Telepartners in Early Diagnosis and Intervention for Children with Disabilities in Remote Communities

(Grant #H324R980113)

EXECUTIVE SUMMARY

Part I. PROJECT SUMMARY
Rural families must travel long distances to find specialty care for diagnosis and treatment of children with disabilities. Financial and sociocultural barriers often prevent them from seeking care. Even if the children are lucky enough to find the right specialists, written reports to the Local Education Agency (LEA) recommending educational interventions are frequently unclear or unworkable in the local community where services and specialty training are lacking. The expense of travel is a barrier as it reduces access to follow-up service. Additionally, time-stressed local service providers and primary care health practitioners have little opportunity for interactive consultation with appropriate distant experts about low-incidence disorders affecting educational programming and often don't have the time or the readily-available e-mail technology to consult with each other across town. The overriding problem then remains one of bringing together all the relevant agencies to produce a coordinated individualized education plan (IEP).

In the three years of OSEP funding (1998 - 2001) for this project, we initially applied the proven model of outreach from the University of Washington to seven remote rural communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) to provide needed services for children with disabilities. We used the existing WWAMI Rural Telemedicine Network for early identification and ongoing consultation via interactive video teleconferencing (IVTC). The project then expanded to additional communities, the availability of specialty consultation for children birth to 21 years, with emphasis on those aged 3-12 for whom the LEA needs advice about medical conditions affecting educational progress. The use of IVTC had enabled more school and community representatives to consult directly with distant specialists rather than requiring the child (and family) to travel to a distant center for diagnosis and intervention recommendations.

A significant feature event occurring during the final year of the Telepartners project was the completion of the K-20 network in Washington State. This state-funded project provided broad bandwidth T-1 connections and videoconferencing equipment to every school district in the state. Telepartners' staff was able to assist school districts in learning how to use their new equipment and the capabilities of the K-20 network. Consultation requests to our project increased as school district personnel became comfortable with using this technology.

In summary, we conducted 27 case consultations in year one, 26 in year two and 16 in the first 9 months of year three. Three full day in-service sessions via videoconferencing for school districts, following up on case consultations, were also conducted.

Part II. PROJECT STATUS
At the conclusion of the Teleprinters' Grant, referrals were transitioned to two new programs that are going to absorb the Teleprinters' client volumes. The University of Washington's Telehealth Program is currently establishing a new technical network in Western Washington and re-developing their program to accommodate new services from a 1.2 million dollar Q-West settlement that is under currently under final negotiation. In addition, Seattle Children's Hospital has received funding from the Office for Advancement for Telehealth to establish the Children's Health Access Regional Telehealth Network (CHART). The CHART Program uses videoconferencing technology and associated peripheral devices to offer assessment, consultation and disease management services for children in sites in Washington and Alaska. Services include behavioral health, among other specialties. Dr. Steve Sulzbacher, co-principal investigator for the Teleprinters' grant, is one of the clinicians contracting with the CHART program for behavioral health consultations.

Objective #2: Direct Consultations

Site Visits
In the final year, the Teleprinters' network was mostly established, alleviating travel time for Teleprinters' staff. Dr. Sulzbacher, Principal Investigator, incorporated site visits into his outreach clinical duties in rural communities.

Partnership development
The network of schools and other agencies included a total of nineteen agencies from Washington, Wyoming, Alaska, Montana and Idaho. Although the majority of partners were school districts, several public health departments and county hospitals participated as well. A complete list of our telepartners is outlined in Table 1.

System Use
Appendix A is a usage log developed to track the various activities of the program including who is using the system. Each activity is coded with a number. The log helps track how often a Telepartners consultant has consulted with a remote educator or health care provider. For example, on November 16, 1998, Dr. Mark Tuccillo of Petersburg, Alaska consulted with Dr. Sulzbacher regarding two children with special health care needs who were having trouble in school. Another example is December 11th when Rande Gray, our technical director, did system testing with the CELL Center in Aberdeen, Washington because they were interested in joining the Telepartners team.

Virtual Office Hours
Dr. Sulzbacher was available for school and mental health consultations each Monday, via videoconference for professional consultation.

Project staff management committee meetings
While not regularly scheduled, meetings between Teleprinters' staff occurred have occurred on a bi-monthly or weekly basis. With the department's successful transfer of the project from the Family Medicine Department to the School of Medicine's Department of Psychiatry and Behavioral Sciences and with some staffing changes, meetings were held more frequently to effectively transfer positions and maintain the project goals without a lapse in services to communities.

