1 Cross-Training Fulfilling Dreams
1 Cross-Training Fulfilling Dreams. 2 A Cross-Training for Promoting Work for people with disabilities.
Dec 29, 2015
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1
Cross-Training
Fulfilling Dreams
2
Fulfilling Dreams
A Cross-Trainingfor
Promoting Work for people with disabilities
3
Fulfilling Dreams
INTRODUCTION Why Cross-Training?
Overview of Grant• Accomplishments• Goals
Increased Education + Increased Outreach = Increased Utilization Increased employment of people with disabilities
4
A Brief History
How did we get here? Many circumstances at play
• Society undervaluing people with disabilities• Federal government’s creation of benefits for
people who were determined unable to work (SSA)
• Benefits tied to income Resulted in
• Dependence on benefits• Fear of working/losing benefits, particularly
Medicaid
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A Brief History
How did we get here, continued
• Growing initiatives in recent years to encourage work and counter the effects of SSA’s benefit rules
• Tri-agency effort – Ticket to Work SSA CMS DOL
• Medicaid Infrastructure Grants
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Work Incentives and Supports
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Work Incentives
Social Security Overview of SSA Disability Programs
• Supplemental Security Income (SSI)• Social Security Disability Insurance (SSDI)
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Work Incentives
Social Security Disability Insurance (SSDI) Title II of the Social Security Act Federally mandated Paycheck withholding Individualized accounts Disabled Adult Children Children of parents with disabilities Medicare
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Work Incentives
Supplemental Security Income (SSI) Title XVI of the Social Security Act. State funded program for low-income or no-income
individuals• SSI-Disabled for those who have disabilities and have no
other income
Maximum amount determined by federal benefit rate (FBR) • 2009 Alabama rate is $674.00 each month (individual)
Medicaid
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SSI and SSDI
Comparison Table of SSI and SSDI See Handout/Page 9 of Handbook
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Work Incentives
Intersection of Work and Disability Social Security Work Incentives
SSI and SSDI include a number of employment support provisions commonly referred to as work incentives
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Work Incentives
Summary of important Title II Work Incentives (SSDI, CDB, DWB)
Trial work period.
Substantial gainful activity level (SGA).
Impairment related work expense (IRWE)/Subsidy and Special Conditions.
Extended period of Eligibility.
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Work Incentives
Summary of Title II Work Incentives, continued
Continuation of Medicare.
Medicare for the working disabled.
Expedited Reinstatement of benefits.
Recovery During Vocational Rehabilitation.
14
Work Incentives Summary of important work incentives
(Supplemental Security Income (SSI))
Substantial Gainful Activity (SGA).
General Income exclusion.
Earned Income exclusion.
Student child earned income exclusion.
Impairment related work expense.
Blind work expenses.
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Work Incentives Summary of SSI work incentives,
continued
Plan to Achieve Self-Support (PASS).
Continuation of Medicaid Eligibility (1619B).
Expedited Reinstatement of benefits.
Recovery During Vocational Rehabilitation.
Student Earned Income Exclusion
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Work Incentives
Ticket to Work Program
Goals of the Ticket to Work Program
What is a ticket?
Ticket benefits
How does it work?
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Work Incentive Program Assistance (WIPA)
WIPA Background• Grant from SSA • Mandated by Ticket to Work and Work
Incentives Improvement Act of 1999• Free program serving SSI and/or SSDI
recipients who want to work and require more intensive long-term case management
• Provides information about SSA disability program work incentives to encourage work
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WIPA
WIPA Goals Promotes paid employment Enhances self-sufficiency Collaborates with community partners to
accomplish 1 and 2 above
WIPA message (see handout)
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WIPA
Who is eligible? At least age 14, but not yet full retirement age, Disabled per SSA definition, and Already receiving Social Security benefits based
on disability (SSI or a title II disability benefit such as SSDI, CDB, or DWB).
