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A partnership of the Montana Department of Public Health and Human Services and the University of Montana Rural Institute, A Center for Excellence in Disability Education, Research, and Service.

Strategic Plan
2006-2010

Table of Contents

Acknowledgements
Distribution and Public Comment
Introduction
Disability Report Summary and Highlights
Vision, Mission, Goal
Primary Partners
Logic Model
Intermediate Outcome Goal One: Build Capacity
Intermediate Outcome Goal Two: Support Direct Services and Programs
Intermediate Outcome Goal Three: Increase Access to Generic Services
Intermediate Outcome Goal Four: Improve Access to Community Environments
Intermediate Outcome Goal Five: Integrate Disability and Health Agenda

Acronyms
Appendix A: Stakeholders

Tables

Table 1: Year 2010 Health Objectives for the Nation: Summary of 2003 Montana BRFSS Data
Table 2. A Medical-Social-Ecological Model of Disability

Acknowledgements

This report represents the collaborative endeavor of: The Montana Disability and Health (MTDH) Program, which is a partnership of the Chronic Disease Prevention and Health Promotion Bureau of the Montana Department of Public Health and Human Services (MDPHHS) and the University of Montana Rural Institute (UMRI): Center for Excellence in Disability Education, Research, and Service. The MTDH Program is responsible for developing and implementing programs and services designed to prevent secondary conditions, promote health, and reduce health disparities existing between Montanans with and without disabilities. The MTDH Program is funded by the National Center on Birth Defects and Developmental Disabilities, Disability and Health Centers for Disease Control and Prevention (CDC).

The following individuals were responsible for writing this strategic plan:

• Marilyn Carlin, MA, Independent Consultant

• Judy Garrity, BA, Independent Consultant

• Meg Ann Traci, PhD, Project Director, MTDH Program, University of Montana

The following individuals provided conceptual input for the strategic plan:

• Members of the Disability and Health Advisory Board as listed in Appendix A

• Staff of the UMRI (listed in alphabetical order):

• Donna Bainbridge, PT, EdD, ATC

• Barbara Cowan, BA

• Kathy Humphries, PhD

• Erica Parker, BA

• Craig Ravesloot, PhD

• Tom Seekins, PhD

• Diana Spas, MSEd

• Meg Ann Traci, PhD

• Lynda Zschaechner, BA

The following MDPHHS Managers reviewed this strategic plan:

• James Driggers, Chief, Community Services Bureau, Senior and Long-Term Care Division

• Todd Harwell, Chief, Chronic Disease and Health Promotion Bureau, Public Health and Safety Division

• Joe Mathews, Administrator, Disability Services Division

The following UMRI staff reviewed this strategic plan:

• Diana Spas, MSEd

The information provided in this strategic plan was supported by the following cooperative agreement with the Centers for Disease Control and Prevention (CDC): MTDH Cooperative Agreement Number U59/CCU824602. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the funding source.

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Distribution and Public Comment

In addition to the key stakeholders listed above, attempts were made to garner support for and enthusiasm about the plan from a number of individuals and organizations as well as the general public. On October 25, 2005, a draft of the plan was mailed to 64 individuals and emailed to 174 others. The plan was also posted on the MTDH website where a total of 136 visitors opened the pdf file as a download in the two weeks of the comment period, ending on November 7. Thus, a total of 374 individuals were exposed to the plan (assuming that each “visit” to the website was unduplicated).

Comments were received from 19 individuals, or 5.1% of those who had access to the draft plan. Suggestions that required only minor adjustments were integrated into the plan. More substantive suggestions were referred to the Advisory Board for discussion and consensus.

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Introduction

The Big Picture

It is estimated that nearly 54 million people in the U.S. (about 20% of the civilian, non-institutionalized population over the age of 5 years) have a disability.¹ “Disability” is a term that covers a broad array of conditions and diseases. It refers generally to a limitation in physical or mental function caused by one or more health conditions. In 2003, one in five non-institutionalized adult Montanans reported that they had experienced activity limitations and/or perceived themselves to be a person with a disability. ²

Disability is not synonymous with poor health. Contrary to what was once a generally accepted notion regarding disability and health, having a disability does not preclude being in good health. In fact, most people with disabilities have the potential to lead healthy and productive lives. Moving away from using a disabling condition as a health status indicator has sparked an increased interest in promoting the health and wellness of people with disabilities. Key to this concern is an awareness that individuals with disabilities may be at increased risk for a number of preventable health problems, referred to as secondary conditions. Secondary conditions are those health circumstances that may be experienced by individuals after they experience a primary (or first) disability.³ Such conditions range from medical complications to problems of psychosocial adjustment and to environmental and quality of life issues. Research suggests that people with disabilities annually experience on average 14 secondary conditions that limit their health and independence. ⁴

Secondary conditions may significantly restrict activities, require extensive care, and cost a substantial amount. On average, the medical expenditures of people with disabilities are more than four times those of people without disabilities.⁵ Consequently, health promotion and wellness activities are particularly important for people experiencing a disability in order to prevent health complications and further disabling conditions.