Objective #2: Direct Student Consultations

Consultation statistics
The Teleprinters' project ran from October 1, 1998 until September 1, 2001. As noted in the original project application, the goal of the project was to extend the successful consultation and inservice training model previously developed in the University of Washington's WWAMI program to LEA. Table 2 summarizes consultation statistics by specialty conducted through the WWAMI program during the Teleprinters' project time (total N = 67). A goal of the project was to seamlessly integrate Telepartners with the existing WWAMI programs to provide true community based services for children with special health needs. Thus the table below summarizes all the activities of our program during our time period. It is worth noting that of the 67 consultations conducted during this period, 57 were done by the principal of the project, Dr. Sulzbacher.

Table 2: Consultations by Specialty

Specialty	Number
Mental Health	67
ADHD	21
Behavioral/Psychiatric Diagnosis	7
Autistic Spectrum Disorders	20
Learning Disorders	5
Seizure Disorders	2
Tourette's Syndrome	1
Mental Retardation	4
Conduct Disorder	3
Cerebral Palsy	1
Down Syndrome	2
Fetal Alcohol Syndrome	1
Total	67

Objective #3: Inservice Continuing Education via IVTC

As we gained experience with case-specific consults via IVTC, we were able to respond to requests from various agencies for inservice sessions about Children with Special Healthcare Needs and also about the IVTC process. In the spring of 2000, a series of classes were conducted for high school students with special needs at Bainbridge High School's Commodore Center. Students received high school credit for attending these seminars on health and technology. The class also made an on-site visit to the University of Washington campus.

Faculty from the Autism Center at UW conducted an all-day multi-site IVTC inservice for several Washington school districts about the latest educational methods for treating autistic spectrum disorders. In spring, 2001, we conducted an all-day IVTC Seminar for the Kennewick School District on the topics of brain injury and seizure disorders. In July 2001, Teleprinters' staff participated in a national teleconference about recent developments in videoconferencing for special needs children in rural communities. Also in July 2001, a graduate seminar was held via IVTC for students at the University of South Dakota, on the topic of technology in psychology and special education.

Objective #4: Dissemination

Teleprinters' dissemination materials (brochures) that were produced in years one and two continued to serve our marketing needs in year three. In addition, the Deputy Director for the WWAMI Research Center began to compile all of the survey instrument data for evaluation purposes. Dr. Sulzbacher presented some of the information gathered from -the Teleprinters' Grant at the American Telemedicine Association's annual conference and the Florida Conference on Child Health Psychology's annual conference.

CD ROM Development
A CD ROM entitled "An Introductory Guide to Videoconferencing for Children with Special Health Needs" was completed in the final year of the grant.

The CD ROM offers a comprehensive overview of telehealth components including:

• Overview of the WWAMI Program at the University of Washington
• Types of video consultations and how to conduct them
• Technical background
• Information to get started including appropriate documents addressing confidentiality and consent
• Information to set up an inservice
• Resources to other Telehealth Programs

The CD ROM and will be widely distributed on request to administrators, teachers, clinicians or parents who may have a potential use for videoconferencing in their community.

A manuscript summarizing the clinical findings of our project has been submitted to The Journal of Special Education Technology.

Regional and national meetings

Leadership advisory committee meeting
The Teleprinters' grant was transferred from the Family Medicine Department to the Department of Psychiatry and Behavioral Sciences in the final year. The transition brought a host of possibilities for continuing services for behavioral health and psychiatry for children in rural communities after the grant has expired. In December, a leadership advisory committee meeting was held to discuss current goals as well potential growth for the Teleprinters' Project. The minutes from the meeting are included in Appendix B.

Present at the meeting were the University of Washington constituents along with representatives from the CHART Program at Seattle Children's Hospital.

Community advisory committee meeting
The community advisory committee was established in year one to promote Telepartner Activities from with in their communities. The committee is comprised of parents and political advocates for special education needs for youth and public health community representatives. A copy of the final report will be sent to all members on the community advisory committee.

Part III. BUDGET INFORMATION

Staff Changes
Sarah Dyck left the University of Washington in September, 2001. Jennifer Mas was hired as Research Coordinator and she and Roxanne Morganthaler, Manager of Clinical Services in the Department of Psychiatry continued Sarah's overall management of the progress of the Teleprinters' Grant in December, 2001. Copies of their resumes are included as Appendix C.