Eligible beneficiaries who have specific interest in work and how work will affect their benefits
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WIPA
WIPA in Alabama ALA-WIN: Central and North Alabama
• Independent Living Resources of Greater Birmingham
• UCP of Greater Birmingham
ADRS: South Alabama
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WIPA: Community Work Incentive Coordinators
WIPA agencies employ CWICs to assist in understanding complex requirements of work incentive programs
CWIC role Ongoing case management Work-related issue counseling Healthcare planning and counseling
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Community Work Incentive Coordinators (CWICs)
What CWICs do Case Management Educate on available work incentives Connect with services and supports Ensure informed choice
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Community Work Incentive Coordinators (CWICs)
Specific CWIC Activities Verify benefits Make formal referrals Proactive Follow-Up Write a Work Incentive Plan (WIP) Resolve work-related issues
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Community Work Incentive Coordinators (CWICs)
CWIC Partners Program Manager for Recruitment and
Outreach (PMRO) SSA staff Local Employment Networks (ENs) Vocational Rehabilitation (VR) agencies WISE: Work Incentive Seminars Events
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CWICs
How community partners support CWICs
Provide quality referrals
Have access to information outside the CWIC's scope
Education and information about scope of services
and eligibility criteria from other partners
Provide other avenues of outreach
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Community Work Incentive Coordinators (CWIC)
Partnership Examples
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Work Incentives
Group Exercise
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CommunityWork Supports
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Community Work Supports
Medicare and Medicaid Common public benefits eligibility for people
with disabilities Links to Social Security
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Community Work Supports
Medicaid vs. Medicare Medicaid is a program that provides medical
assistance for certain individuals and families with low income and resources.
Medicare is a Health Insurance Program for people 65 years of age and older, some people with disabilities under age 65, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
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Community Work Supports
Eligibility for Medicaid Supplemental Security Income (SSI) Alabama “Medicaid for Low Income Families” Pregnant women and children under 6 with family
income below or equal to 133% FPL Residents of medical institutions (nursing homes,
hospitals, or facilities for the mentally retarded) for a period of 30 continuous days and meet very specific income, resource and medical criteria may be Medicaid eligible.
Dual Eligibles
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Community Work Supports
Special Medicaid Eligibility Lost SSI eligibility because of:
• Any reason, but who are not currently entitled to SSI because of Cost-of-Living Allowances SSDI (Pickle Amendment);
• Entitlement to or increase in Childhood Disability Benefits (CDB); or
• Entitlement to Disabled Widow(er)s Benefit (DWB) until Medicare starts.
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Community Work Supports
Special Medicaid Eligibility, continued
Increases: Individual entitled to retain Medicaid under these special provisions if he/she would otherwise be entitled to SSI if the increases had not happened.
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Community Work Supports
Medicaid Funding Federal Funding/State Match
Adjusted Annually 2009 Alabama Funding
68.01% Federal 31.99% State
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Community Work Supports
Medicaid State Plan Services Medicaid Home and Community-Based
Services (HCBS) Medicaid Waivers Keep individuals from being institutionalized
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Community Work Supports
Medicaid State Plan Services vs. HCBS
Example State Plan Services
• Doctor visits
• Home health care
• Durable Medical Equipment
• Ambulance and Non-Emergency Transportation
Example Waiver Services
• Personal care
• Habilitation services
• Home modifications
• Supported Employment
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Home and Community-Based Services
HCBS Purpose and Goals Health and Safety Focus Community integration Avoid unnecessary institutionalization More recent emphasis (last decade) on
independence and productivity WORK
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HCBS
Relationship between Medicaid Eligibility, Waivers, and Income Limits Medicaid eligibility bearing on Waiver
eligibility State Plan and waiver duplication of services 300% rule
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HCBS
Waiver Implementation Responsibility Administrating State Agency
• Always Alabama Medicaid Agency
Operating State Agency
• Department(s) providing services to the target population
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Alabama HCBS
Alabama’s HCBS Waivers State of Alabama Independent Living Waiver Elderly and Disabled Waiver Mental Retardation Waiver Living at Home Waiver Assistive Technology Waiver HIV Waiver
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HCBS
Personal Assistance Services Common variable among most (5 of 6)
HCBS waiver How PAS can support work
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Alabama HCBS Waivers
State of Alabama Independent Living
(SAIL) Waiver(Since 1992)
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Alabama HCBS Waivers
State of Alabama Independent Living (SAIL) SAIL ensures the consumer can live as
independently as possible at home and in the community through three specialized programs:• Homebound• Independent Living Support Services• Waiver services
Operating agency: Alabama Department of Rehabilitation Services
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Alabama HCBS Waivers
SAIL Eligibility To be eligible for services through the
waiver, a person must:• be at least 18 years old • be medically and financially eligible for a nursing
home • have experienced the onset of the disability prior
to age 60 • have a disability as a result of reasons other than
aging
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The SAIL Waiver is approved to serve disabled adults with specific medical diagnosis who are at risk of being institutionalized in a nursing home.
