ATTACHMENT A by yaofenji


									                      ATTACHMENT A
                     Work Group Members

     Member                  Organization Represented
Anthony, Jane         VOR
Barker, George        Commonwealth of Virginia

Senator               Senate
Bennett, Pat          PAIR
Brandt, Carrin        The Arc of Northern Virginia

                      Parent Representative
Brown, Dennis         Fairfax-Falls Church CSB
Bulova, David         Commonwealth of Virginia

Delegate              House of Representatives
Caldwell, Phil        Alexandria CSB
Diorio, Mark          Northern Virginia Training Center

Executive Director
Dix, Heidi            Department of Behavioral Health

                      and Developmental Services
Egle, Jill            The Arc of Northern Virginia
Eisenbaum, Elaine     The Arc of Northern Virginia
Gilmore, Mike         Alexandria CSB

Executive Director
Goodwin, Nan          Alexandria CSB
Graham, Margaret      Northern Virginia Training Center
Hartman, Edward       Chimes of Virginia
Johnson, Thomas       St. John’s Community Services
Jones, Barbara        Arlington County CSB

                      Board Member
Katz, Leslie          Northern Virginia Training Center
Kinzler, Peter        VOR
Koshatka, Cindy       Northern Virginia Regional Office
Manning, Dennis       Community Residences, Inc.
Mercer, Nancy         The Arc of Northern Virginia
Miller, Brian         Prince William County CSB
Ray, Doris            Endependence Center of Arlington
Rudolph, Susan        The Arc of Greater Prince William
Sale, Anne            Prince William County CSB Board Member;

Self, Tracy           Northern VA Training Center (P & A)
Senft, Ed             PAIR
Smith, Karen          The Arc of Greater Prince William

Welsh, Bob            Northern Virginia Training Center (P & A)
Wise-Barnes, Joanna   Arlington County CSB
Witt, Woody           Fairfax-Falls Church CSB Board Member
Wooten, Alan          Fairfax-Falls Church CSB

                                     ATTACHMENT B

                                       Relevant History

   In 1972, Title XIX of the Social Security Act was amended to establish the
    category of “Intermediate Care Facility for the Mentally Retarded
   In 1981, Section 1915c of the Social Security Act established Home and
    Community Based Waivers as an alternative for long term care.
   In 1990, the Americans with Disabilities Act was enacted by the United
    States Congress.
   In 1991, Virginia began offering Medicaid Waiver services. A home and
    community based Waiver is offered to individuals who “waive” their right
    to a Training Center or an ICF/MR and instead request a comparable level
    of supports and care in their own community with the providers of their
   In June 1999, the Supreme Court decision in Olmstead v. L.C. affirmed
    the rights of individuals with disabilities to live in the community. States are
    required to place persons with mental disabilities in community settings rather than in institutions
    when the State’s treatment professionals have determined that community placement is
    appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the
    affected individual, and the placement can be reasonably accommodated, taking into account the
    resources available to the State and the needs of others with mental disabilities. During this
    time, Virginia has offered the option of both community and institutional
    services through its system of Training Centers and CSBs.
   In 2005, HJR 76 recommended that smaller Training Centers serve people
    with higher needs while community services capacity is developed to serve
    individuals with behavioral and medical needs.
   In 2009, Delegate Bulova and Senator Barker tasked this group to
    complete a regional review of the system. Based on a review of both the
    strengths and needs of the region, the group was asked to develop a list of
    recommendations for both short term and long term enhancements.

                                 ATTACHMENT C
                                   Data Sources

State Resources online:

Virginia Office of Behavioral Health and Developmental Disabilities (for both CSBs and Training Centers) (current and historic wait list data) (Comprehensive State Plan) (Overview of Waiver Services) (accountability reports)

Virginia Office of Inspector General (reports on quality improvement for both community
services and Training Centers)

Virginia Department of Medical Assistance Services (VA Medicaid) (data and reports)
(RD216 Report to eliminate Waiting Lists)

Virginia Department of Education
(Annual count of special education students for each Virginia school system)

University of Virginia Weldon Cooper Center for Public Policy (Virginia Census data by jurisdiction)

Other online resources:

Report: Investing in Medicaid Home and Community-Based Services is Cost Effective

Research and Training Center on Community Living (various reports)

United Cerebral Palsy (Report: The Case for Inclusion 2010)

