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					Maine Department of Health & Human Services
        Bureau of Medical Services
                7th Annual Report
        to the Joint Standing Committee
          on Health & Human Services

      Improving MaineCare
         Dental Access
       For Maine Children
            (MRSA 22, § 3174-S)




              February 15, 2005

                       1
Contents                                                      Page
Introduction                                                  1

Member Outreach Efforts
 Targeted Mailings                                            2
 Resource & Referral                                          3
 Education & Awareness                                        3
 Call Tracking Reports                                        4
 Dental Health Promotion Done by WIC                          5

 Resource Guide                                               7
 Outreach Efforts to Dental Care Providers                    9
 Follow Up for Missed Appointment                             9
 Provider Relations                                           10
 Dental Policy Update                                         11
 Provider Relations Enhancement Project                       12
 Dental Advisory Committee                                    13

 Participation on Dental Forums
 Maine Dental Access Coalition                                14

 Conclusion                                                   16

 A.   Periodic Notification Packet
 B.   Home Visit Referral Form
 C.   Dental Call Reason Summary
 D.   Dental Visits Are Important
 E.   Resource Guide, Dental Portion
 F.   Resource Guide, Dental Portion
 G.   Summary of Dental Providers and Expenditures by Month
 H.   Member Education Form
 I.   Summary of 45-Day Dental Provider Survey
 J.   DHS Fact Sheets
 K.   MaineCare Dental Claim Summary




                                         2
                                  Introduction

This report is provided in response to MRSA, § 3174-S: Access to Dental Services for
Children under MaineCare. The goal of this legislation is for all children enrolled in the
MaineCare Program in all areas of the State to have the same access to dental care as
children who have private dental insurance.

The Bureau of Medical Services (BMS), MaineCare Member Services, and the Maine
Dental Access Coalition, continue to work to provide the best possible outreach and
referral services to MaineCare families and dental providers. These services focus on
raising awareness of dental coverage for children with MaineCare coverage, providing
assistance with finding a dentist, working to increase dental community participation,
providing referral services as appropriate, and member education. This report outlines
all of the services provided this year, as well as additional activities undertaken to
improve dental access.

The attachment section includes samples of materials distributed to members,
correspondence, pertinent data, and other pieces of information referred to in the
narrative portion of this report.




                                            3
                       Member Outreach Efforts

                              TARGETED MAILINGS

MaineCare benefits for members under 21 are services administered by BMS
MaineCare Member Services to provide outreach services to members. Services are
available to all MaineCare members under the age of 21. Each new MaineCare
member is informed of his or her benefits within 30 days of becoming eligible for the
Program.

An informing packet (included as Attachment A) is sent to all new members. The
packet includes a letter, a brochure, and a follow-up response card:

          The letter provides general information about available services and the
           toll free number for MaineCare Member Services.
          The brochure provides information about when a child should have a healthy
           visit according to the nationally recognized standard of care known
           as “Bright Futures.” Information about the importance of healthy dental visits
           is also included.
          The postage-paid follow-up response card is included for members to request
           additional assistance.

After members receive the information packets, they will receive periodic notices the
month before they are due for a healthy child visit, that include a letter and a brochure.
The following table shows the number of information packets and periodic notifications
that have been distributed since 1999:

                  2004        2003         2002         2001         2000         1999
Information      80,840      60,585       52,412       60,858       51,333       40,604
Packets
Periodic        131,156     123,198      109,603       103,413      94,312       58,105
Notifications


The informing and periodic notification letters include MaineCare Member Services toll-
free number, a postage-paid follow-up response card offering resource and referral
services, and assistance in finding a physician, a dentist, or any other type of
MaineCare provider, if needed. The Bureau also offers assistance with scheduling
appointments and arranging transportation. (The periodic notification packet is included
as Attachment B.)




                                            4
                                  RESOURCE & REFERRAL

         MaineCare Member Services Telephone Referral Service
       Toll-Free 1-800-977-6740, or if you are deaf or hard of hearing and have a TTY machine call
                                           1-800-977-6741

MaineCare Member Services maintains a toll free number that is the front line for
MaineCare members who need assistance with benefits for members under 21, and
managed care enrollment services. All staff are knowledgeable about the answers to
basic questions regarding MaineCare covered services, provide information about how
to access services, provide education about the importance of regular preventive health
care, and recommended frequency of preventive services.