A change in CO-principal investigators occurred in September 2001. Dr. Eric Trupin, Director of the Public Behavioral Health and Justice Policy Division within the Department of Psychiatry at the University of Washington replaced Dr. Tom Norris, former CO-principal investigator. Dr. Trupin's curriculum vitae is included as Appendix D. Accompanying the change in Principal Investigators came a change in departments. The grant was transferred from the Department of Family Medicine to the Department of Psychiatry and Behavioral Sciences.

Peter House, Project Director, left the Teleprinters' Grant and Eric Trupin assumed project director responsibilities.

Part IV. EVALUATION
In the final year of the grant, several evaluation tools were used to evaluate the program. The first includes a research instrument developed by the WWAMI Research Center that for the Teleprinters' Project, Bench-to-Bedside, and the Rural Outreach Telehealth Grants. Combined, a total of 776 consults occurred. The survey instruments evaluated the telemedicine encounter from three different perspectives. The patient, provider and consultant were all surveyed. Information gathered from the surveys is currently being compiled and will be submitted for publication.

A copy of the three surveys is attached as Appendix E.

In addition, a phone survey was developed (see Appendix F) specifically to evaluate the Teleprinters' project in collaboration with the WWAMI Research Center. The survey was given to Telepartner participants in the WWAMI Region.

The majority of respondents were Somewhat to Very Satisfied with their overall telemedicine encounter and felt that videoconferencing is an effective technology for working with children with behavioral health needs. The overall consensus was that telemedicine Significantly Impacts or Could Impact isolated rural communities lacking access to specialty care. In addition one respondent felt that the technology also afforded the University of Washington the opportunity to follow-up with patients who missed their appointments in Seattle or who opted to receive follow-up care without leaving their community.

Of the 67 consults performed under the Teleprinters' Grant, roughly 30% of patients were diagnosed in the Autistic Spectrum Disorder category. One respondent indicated that their agency would not be able to meet the needs of their community without the Teleprinters' service as there is no autistic specialist within 100 miles and all consult were with autistic children.

All respondents felt that the technology, although impressive, needs to be improved. In some locations, there was a delay making it difficult to talk with the consultant. Also noted was the unreliability of ISDN lines. One respondent is looking towards a standardized wireless IP system.

According to one respondent, "telemedicine is the way of the future and that it will be a 'primary driver for rural communities'."

Attachment B
Minutes from the Telepartners Planning Meeting

Telepartners in Early Diagnosis & Intervention
for Children with Disabilities in Remote Communities
Retreat Meeting
12/21/00 Minutes

Present: Peter House, Steve Sulzbacher, Jennifer Annable, Eric Trupin, Cathy Xu, Sandy Melzer, Rande Gray, Jeff McLaughlin, David Shurtleff, Roxanne Morganthaler

Absent: Sherry Fuller, Allen Glenn, Peter Tarczy-Hornoch, Ron Lemire, Jennifer Mas, Gary Hart, Eric Larson, Nuhad Dinno, Don Hanson, Scott Mah, Dave Masuda, Tom Norris, Bill Winn

• The grant will be transferred from the Department of Family Medicine to the Department of Psychiatry and Behavioral Sciences. This fits with the planned expansion of the Department of Psychiatry into using telemedicine to expand child psychiatry services to rural areas and facilitates clinical support of the educational consults being done within Telekids.
  
  
• Dr. Sulzbacher and Eric Trupin, PhD will serve as co-PIs on the grant.
  
  
• Current statusAs part of a review of the current status of the grant, Dr. Sulzbacher summarized the purpose:
  • Provide consults to schools; increase opportunities for continuing education.
  • By utilizing telemedicine technology, one may provide timely access to expertise and save the time and expense of the child/family traveling to the consultant.
    
    
• Year 2000 Highlights include:
  • Three workshops were held for Washington state school special education directors
  • Demonstration CD ROM was produced in conjunction with King County
  • Presentations were made at multiple conferences and workshops
    
