Judul : Florida Department Of Health License Verification
link : Florida Department Of Health License Verification
Florida Department Of Health License Verification
good afternoon everyone, my name is kristenrego and i am the director of health transformation at the association of state and territorialhealth officials. i would like to welcome you to today's webinar of community healthworker certification and licensure. integrating chw into the healthcare work force is a growingstrategy for increasing access and improving population health while decreasing costs.today's webinar is the first webinar in a
Florida Department Of Health License Verification, community health worker series that is supportedby the health resources and services administration. the objective for today's webinar are to describethe current landscape of chw certification and training across the country; to identifycommon content and methodology that can be included when developing chw certificationprograms; and to describe the opportunities,
challenges, and barriers associated with establishingcertification for chw. we have an esteemed panel of experts thatwill be speaking with you today. following my introductions, we will have two presentationsfollowed by an interactive panel discussion with our experts. if you have a question,you are welcome to post it in the chat box on your screen at any time during the webinar.these questions will be used during the q&a after today's presentation. at the conclusionof the webinar, you will be directed to an evaluation survey. please take a few minutesto inform us about the work that you are doing related to community health workers and toprovide us with feedback on today's webinar. we look forward to hearing about your efforts.
now i would like to introduce today's speakers,kt kramer and carl rush. kt kramer is the director of state health policy at astho whereshe supports a peer network of state legislative liaisons, and tracks and analyzes public healthlegislation, regulation, and executive orders across the states and territories. prior tojoining astho, kt worked as a winston health policy fellow at the senate health committee. carl rush has worked full time for and withchw for the past 19 years. he serves as a core team member of the policy center on chwat the university of texas, houston school of public health and has supported studieson chw employment policy for the states of arizona, texas, and indiana, and for publichealth seattle king county.
our panelists today are gail hirsch, katiemitchell, and sergio matos. gail hirsch is the co-director of the office of communityhealth workers at the massachusetts department of public health. as a longtime leader inchw organizing efforts in the state, she has served as an advisor to other states, federalagencies, and national organizations on chw work force development. katie mitchell is the project director ofthe michigan community health worker alliance. the michigan community health worker allianceis a partner-driven coalition. its mission is to promote and sustain the integrationof chw's into michigan's health and human services system.
sergio matos is the co-founder and executivedirector of the community health worker network of new york city. the network is a professionalassociation of chw's with over 700 members that work to advance the chw work force whilepreserving its integrity. with that, i will now turn it over to kt kramer. thanks, kristen, welcome everybody to thewebinar. as kristen mentioned, i am the director of state health policy at astho and part ofmy role is to track emerging trends and issues. one of the ones that we have been followingclosely is the emergence of community health workers, chw, and the certification and trainingprocess that states and state health agencies and territorial health agencies are undertaking.my presentation is going to be short with
hopefully more time for some of the paneliststo discuss more of the issues on the ground as they saw these programs and processes unfold. so what you are seeing now is a map of thenational landscape for community health worker training and certification standards. we haveseen in the past couple of years 20 states have considered or enacted or created processesand frameworks for community health workers to hit certification standards and training.they have done this in a variety of ways. i think that is sort of an important thingto mention. there is no uniform policy. i think the states have conversations with theirstakeholders about what the role of the community health worker is in their particular system.you wind up with different results. there
are some commonalities. what you see withthe states that are in green are ones where the state legislature has taken a role increating a statutory program for certification. again, i will touch on it a little more later,even within these state laws and regulations, there is variation in sort of how raw definitionsare and how much structure the law puts in versus regulation. legislatures have alsobeen active in states like illinois and maryland in creating advisory boards and passportsfor work groups to look at the issue of whether and how community health worker certificationshould take place in their states. this may be a precursor to legislative activity orto allowing it to happen more organically at a level below legislation and regulation.
the states that are in blue are states wherethe state health agency has taken a lead in creating community health worker certificationstandards within the authority they already have in their health agencies. minnesota hassort of a unique position in that they have gone to the department of health and humanservices and were able to get a waiver so that they could fund the community healthworkers through their medicaid program. the two states are in yellow are ones that legislationthat we are currently following. you have in florida, florid has existing third partycertification program that operates. what the legislation would do is essentially codifythat program. then the bill that is pending in new jersey would create an advisory boardto look at certification standards, but interestingly
also tying it to looking at financing andhow do you fund the work of community health workers through medicaid and through privateinsurance. that is sort of where we are right now. ithink the panelists will be able to talk a lot more about what the different approachesmight look like in a given state and what some of the benefits and drawbacks are asthey move forward. the final slide in my presentation is onewhere we sort of broke down what the different state policies and programs contain. i thinkthe main take away that i would have from this slide is really to sort of reiteratethat there is a lot of variety and a lot of flexibility and how different states structurethese training and certification programs.
