information/education, a follow-up letter and brochure will be mailed. If the member is reached and would like tobacco cessation information/education, the Health Educator will review the members options and get them linked with the resource. A letter, brochure, and tobacco cessation information is sent to the member. Pregnant members requesting tobacco cessation support will receive one-to-one counseling. *It should be noted that the MPAF defines tobacco use as smoking more than 10 cigarettes per day. With this definition there may be many tobacco users that go unidentified. Because of this, HealthPartners has decided to send all Public Programs members, who are identified as being pregnant via the MPAF, a letter and brochure about tobacco cessation.
Prenatal/Postnatal Incentive Program: HealthPartners offers a clinic-based prenatal/postnatal incentive program. Women enrolled with specific clinics are eligible to receive a $5.00 Rainbow Foods gift certificate at the time of each prenatal appointment. The clinics have the gift certificate on-site and then distribute them directly to the member. When the member has completed all scheduled prenatal appointments and delivers, they are eligible to receive a $75.00 Target gift certificate for completing their postnatal visit within six weeks of delivery.
HealthPartners Case Management: The Case Management Department at HealthPartners calls pregnant HealthPartners Medical Group (HPMG) members who will be delivering at Fairview University Riverside or Regions, around the 32nd week of gestation to discuss the discharge plan and potential referrals that could be helpful before delivery. This provides an opportunity for Case Management to gather information and answer any questions the member may have about the delivery and post delivery concerns. Any clinical questions the member may have are directed back to the clinic. All members who deliver at Fairview University Riverside and Regions are followed through discharge.
Maternal case managers provide education, answer any questions and concerns the patient may have, coordinate with health care providers if additional services are required, and provide links with social workers, community resources and interpreters when needed. State Public Programs employs Social Service Specialists as does the case management area to assist clients and make referrals to community agencies regarding non-medical issues. Membership health promotion initiatives coordinated through Medicas Populations Health Department seek to emphasize healthy lifestyle adoption in the areas of nutrition, exercise, avoidance of destructive habits (i.e. smoking, substance abuse) and violence prevention. (Medica confirmed that most contact is made by telephone or mail.)
Metropolitan Health Plan
Women In Need (WIN) Program is a program for public program members who have a high risk pregnancy. Participants who are seen the recommended number of times per trimester and follow their physicians recommendations receive an incentive for that trimester. Participants who need other items (i.e. cribs, car seats, or furniture) are referred to First Call for Help for a variety of sources to help them obtain those items. Those who do not have access to a phone,may qualify for MHPs Cellular Phone program. MHP provides cellular phones that allow members to call a doctor, a nearby relative or friend, social services, or 911. We also inform these participants of the Minneapolis Way to Grow program. At delivery, participants are given a diaper bag with items they can use for the baby. They are also approached about Child and Teen Checkups and registering their child in the BabyTracks and the Follow Along Program. All pregnant members are eligible to use our phone-based Smoking Cessation Program free of charge. Members delivering at HCMC are given a diaper bag with items they can use for the baby. Many of our members sign their children up for the programs.
The goal of UCare Minnesotas Management of Maternity (MOM) program is to identify pregnant members early and offer them resources they need to experience safe pregnancies and deliver healthy babies. MOM provides: telephonic assessment and education at each trimester for early detection of high-risk factors; assessments of members needs and identification of social support systems to help meet those needs; and education and coordination of services for high-risk members. MOM also offers the following services to pregnant members: a prenatal care incentive program, assistance with referrals for mental health/chemical dependency assessments; incentives to attend prenatal and childbirth education classes; individualized smoking cessation programs; information about UCares breastfeeding pump program; information about UCares car seat program; and public health/home care services.
1. Forty percent of all births in the two counties are to low-income women. Minnesota Department of Human Services, personal communication.
Page 20 of 21