    
• Future Directions
  • Dr. Melzer discussed the new Children's Health Access Regional Telemedicine Project (CHART) funded through OAT at CHRMC.
    • CHART's purpose is to establish links with outlying communities including:Yakima, Wenatchee, Anchorage, Olympia and Boise.
    • Weekly tumor board will be held
    • Asthma treatment plans will be developed; endocrine providers and staff will be included to provide diabetes education, nutritional support, etc.
    • Store and forward technology will be used within dermatology
    • Behavioral Health consults will be a part of the activities
    • The funding is $1.4 million over 18 months
    • The team includes Cathy XU, MD, as project manager and Jennifer Mas who is now a part of the Telekids project team as well.
    • Goal of the project is a concentrated presence created using a cadre of dedicated and focused individuals
    • A primary concern is to be thoughtful about the linkage between CHART and psychiatry/behavioral health so our resources do not become too scattered.
  • Dr. Melzer also discussed the Inland Northwest Health Telemedicine consortium based in Spokane.
    • This group (which is well funded by US West monies) is aggressively reaching out to 27 sites including northern Idaho.
    • While the UW and Children's sites are making more clinical use of the technology, the Inland consortium is offering technical support for hospitals around telemedicine.
    • Therefore, there exists competition both for resources and for sites.
    • CHART has a web site and the project abstract is available from Dr. XU
    • There was discussion of sources of future funding for telemedicine activities
  • Dr. Melzer identified the primary sources as schools, jails and local county health districts rather than insurers such as Premera or other third party payors.
    • The Inland consortium is currently working with DSHS regarding funding for telemedicine activities. If DSHS decides to fund such services there may be some restrictions on using grant money to pay for consultations.
    • The plan would be to approach DSHS in some coordinated fashion, keeping in mind the tradeoffs inherent in accepting that reimbursement.
  • Attracting personnel to provide consults is an issue
    • Combining forces should enable us to recruit new people who are interested and have experience, skills and talents in this area.
    • Telemedicine activities have not been a part of the vision of the Department in the past
    • Rural areas have poor access to pediatric resources and child psychiatry/behavioral health problems are often incorrectly diagnosed or neglected resulting in more acute mental health problems.
  • Balance is an issue
    • Should we concentrate in areas where there are resources or
    • Should we concentrate where there is the volume and expertise to support the program
    • Question of maintaining momentum vs. achieving critical mass
      
      
• Strengths, Weaknesses, Opportunities and Threats
  • Strengths
    • Equipment in place at many sites
    • Areas of focus overlap with those of CHRMC
    • Facilitates collaboration and networking
    • CHRMC and psych assessment resources are strong
    • Enthusiasm and innovation gives face validity
    • School focus; tough questions, tough kids
    • Actually doing consultations with clinical orientations
    • Rural and underserved populations
    • Lots of community acceptance and trust
    • Dr. Shurtleff's foundation and reputation
    • Ability to have conference about children in the schools; all caretakers together in one place
    • By focusing on the schools can enable families and schools to work together; can act as an advocate for parents with the schools
  • Weaknesses
    • Protection of confidentiality
    • Reimbursement
    • Under funded
    • Enthusiasm has not broadened to other disciplines
    • Weak institutional buy-off until recently
    • Technology is expensive
    • Technology does not always work smoothly, can be time consuming
    • Can bring technology to them but can't make them use it
    • Outcome data, evaluation data is sparse
    • Not yet a part of regular procedures and systems
    • Lack of follow-up data
  • Opportunities
    • Way to bring people together, agencies together, for example, public health department, DCSF, DD, juvenile justice
    • Allows collaboration without the factors of time and distance
    • Provides high level consultations to remote areas
    • UW is going to fund a telehealth department - hard, not soft money
    • Health services outcome research allows accessing other resources; presents academic opportunities
    • Build infrastructure for sustainable resources
    • Reach out to underserved
    • Add new clinical areas
    • Regional opportunities
    • Tremendous demand for continuing education and continuing medical education
    • Time saving
    • Extends scarce resources
    • Supports faculty salaries and careers
    • Combines clinical activities with technology
  • Threats
    • Threat to traditional health organization
    • Time and funding
    • No additional time created for these activities
    • Makes it difficult to attract people to it
    • Loss of funding
    • Politics and competition
    • Sustainability
    • Dependence upon specific individuals
      
      
• Current Status
  • Data analysis progress
    • Update activity log
      • WWAMI and WSCCHAP data and Telekids data to be matched
      • Compare onsite consults to video consults
        
        
• Consult satisfaction
  • Compare surveys completed by local provider, patient/family, consultant per encounter
  • Track the outcome/plan decided upon during the consult
  • Using existing data structures (from WSCCHAP)
  • Outcome data not captured due to cost
    
    
• Primary dissemination product
  • Need to give better instructions on how to request a consultation
  • Protect confidentiality during consult by how one sites the equipment
    
    
• Dissemination budget
  • 3 meetings x $1200 / meeting
  • Cost of creating CD ROM
    