Virginia Alliance for Community
Report: Reform Now: Community for All

VOR (National Advocacy Organization) (policy statements)
Report: Cost Comparisons of Community and Institutional Residential Settings:
Historical Review of Selected Research (2003 report and 2009 update)

Region 2 includes the following CSBs (2009 population estimates):
Alexandria                   141,738
Arlington                    212,038
Fairfax-Falls Church        1,072,886 (County and 2 Cities)
Loudoun                       298,113
Prince William                437,173 (County and 2 Cities)
TOTAL REGION                2,161,948
TOTAL VA                    7,882,590
Region 2 contains 27% of Virginia’s population.


The Virginia Department of Education (DOE) publishes annual data on prevalence of
special education categories among VA school systems.
The most recent data is from December 1, 2008. “ASDs” refers to students identified as
having Autism Spectrum Disorders. ID refers to students identified as having intellectual

     CSB          # special         # all        % who are       # ASDs             # ID
                  education                       special
                                   students      education     classification   classification
 Alexandria        1,830           11,223         16.3%             81               86
 Arlington         2,933           19,599          15 %            261              107
 Fairfax-Falls    24,220          171,033         14.1%           1,930             891
 Loudoun           5,910           56,949         10.4%            625              240
 Prince            9,600           82,959         11.6%            647              469
 TOTAL            44,493          341,763          13 %           3,544            1,793
 TOTAL VA         166,932        1,236,546        13.5%           8,884           10,014
 % of region to    27%             27.6%                          40%              18%

This illustrates that while Region 2 contains 27% of the State population, 27% of total
students and 27% of special education students, there is a wide variance in specific
categories of special education students.
Specifically, Region 2 has 27% of all Virginia special education students but 40% of all
Virginia students with ASDs and only 18% of all Virginia students with intellectual
disabilities. This prevalence is most pronounced in Fairfax and Loudoun schools.


   Training Center                     Alexandria     Arlington     Fairfax-     Loudoun    Prince
                                                                  Falls Church              William
   CENSUS as of             TOTAL
      3/25/2010              VA
 Northern Virginia                        14            29            97            3         26
 Training Center              169
 Central Virginia                           7           10            30                       2
 Training Center*
 (ICF/MR only)                303
 CVTC Skilled Care             76          3             1             7                       3
 Southeastern Virginia
 Training Center              144
 Southside Virginia                                                    1
 Training Center *
 (ICF/MR only)                267
 Virginia Training
 Center                       191
 Training Center Total       1,150        24            40           135            3         31
 Region 2 total
 233/1,150 (20.3%)

FY10 Budget as of 11/09/09:
 Training Center                                    FY10 Budget          Annual Cost per individual
 Northern Virginia Training Center                  $36,708,740          $213,423
 Central Virginia Training Center                   $79,024,338          $183,351
 Southeastern Virginia Training Center              $25,046,132          $169,231
 Southside Virginia Training Center (a)             $71,426,729          $264,543
 Southwestern Virginia Training Center              $24,964,248          $128,022
 Training Center Total                              $237,170,187         $250,708
(a) SVTC includes 3 facilities-SVTC, CSH and HDMC

Data compares adults from Region 2 served at Training Centers and CSBs

Northern Virginia Training Center residents (Region 2)
Mild           3%
Moderate      11%
Severe        15%
Profound      71%
Unclassifiable 1%
Adults served by CSBs not in Training Centers (Region 2)
Mild          37%
Moderate      36%
Severe        17%
Profound       9%
Unclassifiable 1%

Data representing 1/1/05 through 12/31/09

In the past five years, there have been 12 admissions to NVTC and of those, 5
had previously received emergency respite at NVTC. An additional 9 individuals
received only emergency respite for an unduplicated count of 21 additional
people served in the past five years.

In the same five year period, there have been 36 discharges and the reasons are
provided below:
        19 individuals died
         6 individuals returned to live with their families
         6 individuals moved to Waiver funded group homes
         3 individuals moved to community ICFs
         1 individual moved to skilled nursing facility
         1 individual moved to Hiram Davis, a public skilled nursing facility

This indicates a net decrease of 24 in the number served through admission to
NVTC during the past five years.

