Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil,...

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Richland County Richland County Community Diabetes Community Diabetes Project Project Richland County, Montana Presented by: Tanya Rudicil, Program Director

Transcript of Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil,...

Page 1: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Richland County Richland County Community Diabetes Community Diabetes

ProjectProject

Richland County, Montana

Presented by: Tanya Rudicil, Program Director

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Eastern Montana

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Richland County, MontanaRichland County, Montana

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Community ProfileCommunity Profile Frontier, aging community on the Frontier, aging community on the

border between North Dakota & border between North Dakota & MontanaMontana

Sidney, Fairview, Savage, Lambert, Sidney, Fairview, Savage, Lambert, CraneCrane

Population: 9,155 (4.6 persons per sq. Population: 9,155 (4.6 persons per sq. mile)mile)

Farming (beets), ranching, oil, small Farming (beets), ranching, oil, small businessbusiness

1/3 older adults1/3 older adults Median household income (1999) is 32KMedian household income (1999) is 32K

Page 5: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Climate & locationClimate & location

Cold winters, hot & humid summersCold winters, hot & humid summers 250+ miles to nearest major hospital 250+ miles to nearest major hospital

& specialists& specialists

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CultureCulture

Scandinavian, German homesteaders, ranchersScandinavian, German homesteaders, ranchers Seasonal migrant farmworkers (Hispanic, Native Seasonal migrant farmworkers (Hispanic, Native

American)American) Near 2 Native American Reservations, one Indian Near 2 Native American Reservations, one Indian

Service areaService area Small percentage Native American, Hispanic, Small percentage Native American, Hispanic,

Black American, Asian.Black American, Asian. Hardy, independent, stoic, resistant to change, Hardy, independent, stoic, resistant to change,

wary of outsiders, private, loyal to neighbors and wary of outsiders, private, loyal to neighbors and friends. Resistance to change and territoriality friends. Resistance to change and territoriality Spills over into health care environment as well.Spills over into health care environment as well.

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Richland Health NetworkRichland Health NetworkFormal Partners since 1999, to meet the health and social needs of an aging community.

•Richland County Commission On Aging

•Richland County Health Department

•Sidney Health Center

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PartnersPartners

Richland County Public HealthRichland County Public Health

17+ employees, everything from 17+ employees, everything from breastfeeding coalitions to RSVP.breastfeeding coalitions to RSVP.

Richland Co. Commission on AgingRichland Co. Commission on Aging

Older adult programsOlder adult programs

Sidney Health CenterSidney Health Center

Hospital, Clinic, Extended Care, Assisted Hospital, Clinic, Extended Care, Assisted Living, Fitness Center, Pharmacy Living, Fitness Center, Pharmacy

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CollaborationCollaboration Richland County Nutrition Richland County Nutrition

CoalitionCoalition Sidney Health Center Sidney Health Center

Community Health Community Health Improvement CommitteeImprovement Committee

Parish NursingParish Nursing RSVPRSVP Literacy Volunteers of AmericaLiteracy Volunteers of America LIONS ClubLIONS Club American Diabetes Association American Diabetes Association

– Montana– Montana Montana Migrant Council (on Montana Migrant Council (on

Advisory Board)Advisory Board) McCone County Senior CenterMcCone County Senior Center Montana Diabetes ProjectMontana Diabetes Project Sidney Public LibrarySidney Public Library Eastern Montana Mental HealthEastern Montana Mental Health MediaMedia And more…And more…

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From case management to From case management to diabetes…diabetes…

Large number of case management clients Large number of case management clients had diabetes or other chronic illnesshad diabetes or other chronic illness

Lack of supports for chronic illness Lack of supports for chronic illness management in the countymanagement in the county

Estimated 457 are diagnosed with Estimated 457 are diagnosed with diabetes or metabolic syndromediabetes or metabolic syndrome

In 2002 18% of patients at Sidney Health In 2002 18% of patients at Sidney Health Center (18+) were hospitalized with a Center (18+) were hospitalized with a diagnosis of Diabetesdiagnosis of Diabetes