Member Services is available to MaineCare members to make navigation through the
health care system as barrier free as possible. Many of these services are specific to
dental care. The following dental services may be obtained through the toll free
number:
    Finding a dentist,
    Dental appointment scheduling,
    Dental referral services,
    Further assistance if members are not successful in scheduling an appointment,
    Follow up for missed appointments,
    Follow up for members needing orthodontic care,
    Home visits for members who have no phone or need one-on-one assistance.
       (Included as Attachment C)

An average of 771 requests per month were received in 2004 for assistance with finding
a dentist for a total of 9,259 requests for the year. 590 members received assistance
with access to orthodontic care. In addition, 1,320 families, who had a history of broken
appointments, were contacted to provide education on the protocol for appointment
cancellations, information about transportation services available to MaineCare
members who qualify, and additional education relating to dental services.

(Refer to Attachment D for details on contacts for dental services with MaineCare
members.)


                            EDUCATION & AWARENESS
A brochure (included as Attachment E) is mailed with the periodic notification packet.
The brochure contains information about the importance of keeping dental
appointments and what to do if an appointment must be cancelled. The brochure is also
included when Member Services sends a letter to member who has missed a dental
appointment.
.




                                                5
                        CALL-TRACKING REPORTS

 All telephone requests for dental assistance are documented and tracked. Each ca ll
received and all assistance provided is classified into a category based on specific
criteria. Data classification by category allows the creation of reports, which provide the
user with information for monitoring and improving the benefit. The dental tracking
categories and specific criteria used are listed below:


           No Access, General                   Either the staff was not able to make a
                                                referral or the member did not accept the
                                                referral.
           No Access, Orthodontic               Either the staff was not able to make an
                                                orthodontic referral or the member did not
                                                accept the referral.
           Dental Emergency                     The member indicates that s/he has an
                                                emergency and is not able to receive
                                                services within 7 business days.
           Referral, Dental, General:           The staff gave dental provider name(s) to
                                                the member.
           Referral, Dental, Orthodontics       The staff gave an orthodontic provider
                                                name(s) to the member.

The Bureau of Medical Services compiles a number of reports from the call tracking
systems. Please refer to Attachment D for reports on the number of calls received the
period January 1, 2004 to December 31, 2004. Following is a summary of the totals
reported for the period and a comparison of numbers from 1999 through 2004.

                         2004        2003           2002      2001       2000       1999
No Access, General              78      224            361       167        197        142
No Access,                      19       34              23        31         22        26
Orthodontics
Dental Emergency             253          206           68        136         34        37
Referral, Dental,          9,259        9,864        9,232      7,747      5,125     3.949
General
Referral, Dental,            590         659           553         53        301       339
Orthodontics




                                                6
                   WOMEN, INFANTS AND CHILDREN (WIC)
                    DENTAL HEALTH PROMOTION IN 2004


WIC is the Special Supplemental Nutrition Program for Women, Infants and Children,
funded by the U.S. Department of Agriculture. In Maine, the WIC Nutrition Program is
directed by the State WIC Agency within the Department of Human Services, Bureau of
Health, and Division of Family Health.

WIC is a nutrition program that provides education, counseling, medical and social
service referrals, breastfeeding education and support, and nutritious foods for eligible
women, infants and children to promote life-long optimal health. WIC programs are
administered state-wide by nine local agencies with over 100 clinics in permanent as
well as temporary sites (church basements, town halls, etc.) Approximately 22,000
participants receive benefits through the WIC Program each month. Pregnant,
breastfeeding and post-partum women, and children from birth to age 5 years qualify for
WIC services. Single, married, and foster parents as well as working families can enroll
their children in the Program. To be eligible for WIC, applicants must have income at or
below 185% of the Federal poverty income guidelines. Those receiving TANF, Food
Stamps or MaineCare are automatically income -eligible.