According to the most recent VA State Performance Contract, the average age of
people at all Virginia Training Centers was 48 years of age and their average
length of stay or tenure was 28.6 years. Only 38 (2.6%) had "episodes of care"
of less than 7 days while 145 (10.1%) had episodes of care of more than 50

Region 2 Residential Capacity

Region 2 maintains effective partnerships with private non-profit residential
service providers. Through a combination of directly operated CSB programs
and licenses private vendor programs, the following residential capacity exists in
Region 2.

        Community ICF/MR beds                             61 beds are available
        Intensive 24 hour group homes                     540 beds are available
        Supported living (< 24 hour)                      190 individuals supported

                               MR/ID         MR/ID         MR/ID
                              WAIVER        WAIVER        WAIVER
          CSB                 Urgent       Non-            Urgent &      CSB           Slots
                                                          Not Urgent
                                           Urgent                        WL as       allocated
                               Status      Status                        % of         to each
                                                                         State          CSB
Alexandria                       21             2             23         0.4%             82
Arlington                        24            34             58         1.1%             76
Fairfax-Falls Church            345           262            607        11.5%            635
Loudoun                          84            55            139         2.6%            109
Prince William                   80            73            145         2.9%            215
REGIONAL Total                  554           426            980        18.6%           1,117
STATE Total                    2,878         2,835          5,263                       8,232

                                                                          (b)            (c)
                  DATA as of 4/2/2010

The columns titled urgent and non-urgent refer to State terminology to differentiate two
subgroups of the MR/ID Waiver wait list. Urgency is determined based on a clinical
assessment of criteria such as age and health of caregivers and health and safety risks of
individual. Those who are identified as urgent have needs which must be met within 30
days and if offered a slot, the recipient must accept it. Those who also agree to accept a
slot within 30 days but who did not meet the clinical criteria of urgent are considered
non-urgent. When the State publishes its “Waiver wait list”, it only includes those in
urgent or non-urgent status.
(a) As a reference, this wait list number subsequently increased from 5,034 in December,
2009 which represents a 14% increase annualized
(b) As a reference, northern VA represents 27% of the total State population but 18.6%
of those with urgent or non-urgent need
(c) As a reference, northern VA represents 27% of the total State population but 13.6%
of the total number of awarded slots

The table below also references those who are NOT on the State Wait List.

          CSB                  State        Planning      Not Eligible           Full
                              Wait List                   for Waiver
                                                                             wait list
Alexandria                       23             0               23                46
Arlington                        58             6               15                79
Fairfax-Falls Church            607            53              279               939
Loudoun                         139            15                2               156
Prince William                  153             1               84               238
REGIONAL Total                  980            75              403              1,458
150% of those on the wait list have at least one caregiver aged 55 years or older.

Planning refers to those who are Waiver eligible but who do NOT agree to accept a slot, if
offered, within 30 days. Those who are not Waiver eligible do not meet the Waiver
eligibility criteria which include financial, clinical and citizenship criteria.

     For adults on the wait list, the most requested services are day services and
      congregate residential services (not in natural family)

 Most children placed on the wait list are identified as needing in home supports
  to enable them to remain living with their natural families

2010 Virginia Report
Case for Inclusion
2010, United Cerebral Palsy, National Office
1660 L Street NW, Suite 700, Washington, DC 20036
Phone: 800.872.5827 / 202.776.0406 | TTY: 202.973.7197 | Fax: 202.776.0414

Overall Ranking (among all 50 states and Washington, DC, 1=best): 42

Promoting Independence

             Community-based Data                       Value     Subrank (1=Best)         US Average                             Source
   Percent of Recipients with ID/DD on HCBS             83.3%           38                   84.9%           Research and Training Center on Community Living
    Percent of ID/DD Expenditures on HCBS               61.9%           36                   65.1%           Research and Training Center on Community Living
  Percent of ID/DD Expenditures on non-ICF-MR           70.1%           42                   76.8%                           Coleman Institute

  Individuals Served by Size of Residence Data          Value     Subrank (1=Best)         US Average                             Source
Percent in own home, family home, family foster care
                                                        79.2%             25                  80.8%          Research and Training Center on Community Living
 (1-3 residents) and congregate care (1-3 residents)
    Percent in community settings (1-6 residents)       88.0%             33                  88.6%          Research and Training Center on Community Living
      Percent in Large Settings (16+ residents)          8.6%             40                   5.8%          Research and Training Center on Community Living