Among the concerns specific to people with disabilities, health disparities rank as one of the highest. Health disparities are differences in health status among distinct segments of the population including differences that occur by gender, race, or ethnicity, education or income, disability, and geographic location.⁶ People with disabilities face substantial structural, economic, environmental, and personal barriers to participating in disability-related health promotion activities. Consequently, they are often at increased risk of developing secondary conditions.

¹ Montana Behavioral Risk Factor Surveillance System Report, 2001 & 2003. (pdf file)
   Montana Behavioral Risk Factor Surveillance System Report, 2001 & 2003 (text file)
² Ibid.
³ Marge, M., “Health promotion for persons with disabilities: Moving beyond rehabilitation.” American Journal of Health Promotion. 1988.
⁴ Seekins, T., Clay, J.A., Ravesloot, C., A descriptive study of secondary conditions reported by a population of adults with physical disabilities served by three independent living centers in a rural state. Journal of Rehabilitation. 1994;60:47-51.
⁵ Rice, M.W.,Trupin, L., “Medical expenditures for people with disabilities.” Disability Statistical Abstracts. 1996; 12, 1-4.
⁶ North Carolina 2010 Objectives at http://www.healthycarolinians.org/healthobj2010.htm

Access to Health Care in Montana

As a rural state, Montana faces many challenges in providing public health and human services to people dispersed over large geographic areas far from major metropolitan centers. Many of Montana’s 56 counties are categorized as Health Professional Shortage Areas and Frontier Counties with fewer than six people per square mile. Montana has 62 licensed hospitals; 59 are classified as rural by the Healthcare Financing Administration. The state has 7 licensed outpatient facilities and 25 Rural Health Clinics. There are 181 physicians per 100,000 and a total of 468 registered physical therapists. ⁷

Montana also has a shortage of dentists and dental hygienists. In 2002, seven of Montana’s 56 counties had no dental professionals, 11 had no dentist, and 19 had no dental hygienist.⁸ The lack of health care providers knowledgeable about disability is consistently reported as one of the most significant problems experienced by people with disabilities and rehabilitation providers. Such gaps in services and supports place many people with disabilities at risk, increase the cost of services, and reduce quality of life.

⁷Regional Economic Information System. (2001, May). Local area personal income (Table CA1-3). Washington, DC: Bureau of Economic Analysis. Retrieved December 22, 2004 from http://www.bea.doc.gov/bea/regional/reis/drill.cfm

⁸Rural Disability and Rehabilitation Research Progress Report #30, November 2004.

Montana’s Aging Population

Life expectancy for residents of the United States has reached an all-time high, according to the latest U.S. mortality statistics released February 28, 2005, by the Centers for Disease Control and Prevention (CDC). The median age of the U.S. population in 2000 was 35.3—the highest it has ever been. In comparison, the median age of Montana’s population in 2000 was 37.5.⁹  And, Montana’s 65 and older population is projected to more than double between 2000 and 2030. “Montana is expected to rank 5th in its percentage of residents 65 and older at 25.8 percent. Only Florida, Maine, New Mexico, and Wyoming will have larger 65-and-over population segments.”¹⁰ Greater numbers of older Montanans means increased numbers of people experiencing disabilities as more people begin to experience age-related health complications.

⁹ US census data accessed at http://www.census.gov/population/pop-profile/2000/chap02.pdf

¹⁰ Cooke, Sarah, “State’s Older Population to more than Double by 2030,” Helena Independent Record. 22 Apr. 2005. Data source: US Census Bureau at http://factfinder.census.gov/home/saff/main.html?_lang=en

Montana’s Economy

Montana is an economically poor state. In 1999, 14.6% of Montanans’ incomes fell below the poverty level as compared to 12.4% nationally.¹¹ People with disabilities generally have higher rates of unemployment, lower incomes and fewer educational opportunities. According to the report “Disability Prevalence among American Families” issued by the U.S. Census Bureau, families with members with a disability had lower median incomes than other families.¹²  Montana’s per capita income of $24,906 (2002) has given the state a very low national ranking (45th of the 50 states)¹³ and places its population at increased risk for disabilities.

¹¹ Montana Quick Facts, U.S. Census Bureau, 2000.

¹² Census 2000 Special Reports at http://www.census.gov/prod/2005pubs/censr-23.pdf 

¹³ Prepared by the Montana Office of Rural Health, Montana State University-Bozeman, updated 9/07/04 http://healthinfo.montana.edu/msu/MTstats.html

The Status of Disability and Health in Montana

The number and health status of people with disabilities in Montana is regularly assessed through various surveys, including the following:

• The Behavioral Risk Factor Surveillance System (BRFSS) annual telephone survey for adults conducted by the DPHHS.
• The U.S. Census.

Responses to these surveys provide statewide health and disability prevalence information and indicate trends among Montana adults. It should be noted, however, that the definitions of disability used by the U.S. Census and DPHHS are not the same. ¹⁴

The prevalence of disability in Montana as measured by U.S. Census data estimates that there are 145,732 Montanans aged 21 years and over with disabilities living independently in the community.