i think we kind of see from the dots thatin massachusetts and new mexico, the legislative process was a lot more structured throughtheir laws and regulations. i think some of the states maybe just have advisory bodies.i am very excited to hear the rest of the panelists kind of go through again how toapproach the conversation and engage the stakeholders. with that, i will turn it over to carl. thank you, kt. hello, everybody. i am reallydelighted that you all could join us. i was asked by astho to comment before we get tothe - oops. lost the screen there. okay, i was asked to comment briefly on a projectcalled the chw core consensus or c3 project. this is really an adjunct to the considerationof certification. as kt was saying that the
states are highly varied in their approachto this. part of the thinking behind the c3 project is that the deliberations in eachstate regardless of who is leading it should be informed by some common understanding ofthe pattern of the roles and skills that community health workers play in various states aroundthe country. next slide please. so the purpose is to develop contemporaryrecommendations around the country. each state will take its own lead and follow its ownbest likes in terms of how to use it, but we are talking about core roles, which oftentranslate into scope of practice and core skills that are required to perform thoseroles. there is also a very important notion here of some core qualities. most of you haveprobably heard the term, the phrasing that
a community health worker should be a memberof the community whom they serve. that is kind of shorthand for complicated set of issuesmainly related to shared life experience. that part of the unique capabilities of thecommunity health worker in working particularly in low-income communities and communitiesof color is that they relate to the members of those communities, having lived throughthe same kinds of experiences that those community members have had. next slide please. i will add to that, by the way, in finishingthat last thought, that roles and skills are relatively easy to define. we were talkingabout definitions here, not so much regulation. but the core qualities are very challengingto embody in policy. so how those get handled
because they really are of the essence ofthe practice of the community health worker, how those poor qualities get recognized interms of making sure that the right people are hired for the work is a challenge in everystate. why are we doing this now? there was a seminal study published in 1998, a nationalcommunity health advisor study which was the first real national look at these issues ofthe common roles and skills of community health workers. the findings of that study have beenused in a number of states, both for the initial consideration certification and also for thecreation of educational programs of chw's. we have seen in the last what is now 18 yearsthat times have changed. there is a lot more interest in the healthcare field and in embeddingcommunity health workers in clinical organizations.
that is going to change the picture in termsof roles and skills. i think almost every state in the union now is at least investigatingstandards and potentially certification for chw's. so having some common basis for atleast starting consideration in your state is, we think, a valuable thing. there hasbeen some pressure from national organizations and even inquiries from federal agencies.are there national standards for chw's? i don't know that we will ever actually getthere. states, in general, would prefer to reserve these decisions for the state level.it is still not clear at this point, how much states will agree with each other about suchstandards. many of you have probably asked the question or have been asked the question,what is a good community health worker training
program? there is no real way authoritativelyto say what the answer to that is. next slide. another core value and this has really beenembodied in policy by the american public health association. it's very important, regardlessof who is leading the process or driving the process that the process of defining communityhealth workers, who they are and what they do, be led by community health workers themselves.this is something that almost goes without saying in other professions. yet, we haveseen a pattern in many places of people feeling that they can speak for or make decisionsfor community health workers. this is an important core value that we have tried to bring intothe c3 project itself. next slide. there was some precursor activity to c3, whichwas funded by the amgen foundation in which
one of the area health education centers intexas solicited information on over 40 training programs around the country and has conductedan informal analysis of that. in the next stage of some others of us that became involvedin it, that we started to take a look at a review of roles and competencies from sixwhat we are calling benchmarked states. these are states where there has been a seriouseffort to align the training requirements for chw's with the content of the job, thescope and practice. a cross walk was performed between the scopeof practice and skill requirements in those six states with the original findings fromthe national community health advisor study from 1998 and also the national scope of practicedefinition for community health representatives,
which are part of a program for the indianhealth service and really the only national program of community health workers. thatprocess has largely been completed. this past summer and into the fall, some 20 odd statenetworks of community health workers and some local networks were asked to review and commentbefore their modification was made to this kind of consensus, emerging consensus statementof roles and skills. the report from that process should be coming out in early april.it is now in the final editing and lay out process. that report will, of course, describethe process and give the final recommendations from 2015 about roles and skill and will alsoinclude in an appendix, all of the comments and dissenting opinions and concerns thatwere raised by the various reviewers up to
this point. next slide, please. beginning in the middle of this year and forabout a year to follow, we are going to be changing gears. there will be outreach toadditional community health worker groups, but also consensus building with other stakeholdergroups. we have already established contact, for example, with the american hospital associationand the american nurses' association. we will be looking, certainly for input from them,but eventually some form of endorsement in the sense that that organization representingits constituency believes that this statement of roles and skills is a fair depiction nationallyof what community health workers should do. that outreach is obviously crucial, not onlyto further broaden the consensus, but even
basic education of some constituency groupsabout understanding who and what community health workers are and what they do. the second major task, which has been an ongoingissue, discussion, for some years, now that more community health workers are workingin clinical settings, is there a difference between the roles and the skill sets thatcommunity health workers require in that setting and those required for folks who work exclusivelyin a community setting. that, i think is going to be a very rich conversation and will behelpful to folks in setting standards. for example, in new mexico, they have a core certificationand then a special level one specialization certification that they call "clinical supportskills." that is optional.
the third major task will be coming up withrecommendations on methods of assessing proficiency in these skills. we don't really have timeat the moment to go into this, but it seems clear that many conventional methods of skillassessment through exams and that sort of thing are not appropriate to the skill setof community health workers. something more like performance based assessment, lookingat actual measures and methods for assessing skills using such methods will be helpfulboth in an educational setting and in an employment setting for performance assessment. also,assessing those core qualities, the sense of community connectedness is so difficultto do with conventional means. it is important at least to provide tools to employers tofind ways of assuring that they are, in effect,
hiring the right people. people have the rightdegree of connectedness and credibility and commitment to the community to make a goodcommunity health worker. next slide, please. these are the states. i am not going to gointo detail on this, but these are the states that we looked at and the sources of informationabout scope of practice. we were not able from the indian health service to get a nationalstatement of core competencies. they are still working on that. various regions and tribalgovernments have their own standards for skills. the states involved are in different stagesin developing standards, certainly, but these are all states in which they have given avery serious look at understanding the roles and skills of the community health workerand the congruence between the skills and
the roles that they serve. next slide, please. we are going to make available through asthothat a number of resource documents, obviously, the publication from 2015 recommendationsfrom c3, but also a number of the other very relevant source documents. this is not necessarilya complete list. there also should be in 2017, a national policy study sponsored by cdc oncertification. that study is not going to begin until probably july this year. thatwill also be very valuable, we think, to the states. next slide, please. you will be able to download this informationwhen the slide deck from this webinar is published. for more information, you can send us an email.there is also a link to join our mailing list.
