Strategic Plan 2007-2012

Promoting the health and wellness of ND citizens with disabilities

ND Disability Health Project Staff Dr. Brent Askvig, Principal Investigator

Kari Arrayan, Program Director Kylene Kraft, Project Assistant

Nicole Flink, Administrative Assistant

For alternative formats or additional copies please contact: ND Disability Health Project

ND Center for Persons with Disabilities Minot State University

500 University Avenue West Minot, ND 58707 1-800-233-1737

www.ndcpd.org/health

September 2008

This plan is supported by a grant (1 u59 DD000278-01) to the North Dakota Center for Persons with Disabilities at Minot State University from the Centers for Disease

Control and Prevention (CDC). Opinions expressed are those of the authors and do not necessarily reflect the official policy of the CDC.

1

The ND Disability Health Project is a partnership between:

• The ND Center for Persons with Disabilities at Minot State University • The Center for Rural Health at the University of North Dakota • The ND Department of Health, Office for the Elimination of Health Disparities

Special thanks to the members of the ND Disability Health Project Advisory Council for their time and contributions to the project.

John Baird Pat Conway

Tammy Gallup-Millner Brad Gibbens

Phyllis Howard Jim Moench Kyle Muus Sue Offutt

Bonnie Olheiser Melissa Parsons

Sherri Paxon Revel Sapa

Judith Schlak Suzanne Schlak

Judy Siegle Bob Syverson Becky Telin Bobby Vogel

2

ND Disability Health Project

Mission Statement The North Dakota Disability Health Project will promote the health and

wellness of ND citizens with disabilities, and prevent or lessen the effects

of secondary conditions* associated with disabilities. *Secondary Conditions refers to conditions directly related to the primary disability, such as

contractures in a person who has cerebral palsy, and the impact on a person’s functioning.

Vision Statement All people in ND have access to information and the services they need

to maintain good health and wellness. There are no health disparities

between people with and without disabilities that are based solely on the

presence of a disability.

3

I

Nearly one in five Americans, 49.7 million people, has some type of long lasting condition

or disability. -U.S. Census 2000

ntroduction ately 54 million Americans live with at least one disability (2005 Surgeon

iated

t

akotans age five and older have a disability (U.S. Census, 2008)

and ma

s

alth

health

no specific plan that addresses health

and e

ea of

Approxim

General’s Call to Action). Achieving and maintaining good health and wellness can be

complicated for people with disabilities who are challenged by access to transportation,

attitudinal barriers, inadequate insurance

coverage, and secondary conditions assoc

with their disability. Health and wellness are no

the same as the presence or absence of disability,

they are broader concepts that can directly affect

the quality of a person’s life.

About 15% of North D

ny have health issues associated with their disability. Many of these citizens do not have

access to care and information that makes good health possible. As a rural state, ND has many

challenges to face in providing quality health care to all citizens. Unfortunately, ND health and

disability service agencies have made few coordinated efforts to provide North Dakotans with

disabilities access to health and wellness activities and education. In July 2007 the Centers for

Disease Control and Prevention (CDC) awarded funding to the North Dakota Center for Person

with Disabilities (NDCPD) to launch the ND Disability Health Project. In addition to the

development of this strategic plan, the project has established a state office on disability he

on the campus of Minot State University; provides a system of statewide data collection, analysis

and reporting on the health and wellness of ND citizens with disabilities; develops and

implements collaborative activities in health promotion; and works to improve access to

care and wellness programs for persons with disabilities.

While ND has a Healthy People 2010 plan, there is

w llness issues for people with disabilities. This strategic plan will coordinate with the

efforts of the Healthy North Dakota Initiative and build on the Healthy People 2010 focus ar

Disability and Secondary Conditions; the Surgeon General’s Call to Action to Improve the

Health and Wellness of Persons with Disabilities, and the CDC’s Health Protection Goals

Related to Adults, Older Adults, and Healthy Places.

4

ND Center for Persons 

with Disabilites

ND DOH‐Division of Chronic Disease

ND Disability Health Project

Center for Rural Health‐UND

ollaboration sability Health Project is funded by the Centers for Disease Control and

to

the lead agency for promoting the health

isparities, and

h as the

ng and Physical

l, and

A continuous planning model was used in the strategic planning and development

lanning model diagramed below shows the process for

ability

wellness of ND citizens with disabilities, and

keholders were identified and prioritized for inclusion in

the plan. Collaborations were established with key partners to better access information and for

integration of disability issues throughout the state.

