Montana Disability and Health Program
Strategic Plan 2006-2010
Disability Report Summary and Highlights
Vision, Mission, Goal
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
Table 1: Year 2010 Health Objectives for the Nation: Summary of 2003 Montana BRFSS Data
Table 2. A Medical-Social-Ecological Model of Disability Woman uses leg extension machine at New Directions Wellness Center
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.
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.
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)
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/objectives/summary/objectives.aspx
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.
7 Regional 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.gov/index.htm
8 Rural Disability and Rehabilitation Research Progress Report #30, November 2004.
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://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
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.
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/index.html
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.
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.
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.
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)
- 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.
Table 1: Year 2010 Health Objectives for the Nation: Summary of 2003 Montana BRFSS Data 15
Healthy People 201016 Objectives and Year 2010 Target
|1-1.||Increase the proportion of persons with health insurance to 100 percent.||
|1-5.||Increase the proportion of persons with a usual primary care provider to 85 percent.||
|2-2.||Reduce the proportion of persons with chronic joint symptoms who experience a limitation in activity due to arthritis to 21 percent.||
|2-5.||Increase the employment rate among adults with arthritis in the working-aged population (age 18-64) to 78 percent.||
|5-3.||Reduce the overall rate of diabetes that is clinically diagnosed to 25 cases per 1000 population.||
55 per 1000
106 per 1000
42 per 1000
|12-9.||Reduce the proportion of adults with high blood pressure to 16 percent.||
|12-14.||Reduce the proportion of adults with high total blood cholesterol levels to 17 percent.||
|12-15.||Increase the proportion of adults who have had their blood cholesterol checked within the past five years to 80 percent.||
|14-29a.||Increase the proportion of adults who are vaccinated annually against influenza to 90 percent (age 65 and older).||
|14-29b.||Increase the proportion of adults ever vaccinated against pneumococcal disease to 90 percent (age 65 and older).||
|19-1.||Increase the proportion of adults who are at a healthy weight to 60 percent.||
|19-2.||Reduce the proportion of adults who are obese to 15 percent.||
|22-1.||Reduce the proportion of adults who engage in no leisure-time physical activity to 20 percent.||
|22-2.||Increase the proportion of adults who engage in regular, moderate physical activity to 30 percent.||
|26-11c.||Reduce the proportion of adults engaging in binge drinking in the past month to 6 percent.||
|27-1a.||Reduce cigarette smoking by adults to 12 percent.||
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.
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
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.
Table 2. A Medical-Social-Ecological Model of Disability18
|Definition of Disability|
|An individual is limited in life activities by his/her impairment or condition||An individual with an impairment requires an accommodation to perform functions necessary for life activities||A person is limited in life activities by the interaction of his or her capacities and the demands of the environment|
|Domain of Disability|
|A medical “problem”||A socio-environmental issue involving accessibility, accommodations, and equity||All aspects of the person/ environment interaction that inhibit full participation|
|Strategy to Address Disability|
|Improve functional limitations of the individual||Remove barriers, create access through accommodation and universal design, promote wellness and health||Help individuals maximize function and provide environmental accommodations|
|Method to Address Disability|
|Provision of medical, vocational, or psychological rehabilitation services||Provision of supports, e.g., assistive technology, personal assistance services, job coach||Provide services, supports and opportunities to facilitate achievement in goals|
|Source of Intervention|
|Professionals, clinicians, and other rehabilitation service providers||Peers, service providers, consumer information services||Professionals, clinicians, peers, policy makers|
|Role of Disabled Individual|
|Object of intervention, patient, beneficiary, research subject||Consumer or customer, empowered peer, research participant, decision-maker||Expertise on accommodations needed for full participation|
|Eligibility for benefits based on severity of impairment||Eligibility for individualized accommodations seen as a civil right||Environmental accommodations and access to health care deemed necessary for full participation of all citizens|
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.
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
- 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.
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.
Intermediate Outcome Goals
Increase access to generic services, ensuring civil rights of PWD
Improve access to community environments, ensuring civil rights of PWD
Integrate disability and health agenda into public policies that influence the health of PWD
Short Term Outcome Goals
▪ Train partners to
▪ Support peer
▪ Support removal
▪ Support removal
▪ Educate policy
▪ Partner with
Outputs, Products Activities
▪ Assessment tool
“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.
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.
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.
- 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.
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.
Viable partnerships increase Montana’s capacity to promote the health and independence of people with disabilities.
- 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.
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.
The MTDH Program must expand the capacity to meet its overall mission of improving the health and independence of people with disabilities.
- 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.
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.
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
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.
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.
- 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.
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
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.
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.
- 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.
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.
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.
- 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.
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.
20 U.S. Surgeon General’s Report, 2002
21 Research Progress Report #29
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.
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.
- 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 architectural programs.
- Analyze responses.
- Prepare report.
- Disseminate report with model plans and best practices to The University of Montana Board of Regents as well as to administrators of allied health and architectural programs.
- Incorporate model plans and best practices into curriculum.
- Train those with disabilities to advocate for full access.