next slide, please. transition to our panel. i wanted to justgo over some basics about certifications. this is really not about regulation of anoccupation. we need to make that clear at the outset. certification in general, thesort of dictionary definition, has to do with some issuing authority declaring that theindividual has certain qualifications. it may or may not, but it's generally not thesame as an educational certificate of completion. some states may choose to make that equivalent.that is really up to you. it is important. we are seeing some examples of this already.the issuing authority, per se, does not have to be the state government. it could be aneducational certificate issued by an association
or even an employer based group issuing thecertification. i also want to say that licensing at this point is probably off the table, eventhough that is part of the title of the webinar. we need to say that what we are looking athere is not prohibiting what people do because there are an awful lot of volunteers doingthis kind of work now and have been for decades. there is no particular issue of potentialharm to the public, if the scope of practice of the chw is properly understood. the chwis, first and foremost, not a provider of clinical care. the issues of licensing inseveral states, they have specifically said, "we are not going to license these folks.it's not appropriate for our licensing authority." then lastly, there are folks who have misgivingsabout certification. there are many pitfalls
that can happen along the way. what we areseeing from the pattern of mistakes made in the early states and the reservations thatpeople have, certification in general, there should be multiple paths for entry, includingbased on experience. the process should be user friendly without unnecessary barriers.the state of texas, we don't have any of these requirements as part of certification. ifthere is going to be education required, it needs to be in familiar accessible settingsusing appropriate methods. we have one of our panelists today, one ofthe national experts on popular education for chw's in sergio matos. it is about thecongruence of the educational methods to the skills and the characteristics of the candidatesfor this work that is specified that these
methods are appropriate. if you are goingto have continuing education requirements, than there needs to be adequate access tothose opportunities. in many cases, especially with rural populations, distance learningis going to need to be an option. lastly, i would say we have tens of thousandsprobably of volunteer chw's around the country. the last thing we want to do is impeded themin their work. as you are considering the issue of certification, remember the dictumof the medical profession, which is first do no harm. we don't want to do anything toimpede volunteer chw's and their honorable and very successful work. with that, we are going to turn to our panel.i am going to pose a series of questions.
we are going to ask each of the paneliststo respond to this one question at a time. we have randomized the order of their responses.you won't always be hearing from the same person first on each question. the first questionis what process was followed in considering certification in your state? by that, we aresaying in part who or what has been driving the process up to this point? what stakeholdersor other factors seem to be most influential in the outcome thus far? if we go to the nextslide, please, we will start with our first responder from gail hirsh. hi, hello everyone. you can advance to thenext slide, if you would. in massachusetts, i answered this question. i would say thatthis has grown out of a long-term partnership
between the mass association of communityhealth workers, the department of public health, the massachusetts public health association,and chw training programs. this has been going on for close to 20 years as far as movingfrom being against certification towards supporting certification. the development of this partnershiphappened through the late '90s and early 2000s in synergy with some national efforts to defineand study the workforce. i would say it's been a process of convening key partners,building consensus. there have been multiple legislative and advocacy initiatives, andthen collaborative implementation of laws that have been passed. there has been a dedicationof resources to support community health worker leadership and engagement along the way. thenext slide, please.
brief overview, there was a statewide advisorycouncil that grew out of our health reform law, that wound up recommending certificationamongst its 34 recommendations, which actually set the stage for machw, which again is themass association of community health workers, to track and advocate for rapid passage ofchapter 322 in 2010. that established the board of certification at the department ofpublic health. there was a decision made at that point that the state would be the issuingauthority. we went back and forth on this a lot. as carl mentioned, this is a very importantdecision. we don't know, really, how this is going to go. we know how it has gone sofar. i would just sort of overlay all my comments by saying this is an experiment. we are doingan evaluation, which is really important.
we decided to house this at the departmentof public health because it had capacity. also, we thought that it would give credibilityto the certification. the board is comprised of strong chw representation. it's a voluntarycertification. it's a title act, not a practice act. that means in order to call yourselfa certified community health worker, you need to go through the process, but you not needit in order to practice as a community health worker. also, the law requires the board toset standards for core training programs. thank you. okay, next slide, please. good afternoon, this is katie mitchell withthe michigan community health worker alliance.