During visits with participants, WIC counselors highlight dental health issues. Typical
dental educational activities/messages include:

      infant dental care---washing baby's gums, brushing teeth as soon as they have
       come through the gums
      begin dental care early---routinely referred to Member Services to find a dental
       provider if participant has MaineCare; parents are encouraged to brush their
       children’s teeth and to begin flossing early
      signs of early decay
      no bottles in bed
      formula or water only in bottles
      juice should only be served in cups
      weaning by 12 months
      sip cup training beginning at 6 months (several agencies provide sip cups to
       parents when the baby turns 6 months old)
      limit sweet, sticky snack foods---emphasize healthy snacks for kids
      fluoride supplementation---referrals are given for families with wells to test their
       water for fluoride content
      one agency routinely has toothpaste samples from Tom’s of Maine
      several agencies provide toothbrushes to families to encourage routine brushing
       of children’s teeth
      bulletin board displays encouraging preventive oral health measures


Dental hygienists partner with several local WIC agencies to provide services in the
WIC clinics. Appointments for the children include screenings, cleanings and sealant
applications, along with referrals when treatment by a dentist is needed. Hygienists are
                                             7
able to see children for regular cleaning appointments as early as 12 months, and to
educate mothers about good dental care even for their infants. In the non-threatening
WIC environment, children are able to get used to dental check-ups in a friendly
fashion. In several of these collaborative agreements, older siblings benefit as well.
Parents can make cleaning/screening appointments for their children who are over the
age of 5 along with the child enrolled in WIC. During 2004, these collaborations allowed
more than 4000 children to be seen by a dental hygienist. In addition, some WIC
agencies have dental clinics close by. If a child or parent is in need of restorative
treatment, referrals are routinely made to dentists at these clinics.

The inclusion of dental health as part of the education and benefits provided by the WIC
Program is an excellent example of how one program can impact families in a number
of positive ways.




                                           8
                               Resource Guide

The Resource Guide is a tool used to assist MaineCare members in locating all types of
MaineCare providers, social service resources, and State agencies that provide a
variety of services. Attachment F contains the section of the Resource Guide, which
specifically provides dental resources. Not all dentists wish to be included as a provider
in the resource guide but many will see a limited number of MaineCare members.
Attachment G reports the actual number of MaineCare dental providers, by month,
who provided services during 2004 and the average number of patients seen per
month. Dentists who are listed in the Resource Guide have agreed to see either any
new MaineCare member who has requested assistance with finding a provider, or are
willing to continue to see all of their MaineCare members who are established patients.
All information in the Resource Guide is updated regularly, but the listings of available
MaineCare dental providers are updated through separate surveys at specific intervals:

          A survey every 45 days of MaineCare dental providers listed in the Resource
           Guide;
          An annual survey of non-MaineCare dental providers and MaineCare dental
           providers not listed in the Resource Guide.

When dentists are surveyed, the following questions are asked:

   Are you taking new MaineCare patients at this time?
   Are you only seeing established MaineCare patients?
   If you are taking new or established patients, are you taking more or fewer
    MaineCare patients than in the past? Are you taking more or fewer non-MaineCare
    patients?
   Are there age restrictions? What is the youngest child you will see?
   Are there any geographic restrictions?
   Will you see adults for emergency care?
   What is the broken appointment policy?
   Does your practice provide dentures?
   Is your practice handicapped accessible?
   What is the waiting time for cleaning appointments and urgent care appointments?
   Is there any other information you would like to include?

The answers to these questions allow Member Services staff to be as helpful as
possible when making referrals and providing educational assistance for dental
services. During the call, the dental provider is reminded that if they treat MaineCare
children who have a history of missing appointments, they can either call or fax
MaineCare Member Services for assistance, or they ma y use the Member Education
Request Form (described next in this report and shown as Attachment H).




                                            9
A follow-up contact is made with the family to provide education about the importance of
keeping appointments, and to offer help finding transportation resources. (Refer to
Attachment I for dental provider survey details).




                                          10
          Outreach Efforts to Dental Care Provider


                 FOLLOW UP FOR M ISSED APPOINTMENTS


Missed appointments are regarded by dentists as one of the main reasons that they are
unwilling to see Mai neCare members. In an effort to assist the dental community with
this issue, dentists are provided with an opportunity to let MaineCare Member Services
know when they have a member who has a history of missed appointments so that
education can be provided.

In addition to the option to call, fax, or write, the Bureau has also developed another tool
for dentists to request assistance. The Member Education Request Form is postage-
paid, self-addressed, and contains fields to fill in pertinent information needed in order
to be effective with the follow-up process (included as Attachment H).