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Building Community Supports Building Community Supports for Diabetes Self Management for Diabetes Self Management

GrantGrant The Robert Wood Johnson FoundationThe Robert Wood Johnson Foundation NPO: Washington University, St. LouisNPO: Washington University, St. Louis 1 year pilot 1 year pilot Additional funding awarded for 2 ½ Additional funding awarded for 2 ½

years for implementationyears for implementation Staff: Director, Program Specialist, Staff: Director, Program Specialist,

Administrative Assistant, Nursing Administrative Assistant, Nursing SupervisorSupervisor

Consultants: M.D., R.D., C.D.E.Consultants: M.D., R.D., C.D.E.

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Resources and Supports for Resources and Supports for Self Management (RSSM)Self Management (RSSM)

Individualized assessment (w/ attention to Individualized assessment (w/ attention to cultural and social factors)cultural and social factors)

Collaborative Goal SettingCollaborative Goal Setting Instruction in key skillsInstruction in key skills Ongoing follow-up and support (family, Ongoing follow-up and support (family,

friends, lay health workers, health care friends, lay health workers, health care providers, etc)providers, etc)

Access to Resources (for healthy diet and Access to Resources (for healthy diet and physical activity)physical activity)

Linkages /coordination (among pertinent Linkages /coordination (among pertinent community organizations and services)community organizations and services)

Access to high quality clinical careAccess to high quality clinical care

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Year OneYear One

Developed an 18 member Advisory Developed an 18 member Advisory Board (health care providers, Board (health care providers, pharmacy, Parish Nurses, diabetics, pharmacy, Parish Nurses, diabetics, business persons, LIONS club, Nurses, business persons, LIONS club, Nurses, CDE, aging services staff, etc.)CDE, aging services staff, etc.)

Conducted community focus groupsConducted community focus groups Piloted 4 community based Projects, in Piloted 4 community based Projects, in

additional to other activities over 4 additional to other activities over 4 monthsmonths

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Focus Group resultsFocus Group results CommunityCommunity

57 attended57 attended Accountability, low cost exercise opps, Accountability, low cost exercise opps,

support group, education other than support group, education other than brochures, info on what to eat, formal brochures, info on what to eat, formal comprehensive education programcomprehensive education program

Health Care ProvidersHealth Care Providers 11 attended11 attended Support group helpful, education is already Support group helpful, education is already

provided (most felt) but additional education provided (most felt) but additional education would be helpfulwould be helpful

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Walking ClubWalking Club

Arranged free indoor walking at Arranged free indoor walking at schools & a church.schools & a church.

Free pedometers, tracking formFree pedometers, tracking form 42 participants42 participants Continued in Phase 2Continued in Phase 2

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Diabetes WatchersDiabetes Watchers

Weighed in once weekly at officeWeighed in once weekly at office Goal setting formsGoal setting forms Information on safe weight loss, Information on safe weight loss,

recipesrecipes 20 participants20 participants Continued in Phase 2Continued in Phase 2

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Diabetes Education &Diabetes Education &Support GroupSupport Group

Monthly meetingsMonthly meetings Health care providers, other Health care providers, other

professionals speak on a variety of professionals speak on a variety of topicstopics

Lunch meetings added – potlucks Lunch meetings added – potlucks and recipe swapsand recipe swaps

35 participants35 participants

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Diabetes ResourcesDiabetes Resources

CDE reviewed educational CDE reviewed educational materials at Public Librarymaterials at Public Library

Ordered new books, videos, Ordered new books, videos, cookbooks for Library and for cookbooks for Library and for health care providershealth care providers

Developed a Local Diabetes Developed a Local Diabetes Resources & Prevention GuideResources & Prevention Guide

17 participants 17 participants Discontinued as a main project, Discontinued as a main project,

but kept as an activitybut kept as an activity

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Other activitiesOther activities