i am going to show you a little bit our processin michigan. so michw was founded in 2011. we have been in process in tackling the questionof certifications since our founding. it was identified really early on as an essentialdiscussion item and that very much fit under our mission of promoting and sustaining theworkforce of chw's. since 2011, we have had significant discussions with stakeholdersand other groups of chw's, employers, and others even broader, to really tackle thisquestion of what does certification mean. the way that michw is structured is that wehave working groups, a steering committee. we also host a lot of conferences and eventsto bring others in, to make sure that we are being as collaborative as possible in thisprocess. we spent a good part of 2012 doing
a lot of research. we hosted some chw onlydiscussion forums at the beginning of 2013. we presented a lot of that research and providedchw's an opportunity to really get together with each and hash out different thoughtsand opinions and feelings about all of that work that had been done. we issued a policybrief in 2013 indicating our support for recertification system, keeping in mind that for our purposesit is called certification is voluntary. it is not something that would be mandated. itwould be an option. then we continued our journey into this by doing more research. a big part of it is that with certification,there are a lot of elements. gail alluded to many of them as part of the process inmassachusetts. we are still tackling a lot
of those in michigan. when you think aboutwhat goes into certification that includes things like time frames and standards, andcurricula and all of that. we have spent the last couple of years doing additional research.we have also looked at the processes in other states, as well as for other professions tofind good models. at the end of 2014, we determined that michw would manage the certificationprocess versus a different type of authority such as the state government. in 2015, wewere able to take all of this information back to our larger stakeholder group, includingchw, health plans, health systems, employers, and gather additional support. we have also used a lot of tools to supportthis discussion. these are two pictures during
some of our forums in 2013 with our chw's.we have done a lot of this work over conference calls. we have done surveys. we had a statewidesurvey in 2014. we do a lot of polling. we are doing polling right now, actually, onthe grand parenting provision of this part of certification. the process is iterativeand ongoing. it takes a lot to engage various types of stakeholders and a lot to educate.we really focused on making sure that at all times, we were engaging people and makingsure that people are aware of what is happening. some of the challenges to the process though,are making sure that all of those people are included and that all of those voices arerespected. that is part of our corporate focus is to really make sure that that collaborationis participatory. we really do work hard at
making sure that all voices are brought inas much as possible. it also takes a lot in terms of challenges to get people up to speedon what decisions are being considered and why. even giving overviews on a webinar likethis can be really helpful in moving the process forward by giving an overview of what someof the options in considering some of those what ifs. what if certification was in place?what if there are volunteers? things like that. we also are still in process of getting caughtup in all of the details versus the big picture. that is something that is very common, thinkingabout the bigger reality that would be created by certification. sometimes those detailscan bog things down. really, it's a collaborative
process. in michigan, we have worked reallyhard to counter beliefs that stakeholders can only be reactive versus proactive. thatcertification ultimately is something that community health workers really need to havethe true say on in the end. michw can serve as a place to foster all of those voices andreally support all of the community health worker, employer, and other stakeholder voicesthroughout this process. i will turn it over from there to sergio. thank you, katie, and everyone. welcome everyoneto this webinar and thank you for joining us. i am sergio matos. i am the cofounderand executive director of the community health network of new york city. you see before youon the slide there our mission. i give you
a second to read that. i just wanted to saythat all of the comments that i make, i make within the context of my position as a leaderof a workforce and a professional association of that workforce. the process that we followed started i guessabout seven years ago. having worked for about 15 years to advance the chw work force, weknew that this was going to be a long, an extended effort. the very first thing we didwas secure funding to support a staff, a small staff of people for what we anticipated wouldbe a two-year effort. we wanted to have a dedicated staff that would be able to workfull time on this effort for at least two years.
the other big thing we do with our processis that we committed to a stakeholder led process, in which case i will talk to youa little bit about that in a minute. that whole state led process would be under chwleadership in agreement with a lot of the national policy positions that were emergingat the time, including apha. the other big thing we do with our processes is that fromthe very beginning, we secured academic partners. we sort of had a suspicion that this was goingto take some original research and we wanted to publish our results. we had a vision tobe able to publish our results. we aligned some academic partners. you see some of themhere, although there were five or six others. then lastly, in determining our process, wefelt it important to develop a leadership
group. we wanted that leadership group tobe representative of pretty much all stakeholder sectors that had an interest in the chw workforce.secondarily, we sort of had the sense that at the end of the road, we were going to needto have to change systems and policies. we wanted these leadership advisory group membersto consist of really top leaders, leaders from across the state that might be capable,and if engaged, to be able to realize change down the road when we were able to make ourrecommendations. we wanted to have statewide representation. very similar to the way gailand katie expressed their efforts, we were very focused on supporting regional chw organizingto participate in this statewide effort. actually, in some cases, it took where we had to goto parts of the state and beat the bushes
and find people who were wanting to organizechw and to really help them really develop local or regional network associations tosupport our statewide efforts. then we did support chw's to participate and lead thiseffort throughout the entire period. next slide, please. the other thing about our process is thatonce we convened our leadership advisory group, it was about 60 people. remember, these wereall top leaders of their sectors. for example, when we sought out regulators, we didn�tgo to every elected official in our chambers of congress, but rather we went to the chairsof the health committees in those chambers. when we were looking for hospital representatives,we didn't go to every executive director of
every hospital, but the executive directorof the statewide association of hospitals. we followed that approach in all of the sectors.so anyway, we established that leadership advisory group. they, very early, decidedthat their priority was going to be financing because their goal was to sustain the chwpractice. they very quickly focused on financing. however, they realized that in order to considerfinancing, they needed to have some kind of training or credentialing sorts in mind sothey would know what they were paying for. then, in order to have training or credentialingprocesses in mind, they realized they had to have a scope of practice to figure outwhat it was they were training. they established these three working groupsto do that work. each working group was co-chaired
by a chw and a stakeholder. the work groupefforts were staggered because the leadership advisory group also quickly realized thatthey needed the work of the scope of practice work group in order to do their own work.so the scope of practice work was done at a quicker pace and before the other two workgroups really started their work. the very first thing that the scope of practice toldus was that they needed some rigorous market analysis to be done in order for them to understandwhat were the chw's scope of practice including roles. we had to go out through our academic componentsand actually conduct that rigorous and original scientific research and the enormous dataanalysis that was associated with that. so