Follow-up discussions with families include:

       the importance of keeping appointments,
       office policy for the cancellation of appointments for the specific provider they
        see,
       transportation assistance, or other services that staff have identified from talking
        with the families.

A total of 1,320 families were contacted in the year 2004 in regard to missed
appointments.




                                             11
                      PROVIDER RELATIONS ACTIVITIES

The Provider Relations Unit in the Bureau of Medical Services provides education,
policy interpretation, resolution of billing issues and general assistance to MaineCare
providers. Two provider relations specialists and one billing specialist are assigned to
assist dental providers. The following is a summary of this year’s activities and
upcoming changes.

Statewide pre-MECMS (MaineCare Claims Management System) trainings were
conducted to inform providers about upcoming changes with the implementation of
MECMS the DHHS new claims processing system. Providers were notified of the new
billing changes, issuance of new provider billing and servicing numbers and system
enhancements. The planned enhancements will include web-based billing, claims
status information, web-based eligibility information, reference codes, on-line prior
authorization requests and provider enrollment.

During the upcoming year, the Provider Relations Unit, will conduct statewide MECMS
trainings for all providers. Providers will be notified of the dates and places these
trainings will be held in the near future. All providers will be encouraged to attend.

Planning is underway to change from the current ADA billing claim form to the 2002
version. To ensure a smooth transition to the 2002 claim form, the change to the new
form will occur after the complete implementation of MECMS. Notification and
statewide training will be offered to dental providers on the new form changeover prior
to implementation.

The Provider Relations Unit, along with Member Services staff exhibited at the Maine
Dental Association’s Annual Meeting. Information was available to dental providers for
enrollment, general MaineCare information and assistance with billing/policy issues.

The provider relations specialists provide individual trainings with dental providers and
contact newly enrolled dental providers to offer assistance and training.




                                            12
                      DENTAL POLICY UPDATE

In 2004, the Bureau of Medical Services maintained its recently updated, October
2003, MaineCare Dental Services policy. No new rulemaking was initiated during
the calendar year; however, various interim clarifications were made.

Working closely with the MaineCare Prior Authorization Unit, the coordinator for the
benefits for members under 21, and the Dental Advisory Committee, the Policy Unit
is participating in an analysis of the 2003 “Supplemental Payment to General Dental
Providers for Accepting New MaineCare Patients.” This supplemental payment is a
one-time, per member, per provider, enhanced payment. It is payable to any
enrolled general dentist, clinic, or office for any MaineCare member, age 1 through
20 that the MaineCare general dental provider, clinic, or office has not seen in the
last 3 years, and establishes in his or her practice with the intention of providing
comprehensive dental care on an on-going basis. In spring of 2005, a year of data
will be available and this incentive and alternative incentives will be explored. The
Bureau will continue this ongoing collaborative effort to encourage dental providers
to continue to participate in MaineCare with the limited funding available.

In addition to any changes to this incentive arrangement in 2005, there will be
proposed changes to the MaineCare dental policy. Planned amendments at this
time include updating Chapter III billing codes to the Common Dental Terminology 5
coding and the implementation of the new ADA billing claim form. Together, all
these changes will continue to make participation in MaineCare administratively
easier for dental providers.




                                        13
       PROVIDER RELATIONS ENHANCEMENT PROJECT
The Provider Relations Enhancement Project was initiated in the summer of 2004 with a
short telephone survey administered to a sample of dentists participating in MaineCare.
The project was a cooperative effort between the Division of Health Care Management
in the Bureau of Medical Services and the Bureau of Health’s Oral Health Program, with
assistance from the Maine Dental Association. The purpose of the survey was twofold:
to understand perceived barriers to accepting MaineCare patients in dental practices
and to learn the affects of recently enacted MaineCare improvements over the past few
years. In addition, the Department was interested in how survey responses might help
identify ways in which MaineCare could improve access to dental services for members
by reducing those barriers. The sample was stratified to include representation from
every region of the State. Dental providers with both high volumes and low volumes of
MaineCare members in their practices were chosen to understand the concerns of each
group. Although the number of providers surveyed was not statistically valid, it allowed
the Department to determine if the changes made over the past few years have
changed the dentists’ viewpoint.

The survey analysis revealed responses not unlike what we have heard in recent many
years including but not limited to low fees, problems with patients missing appointments,
poor dental hygiene and the paperwork burden.