    
• Most common diagnoses and treatment questions
  • Autism, ADHD, FAS, TBI, anxiety disorders, neuromuscular disorders, late cognitive effects of medical conditions
  • Usually would be problems of children not being able to self regulate their behavior
  • 1500 consults done within WSSCHAP, 50-60 done within Telekids
• Need to decide when to cut off consultations
• Had considered billing third party payors for consults but had no mechanism to bill for services
• Follow-up: written report for each consult is filed in UWMC medical record
• Focus has been on determining the diagnosis rather than on the treatment plan
• Often recommendations are for further evaluations and testing
  
  
• Data and Evaluation
• Data gathered includes:
• Satisfaction surveys for each consult for the child/family, clinician/educator, referring provider, consultant
• Diagnoses profile
  
  
• Questions to ask
  • Is the interdisciplinary opportunity at the local level efficacious?
  • Can we get this to work in a fee for service environment?
  • Can we help more kids?
  • Application of D.I.S.C. to this modality
  • Reliability
  • Accuracy
  • Can we do more complex and/or comprehensive assessments? (e.g., IQ, Wexler, etc.)
    
    
• Short Term Action Plan
  • Please see Attachment 1

Appendix C
Roxanne Morganthaler
Résumé

Education
M.P.H., 1992
Health Services Administration Emphasis
University of Washington

B.A., 1976
Clinical Psychology
University of Washington

Field Placements included: Behavior Modification Day School at CHRMC, inpatient adolescent psychiatry unit at UWMC and an internship in vocational rehabilitation counseling at HMC on the Rehabilitation and Burn inpatient units

Employment
Department of Psychiatry and Behavioral Sciences
University of Washington
School of Medicine
2000 to present
Administrative Manager of Clinical Service Systems

Design, develop and implement systems to ensure maximum reimbursement is obtained from clinical services to include: preauthorization, coding, billing and documentation training, centralizing appointment scheduling across the academic medical center. Develop and implement contracts utilizing clinical resources in innovative ways such as telemedicine, telephone consultations and team building within rural communities.
Coordinate efforts to assure efficient operations of all site-based billing operations and be responsible for coordinating the information flow between the clinicians, site staff and practice plans.

Medical Centers Information Systems (MCIS)
University of Washington Medical Centers
1998 to 2000
Clinic Implementation Manager

Implement registration, scheduling and managed care applications in ambulatory care clinics at Harborview Medical Center and the University of Washington Medical Center.
Work with clinic staff and vendor to develop and implement rollout plan including training materials, documentation of current workflow, masterfile creation, template building and setup of system security.
Tested, trained and implemented home grown on-line distributed charge entry system at point of service and revised payor plan portion of the legacy registration system.
Participated in Registration Verification Workshop utilizing Rapid Process Improvement techniques.

University of Washington Medical Center
1995 to 1998
Managed Care Operations Coordinator

Developed and implemented orientation, training and resource materials for front desk staff and providers to facilitate daily managed care activities; taught monthly orientation to managed care for new employees; created web-based managed care resource page. Enhanced compliance by creating dialogue within and between clinics using clinic specific denied claim reports and bimonthly end user meetings across clinics for front desk staff to share ideas and concerns.
Supervised registration staff at UWMC Roosevelt.

University of Washington Medical Center
1979 to 1995
Patient Care Coordinator, Otolaryngology Head and Neck Surgery,
Ophthalmology

Scheduled surgeries and admissions for 8 full time surgeons including accepting referrals, obtaining preauthorization, reserving operating room time, scheduling preoperative work-ups. Coordinated weekly tumor board, facilitated communication with referring providers including obtaining outside records and reporting back on the outcome of the patients' evaluations. Facilitated patient's entry into and flow through a complex, academic, tertiary care system.

Volunteer Activities
American Cancer Society: Service and Rehabilitation Chair, President of Seattle Unit Board

Chaired Executive Committee, recruited board members, set goals and monitored yearly activities for five standing committees.

Jennifer Mas
Résumé

EXPERIENCE
Research Coordinator
Telepartners Project
University of Washington, Public Behavioral Health and Justice Policy Department
Seattle, Washington, 2000 - present

• Work with school districts, hospitals and clinics in WWAMI rural communities to help children access specialty health care at the University of Washington via videoconferencing and other telemedicine means. Focus on behavioral and mental health.
• Promote the advancement of telemedicine.
• Research current state and federal policy pertaining to telemedicine and reimbursement issues.
• CD ROM and web site development.
• Grant, Foundation, and Report writing.
• Develop survey instrument for program evaluation.