¹⁴ The U.S. Census Bureau definition of disability: People 21 years and over are considered to have a disability if they have one of the following: a) blindness, deafness, or a severe vision or hearing impairment; b) a substantial limitation in the ability to perform basic physical activities, such as walking, climbing stairs, reaching, lifting, or carrying; c) difficulty learning, remembering, or concentrating; or d) difficulty dressing, bathing, or getting around inside the home. The BRFSS definition of disability includes people over the age of 18 who are limited in any activities or use special equipment.

Montana Disability and Health (MTDH) Program Target Population

The MTDH program has chosen to focus its attention on:

1. Adults with disabilities related to mobility impairments; and
2. Adults with intellectual/developmental disabilities (I/DD) living in supported living arrangements operated under contract with state agencies.

These are areas of clear need and in which the MTDH Program has demonstrated advanced capacity. Strategies and interventions specifically targeting these populations have been designed at the University of Montana Rural Institute. Moreover, established networks with existing capacity for building collaborations and for delivering education and interventions already exist to serve these target groups.

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Disability Report Summary and Highlights

A 2005 report entitled Assessing Disability and Secondary Health Conditions of Montana Adults (This is a pdf file.  Click here for text file) provides information about Montana adults with disability from the 2001 and 2003 Montana Behavioral Risk Factor Surveillance System (BRFSS) surveys. The health indicators highlighted in this report were selected because they were:

• Healthy People 2010 Leading Health Indicators closely related to disability and secondary health conditions;
• Primary conditions known to be associated with activity limitation in adults;
• Socio-demographic and health status indicators that describe the experience of Montana adults with disability.

Report Summary and Highlights

Montana adults with disability compared positively to those without disability in attaining certain Healthy People 2010 objectives. Adults with disability were more likely to have:

• A usual primary health care provider
• Regular blood cholesterol screening
• Immunizations against influenza and pneumococcal disease (specifically adults with disability over 65)
• A lower overall prevalence of binge drinking

Conversely, Montana adults with disability reported significant health gaps and disparities in the attainment of other Healthy People 2010 objectives—particularly those related to chronic joint symptoms and diabetes. In summary, adults with disability in Montana were more likely than adults without disability to:

• Have chronic joint symptoms and arthritis
• Report clinically diagnosed diabetes
• Have high blood pressure or blood cholesterol
• Report clinically diagnosed cardiovascular disease
• Have asthma
• Sustain fall-related injuries
• Smoke cigarettes
• Report no leisure-time physical activity
• Report moderate physical activity levels below recommendations
• Report not being able to see a doctor when needed because of cost

Focusing on reducing these gaps and disparities could contribute substantially to achieving Healthy People 2010 objectives in Montana and, more importantly, to improving the health and well-being of Montana adults with disability.

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Table 1: Year 2010 Health Objectives for the Nation:
Summary of 2003 Montana BRFSS Data ¹⁵

Description of Table 1.

Year 2010 Health Objectives for the Nation: Summary of 2003 BRFSS Data for Montana Adults with and without Disability—highlights and augments the Healthy People 2010 information presented in this report.

For additional information on either of the aforementioned reports, click on the Montana BRFSS website at http://www.brfss.mt.gov

¹⁵ Disability Report Highlights from Assessing Disability and Secondary Health Conditions of Montana Adults, Results from the 2001 and 2003 Behavioral Risk Factor Surveillance System Surveys (BRFSS), Health Planning Section, Public Health and Safety Division of DPHHS.

¹⁶ Public Health Service, Healthy People 2010: National Health Promotion and Disease Prevention Objectives—full report with commentary. Washington, DC: U.S. Department of Health and Human Services, 2000.

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Vision and Mission

Vision

The Montana Disability and Health (MTDH) Program Advisory Board envisions a state where people with disabilities are healthy and have the same opportunities to participate in community as people without disabilities—a place where people with disabilities go where they want to go; do what they want to do; have their individual needs met; are accepted in their communities; and are treated equally with others. ¹⁷

This vision for Montana includes:

• An increased awareness that preventing secondary health conditions (such as pain, depression, obesity, oral health problems, diabetes, and injuries such as pressure sores) is an important component of quality of life for people with disabilities in Montana.
• Strong alliances among people with disabilities, the MTDH Program and other agencies and organizations.
• No health care disparities.
• Resources and efforts to promote healthy lifestyles.
• Integration of people with disabilities in all physical, social and economic aspects of Montana.
• Public awareness of success stories about people with disabilities living healthy lives.

¹⁷ Rule 5 of the Standard Rules on the Equalization of Opportunities for Persons with Disabilities (General Assembly resolution 48/96 of 20 December 1993 annex) considers “accessibility” with reference both to the physical environment and to information and communications services. http://www.un.org/esa/socdev/enable/disacc.htm

Mission

The mission of the Montana Disability and Health Program is to reduce secondary conditions and improve the health of people with disabilities.