Baseline: There is no current information describing the presence or absence of disability issues in any University of Montana health professional or architectural courses and curricula. A faculty and administrator survey will be conducted in the Spring of 2006 to determine this information as well as overall awareness of the need for such content and faculty and administrator readiness to teach such concepts as appropriate in required content areas.
Outcomes: There will be a 25% increase in the number of faculty and administrators who report readiness to teach disability issues relating to their area of expertise. There will be a ten percent increase in the number of allied health and architecture courses with disability content appropriate to course requirements.
Data source: The MTDH Program will develop and disseminate a survey to a representative group of allied health and architecture administrators and faculty in Spring 2006 and Fall 2007.
Short-term Outcome Goal 3B
By 2007, the MTDH Program will increase knowledge and awareness of health disparities and secondary conditions experienced by people with disabilities in Montana by providing health education information and materials to members of: the Montana Health Association; Montana Association of Independent Disability Service Providers; Centers for Independent Living (CILs); and Parents Let’s Unite for Kids (PLUK).
One of the important advanced capacities UMRI provides is extensive experience in disseminating useful and timely disability and rehabilitation information to providers, consumers, and policy makers. Improving others’ capacity through the provision of educational information and materials strengthens the role of the MTDH Program as a provider of technical assistance.
- Maintain the Health Education Committee of the Advisory Board to address issues of health education and information dissemination.
- Use a consumer-directed, market oriented approach for disseminating health and disability information and practices.
- Maintain the MTDH Program web site as a public gateway to health and disability information for Montanans with disabilities, their families, service providers, professionals, and policy and program planners.
- Maintain and expand a Disability and Health Network e-mail distribution list.
- Maintain and expand other e-mail distribution lists and traditional mailing lists that will parallel the electronic distribution list.
- Prepare key health education materials identified by the Core Management Team and Health Education Task Force Committee in regular print, Braille, large-print, and electronic versions for broad dissemination in alternative formats.
Baseline: Although there is information about health disparities and secondary conditions experienced by people with disabilities in Montana, it has not been reviewed by as broad a constituency needed to address these concerns.
Outcomes: Ninety percent of members of the targeted organizations will receive at least two health communications with information on disability and health issues.
Data source: Process outcome results will come from dissemination figures, records of information appearing in organization newsletters, and requests from these organizations for additional information and technical assistance.
Short-term Outcome Goal 3C
By 2007, the MTDH Program will increase knowledge and awareness of effective strategies for preventing secondary conditions and improving the health of people with disabilities to at least 800 professionals and service providers. This goal will be accomplished through: conference presentations; newsletter and newspaper articles; targeted e-mail distribution and postal mailings; and posting information on the MTDH Program website.
Statewide knowledge of the advanced capacities of the MTDH Program to provide technical assistance is limited. Moreover, these capacities cannot address the broad range of health concerns within the diverse populations of Montanans with disabilities.
- Present information at four Montana conferences each year.
- Maintain and enhance the MTDH Program knowledge capacity by participating in: 1) networking activities supported by the CDC and the American Association on Health and Disability (AAHD); and 2) national list serves.
- Develop conference call series, online threaded discussions, and other communication sharing systems.
- Provide information and referral services to Montana professionals, service providers, and policy makers.
- Continue to develop the capacity to deliver LWD through involvement in a National Evaluation Consortium composed of state disability and health grantees implementing LWD.
- Expand dissemination lists to include interested Native American constituencies.
- Develop and share knowledge of health concerns among Native Americans with disabilities in Montana.
- Promote technical assistance capacity through presentations to key public health advisory groups targeted by the MTDH Program Disability Advisors project.
- Match information requests to experts identified through participation in national and state networks.
Baseline: Although no data exist to describe the current status, the levels of awareness of effective strategies for preventing secondary conditions is likely to vary across professionals and providers and to vary in terms of types of secondary conditions and target systems and populations.
Outcomes: Eight hundred professionals and service providers will receive at least two health communications with information about strategies for preventing the most limiting and common secondary conditions experienced by adults with physical and intellectual disabilities.
Data source: Process outcome results will come from dissemination figures and requests from these individuals for additional information and technical assistance.
Short-term Outcome Goal 3D
By 2010, the MTDH Program in partnership with the MDPHHS Diabetes Advisory Coalition will increase by 10% the number of people with disabilities and diabetes who receive diabetes education as measured by the BRFSS.
Montana BRFSS data reported increased incidence of diabetes among people with disabilities.
- Continue the placement of Disability Advisors.
- Provide Disability Advisors with specific information that is aimed at increasing participation of persons with disabilities in diabetes education programs.
- Provide alternative formats of diabetes educational materials.
- Identify where diabetes education is occurring in Montana.
- Partner with the Montana Centers for Independent Living (CILs) disability networks to initiate an awareness campaign.
- Contact local hospitals and medical clinics that conduct blood draw screenings to include disability networks on their mailing lists.
Baseline: According to Montana 2003 BRFSS data, 5.5% of all adult Montanans have diabetes. This figure nearly doubles (10.6%) when estimating the prevalence rate of diabetes among adults with disabilities in Montana.