it was lucky that had established these academiccomponents beforehand, anticipating that we might have that need. the academic partnersdid all of that work and through the chw network conducted a lot of cdpr surveys. i think weinterviewed a couple of hundred chw's and almost 100 employers, payers, regulators,and labor representatives. next slide, please. so the results of if i fast forward two years,the results of our work�this was a statewide chw effort. we adopted the american publichealth association in our own chw definition, which is published and we will be happy toshare with you. we established a statewide evidenced based chw scope of practice. again,that's on our website, which was on my introductory set of slides. that scope of practice articulatesthe chw roles, the chw task, and the chw skills
that all significant stakeholder sectors lookfor. we analyzed the results of that rigorous scientific research using a number of analyticalmethodologies and they were done through our academic partners. then at the suggestionof carl, who was one of our national leaders on our leadership advisory group, we applieda labor functional task analysis, which really is a very rigorous analysis of data. there were two very interesting things thatemerged out of the findings that we did not expect, in spite of our extended experiencein advancing the workforce. one was that employers of chw's identified a number of prioritiesthat they utilize in assessing and hiring chw's. you see those listed. they includeshared life experience, a recognized set of
personal attributes that carl referred to.these are personal qualities. these are like, well, personal attributes that employers veryspecifically look for in employing chw's. that makes this workforce a little differentfrom others and has ramifications when you consider certification because these are reallynot things that can be certified, but yet they are very critically important to employers. employers also look for previous employmentas a chw. then lastly, and actually ironically, least importantly, employers look for previoustraining. many, many, many employers reported to us that previous training often gets inthe way, actually. they have to retrain chw's to not implement a lot of the stuff that theycome with from previous training.
most importantly, we found that actually credentialing,employers didn't care that much about it. it did not influence their decision of whetheror not to employ somebody. it just was not a primary element in their considerations.next slide, please. lastly, i want to say that these statewideefforts that we made to advance the chw workforce, also besides the scope of work, once we hadthat established the other two workers were able to get to work. the training and credentialinggroup published a set of recommendations. the most important thing that this group ofleaders decided was to put certification considerations on hold, primarily driven by the fact thatthere was an employer indifference about certification. the group itself expressed the desire to bethoughtfully deliberate about this.
the other driving force behind this decisionto put the brakes on this whole credentialing process was an examination of the nationalexperience with chw certification that was emerging, which was really providing morecautionary tales than best practices. a lot of the experience coming out of the statethat was certifying was not really serving to advance the chw workforce, although itwas certainly regulating it. the training and credentialing workgroup also made veryspecific recommendations around training content and pedagogy and methodology about the developmentof the training and how that should be done and that chw's be co-trainers, they made recommendationsabout citing and the delivery of the training. they made very specific recommendations abouttraining institutions, requirements for those
training institutions and some thoughts aroundwhat might be a possible credentialing process. then lastly, the financing work group madevery specific recommendations to a variety of pairs about how to go about funding forchw's. i will say that new york since the publication of these recommendations, newyork has become a _____ state and so these recommendations have been really integratedinto the work of our medicaid redesign team and our district design teams. i will turnit back over to our moderator, carl harrison rush. thank you, there you go. okay, great stuffabout the process. now, we have heard some things about reservations and in one of ourpresenters about initial opposition to certification
and things like that. so we decided to aska little bit about, first of all, what are the pros, in other words, the value. who definesthe value of certification? what is it based on? who really initially introduced this kindof value proposition? next slide, please. katie. in terms of value, i am going to talk a littlebit about potential positive impact. so just to start, i wanted to be transparent aboutwhat michw's current recommendations are. when i say that these are michw's recommendations,it means that they have been approved by our steering committee, which is a body made upof community health workers, as well as other individuals, who formally applied to be apart of the committee and serve a two-year
term. individuals represent various typesof organizations all across the state. in 2013, the recommendation came up from ourworking groups, both our community health worker network, as well as our education workforcegroup that michigan should adopt this generalized competency based training and certificationsystem for community health workers. that concurrently, michigan should support policiesfor community health worker reimbursements through medicaid, managed care, and otherpayers. so from there, we started embarking on our journey toward where we are at now,which is we have a standardized curriculum in place. we are actively training chw's throughit. we are looking to scale it in the next year so that it is acceptable throughout thestate versus in some kind of isolated geographic
areas right now based on capacity. but from there, we also move to really gettingmore consensus over what that means. we talk about certification and the question of valuereally does come up. is there value to it? will someone pay a chw more or will therebe more reimbursement opportunities for an employer because someone is certified or not.so in 2015, michw hosted a series of stakeholder forums specifically with our payers to helpaddress that question to an extent. one of the action items from that would be that michwshould develop and implement standard sets for chw certification in michigan. the potential positives that we've identifiedover the course of time include the fact that
right now, the chw role is still a littlebit hazy. having something like a certification would really provide a lot of definition tothe chw's role. that's not to say that a definition or a scope of practice, or a listing of coreroles and skills couldn't do that as well. we have moved towards certification becauseour chw's have really called for that and have supported that. this is one method throughwhich a community health worker can be recognized. it's also an acknowledgement that a minimumstandard of competency and skills have been met. to earn a certification, whether it'sthrough training or through some type of grandparenting process, which we are still figuring out rightnow, it's kind of a stamp of approval that yes, we acknowledged that you have met thisminimum standard of education and training
within your profession as a community healthworker. there is also an element of establishing thechw profession as a profession versus a paraprofessional or unprofessional role. that is still a battlethat a lot of community health workers face is making sure that in conversations aboutcare, about working communities, that the chw isn't ignored or thought of as this lesserprofessional because they don't have a license or because they don't provide direct clinicalcare. certification is one method through which we can acknowledge or recognize thechw as a professional. it's not the only method, but one of them. it's also validation of thechw's investment in training and skill development. there is also impact from multiple stakeholders,which is a point i just really want to emphasize.