            Large State Facilities Data                 Value     Subrank (1=Best)         US Average                             Source
  Percent in Large State Facilities (16+ residents)     7.9%            48                    3.7%           Research and Training Center on Community Living
         Number of Large State Facilities                 5             33                     168           Research and Training Center on Community Living
        Residents at Large State Facilities             1,304           43                   35,035          Research and Training Center on Community Living

  Waivers that Can Promote Self-Determination
                                                        Value           Subrank (1=Best)          US                            Source
             Independence Plus Waiver                                                             19          Centers for Medicare and Medicaid Services
  Other Self-Directed - 1115 or 1915(c) Waiver for
                                                                                                  15                           PAS Center
    Money Follows the Person - Award or Apply            Yes                                      28          Centers for Medicare and Medicaid Services

Quality and Safety

             Quality Assurance Data                      Value             Subrank (1=Best)             US                          Source
   Council on Quality and Leadership participant                                                        24              Council on Quality and Leadership
    National Core Indicators (HSRI) participant                                                         28              Human Services Research Institute
         Noteworthy State QA Initiatives                                                                13                        Quality Mall

                     Safety Data                          Value                Subrank (1=Best)              US Average                            Source
Percent of all those served receiving protection from
                                                          0.5%                       15                          1.1%                          Coleman Institute
                   abuse services

Keeping Families Together

               Family Support Data                           Value                 Subrank (1=highest)                  US                            Source
                 Families Served                             2,917                         30                         428,803                     Coleman Institute
                 Total Spending                            $2,480,413                      45                     $2,305,149,428                  Coleman Institute
               Spending per Family                            $850                         47                          $5,376                     Coleman Institute

Promoting Productivity

              Medicaid Buy-In Data                   Value           Subrank (1=highest)              US                                     Source
                    Enacted                           Yes                                              43                   Centers for Medicare and Medicaid Services
                   Enrollment                         22                       33                    83,424                 Centers for Medicare and Medicaid Services

  Supported or Competitive Employment Data                  Value                       Subrank (1=Best)                        US                              Source
                     Participants                           2,460                             18                              110,539                       Coleman Institute
                       Spending                          $21,670,027                          11                            $708,872,399                    Coleman Institute
  Percent of all Individuals Served in Competitive
                                                               23%                            21                                21%                         Coleman Institute

Reaching Those in Need

                Waiting Lists Data                 Value         Subrank (1=Best)            US                                           Source
        Waiting List for Residential Services      5,076               41                   98,622                   Research and Training Center on Community Living
Percent Growth in Residential Services Required to
                                                   74%                   40                  23%                     Research and Training Center on Community Living
                 Meet Waiting List
        Waiting List - ID/DD HCBS - Kaiser         8,334                 20                 253,306                              Kaiser Family Foundation
Percent Growth in HCBS Services Required to Meet
                                                   107%                  22                  49%                                 Kaiser Family Foundation
                     Waiting List

                 Prevalence Data                      Value                   Subrank (1=highest)                       US Average                         Source
     Percent of Children with Mental Disability       5.2%                            31                                   5.1%                        US Census Bureau
      Percent of Adults with Mental Disability        3.9%                            40                                   4.8%                        US Census Bureau

                                                       Value                  Subrank (1=Best)                         US Average                            Source
   Individuals with ID/DD served per 100k of
                                                                                       35                                                              Coleman Institute
                population Data

                                                       Value                        Subrank (1=Best)                           US Average                         Source
 Ratio of Prevalence to Individuals Served Data        5.6%                               44                                      6.6%                           Calculated

Serving at a Reasonable Cost

                  ICF-MR Data                           Value          Subrank (1=highest)               US                                      Source
                Total Expenditures                   $273,332,795              14                  $11,962,854,423          Research and Training Center on Community Living
                    Residents                           1,656                  15                      94,846               Research and Training Center on Community Living
                Cost per Resident                      $165,106                17                     $126,130              Research and Training Center on Community Living

                   HCBS Data                            Value          Subrank (1=Best)              US                                         Source
                Total Expenditures                   $443,732,502            18                $22,310,392,935             Research and Training Center on Community Living
                    Residents                           7,815                22                    513,304                 Research and Training Center on Community Living
                Cost per Resident                      $56,783               12                    $43,464                 Research and Training Center on Community Living

      Unmatched State ID/DD Funds Data                     Value                       Subrank (1=Best)                         US                               Source
              Total Expenditures                        $196,089,459                         20                           $17,220,293,554                    Coleman Institute
        Percent of total ID/DD Spending                     21%                              40                                33%                           Coleman Institute

            Overall Spending Data                      Value                  Subrank (1=Best)                         US Average                          Source
   ID/DD Spending per $1,000 personal income           $2.58                        45                                    $4.12                        Coleman Institute
           ID/DD Spending per capita                   $120                         41                                    $171                         Coleman Institute

DNF = Did not furnish.