C The ND Di

Prevention for a five year period (2007-2012). ND is one of 16 states to receive this funding

work on various health initiatives and to build overall capacity within the state. The project will

promote the health and wellness of ND citizens with disabilities, and prevent or lessen the effects

of secondary conditions associated with disabilities.

The ND Center for Persons with Disabilities is

and wellness of people with disabilities. Key partnerships have been established with

the ND Department of Health, Office for the Elimination of Health D

the Center for Rural Health at the University of North Dakota. Connections have

also been established with existing health-related state committees suc

Office for the Elimination of Health Disparities, Healthy Eati

Activity committee, Flu Workgroup, Tobacco Prevention and Contro

the ND Diabetes Coalition.

Strategic Planning Model process. The components of the p

development of the strategic plan (see Figure 1).

The mission reflects the purpose and population that will be served by the ND Dis

Health Project, which is to promote the health and

prevent or lessen the effects of secondary conditions associated with disabilities. The vision

specifies where ND wants to be in five years in their work to prevent secondary conditions and

promote the health of people with disabilities. The vision specifies that all people in ND will

have access to information and the services they need to maintain good health and wellness.

There will be no health disparities between people with and without disabilities that are based

solely on the presence of a disability.

The system readiness assessment was completed through the gathering and analysis of

multiple data sources. The needs of sta

5

The goals identify the anticipated results in achieving the vision, while the strategies

identify the steps that will be used to accomplish the goals. The implementation plan describes

the timeline and assigns accountability. The evaluation plan and system improvement

components will determine progress and allow feedback for improvement. Procedures for

reportin s,

Figure 1. ND’s Proposed Strategic Planning Process

g and documentation will identify documents that will be used for conveying the goal

progress and results of the project work to stakeholders and others.

6

7

Health is

physical,

a state of complete

mental and social

w

~W

ell-being, and not merely the

absence of disease or

infirmity.

orld Health Organization, 1948

The Advisory Council members of the ND Disability Health Project reviewed all

elements of the plan and provided feedback for all

aspects

o

ed to

The ND Disability Health Project has adopted the definition of disability as

y the United States Healthy People 2010 plan. This definition is also used by the

efined as a

ane, a wheelchair, a special bed, or a special telephone?

nication

or other impairments that affect their ability to answer the telephone or telephone survey

p

ancy

of access to and the quality of health care that is

person’s functioning.

of the strategic planning process. In an effort to

gain support for the plan, a draft of the plan was als

sent to individuals and agencies. Suggestions that

required only minor adjustments were integrated into

the plan. More substantive suggestions were referr

the Advisory Council members for discussion.

Definitions

recommended b

Behavioral Risk Factor Surveillance Survey (BRFSS) and the CDC. A disability is d

“Yes” response to either or both of the following questions:

Question 1: Are you limited in any way in any activities because of physical, mental, or

emotional problems?

Question 2: Do you now have any health problem that requires you to use special

equipment, such as a c

It should be noted that this methodology (1) does not include adults with commu

questions, and (2) does not include adults who live in institutions in the survey sample, such as

nursing home or other long term care facilities, state facilities, prisons, or residential grou

homes.

The term health disparity addresses the discrep

provided between various populations. Secondary

Conditions refers to conditions directly related to

the primary disability, such as contractures in a

person who has cerebral palsy, and the impact on a

People with 

Disabilities17%People 

without Disabilities 

83%

Disability Prevalence among North Dakota Adults

Combined Years 2001‐2006

Impact of Disabilities in ND

In preparation for development of thi

and without disabilities have been analyzed u ive data sources including

nce Survey (BRFSS), Children with Special Health Care

n

ilities

impact the quality of life for people with disabilities in

services and information, health discrepancies, affordable health

sportation, and prevention. Highlights from the data analysis are

-

s strategic plan, health related issues for people with

sing multiple quantitat

the Behavioral Risk Factor Surveilla

Needs (CSHCN), Kids Count ND,

U.S. Census Data, Youth Risk

Behavior Survey (YRBS), and the

Behavioral Health Workforce in ND

status report. In addition, new

qualitative data were gathered

through focus groups and surveys to

obtain more specific informatio

directly from people with disab

and their families. Both the

qualitative and quantitative data

indicate several issues that negatively

ND. These include access to

care, transition, quality care, tran

outlined below. For a complete review of the data analysis, refer to the Impact of Disability in

North Dakota, Health Status and Disparities report (Arrayan & Askvig, 2008), and the Health

Related Attributes of North Dakota Adults with Disabilities: Analysis of 2001-2006 BRFSS Data

(Muus, 2008). Both reports can be found on the ND Disability Health Project website at

www.ndcpd.org/health.