Of those Montanans reporting clinically diagnosed diabetes:
- People with disabilities (52.9% reported ever having received education in the self-management of diabetes; 47.1% had not received education)
- People without disabilities (61.3% reported ever having received education in the self-management of diabetes; 38.7% had not received education).
Outcomes: An increase in the number of persons with disabilities and diabetes receiving diabetes education will be observed from 2003 to 2010.
Data source: Montana BRFSS core module and state-added module on diabetes.
Short-term Outcome Goal 3E
By 2007, the MTDH Program, in partnership with the Montana Department of Transportation, and Montana Department of Fish, Wildlife and Parks, will increase the awareness and knowledge of Montana public health professionals of the information needs of Montanans with low vision and blindness and other people with disabilities. This will be accomplished by providing accessible formats and/or sensitivity and inclusion education for five state health promotion campaigns and/or data collection activities.
Accessible formats and education increase the effectiveness and outreach of state health promotion campaigns and data collection activities.
- Identify priority public health awareness campaigns planned within the PHSD as well as important communications about programs and services being disseminated to consumers of PHSD services and programs, DSD Developmental Disabilities Program and SLTC Community-Based Services Program.
- Work with agency and program staff to convert communications into accessible formats (e.g., ASCII text, Braille, and large font).
- Work with agency and program staff to expand dissemination targets in communities to ensure accessible materials are available to community members with low vision and blindness or others with disabilities experiencing information barriers (people with intellectual disability with distinct health literacy needs).
- Work with agency and program staff to depict people with disabilities along with other community members in communications when appropriate.
Baseline: Two health promotion campaigns conducted in targeted communities in the state disseminated their health messages in ASCII text, Braille, and Large Font through community-based providers.
Outcomes: Five additional health promotion campaigns will disseminate their health messages in alternative accessible formats and will collaborate with community-based service providers to increase outreach to people with disabilities living in targeted communities.
Data source: The MTDH Program will track the number of campaigns and printed public health messages converted to and produced in alternative accessible formats. The number of copies distributed to community-based providers will also be evaluated. Efforts will be made to follow-up with community-based providers to evaluate the number of alternative accessible materials that were distributed.
Short-term Outcome Goal 3F
By 2010, the MTDH Program in partnership with the University of Montana and the Information Technology Services Division of the Montana Department of Administration will ensure that all information on web pages associated with programs in the CDHP Bureau will be accessible to people with disabilities in accordance with state and federal law.
In 1998, Congress amended the Rehabilitation Act, requiring federal agencies to make their electronic and information technology accessible to people with disabilities. In 2001, the Montana Legislature passed a law providing for access to information technology for people who are blind or visually impaired. Many websites are accessible; however, the documents containing important information are often in PDF or other formats less accessible to some versions of computer screen readers and often include photos, graphics, figures, and tables needing narrative descriptions to be decipherable by screen readers.
- Work with agency and program staff to make priority documents such as public health state plans and public health communications available in ASCII text with narrative descriptions of all photos, graphics, figures and tables for people using screen readers.
- Work with agency and program advisory groups to adopt a policy regarding the posting of all documents on websites that would require accessible formats of documents including narrative descriptions of photos, graphics, figures, and tables.
Baseline: Staff of the MTDH Program will review a random sample of documents available on the MDPHHS website to determine the percent accessible to users of standard screen readers.
Outcomes: By 2010, all documents will be available in formats accessible to users of standard screen readers.
Data source: Random samples of documents will be conducted annually to track progress on this short-term outcome goal. Experts in the area of screen readers and document accessibility will be recruited to evaluate the documents.
Short-term Outcome Goal 3G
By 2010, the MTDH Program in collaboration with the Montana Developmental Disabilities Program (DDP) and the Montana Tobacco Prevention Program will increase the knowledge and awareness of service providers regarding the effects of second-hand smoke and strategies for reducing second-hand smoke exposure. Consumers of DDP services and supports also will have an increased awareness of the effects of second-hand smoke as well as programs available to support smoking cessation.
Smoking and exposure to second-hand smoke are major causes of disease and mortality in Montana. According to the 2003 Montana BRFSS, one in four Montana adults with disability smoke, and one in five Montana adults without disability smoke. 22 According to a state-wide survey conducted with adult consumers of DDP services in 1999, relatively small percentages of respondents smoked or chewed tobacco (i.e., 6% and 2% respectively). However, the supports available for Montanans to quit are not always accessible to people with intellectual or developmental disabilities because of various programmatic barriers. The 1999 survey also showed that exposure to second-hand smoke occurred in an average of 12% of adults’ daily living settings. Ten percent of adult respondents were exposed to second-hand smoke in nearly half of their daily living settings and two percent were “always exposed” to second-hand smoke.
Work with agency and program staff to interpret the 2005 Montana smoking legislation for daily living settings of adult consumers of state DDP services. Establish effective policies and practices based on these interpretations.
- Educate adult consumers and direct care providers about the harmful effects of second-hand smoke and tobacco use.