there has been in other places, conversationabout really what this value is to the chw, as well as the employer. so for the chw, wecare a lot that there is a personal value. from a chw perspective, there is a value inbeing able to say, "i am certified. i have met this particular standard." or "i wouldlike to be certified so that i can say that i have met this particular standard." thenthere is also professional value in acknowledging and validating where that particular personis in their professional career. there is also value to the employer in acknowledgingthat "yes, my individuals are certified. therefore, they have met these particulars standards.again, in michigan, this is not in place right now, but these are potential positive impactsthat have been cited.
there is also a lot of positive impact thatwe are not quite sure about yet. for the chw, one of the most common questions that i getis will my pay go up if i am certified? the answer is that we don�t know. we don't knowif a wage increase will follow. we also don�t know whether or not we will have defined gatewaysto new education opportunities. the intent with our standardized curriculum, which wedelivered in partnership with community colleges, is that at some point, because of our connectionto the education system, there will be opportunities for that chw to move through that system inanother way if they would elect to. we also anticipate that there will be increasedpersonal and professional efficiency for that chw that they will themselves, would be empowered,and feel like that they have more agency over
their profession and their activities. again,that is a potential positive impact. there is a lot of chw's right now. i am not oneof them. i am not a chw. there are a lot of chw's who are very, very confident in whatthey do and who they are as a community health worker. certification may or may not increasethat confidence or impact them in that way. we are not quite sure. for the employer, there is also potentialopportunities for new funding streams, but we don't quite know what those are yet. thereis a lot of educated guesses being made as _____ about whether or not a certified chwwould be eligible for reimbursement or not, whether it's through medicaid or through othermechanisms or whether or not health plans
or others would acknowledged the certificationas a minimum standard that they could get behind with some type of increased payment.we also anticipate that certification would create some type of workforce standard thatyou could kind of more generalize where people are and who they are and what they do, especiallywhen you have so many people under different titles. you have such varying roles withintheir different agencies that all fall under the chw umbrella. that could be a way to reallyhonor the diversity of the workforce, but still set the standard of competency or skillthat people could align with in some way. again, that is something that we anticipate,but is not guaranteed in any way. sergio. are you on mute, sergio?
i am so sorry, i was on mute. so thank you,katie. in considering the pros of certification, and in part of conducting our statewide cvprwork, original research, we actually asked people and groups of people, what is it thatyou are looking for in a credential? many of the issues that were raised were the onesthat katie just itemized. the question of increased funding was usually central to mostpeople's consideration of this issue. in particular, because so many community health worker programsare grant funded or were at the time. so people were concerned and were wanting a certificationto give them more funding availability and sustainability. we are actually finding asa result, that a more recent development in new york, especially with _____ that it isactually the business case that is most effective
to both chw's and payers and healthcare administratorsand designers. it is the evidence that exists improved outcomes, cost savings, return oninvestment, and value added, that is driving funding of chw's, not so much the certification. the other big thing that chw's always toldus is that they expect better opportunities and wages, similar to what katie said. infact, employers don't care about that. so they are not asking for that certification.i don't know how much relativity there is to that. the other things is that people feltthat a certification would give them more prestige recognition and stability at theirwork so they wouldn't get fired every two years when the grant runs out. again, we don'tknow that there is any existing evidence for
that. in fact, a lot of the recognition orprestige that might be associated with credentials depends very much on who the governing partyis for that credential. there are some states where other professional associations havetaken over governance of the chw's and have actually created less prestige and less recognition.that evidence is the jury is still out on then lastly, there was a sense that a credentialmight provide increased cooperation with the healthcare community. again, we have foundthat that doesn't depend so much on the credential, but really on understanding the role and thetasks and the skill set that chw's bring. that's what makes them the most effectivemember of the evolving healthcare teams that are coming out of these new innovations. whenwe find out when providers, particularly medical
providers and employers witness the successthat chw's bring and the cooperation with those communities increases. thank you. gail. this is gail. i think katie touched on a lotof what i was going to touch on. i would emphasize that we see this as a piece of advancing,not everything. i would just add that from various perspectives here, what some of thepotential benefits that were anticipated might be. i would say that the community healthworkers, they see it as an opportunity to better define a practice. that is to createawareness of and clarity around the scope and the skills, the competencies, and to buildprofessional identity. i will just add to that right now that i think what we have foundhere in massachusetts is that when we have
some kind of legislatively mandated processthat is underway, it kind of gently encourages people to participate in it or forces peopleto participate in it, as it were. i actually sort of makes people pay attention to communityhealth workers and to create consensus around it and buy in an ownership of advancing thefield. i would say that every legislative process we have has built consensus and grownprofessional identity within massachusetts. other things, there are the things that katiementioned around increased pay, benefits, supervision, training, and career letters.we don't know how that will play out yet, but it is certainly we are hopeful. we hadsome providers and employers, we actually did have support for moving ahead with certificationto help them understand what a community health