Bike & Trike Ride for DiabetesBike & Trike Ride for Diabetes Diabetes ConferenceDiabetes Conference American Diabetes WalkAmerican Diabetes Walk Tasty Fork – (Richland County Nutrition Tasty Fork – (Richland County Nutrition

Coalition)Coalition) 6 local restaurants offered dietitian approved 6 local restaurants offered dietitian approved

healthy entrees on their menus for one month. healthy entrees on their menus for one month. Items were judged for taste and appearance by Items were judged for taste and appearance by the community. The winner received a “Tasty the community. The winner received a “Tasty Fork” inscribed glass plate to display at their Fork” inscribed glass plate to display at their business. Six of the 7 restaurants kept the business. Six of the 7 restaurants kept the “Tasty Fork” item on their menu.“Tasty Fork” item on their menu.

Page 20: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

EvaluationEvaluation

-Pre/post participation survey-Pre/post participation survey

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Diabetes Project Participation QuestionnaireDiabetes Project Participation QuestionnaireAll of this information will be kept All of this information will be kept CONFIDENTIALCONFIDENTIAL..PID#_______________ (office use only)PID#_______________ (office use only)Name_________________________________________Name_________________________________________ DOB___________ Sex: M FDOB___________ Sex: M FAddress_______________________________________Address_______________________________________ City______________ State____ Zip______City______________ State____ Zip______Phone(s)__________________________ Best time to call? M T W TH F Phone(s)__________________________ Best time to call? M T W TH F AMAM PM PM

Evening EveningE-mail______________________________________________E-mail______________________________________________Insurance Provider____________________________________Insurance Provider____________________________________Primary Health Care Primary Health Care

Provider___________________________________________________________Provider___________________________________________________________For how long? ____________________________________For how long? ____________________________________Emergency contact person_____________________________Phone(s) Emergency contact person_____________________________Phone(s)

____________________________________________________Education Level: Elementary Education Level: Elementary High SchoolHigh School Bachelor’s Bachelor’s Master’s Master’s

Doctorate Doctorate Race: CaucasianRace: Caucasian HispanicHispanic Native AmericanNative American LatinoLatino SpanishSpanishWhen were you diagnosed with Diabetes? ____________________________________________When were you diagnosed with Diabetes? ____________________________________________Has a doctor ever told you that you have high cholesterol? Has a doctor ever told you that you have high cholesterol? YES YES NO NOHas a doctor ever told you that you have high blood pressure?Has a doctor ever told you that you have high blood pressure? YESYES NONOAre you a smoker?Are you a smoker? YESYES NONOHeight__________Height__________Weight__________ Date_______Weight__________ Date_______ Weight__________Weight__________ Date________Date________Blood Pressure__________ Date______Blood Pressure__________ Date______ Blood Pressure___________ Blood Pressure___________

Date_________Date_________Fat %/BMI___________ Date_______Fat %/BMI___________ Date_______ Fat %/BMI______________ Date_________Fat %/BMI______________ Date_________

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Please Please circlecircle the correct answer. the correct answer.1. I am diabetic.1. I am diabetic. YESYES NONO Type?Type? 11 222. If not diabetic: I am family/friend to a diabetic.2. If not diabetic: I am family/friend to a diabetic. YESYES NONO3. I am employed.3. I am employed. YESYES NONO RETIREDRETIRED4. I have had my clinical foot examination within the past year.4. I have had my clinical foot examination within the past year.YESYES NONO5. I have had an eye exam within the past year.5. I have had an eye exam within the past year. YESYES NONO6. I have been tested for microalbuminuria (urine) test within the past year. YES6. I have been tested for microalbuminuria (urine) test within the past year. YES NO NO7. I have received my flu shot within the past year.7. I have received my flu shot within the past year. YESYES NONO8. I have received a pneumonia shot.8. I have received a pneumonia shot. YESYES NONO9. I receive my HbA1C (average blood sugar) test regularly.9. I receive my HbA1C (average blood sugar) test regularly. YESYES NONO10. I have NOT received the above tests because TOO EXPENSIVE10. I have NOT received the above tests because TOO EXPENSIVE NO INSURANCE NO INSURANCE