8

Data Highlights

Approximately 18% of adults in ND report limitations from a physical, mental, or

motional problem. Approximately 38% of these respondents described their health as being fair

with just 7% of the general population. The data indicate adults with

,

ut

ch

e

or poor compared

8

%

Prevalence of Fair/Poor Health among North Dakota Adults,by Disability Status and Age, Combined Years 2001-2006

Source: ND BRFSS*Ages 18 and older Age

disabilities are more likely than people without disabilities to have chronic joint symptoms

arthritis, high blood pressure, high cholesterol, cardiovascular disease, a recent fall-related

injury, asthma, and diabetes. ND adults with disabilities are more likely than those witho

disabilities to be overweight/obese and smoke cigarettes, and are less likely to be physically

active. People with a disability are more likely to have one or more days each month in whi

their mental health is not good (42%), than people without disabilities (31%). People with

disabilities are more likely to be unemployed, not see a physician due to financial limitations,

and have lower income than people without disabilities (Muus, 2008).

9

Health conditions among North Dakota adults with and without disabilities, by age group, BRFSS ombined years 2001-2006.

Total Age 18-64 Age 65 or Older N (%) N (%) N (%)

21 (84.65) 112,125 (83.08) 71,015 (87.07) Without disability 9.3 ) .73)

is ** 8 (56.41) 91,029 (47.48) 84,510 (70.30)

1H

lity 131,584 (48.74) 59,257 (36.71) 71,071 (66.66) 1 1

H 6,353 (44.48) 58,134 (39.15) 57,350 (51.60)

2 1C as

64,985 (24.87) 12,394 (23.27) 45,246 (39.15)

Fell and was Injured *8 (18.63) 5,728 (21.25) 5,006 (16.30)

A82,846 (17.39) 56,157 (19.26) 26,561 (14.59)

2 18 2D

isability 69,473 (14.56) 29,304 (10.03) 39,579 (21.69) 1

N regnancy s.

**

y 1 ,500 ch ren, ages 0-17 years, with special health care needs in

have conditions that affect their activities

usually, alw

c Chronic Joint Symptoms **

With Disability 184,4313,423 (5 0 237,655 (56.52) 74,741 (70

ArthritWith Disability 177,00Without disability 302,134 (19.41) 191,365 (14.66) 08,950 (44.93) igh Blood Pressure ** With DisabiWithout disability 296,909 (24.02) 79,447 (17.64) 15,198 (54.49) igh Cholesterol **With Disability 11Without disability 341,607 (30.33) 32,611 (26.08) 06,482 (47.10) ardiovascular Dise e *** With Disability Without disability 65,325 (6.45) 13,815 (7.70) 39,241 (16.10)

With Disability 10,90Without disability 21,402 (11.83) 15,219 (13.15) 6,122 (9.72) sthma With Disability Without disability 11,611 (8.92) 5,584 (9.33) 4,853 (6.74) iabetes With DWithout disability 05,219 (4.43) 60,925 (3.06) 43,571 (11.81) ote: Diabetes defined as type I or II only, not p diabetes or pre-diabete

* 2003 * 2001-2003, 2005 ** 2001, 2003, 2005, 2006 Source: Muus, 2008

There are approximatel 6 ild

ND (CSHCN, 2008). Twenty percent of these children

ays, or a great deal; this is slightly less than the national average of 24%. Thirteen

percent of children with special health care needs have 11 or more days of school absences due

to illness. In 2006, 26% of children with special health care needs had insurance although it was

considered inadequate, compared to 33% at the national level. Eleven percent of these children

had unmet needs for specific health care services, below the national level of 16%. Nearly 6% of

ND babies were born to mothers receiving inadequate prenatal care in 2005, and this increased

from 4.2% in 1995 (Fassinger, 2007).