Department staff will continue to meet to analyze responses and develop strategies to
resolve major concerns.

The survey and report were supported with funds from the Cooperative Agreement
between the University of Southern Maine and the Department of Health and Huma n
Services and from the Provider Relations Enhancement Project, supported by HRSA
grant # 6 H47 MC 02027-01 to the Oral Health Program, in the Bureau of Health.




                                           14
                       DENTAL ADVISORY COMM ITTEE

The Dental Advisory Committee is made up of a group of dentists, a hygienist, and
DHHS representatives working together to create better access to dental services
across the State. The group has been working together for about 5 years and has
many members who also serve on the Maine Dental Association and the Dental Access
Coalition.

The Committee meets quarterly and advises the Department on dental issues. The
following list represents the highlights for 2004.

      The Department began a supplemental payment of $150.00 to dentists who
       provided new dental homes for MaineCare members. The goal of this change
       was to improve the percentage of children and adolescents who receive
       preventive dental services. The Committee provided advice to the Department
       on a number of matters surrounding that change and began to track the
       statewide effectiveness of the change.

      The Committee arranged for the Maine Dental Association (MDA) to invite
       MaineCare to participate in the annual meeting sponsored by the MDA.
       Resulting from that invitation, MaineCare representatives attended the annual
       meeting and exhibited the changes the Department has made in recent years to
       help make the Program easier for dentists to navigate. The networking
       opportunity resulted in two new dentists becoming MaineCare providers.

      The Committee reviewed the new billing codes for 2004 and shared clinical
       expertise to help the Department determine coverage and reimbursement rules.

      The Committee continued to provide advice on the prior authorization criteria
       used in determining coverage for dental services.

      The Committee participated in the development of the Provider Relations
       Enhancement survey to collect feedback from dentists about their thoughts on
       MaineCare.

The Department appreciates the work of the Committee for its important efforts in
improving access to dental care for MaineCare members.




                                           15
                  Participation on Dental Forums

                         Maine Dental Access Coalition

The Maine Dental Access Coalition was first convened in June of 1997 by the Maine
Children’s Alliance through its Child Health Access Project, with assistance from the
Oral Health Program in the Bureau of Health. The Oral Health Program has continued
to provide support to the Coalition through its own resources and grants from the federal
Health Resources and Services Administration, Maternal and Child Health Bureau. The
Coalition’s mission is to improve access to quality oral health care services throughout
Maine through the development of a system that emphasizes the importance of
preventive and restorative oral health care. This ad hoc coalition includes about 125
individuals representing consumers, advocacy organizations, legal services, Community
Action Programs, the Maine Dental and Dental Hygienists’ Associations, health
insurers, the Maine Public Health Association, local community groups concerned with
access to dental care, State agencies including the Bureau of Health, the Bureau of
Medical Services, and the former Department of Behavioral and Developmental
Services as well as individual medical and dental health professionals, State legislators
and interested individuals.

Staff from both the Bureau of Medical Services and the Bureau of Health continue to
participate in the Maine Dental Access Coalition. Staff from DHS who have actively
participated in the Coalition during the past year i nclude:

Judith Feinstein, Oral Health Program (BOH)
Sophie Glidden, Office of Rural Health and Primary Health (BOH)
Marc Coulombe, Office of Rural Health and Primary Health (BOH)
Kristine Perkins, Oral Health Program (BOH)
Karen Gallagher, WIC Program (BOH)
Pat Scheuerman, Member Services Advisor, (PCG)
Kip Neale, MaineCare Policy Development (BMS)
Donna Esterline, Provider Relations Specialist (BMS)
Karen Casey, Coordinator, Benefits for Members Under 21 (BMS)
Janie Turner, Provider Relations Specialist (BMS)


The Coalition continues to be recognized as an avenue for maintaining the general
momentum in the State for emphasizing the lack of and need for improved access to
quality dental care for all Maine citizens. The ongoing broad-based membership of this
group, its positioning as a neutral party, and the continuing interest in its work have
helped assure involvement and response by both the public and private sectors. The
Coalition continues to serve as a sounding board for ideas and strategies geared toward
improving access, and provides the structure, through its committees, to propose
options for improving access and to pursue strategies toward that goal.