The SAIL Waiver is approved to serve 630 individuals.
SAIL Target Population
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SAIL Waiver Services are provided to, but not limited to persons with the following diagnoses:
Quadriplegia Traumatic brain injury Amyotrophic Lateral Sclerosis Multiple Sclerosis Muscular Dystrophy Spinal Muscular Atrophy Severe Cerebral Palsy Stroke Other substantial neurological
impairments, severely debilitating diseases, or rare genetic diseases (such as Lesch-Nyhan disease).
SAILTarget Population
47
Individuals receiving SSI;
Individuals receiving State Supplementation;
SSI related protected groups deemed to be eligible for SSI/Medicaid;
Special HCBS Waiver disabled individuals whose income is not greater than 300% of the SSI Federal Benefit Rate.
SAILFinancial Eligibility
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Case Management*
Personal Care Services
Environmental Accessibility Adaptations*
Personal Emergency Response System (Initial Set-up)
Personal Emergency Response System (Monthly)
Medical Supplies
Minor Assistive Technology
Assistive Technology
Evaluation for Assistive Technology*
Assistive Technology Repairs
Personal Assistance Services
*Includes Transitional Services
SAIL Covered Services
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Alabama HCBS Waivers
Elderly and Disabled Waiver (E&D)
(Since 1982)
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E & D Waiver
Elderly and Disabled Waiver Designed to provide services to allow elderly and/or
disabled individuals who would otherwise require care in a nursing facility to live in the community.
Operating Agencies:• Alabama Department of Public Health• Alabama Department of Senior Services
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No age requirement
Must meet current level of care admissions criteria for nursing facility care.
9,205 waiver slots
E&D Target Population
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E&D Financial Eligibility Criteria
Individuals receiving SSI and/or State Supplementation
Federal and State Adoption Subsidy
SSI related protected groups deemed to be eligible for SSI/Medicaid
Individuals who would be eligible for Medicaid in an institution because income from either parents or a spouse is not deemed available to them (referred to as institutional deeming).
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E&D Covered Services
Case Management Homemaker Services Personal Care Adult Day Health Respite Care (Skilled and Unskilled) Adult Companion Services Home Delivered Meals
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Alabama HCBS Waivers
Mental Retardation(MR) Waiver
(Since 1981)
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MR Waiver
Mental Retardation Waiver Provides Home and Community-Based Services to
Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).
Operating Agency• Alabama Department of Mental Health and
Mental Retardation
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MR Waiver
Target Population
3 years of age and above
5260 waiver slots
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MR Waiver Financial Eligibility Criteria
Low income families with children
Social Security Income (SSI) – protected groups deemed to be recipients of SSI
Special home and community-based optional categorically needy groups whose income is not greater than 300% of the SSI federal benefit rate.
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MR Waiver Medical Eligibility
Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded) Facility.
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MR Waiver ICF/MR Level of Care
Intermediate care services for the mentally retarded are those services which are needed because of the severe, chronic nature of the mental impairment that results in substantial functional limitations in three or more of the following areas of life activities:
• Self Care• Receptive and expressive
language • Learning
• Mobility • Self Direction • Capacity for independent
living
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MR Waiver Covered Services
Residential Habilitation Training
Day Habilitation & DH w/
Transportation
Prevocational Services
Supported Employment
Occupational Therapy Services
Speech and Language Therapy
Physical Therapy
Behavior Therapy – Levels 1-3
In-Home Respite Care
Out-of-Home Respite Care
Institutional Respite Care
Personal Care
Environmental Accessibility
Adaptations
Specialized Medical Equipment
and Supplies
Skilled Nursing
Assistive Technology
Adult Companion Services
Crisis Intervention
Community Specialist Services
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Living At Home Waiver(Since 2002)
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Living At Home Waiver
Provides Home and Community-Based Services to Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded.
Operating Agency Alabama Department of Mental Health and Mental
Retardation
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Living At Home Waiver
Target Population
3 years of age and older
569 waiver slots
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Living at Home WaiverFinancial Eligibility
Criteria
Social Security Income (SSI) - protected groupsdeemed to be recipients of SSI.