- Work with agency and program staff and advisory groups in collaboration with National Jewish Medical and Research Center23 to identify and address barriers to the Montana Tobacco Quit Line.
- Educate adult consumers about the Montana Tobacco Quit Line and other local supports for tobacco cessation.
- Inform private service corporations contracted to the Montana DDP about work life wellness programs supporting tobacco cessation.
Baseline: Little is known about the knowledge and awareness of the risks of second hand smoke among providers and consumers of adult DDPs. In addition, little is known about the knowledge and awareness among adult consumers of DDP concerning the risks of smoking.
Outcomes: Providers and consumers will receive or be exposed to at least one health communication about the risks of second hand smoke. Consumers will receive or be exposed to at least one additional health communication about the risks of smoking.
Data source: Process evaluation results will be reflected in dissemination data tracking the number of copies of health communications and number of recipients. Also, locations where such information is posted will be tracked. One month after posting information, at a random sample of such locations, a convenience sample of persons will be asked about their awareness of the posting and the content of the message.
Short-term Outcome Goal 3H
By 2007, the MTDH Accessibility Advisors, in collaboration with Montana People First (MPF) chapters and the Montana Council on Developmental Disabilities (MCDD), will raise awareness of the need for specific accessibility improvements among Community Health Center (CHC) administrators and boards in six Montana communities—Butte, Billings, Helena, Great Falls, Miles City and Missoula.
Equal access to health care for people, regardless of their impairment status, is a civil right. Removing barriers to health care experienced by persons with disabilities could alleviate some of the health disparities observed between persons with and without disabilities. Community Health Centers are targeted because they are designed to provide accessible personal health services to people who are uninsured, under-insured or beneficiaries of Medicaid. Most persons with disabilities fall in one of these three categories.
- MTDH program staff will recruit and train persons with disabilities to act as MTDH Accessibility Ambassadors in their communities and the state.
- MTDH Accessibility Ambassadors will recruit and train partners from local MPF chapters to assist with accessibility assessments and disability awareness activities.
- MTDH Accessibility Ambassadors and local MPF chapters establish relationship with local CHC administrators and Boards of Directors. Ambassadors and MPF members conduct an accessibility assessment on the local CHC facility with representative CHC staff.
- MTDH Accessibility Ambassadors and People First chapters will share accessibility assessment results, suggestions for improvements, and community and national resources with CHC Administrators and Boards of Directors.
- MTDH Accessibility Ambassadors follow-up with CHCs to document improvements made and objectives for accessibility improvements in short- and long-term planning documents.
Baseline: Community Health Centers are public or private corporations with most receiving partial funding from U.S. Public Health dollars. Because there have been no comprehensive accessibility assessments conducted in CHCs in Montana, no accessibility baseline exists. The proposed six CHCs to be assessed will provide a base for further surveys, as well as indicators of common accessibility barriers and facilitators.
Outcomes: Community Health Center administrators and boards will receive reports chronicling access issues and possible solutions prepared by an MTDH Accessibility Ambassador and a person with a developmental disability from an MPF chapter. An MPF member will also present the results of the survey to his/her own members, increasing member awareness of available health care services. Finally, the state’s Parents Let’s Unite for Kids (PLUK) newsletter will feature an article on the project, again increasing the awareness of CHCs and their services to people with developmental disabilities and their families.
Data source: Results of the accessibility assessments will be formatted into an Accessibility Plan of Action report highlighting strengths and areas for improvement for CHCs. MTDH Accessibility Ambassadors will recontact CHC administrators six months after disseminating the report to evaluate whether improvements: a) have been made; and b) are included in CHC short- or long-term planning documents.
22 Cummings, S.J., Oreskovich, J., and Traci, M.A., Assessing Disability and Secondary Health Conditions of Montana Adults, Results from the 2001 and 2003 Behavioral Risk Factor Surveillance System Surveys, Health Planning Section, Public Health and Safety Division of DPHHS.
Access to civic life is a fundamental part of American society. Research shows that people with disabilities often have more problems accessing social and recreational activities, employment, and health care than people without disabilities. Within the new disability and health paradigm, disability is considered a socio-environmental issue involving accessibility, accommodations, and equity rather than a medical issue or problem. Environmental factors such as physical barriers, knowledge, attitude and belief barriers, as well as geographic and economic barriers—not personal impairments—are viewed as the primary obstacles contributing to health disparities existing between people with and without disabilities. 24
Full access includes an environment that presents opportunities for inclusion and personal choice by integrating people in all social and economic aspects of life. Improving access for people with disabilities to community environments—to health care, public buildings, businesses, education, recreation, and private living spaces—enables participation in everyday commercial, economic, and social activities.
In 1990, Congress passed the ADA, which prohibits discrimination on the basis of disability by public accommodations and requires places of public accommodation and commercial facilities to be designed, constructed, and altered in compliance with the accessibility standards established within the law. Passage of the ADA compliance standards and requirements has significantly improved public accessibility for people with disabilities, however, there is still much to be accomplished. Moreover, the ADA has no authority over private residences. Movement toward full integration, without barriers—attitudinal or otherwise—is key to achieving the ideal community for people with disabilities.