Long-Term Outcome Goals

The long-term outcome goals of the Montana Disability and Health Program are to:

1) improve the health of individuals with disabilities;
2) prevent and manage secondary conditions; and
3) eliminate health disparities experienced by people with disabilities.

The vision, mission, and long-term outcome goals are based on the history and forward momentum of the national disability and health movement as well as the recognized expertise of the University of Montana Rural Institute (UMRI) to provide leadership for this effort.

During the past 15 years (1990 to 2005), several factors have converged to dramatically move disability and health issues to the forefront:

• People with disabilities successfully advocated for independent living and civil rights.
   
• Congress passed the Americans with Disabilities Act (ADA) acknowledging that individuals with disabilities have fundamental rights of equal access to employment, health care, transportation, and services.
   
• The National Center for Injury Prevention and Control was established to reduce morbidity, disability, mortality, and costs associated with injuries.
   
• Phases I and II of the National Health Interview Survey on Disability were conducted.
   
• The National Center for Birth Defects and Developmental Disabilities was established to prevent secondary conditions and promote health and wellness and quality of life for Americans with disabilities.
   
• The World Health Organization (WHO) created the International Classification of Function, Disability and Health (ICF) that describes how functionality for people with disabilities occurs within the context of society and the environment.
   
• The Olmstead Decision required states to support people with disabilities in least restrictive settings (i.e., community versus institutional settings).
   
• The Healthy People 2010 Objectives were released with a specific chapter on preventing secondary conditions and improving the health of people with disabilities.
   
• The 2002 Surgeon General Report, Closing the Gap, focused on improving the health of people with mental retardation and the 2005 Surgeon General’s Call to Action, focused on improving the health and wellness of people with disabilities.
   
• In 2001, CDC began sponsoring a Core Module on Disability in the Behavioral Risk Factor Surveillance System (BRFSS).
   
• Breakthroughs in biomedical and technological sciences provided distinct possibilities for longer and more fulfilling lives for individuals with disabilities.
   
• A plethora of scientific research has highlighted the disparities in health care between people with disabilities and those without disabilities.

These events have been instrumental in shaping disability and health policy as well as our understanding of disability and health. Prior to the 1980s, disability was conceptualized as a medical model that placed the disability within the person. As the independent living movement grew during the 1980s and 90s, an alternative model was developed. This model placed the locus of disability within the built and social environment. While this transformative conceptualization of disability has been crucial to the rights and quality of life of people with disabilities, it tends to deemphasize the role of rehabilitation and technological advances that operate to increase the functional capacity of the individual.

For the purposes of this plan, the interaction between the person and the environment is emphasized by combining the medical and social models of disability into an ecological model of disability. This model underscores the need for both person- and environment-oriented services.
Table 2 contrasts these three paradigms across seven different dimensions.

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Table 2. A Medical-Social-Ecological Model of Disability¹⁸ Description of Table 2.

¹⁸ Adapted from US Department of Education, Office of Special Education and Rehabilitative Services, National Institute on Disabilities and Rehabilitation Research, Long-Range Plan 1999-2003. Washington, DC: GPO, 2000.

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Primary Partners

Three major divisions of the Montana Department of Public Health and Human Services (MDPHHS) have partnered to attain the long term outcome goal for this state plan:

1. The Public Health and Safety Division (PHSD)
2. The Disability Services Division (DSD)
3. The Senior and Long-Term Care Division (SLTCD)

All three divisions are represented on the Advisory Board as well as the Core Management Team of the MTDH Program.

The MTDH Program is the result of a cooperative agreement between the:

1. Centers for Disease Control and Prevention (CDC); and
2. Chronic Disease Prevention and Health Promotion Bureau (CDHPB) in partnership with the University of Montana Rural Institute (UMRI): Center for Excellence in Disability Education, Research, and Service.

The Chronic Disease Prevention and Health Promotion Bureau, located within the PHSD, is a composite of the following:

• Breast and Cervical Health
• Cardiovascular Health
• Cancer Control
• Central Tumor Registry
• Diabetes
• Emergency Medical Services and Trauma Systems
• Tobacco Use Prevention

The Rural Institute: Center for Excellence in Disability Education, Research, and Service, is part of the national network of programs funded by the Federal Administration on Developmental Disabilities (ADD) committed to increasing and supporting the independence, productivity, and inclusion of people with disabilities into the community. Since 1979, the Institute has designed, implemented, and evaluated specific programs and services to prevent secondary conditions and promote the health of Montanans with disabilities.

These primary partnerships facilitate the collection of data, dissemination of information, training of professionals, and other activities that relate to more than one program or one division. The MTDH Program provides a mechanism whereby people with disabilities are included in policy advisory boards within the three partnering divisions so that their unique needs are factored into any efforts to prevent secondary conditions.