worker does compared to other workforces andto establish what the training standards would be for that workforce. for us, as well, inmassachusetts, with our public and private insurers, we really actually found that weweren't able to kind of move forward without thinking about certification. what we havetried to do for perspective is create a process that would be led by community health workersthat is both our public and private insurers are paying much more attention to this, areengaged in it, including our medicaid agency because we are actually talking about definingthe qualities and qualifications are of the workforce. i think we can move on to the nextquestion. thank you, the final question, as you mightimagine, a little symmetry here, the cons
or potential negative impacts, and its inevitablethat there would be pushback, skepticism, even resistance, but in your experience, whenin the process were these negatives first articulated and how influential do you seethem having been on the outcome in your state? next slide, please. sergio? you are on muteagain. thank you, carl. as you can probably imagine,i am more in this camp, than the previous camp. i have arrived there over many yearsof experience. the concerns that people have raised around certification. the responsesthat i get from people and that we got from people when we were doing our statewide research,and some of the evidence that is emerging from the experience of other states is thatprimarily certification could redefine the
practice. in fact, we define it to the extentthat it would no longer even be recognizable. there might be a loss of identity and specificallythe power of chw's to determine their own practice. this has actually already happenedin a number of states. we talk about self-determination as sort of the silver bullet to try to addressthis whole issue of redefining the practice. in fact, i know one state turned governanceof chw's over to a different profession. now that different profession has imposed theirculture and standards and norms onto chw practice to where they are not even really recognizableanymore so there is that danger. the other thing is that a certification tendsto establish restrictions on a practice so that there is the potential that the scopeof work could become limited, especially if
it is not informed by the evidence base. thereare other requirements generally for a certification, which would have to be addressed, like educational,academic, higher education requirements that might not be relevant, immigration statusin some states might be an issue. typically, i just finished publishing a book on how immigrantsimproved their health and how chw's improved the health of immigrant communities. thosechw's are generally immigrants. immigration status might be an issue. english only statesmight have an issue with establishing a credential. of course, financial responsibility for thetraining and credentialing might be a burden. the other big thing is these criminal backgroundchecks. like i said, chw employers look for chw's because of their shared life experience.well, if you are looking for somebody to work
with teenager prostitutes, than you are goingto probably want to find somebody who was a teenage prostitute. that person might verywell have a criminal record. people's criminal history might interfere with a credentialingprocess that uses that as a block. the other big thing is that it might not benecessary. people in our processes, there is really no need for it. nobody is askingfor it. the business case for chw effectiveness is extensive and convincing. employers arereally looking for personal qualities, not a credential. so people are asking well, andactually one of the participants on this very webinar posted a question about that and ihope we get to address that. then the big thing is that from the national experience,certification alone does not provide, is not
showing to provide any of those things thatpeople are searching for in a credential. the other big warning point that our�thiscame from our business community in the advisory group, is that if you pass a bill that requiressomething, than that bill has to be funded. any credentialing process that any state decidesto embark upon, there is some expense associated with it. somebody is going to have to maintaintesting and evaluation. somebody is going to have to maintain a registry of certifiedpeople and keep that current. somebody is going to have to enforce that credentialingor regulation. that is going to cost money. in general, the political climate across moststates is that people are not looking to expand government or increase spending right now.taking a legislative agenda or establishing
a process that's going to require investmentisn't really very attractive to many states. i will turn it over to katie, i guess. oh,no, gail. yeah, it's actually gail. definitely whatyou said was true that your last point about the challenges of state government spendingmoney on a certification process. we are specifying and we are tightrope walking as well. i justto get into some of the challenge that we talk about in terms of certification, we acknowledgethat it means different things to everybody, actually, probably of the hundreds of peopleon this call, something different comes to their mind about what certification reallyis. it can be different. it can be shaped differently and designed differently. that'sreally sort of the main take home here. if
it is done well, at least you have a betterchance of having it be responsive to the needs of the workforce. obviously, some of the potentialadverse impact which were already mentioned is that we do not want to erect barriers toentering the workforce or practicing for effective community health workers that are alreadypracticing. we don't want to diminish effectiveness of community health workers by distortingthe identity of community health workers or over medicalizing the practice. we don't wantto restrict community health workers because they are very creative and respond to complexneeds. the other thing we also want to be careful about is creating separate classesof community health workers. that is, those who were certified and those who are not.that is tricky.