Short-term Outcome Goal 4A
By 2007, the MTDH Program Advisory Council will disseminate findings from accessibility assessments in five Montana communities. This information will increase the awareness of city councils, city planners, and people with disabilities about existing environmental barriers that limit people with disabilities’ participation in social activities, health care, and health promotion activities.
Disability can result from an interaction between a person’s capacities and the demands of his or her environment. 25 To effectively reduce primary and secondary disability, interventions targeting improvements in community environments are needed in addition to traditional direct services that tend to be person-centered prevention interventions. 26
- Collect and report survey data from neighborhood and community surveys with results from a comprehensive review of the literature about environmental barriers and facilitators.
- Present information to the MTDH Program Advisory Board. In collaboration with the Board, the MTDH Program staff and core management team members will select five barriers and five facilitators to study in five targeted communities or counties.
- Partner with related Rural Accessibility Project staff to develop sampling and assessment methodology.
- Formalize Accessibility Ambassadors program in targeted communities.
- Train Accessibility Ambassadors in assessment techniques.
- Recruit additional community partners to help with accessibility assessments (such as senior case managers, fire marshals, and members of volunteer fire departments).
- Complete an assessment of five key environmental barriers and five facilitators in targeted Montana communities or counties.
Baseline: Very little is known about the accessibility of Montana communities. A series of assessments of a random sample of community buildings and facilities will be conducted to determine the presence of key barriers and facilitators in five targeted communities.
Outcomes: City councils, city planners, and people with disabilities living in these communities will receive reports from these assessments with recommendations for short- and long-term planning initiatives.
Data source: Process evaluation results of dissemination records and records of requests for technical assistance will be used to evaluate progress on this short-term outcome goal.
Short-term Outcome Goal 4B
By 2010, the MTDH Program (in partnership with the UMRI, Montana Centers for Independent Living, the Senior and Long-Term Care Division of the MDPHHS, the Montana chapter of AARP, the Montana Department of Labor and Industry (DOLI), and the Montana Legislature) will increase awareness and knowledge of Montana legislators, the MSU school of architecture, the Montana Home Builders Association, Montana Realtors, and Montana Public Health officials about visitability in Montana with recommendations for supports that would increase the proportion of visitable homes in the state.
People with disabilities represent a significant portion of Montana’s population. Reports from the U.S. Census 2000 estimate that 17.5 percent of Montanans over the age of five reported some form of disability (i.e., 145,732 of the 831,694 Montanans over the age of five).27 A large proportion of those individuals experience physical disabilities and could benefit from improved accessibility of the physical environments in their communities, especially their homes. Homes that are “visitable” include features that prevent injuries from falls and welcome visitors with physical disabilities, many of whom are at risk for secondary health conditions such as social isolation, depression, and anxiety. 28
- Partner with Montana newspapers and journalists (e.g., those specializing in universal design articles) to distribute these articles and related information more broadly in the state.
- Formalize a partnership with the Montana Home Builders Association.
- Collect, analyze, and disseminate BRFSS data (2005 and 2009) regarding the number of visitable homes in the state.
- Integrate universal design concepts into architectural curriculum at MSU-Bozeman.
- Work with Montana legislature to develop and evaluate a system of state tax incentives for building modifications to improve visitability.
- Work with Montana realtors to identify the target groups and groups valuing visitable homes.
- Work with public health officials and SLTCD staff on injury and fall prevention. Consider a public health communications campaign about aspects of visitable homes and methods for making homes safer and more accessible for people with mobility impairments.
Baseline: Limited information is available about visitable homes in Montana and strategies for supporting increases in the number of visitable homes in the state.
Outcomes: Target groups will receive at least one publication outlining the results of the 2004 Montana BRFSS indicating that 19.2% of Montana’s homes had basic visitability features, with higher percentages being observed among Montanans older than 64 years of age and among Montanans who reported having health problems that required them to use special equipment (such as a cane, a wheelchair, a special bed, or a special telephone). Publications will also describe programs that have increased the number of visitable homes in other areas that may be appropriate for adoption in Montana.
Data source: Process evaluation results from dissemination records will be used to track progress on this short-term outcome goal. Requests for technical assistance on this issue will also be tracked. Noteworthy impacts (such as adoption of strategies by state agencies and other organizations) for increasing the number of visitable homes will be tracked. The state-added BRFSS item on visit-able homes will be supported again in 2009 to establish a trend on this data point. This item reads: “If a person who uses special equipment such as a wheelchair came to visit you, could they get into your house without being carried up steps or over other obstacles?”