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Logic Model

The logic model developed for the MTDH Program State Plan reflects the program’s “theory of the problem”. (See illustration below for an abbreviated version of this model). Specifically, five key intermediate goals or “pathways of influence” are accepted by public health practitioners as having a high probability for achieving the long-term outcome goal of improved health, prevention and management of secondary conditions, and elimination of health disparities experienced by people with disabilities.

The first intermediate goal—Building capacity—focuses on strengthening the abilities of the MTDH Program and its partners to implement the remaining four intermediate outcome goals. It involves ongoing systems of data collection and dissemination, education of current and future partners, and procurement of additional funding.

The second intermediate goal—Support direct services and programs—addresses the need to increase the availability of effective health promotion and prevention programs designed specifically with the strengths and needs of people with disabilities in mind.

The third intermediate goal—Increase access to generic services—reflects inclusion of people with disabilities as a civil rights issue. It increases the accessibility of publicly-funded health resources to people with disabilities through social marketing campaigns, accommodations, and provider education.

The fourth intermediate goal—Improve access to community environments—acknowledges that all impairments, disabilities, and health problems are dynamic experiences. In interaction with environmental barriers, these factors result in more isolation and less community participation for people experiencing them. Removal of such barriers is one way to support people with long-term disability and chronic conditions to live more independent lives and to find the resources they need to be healthier. Adding design features that facilitate community participation is a proactive strategy that often is a direct outcome of people with disabilities’ involvement in community planning.

The fifth intermediate outcome goal—Integrate disability and health agenda—targets public policies that influence the health and wellness of people with disabilities now and in the future. The primary strategies are to: educate professionals about disability and health issues; expand partnerships with other agencies/organizations; and assure that issues relevant to disability and health are voiced on a variety of policy advisory councils or boards by people who are active consumers of disability and health services.

The short-term goals and activities that will contribute to the achievement of intermediate goals during the next five years were identified through a year-long strategic planning process and are described in sections 6 through 10 of this document. Each section begins with an introduction of the intermediate outcome goal followed by the associated short-term outcome goals and activities.

Description of chart.

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Intermediate Outcome Goal One: Build Capacity

“Capacity” is an expansive term that is defined as “the ability to contain, absorb, or receive and hold.”¹⁹  In a short period of time, the MTDH Program, in partnership with the MDPHHS, has made significant strides in building program capacity by:

• Providing surveillance of disability and health in Montana
• Initiating strategic partnerships
• Providing technical assistance to communities
• Providing education and health promotion programs
• Training health professionals
• Facilitating access to services

In a world of growing complexity, ongoing capacity building is essential to keep pace with the needs of an evolving society. The MTDH Program will continue to build the capacity of the program and, in turn, increase the participation of Montanans with disabilities in all aspects of society.

¹⁹ The American Heritage® Dictionary of the English Language, Fourth Edition, Houghton Mifflin Company, 2004. Answers.com GuruNet Corp. 22 Sep. 2005. http://www.answers.com/topic/capacity

Short-term Outcome Goal 1A

By 2007, the MDPHHS will improve the availability, accessibility, and utilization of data related to the health status and health behaviors of people with disabilities.
 

Rationale

A central aspect of the MTDH Program involves building an evidence-based program to promote the health and wellness of Montanans with disabilities. However, the MTDH Program operates in an environment where resources are limited and the needs of the disabled populations are substantial, varied, and frequently misunderstood. Building capacity in epidemiology and survey work will assist policy makers and program developers to allocate resources efficiently and effectively using accurate and timely information about the needs of people with disabilities.

Activities

• Maintain and expand the MTDH Program Advisory Board’s Committee on Epidemiology and Surveillance to assist in identifying useful applications for surveillance.
• Review existing data reflecting the health status of Montanans with disabilities, including Montana American Indian Health Survey data.
• Participate in the Montana BRFSS Workgroup to represent disability issues in data collection, analysis, and reporting.
• Develop and share knowledge of health concerns among Native Americans with disabilities in Montana.
• Infuse disability and health into ongoing epidemiological studies conducted by various agencies and organizations.
• Develop a long range plan for enhancing the MTDH Program epidemiological capacity.
• Include in the core of all relevant surveillance instruments a standardized set of questions that identify “people with disabilities”.
• Include priority health outcomes for people with disabilities in public health surveillance efforts and evaluation activities (e.g., physical access problems, satisfaction with life and social participation as they are conceptualized by people with disabilities, and common or severely limiting secondary conditions such as depression).
• Review, analyze, and disseminate useful administrative data regarding people with disabilities (e.g., Indian Health Services data, Developmental Disabilities Program data, and Medicaid claims data).
• Evaluate activities in this state plan for effectiveness in reducing the severity of limitation due to secondary conditions reported by Montanans with disabilities. Evaluations will have a particular focus on: leading health indicators; areas of known health disparities; reducing the number of people with disabilities reporting feelings (such as sadness, unhappiness, or depression) that keep them from being active; increasing the proportion of adults with disabilities who participate in social activities and who report satisfaction with life.
• Partner with Montana Fish Wildlife and Parks (FWP) to evaluate the accessibility of state parks using data from an Outdoor Recreation Module in the 2006 BRFSS. Because FWP supported this module in 2002 as well, there may be opportunity to examine data for trends.