I’M NOT DIABETICI’M NOT DIABETIC OTHER____________OTHER____________

11. My 11. My mainmain support is from DOCTOR support is from DOCTOR FAMILY FRIENDS OTHER______________ FAMILY FRIENDS OTHER______________12. Number of work days missed in the last year because of diabetes. 0 1-10 12. Number of work days missed in the last year because of diabetes. 0 1-10 11-25 11-25

26+ 26+13. I perceive my health status as13. I perceive my health status as EXCELLENTEXCELLENT GOODGOOD

FAIRFAIR POORPOOR14. Would you be willing to share your health test (i.e. HbA1c) scores with us? YES 14. Would you be willing to share your health test (i.e. HbA1c) scores with us? YES

NO NOIf YES, please sign form. Thank you.If YES, please sign form. Thank you.

15. I feel my knowledge on diabetes is15. I feel my knowledge on diabetes is EXCELLENTEXCELLENT GOOD GOOD FAIR FAIR POORPOOR16. I exercise16. I exercise 1-3X/WEEK1-3X/WEEK 4-7X/WEEK4-7X/WEEK NONENONE17. How did you hear about our projects? RADIO 17. How did you hear about our projects? RADIO NEWSPAPER NEWSPAPER MAILING T.V MAILING T.V DOCTORDOCTOR FRIEND/FAMILY FRIEND/FAMILY OTHER_________ OTHER_________

PROJECTS PARTICIPATING IN:PROJECTS PARTICIPATING IN:____DIABETES WALKING CLUB____DIABETES WALKING CLUB _____DIABETES WATCHERS _____DIABETES WATCHERS ____DIABETES EDUCATION GROUP____DIABETES EDUCATION GROUP _____DIABETES EDUCATION CENTER_____DIABETES EDUCATION CENTER____ OTHER ACTIVITIES ___________________________________________________________ OTHER ACTIVITIES _______________________________________________________

Page 23: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Evaluation continued…Evaluation continued… Pre/post participation surveyPre/post participation survey

Improvements noted in self reported knowledge of Improvements noted in self reported knowledge of diabetes, perceived health status, clinical foot diabetes, perceived health status, clinical foot exams, regularity of A1c testes, pneumonia exams, regularity of A1c testes, pneumonia vaccinations, > days per week of exercise, < days vaccinations, > days per week of exercise, < days of work missed due to diabetes and of work missed due to diabetes and microalbuminuria tests. microalbuminuria tests.

Hemoglobin A1c’s (consent from hospital lab)Hemoglobin A1c’s (consent from hospital lab) 4 participants lowered A1c’s during the 4 months4 participants lowered A1c’s during the 4 months

Weight loss records – nearly 50 pounds lostWeight loss records – nearly 50 pounds lost

Page 24: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Phase 2 Phase 2 (May ’04 to Oct. ’06)(May ’04 to Oct. ’06)

Diabetes Watchers, Walking Club, Diabetes Watchers, Walking Club, Education & Support group continued Education & Support group continued with improvements.with improvements.

Additional activities added or begun.Additional activities added or begun.

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Participant Pre-Participation Questionnaire and activity sign up. Information on available programs, forms given. If participant chooses walking as an activity, free pedometer and instruction on use given. Goal setting conducted. If goal setting does not occur at sign-up, appointment made for goal-setting session to occur in no more than one week by phone or in person. Goal sheet sent to health care provider with permission.

1 week or less after sign up –Participant contacted to turn in baseline steps (if walking) and to set goals. Goal sheet sent to health care provider with permission, if not already sent.

One Month after sign-upParticipant contacted to review/modify goals. Updated goals sent to health care provider (with permission)

2 months after sign up and every 2 months thereafter-Participant contacted to check progress, review/modify goals. Updated goals sent to health care provider.

Incentives given.