Project Coordinator
Children's Health Access Regional Telemedicine Network (CHART) Project
Seattle Children's Hospital
Seattle, Washington, 1/2/01 - present

• Coordinate with the regional spoke sites. Assist Regional Director on the management of regional linkages, physician relations and community liaison.
• Provide rural health needs assessment and investigate the health access needs in rural and medically underserved areas.
• Assist Clinical Director developing and administering evaluation instruments, collecting the standard encounter data requested by funders and analysis of project outcomes data.
• Provide research and analysis on regulatory and reimbursement issues.

Program Coordinator
SPARX (Student Providers Aspiring to Rural and Underserved Experiences)
University of Washington School of Medicine, Office of the Dean, Regional Affairs and Rural Health
Seattle, Washington, 1998 - 2000

• Program development, coordination and oversight for health care programs, projects and functions for multidisciplinary students from the health science schools, including Dentistry, Medicine, Nursing, Pharmacy, Public Health and Social Work. Focus activities around recruitment and retention of health providers to rural and urban medically underserved areas.· Fundraising and grant writing for federal, local and foundation funding.
• Manage the project advisory board.
• Design and management of project data system, web page design and listserve, marketing information.
• Create and maintain the program budget.
• Focus on University involvement with Migrant Hispanic Farmworker populations in Eastern Washington and Urban Homeless Youth issues.

Program Coordinator
Washington, Wyoming, Alaska, Montana, Idaho Area Health Education Center (AHEC)
University of Washington School of Medicine, Office of the Dean, Regional Affairs and Rural Health
Seattle, Washington, 1998 - 2000

• Primary grant writer for National AHEC grant program office. Grant is roughly worth $750,000 in entirety.
• Write Program Office quarterly and annual reports.
• Maintain AHEC budget.
• Coordinate outline for six AHEC centers to follow for federal grant deadlines.
• Compile materials for national AHEC quarterly reports.

EDUCATION
BS in Environmental Science, The Evergreen State College
Focus in Environmental Health
Olympia, Washington 1999

COMMUNITY ACTIVITIES
Seattle Human Rights Commission, Commissioner
Seattle, Washington, 1999 - 2001

• City Council appointee to Commission. Work in an advisory capacity to the Mayor, City Council, Seattle Office for Civil Rights and other City departments in matters affecting Human Rights.
• Chair, Youth in Schools Committee.
• Member, Appeals Sub-Committee.

Girls Basketball Coach, Head Coach
ASA Mercer Middle School, Beacon Hill, Seattle, Washington, 2000 - 2001

PROFESSIONAL MEMBERSHIP/COMMITTEES
MedRest, Steering Committee Member
Seattle, Washington, 1999 - 2000

• Assist with fundraising searches and writing of grants.

Safe Links, Board Member
Seattle, Washington, 1999 - present

• Recruit, organize and schedule University of Washington SPARX students and preceptors involvement with Safe Links, a medical van that performs medical, mental health and educational outreach to homeless youth in the University District and Capital Hill.
• Accompany the van on some evenings to assist with the medical history and outreach service to homeless youth.
• Co-author all proposals for expanding Safe Links services, utilizing University of Washington resources.

U. District - University Partnership for Youth, Member
Seattle, Washington, 1999 - present

• Mediate meetings between community, business members and homeless and runaway advocates.
• Fundraising for projects through grant searches.

Washington Rural Health Association, Member

American Telemedicine Association, Member

PRESENTATIONS
"SPARX: A Health Workforce Resource", Northwest Regional Rural Health Conference, Spokane, Washington; March, 1999.

"Nursing in Rural Communities", University of Washington School of Nursing, Seattle, Washington, February, 2000.

"Case Study of Homeless Youth in King County", Holy Family Church, Auburn, Washington, March, 2000.

"Partnership for Youth: A Tool for Community Development", University of Washington School of Social Work Open House, Seattle, Washington, March 2000.

"An Open Forum on Farmworker Issues" University of Washington School of Social Work, Seattle, Washington, May, 2000.

"An Overview of Available Services in North Central Washington for Pediatric Specialty Care", Women's Guilds of North Central Washington, Omak and Wenatchee, Washington, April, 2001.

"Health Status of Migrant Hispanic Farmworkers", U-Conjoint 414, University of Washington Health Science Schools, Seattle, Washington, May 2001.