Evaluation

Baseline: The MTDH Program published a Disability and Health Chart Book in 2005.

Outcomes: The MTDH Program will publish the aforementioned report on a biennial basis and will post it on the MTDH website. This report will be available in alternative accessible formats. The MTDH Program will support MDPHHS efforts to include disability descriptions in other data publications, especially those yielded from analyses demonstrating health disparities in underserved and minority populations. The MTDH Program will support MDPHHS efforts to make data publications available in alternative accessible formats. We will also evaluate our ability to link outcomes to planned activities. In some instances such as direct services and programs, our evaluation methods are fairly well described; however, in other areas of planned activities, we will need to increase our evaluative capacity.

Data source: Process outcome results. Publication and dissemination of data reports will be tracked. Also, our ability to report satisfactory evaluation data to the MTDH Core Management Team, MTDH Advisory Boards, and partners will be evaluated.

Short-term Outcome Goal 1B

By 2010, the MTDH Program will increase the awareness and knowledge of at least three new state and community agencies or programs about the MTDH Program, this state plan, and related publications in ways that lead to collaborations on three new activities.

Rationale
Viable partnerships increase Montana’s capacity to promote the health and independence of people with disabilities.

Activities

• Transition the administrative leadership of the MTDH Program to the PHSD of the MDPHHS.
• Finalize and implement management and program evaluation plans.
• Identify new opportunities for future programmatic growth.
• Develop two types of new partnerships: 1) those that are built around a project or activity of interest to the MTDH Program; and 2) those that are forged to expand stakeholders’ voices in the MTDH Program activities.
• Explore new partnerships with Special Olympics, Humane Society, People First, Saddle Clubs, YMCA, schools, houses of worship and faith-based organizations, correctional facilities, and others to prevent sadness and depression among people with disabilities.
• Collaborate with partners to provide social activities as a means of preventing and improving depression.
• Maintain and/or explore new partnerships with NAMI, state professional groups of clinical counselors and mental health professionals, doctors, the Quality Control Council, the MDPHHS Addictive and Mental Disorders Division, mental health hotlines, and others to more effectively treat sadness and depression among people with disabilities.
• Partner with other states to use health programs that are tested in the populations of people with disabilities and are ready for dissemination.
• Identify additional partners in Montana that can assist in disseminating the health programs that are available to people with disabilities.

Evaluation

Baseline: Currently, the MTDH program collaborates on activities with MDPHHS Public Health and Safety Division, Disability Services Division, and Senior and Long Term Care Division.

Outcomes: The MTDH program will collaborate with three additional state and community agencies on three new activities that will further the goals of this five-year state plan.

Data source: Process outcome results, including letters of agreement and revised portions of the five-year state plan.

Short-term Outcome Goal 1C

By 2007, the MTDH program will work with its partners to develop funding for ongoing implementation of this strategic plan. Opportunities to expand the program will also be identified and incorporated into the plan as funding is secured.

Rationale

The MTDH Program must expand the capacity to meet its overall mission of improving the health and independence of people with disabilities.

Activities

• Review policies and procedures for supporting a full-time MTDH Program staff person at the MDPHHS.
• Identify and pursue future opportunities for collaboration.
• Identify and apply for relevant competitive grants.
• Seek support from private foundations and corporations.

Evaluation

Baseline: The MTDH Program identifies funding opportunities on a regular basis and communicates these opportunities to partners.

Outcomes: The MTDH Program and partners will communicate about funding opportunities and will apply for competitive funding that supports activities specified in this strategic plan. The MTDH program also will compete for future disability and health state grantee funding.

Data source: Process outcome results.

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Intermediate Outcome Goal Two: Support Direct Services and Programs

Health promotion for people with disabilities can reduce the incidence and severity of secondary conditions that further limit their participation in society. Increasing the availability of direct services and programs designed specifically for this target group has been shown to improve health, prevent secondary conditions, and create greater consumer participation in health promotion activities.
The University of Montana Rural Institute: A Center for Excellence in Disability Education, Research, and Service has designed specific programs to fit the needs and strengths of people with disabilities—Living Well with a Disability (LWD), MENU AIDDS, and Have Healthy Teeth. These programs are effective in improving participant health and well being and are slated for expansion over the next five years.

Short-term Outcome Goal 2A

By 2007, the MDPHHS Developmental Disabilities Program will:

1) Coordinate training of at least 50% of group home managers on programs to improve the nutrition of adults living in group home; and
2) Evaluate changes in group home food systems and nutrition of residents with support from the MTDH Program.

Rationale

The availability of nutritious foods for adults with I/DD residing in Montana group homes is well below minimum USDA recommendations. Additionally, the prevalence of underweight and overweight adults documented in the literature and observed in these settings is alarming. There is a need for increased use of strategies for supporting good nutrition in group homes among managers and their staff. The MENU-AIDDs program is one strategy for changing the food systems in group homes that has demonstrated improvements in access to and consumption of nutritious food.