Participant data

entered into

database

Project Flow Chart –

•Walkers•Watchers•Education Group

Page 26: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

ImprovementsImprovements

Adding social activitiesAdding social activities Varying topics, adding physical Varying topics, adding physical

activity into education group activity into education group meetingsmeetings

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Other ActivitiesOther Activities

What physical activity means for men in Eastern Montana…..

Page 28: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Chronic Disease Chronic Disease Self–Management ClassSelf–Management Class

Stanford University (Kate Lorig, RN, Stanford University (Kate Lorig, RN, DrPH, Virginia Gonzalez, MPH, Diana DrPH, Virginia Gonzalez, MPH, Diana Laurent, MPH)Laurent, MPH)

6-week class -led by one health care 6-week class -led by one health care professional and a lay person with a professional and a lay person with a chronic diseasechronic disease

http://http://patienteducation.stanford.edu/patienteducation.stanford.edu/programs/cdsmp.htmlprograms/cdsmp.html

Page 29: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Diabetes Education CenterDiabetes Education Center

Coordinating the DEC, seeking ADA Coordinating the DEC, seeking ADA recognition.recognition.

Office located at Sidney Health Office located at Sidney Health CenterCenter

Instructional staff: R.D., R.N., Instructional staff: R.D., R.N., employees of hospitalemployees of hospital

Program Coordinator is also the Program Coordinator is also the Program Specialist for the Community Program Specialist for the Community Diabetes Project, employed by both Diabetes Project, employed by both hospital & health departmenthospital & health department

Page 30: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

DEC continued…DEC continued…

Patients referred to the DEC are also Patients referred to the DEC are also referred to Community Projects & referred to Community Projects & vice versavice versa

Data shared between projectsData shared between projects DEC using Diabetes Quality Care DEC using Diabetes Quality Care

Monitoring Database System used by Monitoring Database System used by the state.the state.

Page 31: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Diabetes AmbassadorsDiabetes Ambassadors

Modeled after promotora, lay health Modeled after promotora, lay health worker model.worker model.

Non-stipened -volunteers (through RSVP & Non-stipened -volunteers (through RSVP & Citizen Corps)Citizen Corps)

Provided with training by a CDEProvided with training by a CDE Level 1 – provide social support and a Level 1 – provide social support and a

listening ear, non-medical advicelistening ear, non-medical advice Level 2 – conduct Chronic Disease Self Level 2 – conduct Chronic Disease Self

management class, assist with education management class, assist with education group and activities.group and activities.

Page 32: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Community Walking PromotionCommunity Walking Promotion

Partnered with Montana State Partnered with Montana State University Extension Service, University Extension Service, local office, and North Dakota local office, and North Dakota Extension ServiceExtension Service

1 - 9-week walking promotion, 1 - 9-week walking promotion, 1 8-week walking promotion1 8-week walking promotion

Turned in steps on line or by Turned in steps on line or by mailmail

Incentives to participateIncentives to participate http://www.walknd.comhttp://www.walknd.com

Page 33: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Workplace WellnessWorkplace Wellness

Piloted walking promotion at Health Piloted walking promotion at Health DepartmentDepartment

Gathering assessments & ideasGathering assessments & ideas Evaluate workplaces & encourage Evaluate workplaces & encourage

policy change ie,policy change ie, Adequate breaksAdequate breaks Encourage physical activityEncourage physical activity Encourage healthy snacksEncourage healthy snacks

Page 34: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Health LiteracyHealth Literacy

Collaboration between Literacy Volunteers Collaboration between Literacy Volunteers of America Representative, hospital quality of America Representative, hospital quality assurance representative, and RCCDP.assurance representative, and RCCDP.

Conducted 2 trainings, one for health care Conducted 2 trainings, one for health care providers and one for office staff, nurses, providers and one for office staff, nurses, and social workers.and social workers.

One day after the training a referral made One day after the training a referral made to literacy program for a diabetic whose to literacy program for a diabetic whose first language is Spanish and can’t read or first language is Spanish and can’t read or write either Spanish or English.write either Spanish or English.