Note: For more information on the actual source of the data presented, please see the printed report or sources.

                                 ATTACHMENT D


The following principles serve as guidance for a system of public private
partnerships to enable individuals with intellectual disabilities to increase their
independence and community participation while ensuring health and safety.
Investing in individuals with intellectual disabilities allows for community
inclusion and giving back to society.

   o A proactive coordinated system which offers supports as soon as needed
     and continues supports throughout the lifespan of the individual at
     variable intensity to best utilize valuable and scarce support resources

   o There is sufficient oversight to ensure health, safety and wellness and
     effectiveness while preventing abuse, exploitation, fraud and waste

   o Supports are affordable, accessible, available, effective, timely and reliable
     regardless of where the individual lives

   o Supports are available through a “single point of entry”, are individualized
     and flexible and allow seamless transition across the lifespan

   o Supports are adequately funded to ensure resource availability across the
     lifespan, with attention to the dramatic increase in longevity of individuals
     with intellectual disabilities

   o Supports and resources should be based on desired outcomes and not
     limited by available resources

   o Resource availability is strengthened through provider and family training
     and development and sustained through partnerships and networks

   o Supports offer choice for the individual and family and respect personal
     decisions while strengthening individual responsibility

   o Supports are culturally and linguistically diverse, relevant and respectful

   o Supports strengthen and honor the integrity of the natural support
     system/family while maximizing the individual’s potential for maximum
     community inclusion and participation

                              ATTACHMENT E

                                 Service Needs

Crisis prevention, stabilization and restoration

Definition: A safety net must be provided through a team of well trained
professionals to meet individual needs wherever needed (family or congregate
residential) and throughout the lifespan of the individual.

These services should:
   Be proactive, preventive and offer immediate responsiveness
   Offer out of home intervention when needed
   Transition throughout all ages and offer specialized wrap around services
     for a holistic approach
   Offer supports and identify resources to family/caretaker to preserve
     current support system
   Provide training within the community for generic services such as public
     safety and medical staff
   Encourage provider training to increase the capacity of specialized
     behaviorists and encourage training of direct caretakers and families

System issues and recommendations:
    The current Medicaid reimbursement system provides for the purchase of
     therapeutic consultation but NOT the implementation of behavioral
         o Recommendation: The array of services available through Waivers
            should be revised to include behavioral intervention in addition to
            behavioral consultation. At the same time, extensive provider
            development and training is needed to enhance the availability of
            this resource.
    The current Waiver system offers crisis stabilization only in concert with
     congregate residential services and not for family based or day support
     based crises
         o Recommendation: The array of services available through Waivers
            should be revised to include the provision of crisis stabilization
            services for recipients who choose to receive residential supports
            through their family or other natural supports.
    The funding for ICFs is “bed based” while Waiver funding is hourly based;
     as a result revenues are lost when crisis management occurs separate from
     residential setting
         o Recommendation: The Waiver regulations should be revised to
            allow for compensation to residential providers while recipients
            temporarily leave their residential program to receive more
            intensive crisis stabilization services.
    Allow ICFs such as Training Centers to also sell outpatient services
     separate from their license as an ICF

          o Recommendation: Training Centers should be allowed to establish
            and provide outpatient services separate from their ICF/MR

Physical and behavioral health care supports

Definition: To ensure health and safety, an array of supports should be
provided by well trained professionals within both the specialized and the general
health care community. These supports may include medical, dental, and
therapeutic supports such as physical or speech therapy.