27 Montana Quick Facts from the US Census Bureau, http://quickfacts.census.gov/qfd/states/30000.html
Policies influencing the health and well being of people with disabilities must be integrated into all public health systems of services and supports through advocacy and public policy. Most Americans will experience a disability at some time during the course of their lives. Life expectancy in the United States has nearly doubled since the beginning of the 20th century. Persons who were born with disabilities as well as those who were disabled as a result of illness or injury in later life are also living longer. “Consideration of the impact of this expanding population on the health system is critical to ensure the nation’s public health. Development of health policy, health programs and health financing must address the need for access to services and supports for persons with disabilities.” 29
In his recent Call to Action to Improve the Health and Wellness of Persons with Disabilities (2005), Surgeon General Richard H. Carmona set an agenda calling for new partnerships and collaborations. “…Persons with disabilities must have accessible, available and appropriate health care and wellness promotion services. They need to know how to—and to be able to protect, preserve and improve their health in the same ways as everyone else. This Call to Action encourages health care providers to see and treat the whole person, not just the disability; educators to teach about disability; a public to see an individual’s abilities, not just his or her disability; and a community to ensure accessible health care and wellness services for persons with disabilities.” 30
The Surgeon General’s Call to Action emphasizes the importance of a bio-psychosocial approach to disability—a combination of factors at the physical, emotional and environmental levels. This approach diverges from the “illness” model that approaches disability from the perspective of diagnosing, treating and discharging. In contract, the bio-psychosocial approach focuses on three interrelated concepts that extend beyond the individual: (1) impairments; (2) activity; and (3) participation. 31
Short-term Outcome Goal 5A
By 2010, the MTDH Program in partnership with the Senior and Long-Term Care Division and the Disability Services Division will provide education to professionals, service providers and persons moving to the community from institutional settings about secondary condition prevention strategies and health resources available in Montana’s communities.
Currently, there are 4,500 nursing facility residents and 80 adult consumers of Montana Developmental Disabilities Programs residing in the Montana Developmental Center at Boulder. Support in the least restrictive settings has been mandated by the U.S. Supreme Court (Olmstead v. L.C. by Zimring, 527 U.S. 581) and has pushed states to develop and support community-based options in lieu of traditional institutional placements. Additionally, this trend of “deinstitutionalization” also is a key objective in Healthy People 2010 Chapter 6, the chapter in our nation’s health agenda that is devoted to the health of persons with disabilities. A critical component of these community-based options includes identified health resources and adequate transition of health routines established in institutional settings to community-based alternatives.
The MTDH Program will work with the Governor’s Council on Disabilities to support the inclusion of objectives describing effective community health resources in the integrated Olmstead Plan being developed for the state of Montana. 32 The MTDH Program will develop a state guide to health resources targeting the needs of people with disabilities transitioning from congregate care or institutional settings to community settings. A series of publications with community specific information will accompany this guide. These materials will be disseminated to service providers and will be available on the MTDH website.
The MTDH Program will provide technical assistance to relevant MDPHHS divisions on developing training and materials for health professionals and service providers supporting persons moving to the community from institutional settings.
Baseline: There are programs and supports for transitions to community settings. However, as persons with more intense medical needs prepare to move to the community, there may be new needs for information and training among health professionals, service providers and consumers.
Outcomes: The MTDH Program will provide ongoing technical assistance and information related to health maintenance and promotion that meets the emerging needs of persons transitioning from congregate care or institutional settings to community settings.
Data source: Process outcome results.
Short-term Outcome Goal 5B
By 2007, the MTDH Program will increase the knowledge and awareness of disability and health issues on key MDPHHS advisory groups and integrate disability and health issues into the MDPHHS planning documents. This will be accomplished by increasing from six to ten the number of MDPHHS standing advisory boards that have Disability Advisors as members.
Placing Disability Advisors on additional advisory boards (of statewide and local organizations) serves to introduce disability and health issues for consideration in developing policies, regulations, and plans. The presence and perspective of the Disability Advisor helps to ensure that disability and health issues are incorporated into other programs, plans, policies, and regulations.
- Identify four additional MDPHHS key advisory groups guiding activities of programs of priority interest to people with disabilities.
- Recruit and train four Disability Advisors to participate in identified advisory groups.
- Train facilitators of advisory groups on the guidelines for conducting accessible meetings.
- Provide support for Disability Advisors in integrating disability and health issues into other long-range plans.
- Work with the MTDH Program Advisory Board to develop specific recommendations for state department agencies and programs.
- Reinforce specific policies and activities furthering the health and wellness of Montanans with disabilities.
- Modify policies and document barriers.
- Encourage the widespread adoption of policies and regulations contributing to the attainment of the MTDH Program goals.
- Support participation of the disability community in public comment periods for long-range plans developed in health departments and local transportation and city planning agencies.
- Support participation of health, transportation, and city planning agencies in the long-range plans within disability agencies and programs.
Baseline: Currently, six Disability Advisors represent disability issues on six key MDPHHS Advisory Boards, Groups or Task Force Committees.
Outcomes: Four additional Disability Advisors will join and participate in MDPHHS key advisory groups.
Data source: Process outcome results.
Short-term Outcome Goal 5C
By 2010, the MTDH Program will partner with at least three other state agencies to:
1) Include appropriate objectives addressing the health and wellness of people with disabilities in long-range plans; and
2) Address the health and wellness needs of people with disabilities by explicitly integrating them as a population to be served.
- Meet with the Disability Action Alliance of Montana and the Governor’s Policy Advisor to develop a plan.