10

Issues that arose consistently during focus group discussions and through surveys

included concerns surrounding insurance in general but specifically Medicaid and Medicare

cov rag

for

sabilities. The

aviors is higher among people with

disa il

f

d

all of these issues cannot be addressed within this

stra

ss

After analyzing existing ND disability-related data, gathering and reviewing new data,

from the ND Disability Health Project Advisory Council, three goals were

rmula

e e; lack of transportation in rural areas and limited access in urban areas; need for

training/education for doctors and other health providers; assistance with coordination of care

people with disabilities and their families; caregiver issues such as turnover, low pay, and

shortage of workers; the need for more health care providers such as dentists,

psychiatrists/mental health workers, and other specialists.

Clearly there are health disparities between people with and without di

prevalence of specific health conditions and certain risk beh

b ities. In general it is also more difficult for people with disabilities to obtain care due to

difficulties with transportation, insurance, lower income, and service coordination. The quality o

care is sometimes deficient due to lack of knowledge on the part of health service providers

regarding disability issues and sensitivity issues. Quality of life for people with disabilities can

be negatively impacted by health issues which may prevent involvement in usual activities an

problems finding good quality caregivers.

These findings are presented fully within the 2008 Data Impact Report and provide a

baseline to measure future progress. While

tegic plan due to time and resource constraints, these data will help to determine priority

areas and guide the ND Disability Health Project in its efforts to promote the health and wellne

of people with disabilities.

Priority Areas

and soliciting input

fo ted to focus the direction of the strategic plan and address the health and wellness of

people with disabilities.

11

Rationale: ND data indicate people with disabilities are more

,

re is evidence to support that a healthy diet and

e

ng.

ot

h the

te

Annual review of ND data will indicate changes in the disparities between people with

likely than people without disabilities to be overweight or obese

have diabetes, experience mental health issues, and to use

tobacco.

The

exercise can reduce the risk of a variety of health conditions

including obesity, heart disease, diabetes, high blood pressur

and cholesterol. It is also recognized that regular exercise can

help to alleviate depression and anxiety and improve mental

health. Health promotion programs can help people develop

lifestyles or behaviors to maintain and enhance their well-bei

There is often an assumption that people with disabilities or

chronic poor health conditions cannot benefit from health

promotion or preventive practices. As a result preventive

screenings or other health promotion activities are often n

offered or accessible to people with disabilities. People with

disabilities need to have the same access and opportunities to

health promotion information and services as people without

disabilities. These four areas of health and wellness were

targeted because it is believed they can be impacted throug

activities of the ND Disability Health Project. They are also

areas being focused on in the Healthy ND state plan. Project

staff have developed collaborations with groups within the sta

health department that are addressing these issues.

Goal #1 

Improve health and wellness for

people with disabilities,

specifically in the targeted

areas of obesity, diabetes,

tobacco use, and mental health.

 

and without disabilities regarding the health conditions specifically targeted in this goal.

12

Strategies for all targeted areas

th and disability professionals regarding the

ilities,

te

e with disabilities. This may

r all people to recreation programs,

es to ensure disability issues

s

Strategies for Obesity

• Increase awareness among heal

importance of quality health and wellness opportunities for people with disab

accessibility, and/or prevention strategies. Distribute monthly fact sheets featuring

specific wellness topics and offering tips and guidelines to health care providers,

people with disabilities, schools, advocates, community service providers, and sta

and local agencies via electronic and postal mailings.

• Promote advertising venues that are accessible to peopl

include large print, adjusted reading levels, etc.

• Enhance statewide awareness regarding access fo

fitness centers, community health initiatives, and screening facilities by providing

information and/or technical assistance upon request.

• Collaborate with existing state committees or task forc

are addressed and included in state plans. Promote an understanding of what it mean

to really include people with disabilities to be active participants.

onstration projects in targeted communities to promote

robics

Do It! program. This

ing Well with a Disability or the Healthy Lifestyles curricula in a

Implement model dem•

preventive health and wellness activities. Include activities such as adaptive ae

and gamercize activities that include people with disabilities.

• Request funding for and, if approved, implement the ND I Can

program will match adult mentors, with or without disabilities, with youth who have

disabilities to teach the youth about making good nutritional choices and increasing

physical activity.