Activities

• Facilitate collaboration between the MDPHHS Developmental Disability Services Division staff and with the Montana Association for Independent Disabilities Services (MAIDS) to develop training content for group home managers and to disseminate the MENU-AIDDs program statewide.
• Recruit nutrition experts from each of the five state service regions to provide additional training and support to staff of local implementation sites.
• Train the nutrition experts and service providers at the annual DDP and Montana Dietetic Association conferences, with regional follow-up training.

Evaluation

Baseline: Currently, there is no standard method for training group home staff and residents on good nutrition strategies. Additionally, data collected in the fall of 1999 through a state-wide survey of adults with intellectual or developmental disabilities indicated 49% of group home residents were overweight, 22% who were obese, and 9% were underweight. Additionally, 42% of group home residents reported being significantly limited by the secondary health condition, “weight problems.”

Outcomes: The MTDH Program, with its collaborators, will deliver a standard training to at least 50% of group home managers to implement nutrition programs in group homes. In homes that show significant adoption of the MENU-AIDDs system (see evaluation of adoption below), the approximately 740 adult consumer residents will enjoy improved nutrition as indicated by improved dietary adequacy described in weekly, written menus. Additionally, half of the residents experiencing weight problems will report reduced limitation associated with this secondary condition at six months post-intervention; 50% of the underweight (BMI <19) residents will gain weight to raise their BMI one point (average of 5-8 pounds) six months post-intervention; and 50% of residents who are overweight (BMI 25-29.9) or obese (BMI 30+) will lose weight to lower their BMI one point (average of 5-8 pounds) six months post-intervention.

Data source: Process evaluation results will be used to measure the success of the training and dissemination activities, testing trainee satisfaction and program implementation and fidelity. Targeted evaluation will be conducted with residents one week prior to training and program implementation, two months post training and program initiation, and six months post training and program initiation. Evaluation data will come from administrative records of menus, residents’ weight records (updated weekly at some homes and monthly at others), and brief paper-pencil surveys. Consumers’ data will be gathered and presented anonymously. Appropriate Human Subjects Reviews will be undertaken to protect the rights and privacy of the consumers and staff.

Short-term Outcome Goal 2B

By 2007, the MTDH Program will develop and implement a business model for Living Well with a Disability (LWD) that increases external funding for program implementation from 0% to 30% of total program costs without decreasing program effects on secondary conditions, symptom days and healthcare costs. Montana Home and Community-Based Services and Vocational Rehabilitation will establish procedures for reimbursing Centers for Independent Living to provide the Living Well with a Disability Workshop to their consumers.

Rationale

The LWD program has been proven to be effective for reducing limitation due to secondary conditions reported by adults with mobility impairments allowing them to pursue and achieve important participation goals (e.g., employment). Additionally, the program has demonstrated cost savings to third-party payers based on the difference between program implementation costs and cost of medical care reductions reported by participants. On this basis, funding for the program should be expanded to other state and private entities. Between spring 2002 and spring 2005, LWD reached 90 consumers in 15 workshops in 11 different communities. Funding was entirely from the MTDH Program grant. By 2007, only 70% of the funding for the program will be derived from the MTDH Program grant funding.

Activities

• Schedule meetings between the MTDH Program staff, CIL representatives, and representatives from the Medicaid Waiver and Vocational Rehabilitation programs to specify eligibility criteria and billing procedures for a LWD reimbursement model.
• Develop marketing materials for: 1) home and community-based services (HCBS) case managers; 2) vocational rehabilitation (VR) counselors; and 3) consumers of both agencies.
• Schedule meetings between CIL representatives, HCBS, and VR to review marketing materials and establish working relationships. HCBS Advisory Board members provided materials for their review and comments.
• Facilitate ongoing dialogue between the CILs and the state agencies to solve problematic issues and continue program development.
• Produce a report on the experiences, successes, and problems CILs encountered in providing LWD services to clients from these agencies.
• Submit the report to the Advisory Board for review.
• Utilize the $6,000 earmarked in the SLTCD FY 06 budget to demonstrate business model and effectiveness of LWD with at least 20 consumers of SLTCD Community Based Services.
• Eliminate barrier of paying for LWD without opting out of other needed services.

Evaluation

Baseline: Between spring 2002 and spring 2005, LWD reached 90 consumers with 15 workshops in 11 communities. This effort was funded entirely from the MTDH Program grant.

Outcomes: The four CILs and their satellite offices in Montana will organize eight LWD programs from 2005 to 2007. The total cost for implementing these eight programs is $24,000. The established rate for providing the Living Well Program is $37.50 per person per session.

Using materials developed by the MTDH staff, these programs will be marketed to HCBS case managers, VR counselors and the consumers of these agencies. Of the 80 program slots available during this time period, 24 of them will be filled by HCBS and VR consumers who will participate with funding from each respective agency. On this basis, the share of total program costs paid for by the MTDH program will be $16,000; the two state agencies will pay $8,000.