- Contact the Administrator of the SLTC Division to discuss a new work group that would include the Montana Department of Corrections for the specific purpose of addressing Medicaid parolees, specifically parolees with disabilities.
- Support the integration of PHSD’s Olmstead Plan with other state agency Olmstead plans by participating in the Governor’s Advisory Council on People with Disabilities.
Baseline: Currently, the MTDH Program works with the MDPHHS Public Health and Safety, Disability Services , and Senior and Long Term Care Divisions to develop disability and health objectives in long-range plans and to ensure integration of persons with disabilities in health and wellness programs and services.
Outcomes: The MTDH Program will work with three additional state agencies to achieve similar outcomes.
Data source: Process outcome results, including state objectives in long-range plans and agency output data documenting the number of people with disabilities participating in health and wellness programs and services.
29 The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities, July 26, 2005
32 Montana Executive Order No. 4-2005, “Executive Order Continuing the Governor’s Disabilities Advisory Council”, signed 3/3/05
AAHD: American Association of Health and Disability
AARP: American Association for Retired People
ADD: Administration on Developmental Disabilities
ADA: Americans with Disabilities Act
BMI: Body Mass Index
BRFFS: Behavioral Risk Factor Surveillance System
CDC: Centers for Disease Control and Prevention
CDHPB: Chronic Disease and Health Promotion Bureau of the Montana Department of Public Health and Human Services
CHC: Community Health Center
CIL(s): Center(s) for Independent Living
DDP: Developmental Disabilities Program
DOLI: Department of Labor and Industry
DSD: Disabilities Services Division of the Montana Department of Public Health and Human Services
HCBS: Home and Community-Based Services
ICF: International Classification of Function, Disability, and Health
ICIDH: International Classification of Impairments, Disabilities, and Handicaps
I/DD: Intellectual/Developmental Disability
LWD: Living Well with a Disability
MAIDS: Montana Association for Independent Disability Services
MCDD: Montana Council on Developmental Disabilities
MDPHHS: Montana Department of Public Health and Human Services
MENU-AIDDs: Materials supporting Education and Nutrition of Adults with Intellectual or Developmental Disabilities
MPF: Montana People First
MTDH: Montana Disability and Health
NAMI: National Alliance for the Mentally Ill
NCEH: National Center for Environmental Health
NIDRR: National Institute on Disability and Rehabilitation Research
PDF: Portable File Document
PHSD: Public Health and Safety Division of the Montana Department of Public Health and Human Services
PLUK: Parents, Let’s Unite for Kids
SLTCD: Senior and Long-Term Care Division of the Montana Department of Public Health and Human Services
UMRI: University of Montana Rural Institute
VR: Vocational Rehabilitation
WHO: World Health Organization
The Montana Disability and Health (MTDH) program’s mission is to promote the health and independence of Montanans with disabilities. To that end, a collaborative approach involving academic, government, public health, non-profit, business, and advocacy organizations representing Montanans with disabilities drives this strategic planning process.
Montana Disability and Health Program Organizational Structure
Stakeholder involvement is rooted in a strong well-established collaborative partnership between the University of Montana Rural Institute on Disabilities and the Montana Department of Public Health and Human Services. Many of the key players know each other and have worked together in the past on various disability-related issues. Historically, these partnerships have resulted in a number of successful ventures including the MTDH Program, Living Well Under the Big Sky.
As testament to the demonstrated strength of collaborative commitment, the administrative component of the Montana Disability and Health Program has been transitioned to the Bureau of Chronic Disease Prevention and Health Promotion within the MDPHHS. This new MTDH Program organizational structure assures the involvement of experts in the prevention of secondary conditions as well as those individuals with expertise in other chronic diseases. Under this arrangement three divisions within the MDPHHS; Disability Services, Senior and Long Term Care, and Public Health and Safety, share administrative and program planning and implementation responsibilities with the University of Montana Rural Institute.
Todd Harwell, Chief of the Chronic Disease Prevention and Health Promotion Bureau chairs the Core Management Team which functions as the central managing body responsible for the execution of the MTDH Program. Also included on the Core Management Team are the Administrator of the Disability Services Division of MDPHHS, Joe Mathews, and the Bureau Chief of the Community Services Bureau in the Senior and Long Term Care Division of MDPHHS, James Driggers. The Director of the University of Montana Rural Institute Research and evaluation Unit, Tom Seekins, and MTDH Project Director, Meg Traci, also serve as members of the Core Management Team.
MTDH Advisory Board
Established to represent agencies and programs as well as provider and consumer groups, the Montana Disability and Health Advisory Board held its first organizational meeting in 2003. The Advisory Board is responsible for work at committee levels and for overall guidance of the program through the MTDH Core Management Team. They set priorities, review progress, and organize public support for MTDH initiatives. Their involvement is instrumental in the initiation and development of the Montana State Plan for Disability and Health. Currently, there are eleven board members from across the state representing consumers with mobility impairments and adults with developmental disabilities residing in supported living arrangements operated under contract with state agencies, community service providers, and policy and planning groups. Fifty-four percent of The Advisory Board members have personal experience with disability. A listing of MTDH Advisory Board Members is listed below.