• Implement the Liv

targeted community to teach people with disabilities strategies for the best possible

lifestyle to promote good health and wellness.

13

0

5

10

15

20

25

Age 18-64 Age 65 or Older Total

Perc

enta

ge

Age

Diabetes among North Dakota adults with and without disabilities, by age group, BRFSS combined

years 2001-2006.

With Disabilities

Without Disabilities

0

10

20

30

40

50

With Disabilities Without Disabilities

Perc

enta

ge

Engagement in moderate physical activity among North Dakota adults with and without disabilities,

BRFSS combined years 2001-2006.

With Disabilities

Without Disabilities

Strategies for Diabetes

• Collaborate with the ND Diabetes Coalition to ensure people with disabilities are

included in diabetes prevention and treatment activities.

14

Strategies for Tobacco Use

• Collaborate with the Department of Health, Division of Tobacco Prevention and

Control to include people with disabilities in their strategic plan.

• Provide information regarding cessation programs for people with cognitive

disabilities, and other information, upon request.

0

5

10

15

20

Age 18-64 Age 65 or Older Total

Perc

enta

ge

Age

% of persons having 15-30 days of poor mental health in the past month, status among North Dakota adults with and without disabilities, by age group, BRFSS combined

years 2001-2006.

With DisabilitiesWithout Disabilities

0

5

10

15

20

25

30

35

With Disabilities Without Disabilities

Perc

enta

ge

Tobacco Use among North Dakota adults with and without disabilities, BRFSS combined years

2001-2006.

With Disabilities

Without Disabilities

Strategies for Mental Health

• Provide technical assistance and/or resources as requested from individuals or groups.

15

Strategies for other related areas:

• Provide people with disabilities information to make informed choices about their

health care.

• Promote specific health promotion information and activities and prevention topics

such as flu vaccinations, breast cancer screening, blood pressure and cholesterol

screenings, and nutritional awareness.

Rationale: Misconceptions and gaps in information lead to

insensitivity and poor quality of care. Some professionals, and

some people in the general public, are not aware of issues

important to people with disabilities, such as people first

language and general disability etiquette. There is also a lack of

understanding about how to adapt educational material and the

physical environment to accommodate various needs.

Provision of information and technical assistance will

help to bridge gaps surrounding disability issues for

professionals and others. Knowledge and understanding will be

enhanced and the quality of information and service provision

will be improved. Health service providers and ND communities

in general need to demonstrate awareness of disability issues and

disability etiquette through words and actions.

Progress toward this goal can be evaluated through input

from people with disabilities and their families via focus groups

and satisfaction surveys.

Goal #2 

ND citizens will have accurate

information on disability and health issues.

 

Strategies:

• Develop and implement a technical assistance request process that will provide state-

wide assistance to be provided to health service providers on-site or through the

provision of informational materials.

16

• Support the inclusion of disability and health related issues at workshops,

conferences, and through speakers at organized events.

• Promote public awareness using television, radio, and/or newspaper announcements

to convey personal stories and disseminate educational materials specific to health

and disability issues.

• Educate health care professionals via fact sheets and information booklets regarding

specific disability issues.

“Every human being is the author of his own health or disease.”

~ Hindu Prince Gautama Siddharta, the founder of Buddhism, 563-483 B.C.

• Utilize resource centers, such as the National Center on Physical Activity and

Disability, Amputee Coalition of America and the Christopher Reeve Paralysis

Resource Center, for resources on disability and health issues, and to assist them with

identifying peer visitors/trainers

for ND. Also utilize resources

among other Disability and

Health state grantees.

17

Goal #3 

ND citizens with

disabilities will

have improved

health care

through cross

system

communication,

planning, and

implementation

for health and

disability related

services.

 

Rationale: People with disabilities and their families often

struggle with finding, keeping, and effectively utilizing existing

services. The process of paperwork can be overwhelming and

confusing, resulting in the loss of services or disqualification from

other services. Assistance from a central person or agency to

oversee all individual and/or family services, and to act as a

referral source, would provide a continuum of services that would

benefit many people with disabilities and their families.

Many stories were told during focus groups and one-on-

one conversations with people who have disabilities and their

families. People expressed great discontent in being sent from one

person to another for assistance, sometimes getting incorrect or

incomplete information. Many people also do not know about

existing services unless they hear about them inadvertently.