Primary program outcome effects on secondary conditions, symptom days, and healthcare utilization will be collected using the survey instrument created by the National LWD Evaluation Consortium to monitor program effectiveness through this change in funding context.

Data source: CILs that receive MTDH program funding to organize and evaluate the LWD Program will keep records of reimbursement from the two state agencies. The MTDH Program will collect this information after the conclusion of each program workshop. CILs will distribute and collect three waves of survey data (pre-intervention, post-intervention, and three-month followup) from consumers to monitor program effectiveness.

Short-term Outcome Goal 2C

By 2007, the MTDH Program will increase the awareness and knowledge of Montana People First chapters in Helena, Missoula, Great Falls, and Billings of peer-support strategies for improving the health of its members by introducing programs such as the oral health program, Have Healthy Teeth, that lead to routine tooth brushing and the reduction of oral health risk indicators such as plaque, gingivitis, and presence of debris.

Rationale

People with intellectual or developmental disabilities are at increased risk for a variety of health problems.²⁰ Oral health conditions are among the most common and severe secondary conditions facing Montanans with intellectual developmental disabilities (I/DD).²¹ The Have Healthy Teeth pilot program provides a choice of toothbrushes and behavioral supports for a cost-effective method of promoting oral health. Montana People First is composed of motivated and committed individuals. This organization has great potential for improving the health for its members and other peers.

²⁰ U.S. Surgeon General’s Report, 2002
²¹ http://mtdh.ruralinstitute.umt.edu/Publications/OralHealth.htm

Activities

• Phase-in the Have Healthy Teeth program by offering it to a maximum of 30 members of Montana People First (MPF) chapters in Helena and Missoula in the first year and repeating the process for up to 30 MPF members in Great Falls and Billings in the second year.
• Train participants and peer supports in the brushing and reinforcement components of the program.
• Train interested participants to be trainers for future peer support members.
• Engage the Dental Hygienist and Dental Assistant Programs at MSU-Great Falls as the future source of dental hygienists for the program.
• Collect and report oral health screening data to interested program participants, the Advisory Board, and Montana oral health professionals.

Evaluation

Baseline: In a statewide survey of adult consumers of state DDPs, dental/oral hygiene problems were reported as one of the most common and severely limiting secondary health conditions. Thirty-nine percent reported having dental/oral hygiene problems that limited their activities 5-10 hours per week. Poor dental/oral hygiene ranked as the sixth most limiting of 45 secondary conditions. Only communication, physical fitness, weight, personal hygiene, and persistence/low frustration problems ranked higher. Presently, peer-based support programs for improving oral health are available in Missoula. Extension to Helena area residents with I/DD will be implemented before 2006.

Outcomes: People First chapters in Missoula and Helena will continue participation in peer-support efforts to improve the oral health of members. These two chapters, with support from the MTDH Program and its partners, will conduct outreach training to People First chapters in Great Falls and Billings. All participants in supported oral health programs will experience reduction in plaque, gingivitis, and presence of oral debris in their mouths two months and six months post-intervention.

Data source: Success of the program will be measured by People First members’ reports of satisfaction and self-efficacy in the area of oral health routines on paper-pencil surveys. Also, results of standard of program participants’ oral health conducted by trained oral hygienists immediately pre-intervention, two months post-intervention and six-months post-intervention will yield scores on the following oral health indices: Lobene Stain Index, Gingivitis Index, and Debris and Calculus Index.

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Intermediate Outcome Goal Three: Improve Access to Generic Services

Fundamental to the right of public access granted by passage of the ADA in 1990, is the responsibility to increase the general public’s knowledge and awareness of the needs of people with disabilities. Programs and services offered to the general public must also be made available to people with disabilities. In order to achieve the goal of full access for all people, professionals, service providers, and others in positions of influence must be educated about the needs of people with disabilities and on how to recognize and eliminate potential barriers. A better understanding of ADA requirements requires increased dialogue and cooperation between health and disability educators and those who are best positioned to reinforce the shift in disability paradigm from that of disability as a medical problem to that of an issue involving accessibility, accommodations, and equity.

Short-term Outcome Goal 3A

By 2007, the MTDH Program will address the need for improving student training about the needs of people with disabilities. This objective will be accomplished by increasing the awareness and knowledge of preventive health care training and universal design curricula among the following groups:

1) University of Montana (UM) Board of Regents;
2) Administrators of UM allied health programs; and
3) Montana State University (MSU) allied health and architectural programs.

Rationale

One of the best and most logical ways of increasing general awareness and knowledge of the needs and concerns of people with disabilities is to provide pertinent information and training to nursing, pharmacy, physical therapy, and dental services students.

Activities

• Develop a tool to assess preventive health care training programs that address concerns of people with disabilities.
• Disseminate assessment to administrators of allied health programs (e.g., nursing, pharmacy, physical therapy, dental hygienist and assistant programs) and architectur