SSI Recipients
Individuals Receiving State Supplementation
Low Income Families with Children
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Living at Home WaiverMedical Criteria
Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)
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Living at Home WaiverCovered Services
Residential Habilitation In-Home
Day Habilitation – Level 1-4
Day Habilitation with Transportation – Level 1-4
Prevocational Services
Supported Employment
Occupational Therapy Services
Speech and Language Therapy
Physical Therapy
Behavior Therapy – Level 1-3
In-Home Respite
Out-of-Home Respite
Personal Care
Personal Care on Worksite
Personal Care Transportation
Environmental Accessibility Adaptations
Specialized Medical Equipment and Supplies
Skilled Nursing
Community Specialist
Crisis Intervention
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Technology Assisted (TA) Waiver for
Adults(Since 2003)
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For individuals who received private duty nursing services through the Early Periodic Screening Diagnostic Test (EPSDT) Program under the Alabama Medicaid State Plan, who will no longer be eligible for this service upon turning age 21 and for whom private duty nursing services continues to be medically necessary based upon approved private duty nursing criteria.
Technology Assisted Waiver
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Operating Agency: Alabama Medicaid Agency
The TA Waiver is approved to serve 40 individuals.
Technology Assisted Waiver
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Individuals receiving SSI Individual receiving State Supplementation SSI related protected groups deemed to be
eligible for SSI/Medicaid Special HCBS Waiver disabled individuals
whose income is not greater than 300% of the SSI Federal Benefit Rate
Low income families with children.
TA Waiver Eligibility
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Private Duty Nursing Personal Care/Attendant Service Medical Supplies Assistive Technology Targeted Case Management (TCM)
TCM for the TA Waiver for Adults is under the Medicaid State Plan and is provided by the Alabama Department of Rehabilitation Services
TA Waiver Covered Services
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Alabama HCBS Waivers
HIV/AIDS Waiver(Since 2003)
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For individuals with a diagnosis of HIV/AIDS and related illness and meeting the Nursing Facility Level of Care
The HIV/AIDS Waiver is approved to serve 150 individuals.
Operating Agency: Alabama Department of Public Health
HIV/AIDS Waiver
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Individuals receiving SSI
Disabled individuals with income up to 300% of the SSI income level.
HIV/AIDs Financial Eligibility Criteria
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Case Management Personal Care Homemaker Services Respite Care Skilled Nursing Companion Services
HIV/AIDSCovered Services
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HCBS: Waiver Case Management
Waiver Case Management Service Coordination
Role of Service Coordinators Ensure health and safety Coordinate services to maximize
• Quality of life• Independence• Productivity
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HCBS What Service Coordinators…
May be slightly different from waiver to waiver
…Can’t Do
• Make decisions for the individual
• Act against the wishes of the individual’s family if the family is a legal guardian
• Provide direct services
• Job search for individual
• Provide on-the-job supports
Can Do…
• Advocate for the individual
• Conduct person centered planning to determine personal goals, e.g. work goals
• Help develop community connections
• Identify new service providers
• Counsel on service and supports
• Help evaluate the quality of supports
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HCBS
How Service Coordinators can promote work Educate regarding return-to-work process Ensure equal and continued access to
benefits Analyze essential job functions Identify job accommodation options Promote interactive dialogue Clarify work abilities and needed supports
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HCBS
Service Coordinator Community Partners Social Security eligibility workers Medicaid eligibility workers Centers on Independent Living Community-based providers Civic organizations Supported employment agencies/workers CWICs
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HCBS
Service Coordinator Community Partnership Examples
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Cross-Collaboration
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Cross-Collaboration
How Waiver Service Coordinators and CWICs Can Partner Ensure partners are informed of new developments
and information that affect or have the potential to affect services to individuals
Cross-consulting to• identify solutions to barriers• assure understanding of an individual’s benefits situation
and effect of increased income
Make cross-referrals to ensure all sources of support are tapped for the individual
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Cross-Collaboration
Referrals
Process of making a referrals
• CWICS to community partners
• Service Coordinators to community partners
Consent to share information requirements and Form
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Cross-Collaboration
Role of MIG Staff Grant Coordinator, Regional Coordinators
Serve as additional information source Supplement training Identify community-resources
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Fulfilling Dreams
Participant Exercise/Training Evaluation
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Fulfilling Dreams
Cross-Training Next Steps Training - Phase 2
• Field Work
Training – Phase 3• Report Findings
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