People with disabilities and their families need to be aware of

available services that address their individual needs, and need to

be able to access those services without significant difficulty.

Subsequent information gathered through focus groups or surveys

will indicate changes in the perception of the coordination of

health care.

People with disabilities and their families often experience

a sense of displacement during periods of transition between

services (i.e. child moving from pediatric to adult health care

services). A change in services can also be detrimental financially

for those not familiar with requirements for eligibility of services.

For example, a family can be referred for a support service only

to find that after they apply and are approved, they have

inadvertently become ineligible for another service they were

receiving.

Many service entities in ND work in a compartmentalized

manner, but are willing to collaborate when approached by

18

another service provider. This collaboration is especially critical during periods of change for

people with disabilities and their families. Disability and health service providers need to

engage in intra-agency collaboration to provide comprehensive services to people with

disabilities and their families. Review of the strategic plan activities will indicate collaboration

between entities though cross-agency meetings, facilitation of information exchange, and

provision of technical assistance.

Strategies:

• Provide referral assistance through the Technical Assistance request process.

• Support the efforts of state agencies to achieve a medical home model of care in ND.

• Disseminate information on the availability of services and resources within the state

as requested.

• Promote familiarity and networking between disability and health providers through

participation in state-wide conferences, community health fairs, and other venues.

• Facilitate collaboration between disability and health entities by partnering with

existing state or local committees such as the Office for the Elimination of Health

Disparities, Flu work group, Physical Activity and Healthy Eating committee,

Division of Tobacco Prevention and Control, the ND Diabetes Coalition, and others

as appropriate to ensure disability and health related issues are addressed through

joint efforts and included in applicable state plans.

• Request funding for and, if approved, implement the ND I Can Do It! program.

Through this program, provide leadership for cross collaboration with faculty and

students from various departments/programs at Minot State University including

teacher education, special education, physical education, the MSU campus fitness

center, as well as students and special education directors and teachers from the

Minot Public Schools system.

• Document the need for Health Care Benefits Planners/Coordinators throughout the

state to assist families in

planning for services. Unity is strength... when there is

teamwork and collaboration, wonderful things can be achieved.

~Mattie Stepanek

19

Monitor and update the plan To accomplish the goals of the strategic plan, the ND Disability Health Project will

closely monitor progress, activity, and feedback from people with disabilities, their families, and

disability and health service providers. The structure of the plan allows for continuous

evaluation, reporting, and assessment to determine if modifications are needed. An Executive

Management team has been formed to review progress, identify barriers, and delineate solutions

on a monthly basis. In addition, the Advisory Council will convene quarterly to review progress

and make recommendations as necessary. Collaboration with other grantee states will be

beneficial to exchange ideas and share information between states; conference calls and annual

grantee conferences will provide opportunities to network with other states who have disability

health plans. A project evaluator will monitor activity, meeting with key project staff quarterly,

and will prepare annual reports. Data analysis will be updated on an annual basis to ensure

critical issues are being addressed as identified by constituents within the state.

Stakeholder involvement and collaborations with other state entities are critical to the

success of the strategic plan. The ND Disability Health Project will continue to collaborate with

key partners, build new partnerships, and maintain an active Advisory Council to receive input

and recommendations on activities and new ventures.

20

21

References

Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved 2/6/08 from www.cshcndata.org Fassinger, P. (2007). 2007 Overview of children’s well-being in North Dakota; Our children, our state. North Dakota Kids Count: North Dakota State University. Muus, Kyle. (2008). Health-related attributes of North Dakota adults with disabilities: Analysis

of 2001-2006 BRFSS data. Grand Forks, North Dakota: Center for Rural Health, University of North Dakota.

U.S. Census Bureau. (2008). State and County Quick Facts. Retrieved February 28, 2008 from http://quickfacts.census.gov/qfd/states/38000.html.

U.S. Department of Health and Human Services. The Surgeon General’s Call To Action To Improve the Health and Wellness of Persons with Disabilities. US Department of Health and Human Services, Office of the Surgeon General, 2005.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2008). The national survey of children with special health care needs chartbook 2005–2006. Rockville, Maryland: U.S. Department of Health and Human Services. Western Interstate Commission for Higher Education. (2007). The behavioral health workforce in North Dakota: A status report. ND Mental health Program: Division of Mental Health and Substance Abuse Services.

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