MTDH Advisory Board Members
North Central Independent Living Services
MDPHHS Senior and Long-Term Care Division
Spring Meadow Resources
Silver Bow County DD Council
People First – Helena
Summit Independent Living Center
Big Fish Enterprises
DPHHS Division Partner Representative
Disability Services Division Partner Representative
Living Independently For Today & Tomorrow Independent Living Center
Mountain View Social Development Center
Six individuals, referred to as Disability Advisors, represent disability issues on DPHHS standing advisory committees and at the national level. The advisors and the groups they represent are listed below.
Comprehensive Cancer Control Group
Montana Diabetes Advisory Council
Public Health Emergency Preparedness
Dental and Oral Health Advisory Council
Cardiovascular Disease/Obesity Prevention Task Force
Advisory Council on Food & Nutrition
To begin the strategic planning process, a meeting of advisory board members, disability advisors, and DPHHS and University of Montana Rural Institute staff was held on November 19, 2004. At this meeting, participants formulated a vision, developed a mission statement, and identified several goals for the MTDH program. They also discussed seeking the input and participation of the individuals and groups likely to have a vested interest and/or be involved in providing resources and/or implementing the plan. Accordingly, the MTDH Advisory Board identified a number of key stakeholders including service providers, state and federal agencies, consumers, businesses, and statewide associations/organizations. This master list of key stakeholders was then used to compile a list of individual informants who were contacted in February and March of 2005. In total, 56 key stakeholders representing a balance among academic, government, public health, non-profit, business and advocacy organizations were interviewed. A number of the interviewees function in leadership roles within their businesses or organizations. Forty-seven informants were agency/organization representatives and nine were consumers. A draft report of the results of key stakeholder interviews was introduced at the March 18, 2005 MTDH Advisory Board meeting for review and approval by the Advisory Board. The report documents the input of the key stakeholders listed below.
Key Stakeholder Interviewees
Mental Health Ombudsman
Alliance for Disability and Students at The University of Montana (ADSUM) Consumer Focus Group
Kirk Astroth, Director
Montana 4-H Program
Montana State University-Bozeman
Ninea Baer, Manager
Nutrition and Physical Activity Program
Montana State University – Bozeman
Cindy Baril, Director
Senior Companion Program
Bob Bartholomew, State Director
American Association of Retired Persons (AARP)
Beverly Berg, Program Administrator
Vocational Rehabilitation Program
Blind and Low Vision Services
Disability Services Division, DPHHS
Ron Caldwell, CEO
Westmont Independent Support Services
Trudy Carey, Coordinator
Disability Support Services
Montana State University – Billings
Rev. Amy Carter, President
Missoula Ministerial Association
Montana Independent Living Program
Scott Duke, CEO
Glendive Medical Center
Don Dunwell, News Director
KTVH television station
Linda Fillinger, Chief
Early Childhood Services Bureau
Human and Community Services Division
Montana Department of Transportation
Branch Office for North Central Independent Living Center
Lehni Garza, Events Coordinator
Broadwater Health Club
Director of Review Services
Mountain-Pacific Foundation for Quality Medical Care
Todd Harwell, Chief
Chronic Disease Bureau
Public Health and Safety Division
Robin Homan, Program Manager
Home and Community Based Services
Hank Hudson, Administrator
Human and Community Services Div.
Margie Irvine, EEO Specialist
US Forest Service
Maternal and Child Health Program Officer
Billings Area Indian Health Services
Social Security Administration
Bob Maffit, Director
Montana Independent Living Center
Debra Mason, Specialist
North Central Independent Living Services
Joe Mathews, Administrator
Disability Services Division
Mike Mayer, Director
Summit Independent Living Center
Mike McInally, Editor
The Missoulian newspaper
Gary Mihelish, DDS, Co-Director
Montana Chapter of NAMI, National Alliance for the Mentally Ill
Dennis Moore, Executive Director
PLUK (Parents, Let’s Unite for Kids)
Glen Moyer, Pastor, President
Missoula Evangelical Ministerial Assoc.
High Point Church
Bob M. Norbie, President and CEO
Special Olympics Montana
Jim Nolan, Chief
Intergovernmental Services Bureau
Human and Community Services Division
Senior Companion Program
Eastern Montana Region
Assistant Director of Special Education
Montana Office of Public Instruction
Helena Area Transit System and Helena Area Transportation Council
Marsha Sampson, Interim Director
Montana Center on Disabilities
Montana State University-Billings
Special Populations Grants Coordinator
Public Health and Safety Division
Montana Department of Transportation
Dave Swanson, Director
Living Independently for Today and Tomorrow
Myrle Tompkins, President
Montana Association for the Blind
Jaime Tompkins, Outdoor Recreation Planner
U.S. Forest Service
Paul Valle, Chief
Design and Construction Bureau
Montana Department of Fish, Wildlife and Parks
Betty VanTighem, President
Montana Association for the Deaf
Lee Wilkins, Counselor
Vocational Rehabilitation Services
Disability Services Division
Chronic Disease Program
Montana State University – Bozeman