                                           16
Although the Coalition did not hold its annual planning retreat, its stated ongoing
objectives and activities as well as the work of the its standing committees (Provider
Issues, Community Coalitions, Legislative Issues and Education Issues) were reviewed
and refined throughout the year as needed. The Coalition’s Education Committee, in
conjunction with the Bureau of Health’s Oral Health Program, completed the
development of education and training materials for non-dental health professionals
focused on Early Childhood Caries prevention and intervention efforts. The Oral Health
Program received a grant from the Maine Health Access Foundation to support this
initiative. The cornerstone, a training curriculum, was piloted with pediatric health
providers in the fall of 2004 and additional training events with several non-dental health
provider groups are planned for 2005.

The Oral Health Program received funding in September 2003 for one year and in
September 2004 for three additional years through the State Oral Health Collaborative
Systems grant program of the federal Health Resources and Services Administration,
Maternal and Child Health Bureau. Continued support of the Coalition and of projects in
which Coalition members will be involved were written in to both of these grant
applications. As such, individuals from both the Bureau of Health and the Bureau of
Medical Services will be involved in staff support, consultative, and advisory capacities,
as all of these projects either directly or indirectly are intended to increase access to
dental services for uninsured, underinsured, and MaineCare-eligible children and their
families.




                                            17
                                CONCLUSION

This year, MaineCare spent over $21 million for dental services, a $4 million increase
from 2003. The number of members receiving dental services rose to 73,504 members,
an increase of 12,190 members from 2003. The number of dentists who submitted at
least one claim for dental services decreased from 282 dentists in 2003 to 278 in 2004.
This is the lowest number of participating dentists since we began writing this report in
1999.

Despite the decrease in the number of private practice dentists who saw children with
MaineCare coverage, more children were provided dental services in 2004. Private
practicing dentists saw 66,925 MaineCare members in calendar year 2004, an increase
of 5,611 members seen by fewer dentists. Even though there was a decline in the
number of dentists who saw MaineCare members, two new dentists enrolled in
MaineCare in calendar year 2004. Dental practices within Federally Qualified Health
Centers saw 791 members. Over 6,500 children were seen by dental hygienists
providing screening and preventive services practicing under the supervision of a
dentist, but not employed by a dentist.    (Please see Attachment L for a further
breakdown of the claims information.)

MaineCare has been working with many groups to broaden dental access for
MaineCare members. The problem is far reaching, has spread throughout much of the
country, and is being tackled on a number of fronts. A shortage of dentists statewide,
regardless of payor source, still remains, and many practicing dentists are nearing
retirement. The Maine Dental Association with the help of other groups, including State
agencies, have worked to establish dental school loan and loan repayment programs
through the Finance Authority of Maine, to attract new dentists to the State. An
agreement was signed to reserve six spots each year for Maine residents to go to
dentistry school in Halifax, Nova Scotia. Many groups throughout the State are working
to generate interest in dentistry as a career choice among young adults. BMS and its
partners continue to work to improve dental outreach and educational services to
dentists and members.

This year has begun to show positive results. An achievement of note are the many
workgroups, advisory committees, and coalitions collaborating closely to attract new
dentists to the State, keep current MaineCare dentists participating, and to generate the
many ideas and sometimes unusual solutions needed to tackle this serious problem.
Dental hygienists saw 6,500 children and adolescents with MaineCare coverage, a
number that would not have been possible prior to the change in MaineCare policy
allowing hygienists to participate as individual providers with a supervising dentist.
Dental providers who have opened their doors to MaineCare members in the past are
beginning to provide services to more members. Some Federally Qualified Health
Centers are beginning to hire dentists to provide dental services in their facilities. The
Maine Dental Association has worked closely with MaineCare to appeal to their
members to see children who have MaineCare coverage. MaineCare implemented the
supplemental payment to pay dentists more for the initial visit if the dentist agrees to


                                           18
take the MaineCare member on as a patient of record. These are all very positive
changes, but still there is much to do.

Over the next year, MaineCare will monitor the supplemental payment with the Dental
Advisory Committee and other partners to track progress, assess the impact of the
change, and make adjustments. If we find that the supplemental payment is not
successful in generating the desired results, we are considering a dental incentive
payment. Early projections indicate that the supplemental payment is not making as big
an impact as we had hoped. We will also continue to collaborate with the many groups
across the State to continue past efforts as well as generate new ideas.




                                         19

				
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