Page 35: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Motivational Interviewing Motivational Interviewing trainingtraining

Organized a 2-day Organized a 2-day workshop on MI in workshop on MI in conjunction with conjunction with Montana Gerontology Montana Gerontology Society MeetingSociety Meeting

Attended by Attended by approximately 50 approximately 50 professionalsprofessionals

Separate lunch mini-Separate lunch mini-training held for health training held for health care providerscare providers

Arranged for follow-up Arranged for follow-up via Telemedicinevia Telemedicine

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InsuranceInsurance

Planning an “Insurance Summit”, to Planning an “Insurance Summit”, to encourage insurance providers to encourage insurance providers to provide discounts or incentives for provide discounts or incentives for people engaged in programs for people engaged in programs for chronic disease self-management.chronic disease self-management.

Page 37: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Tasty Fork/Tasty BitesTasty Fork/Tasty Bites

This year’s Nutrition Coalition project:This year’s Nutrition Coalition project: To expand the contest to include side To expand the contest to include side

dishes, dressings, etc.dishes, dressings, etc.

Page 38: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Exploring linkagesExploring linkages

Trenton Indian Service AreaTrenton Indian Service Area Montana Migrant CouncilMontana Migrant Council ??

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Resources/TrainingResources/Training

Nutrition analysis software for restaurants, Nutrition analysis software for restaurants, public to use in analyzing their public to use in analyzing their menus/favorite recipesmenus/favorite recipes

Organizing meetings and trainings related Organizing meetings and trainings related to diabetes care as well as informing local to diabetes care as well as informing local providers and staff of educational providers and staff of educational opportunitiesopportunities

Building a Diabetes Resource Library at Building a Diabetes Resource Library at Sidney Health CenterSidney Health Center

Page 40: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

EvaluationEvaluation

Pre/post participation surveysPre/post participation surveys A1c’s & Lipid Panels A1c’s & Lipid Panels Program database (designed by RTI) Program database (designed by RTI)

and DQCMS (from state) for Diabetes and DQCMS (from state) for Diabetes Ed. CenterEd. Center

RTI Research Triangle – site RTI Research Triangle – site evaluation & cross site evaluationevaluation & cross site evaluation

Page 41: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Shining StarShining Star

Participant A:Participant A: Joined Walking Club, Education group, Joined Walking Club, Education group,

and Watchersand Watchers Lost 37 lbs in 5 months, < A1cLost 37 lbs in 5 months, < A1c Won 2Won 2ndnd place in local Walk for Diabetes place in local Walk for Diabetes ““I just didn’t know I was so sick until I I just didn’t know I was so sick until I

was well. Diabetes has changed my life was well. Diabetes has changed my life completely.”completely.”

Page 42: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

SustainabilitySustainability

To expand these programs to other To expand these programs to other chronic diseaseschronic diseases

Community ownershipCommunity ownership ADA program – limited fundsADA program – limited funds Medical community support – Medical community support –

collaboration (ie, ADA progam)collaboration (ie, ADA progam) VISTA Project – will have one VISTA VISTA Project – will have one VISTA

assigned to Chronic Disease Teamassigned to Chronic Disease Team

Page 43: Richland County Community Diabetes Project Richland County, Montana Presented by: Tanya Rudicil, Program Director.

Web sitesWeb sites

DIABETES INITIATIVE:DIABETES INITIATIVE: http://diabetesnpo.im.wustl.edu/http://diabetesnpo.im.wustl.edu/

RICHLAND HEALTH NETWORK: (being RICHLAND HEALTH NETWORK: (being updated):updated): WWW.richland.org/rhnWWW.richland.org/rhn

WASHINGTON STATE DEPARTMENT OF WASHINGTON STATE DEPARTMENT OF HEALTH:HEALTH: http://www.doh.wa.gov/cfh/wsc/Model_Info/Selfhttp://www.doh.wa.gov/cfh/wsc/Model_Info/Self

_Management_Support/SMSpage1.htm_Management_Support/SMSpage1.htm