These services should:
         Be affordable, accessible, equitable
         Develop specialized skill training for professionals and facilitate
           cross training among professionals, caretakers and families

System issues and recommendations:
    The current system does not include a sufficient number of effective
     partnerships among health care providers
        o Recommendation: Develop and sustain partnerships with INOVA
            and other academic teaching hospitals, community college nursing
            programs, local Departments of Health
        o Recommendation: Develop internships for medical students (such
            as KOVAR Summer Institute) and strengthen community-based
            nursing teams
        o Recommendation: Diversify RCSC service capacity geographically
            to provide comparable accessible services for citizens in Western
            Fairfax, Prince William and Loudoun Counties.
    The current system does not provide sufficient general funds for health
     care services for those who are not Waiver eligible
        o Recommendation: Simultaneous to Waiver slot approval, the
            General Assembly should award general funds to provide services
            for individuals who are NOT eligible for Waivers, including health,
            residential and day activity supports
        o Recommendation: Increase funding support to RCSC to enable
            geographic expansion to provide accessible services to communities
            in the Western area of Region 2.
    The current system does not provide funding for dental services
        o Recommendation: The array of services available through Medicaid
            and general funds should include funding for dental services for
            qualified children and adults.
        o Recommendation: Since the RCSC has proven that this service can
            be provided through its facilities, there must be a financial plan to
            ensure sustainability of efforts.
    The current system has underutilized physical resources
        o Recommendation: The facilities at NVTC and NVMHI should be
            retrofitted to include services for individuals residing in the
            community and not be limited to those admitted as an inpatient

          o Recommendation: The facilities at NVTC should be retrofitted to
             add a Skilled Nursing Facility
      The current system does not acknowledge the career needs of direct care
          o Recommendation: The direct care work force must be strengthened
             through acknowledgment of the career status and
             professionalization of the field through certification

Residential services and supports

Definition: To meet the individualized and changing needs of individuals, an
array of supports is needed which accommodate the changing needs across the
lifespan of the individual.

These services should:
   Be affordable, accessible and apply universal design to enable aging in
   Be fluid, flexible, and individualized while respecting individual and family
   Include specialized supports for individuals with dementia
   Follow best practice achieved through provider training and development
   Integrate with public planning for cluster-style mixed use developments
   Include facility based respite as an option

System issues and recommendations:

      The current system does NOT provide adequate tax relief for residential
       services providers
          o Recommendation: Tax laws should allow for tax exempt status for
              facilities operated to provide residential services to qualifying
      The current system does not maximize all available public and private
       funding sources
          o Recommendation: There is a need for a strategic and coordinated
              review of all available funding sources such as HUD, Housing
              Choice, VA Housing Development, Money Follows the Person,
              corporate sponsorship, leveraging family estate planning and gift
              annuities as a resource and leveraging faith based partnerships
      The current system does not have a focus to maximize use of available or
       surplus public properties
          o Recommendation: There is a need for CSBs and Training Centers to
              work collaboratively with State and Local municipalities to review
              all surplus properties to determine if they could be retrofitted to
              support qualifying individuals

Day activity including day support, training, employment, recreation

Definition: Individuals with intellectual disabilities need an array of individual
opportunities for community engagement. This array should include activities
valued by our community and must accommodate individual and family choice.

These services should:

     Increase opportunities for paid employment, especially for Waiver
     Coordinate school-based education with home life for children
     Offer long term supports spanning the lifespan of the individual, including
      academic training through life long learning supports as well as home
      based options
     Include reliable, affordable and accessible transportation
     Allow for seamless transition among and between service options
     Maintain high standards through continued mandate of national
     Include provider training to support individuals with dual diagnosis
      and/or challenging behaviors

System issues and recommendations:

     The current system must enhance provider development especially in
      areas of recreation and home based day activities
          o Recommendation: While training is available for traditional day
             support and employment services, there is a need for training to
             stimulate and develop services for individuals who want to choose
             an alternative day activity. Additionally, generic community
             resources such as recreation centers and libraries should be utilized
             as service sites
     Business partnerships can be strengthened through increased economic
          o Recommendation: While the current system has numerous
             business partnerships, these should be strengthened and should be
             expanded to include more employment opportunities to employ
             individuals with intellectual disabilities within the public sector
     We should strengthen partnerships with colleges and universities for cross
      training within our region
          o Recommendation: Through matching the needs for practical
             experiences and internships of students with work force needs of
             service providers, we can enhance the relevance of academic
             training of future service providers. Similarly, colleges and
             universities could offer assistance to providers for grant writing to
             maximize leveraged funds


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