moving forward. here is the next one. cansomebody advance it to the next slide, please, there we go. okay so thank you. what someof the ways that we are addressing anticipated challenges is we are including a grandparentingprovision that recognizes work experience. it recognizes voluntary and part time workexperience. there will be flexible training program approval standards, that is the curriculumneeds to be based on adult learning principles, but it is not going to be proscribed. thetraining programs will need to address the core competencies. we are creating a userfriendly application. there are no minimum educational requirements. we will not be requiringproficiency in english. there will not be a test, but we will be doing along the linesof a call test, some kind of performance competency
based assessment. the fee will be affordable.can somebody move it to the next one? thank you. lastly, or almost lastly, some of the thingsthat we are doing on a broader level to address some of these challenges are to engage peopleat every step of the way and create ownership. somebody asked the question about activelysupporting chw leadership with resources. i can try to get some more detail about that.in essence, the state public health department is providing resources, financial resourcesand technical support for chw association to be engaging community health workers atevery step of the way. the whole time we are going through this, we are recognizing theinherent tension of the work of formalizing
a chw profession while retaining and supportingthe grass roots nature of the profession. then lastly, what we are always careful todo is to include community health workers who work in community based settings as well,not only in healthcare so that this doesn't become a healthcare driven process that weare really recognizing the broad spectrum of community health workers that are workingout there in the field now and who want to enter the field. i think we can move on. great, so i am going to finish up here realfast so we have time for some q&a. one of the big things that has been touched on alreadyis just in terms of negative impact, the chw role has really historically been grass roots,community based, oftentimes an opportunity
for entry into the work force, many timesfor the first time, and really centered around this concept of life experience and/or uniqueconnection to community. there is always concern as to what certification may be do for that.what's been really interesting as we tackle the question about whether or not certificationdilutes the workforce by ignoring some of those things or whether it actually supportsthose, is that in michigan our conversation looked different. some days, chw have thisconcern. other days, it was employers have this concern. because there is a perceptionthat when you have someone who is truly grass roots of the community, community based, thatthat person getting the certification somehow is not that anymore. so that is a tensionthat we are actually battling all the time
and really trying to talk through and getdifferent people's perspective. as a disclaimer, as i've already stated, michiganreally is pursuing this because of our chw's and our employer stakeholders have supportedit. some of the potential negatives otherwise that have been recorded during this processinclude the cost of regulation and oversight, as well as decision making over the courseof time. these have all already been touched on by the potential exclusion of chw's, aswell as cost to the employer. it is cost to the chw, if the employer is unwilling to payor if the community health worker is a volunteer. in terms of handling it, how do we handlethese potential negatives? we talk a lot. this is something very, very common for us.we discuss pros and cons in conference calls
and in person discussions. we make sure thatwhoever is on this call is up to date as to what is going on. it's a huge challenges sometimes.we really are built on participatory principles, meaning that we really value all voices. wemake decisions by consensus, not voting, so we don't take individual tallies, but we don'tmove forward unless we are really all on board or we are enough on board that we feel comfortablein taking the next step forward. next slide. some additional concerns cited by chw's employershave led us to pursue various aspects of certification over others. as a result, things that we arepursuing now include michw managing certification versus an external party. michw was identifiedas this potential third party versus someone else because we are the community health workeralliance. we are not formally associated with
a specific employer group or another association.there was some general consensus that if michw was over it than community health worker voicecould be maintained and really be sought out and acknowledged as a part of the whole process.we have also made sure to include a grandparenting provision, which we are talking through rightnow. it's a voluntary process, which is inherent as part of certification. we are also pursuingemployer paid certification when possible. we polled our employers and had fairly positiveresponses for all of them. we are also launching a registry for community health workers thatyou can enroll in as a chw regardless of your certification status. there will be a methodon the registry to identify who is certified and who is not. that will be the method bywhich michw certifies chw's, but any chw has
the freedom to register, which we are alsohoping will help reduce some barriers for chw's who may feel in a different class thansomeone else as gail stated. with that, we will move on to q&a. carl? great, thank you. i want to thank all of ourpanelists, a lot of important perspectives here for our participants. i am going to askkristen to field or select the questions. our main intent here is for the panel to beable to respond to questions from the participants. we will be, since we are running a littlelow on time, we will make the commitment to ask these panelists to respond in writingto any of them that we are not able to handle verbally. kristen, do you want to toss outa question we have received by the chat box?
sure, the first question will be for gail.could you speak more about the dedication of resources to support chw leadership andwho from and how much? sure, so this is an almost 20 year processof ongoing support from the state for the mass association for community health workersthat somebody else actually asked about as well around seeding the formation of it backin 2000. but more recently, with the certification process, the department of public health usedsmall pockets of resources for machw to convene town halls across massachusetts to get communityhealth worker input on certification before the decision was made to go forward, to workwith the code of ethics and adapt that for massachusetts to hold educational forums acrossthe state; to help community health workers
understand what certification and what ishappening with certification; to gather input from them about the process to bring themto certification board meetings; help them have an organized voice at certification meetings;and to also develop materials that are friendly around application and around the process.i am sure there are other things, too, but that those were the quick things i jotteddown in response to that question. in essence, we do not move forward on anything here withoutsignificant community health worker input and also leadership around convening communityhealth workers to gain leadership skills as well. okay, thanks, gail. this next question isfor carl. can you define provider clinical
care further and could you tell us more aboutnon-clinical tasks that are being set that may require a license to practice? sure, well, i think the first thing to sayis that clinical license mean that someone who does not have a license, it is illegalfor them to perform the tasks that that licensed profession is allowed to perform. one of thethings that we run into is that particular in healthcare organizations, is that folkshave a hard time wrapping their heads around how someone can be effective in their organizationwithout significant clinical training. the point is that community health workers donot diagnose or treat or dispense medications. they do not perform lab tests and so forth.they may perform vital signs that an individual
should be able to perform for himself or herselflike it doesn't take a license to take your own blood pressure, that sort of thing. thoseare about as far as a community health worker might go in providing clinical care. thatis anything involved in actually diagnosing or treating illness. there is sometimes some confusion betweencommunity health workers and direct care workers like personal care attendants or home healthaides. these are very different skill sets because those individuals are providing directservices necessary for maintaining or improving the patient's health. the community healthworker is much more in a mode of coaching, supporting, advocating for, teaching, supportingadherence to treatment, things like that,
helping people overcome barriers to keepingappointments. these are not things that require clinical training. this can be very importantfor the organization in terms of improving communication, increasing levels of trustand relationship between provider and patient. these are all strength that community healthworkers have that are not directly involved in the provision of clinical care. lastly, one thing that has become extremelyimportant is assisting with the management of social determinance of health, both byhelping providers, clinical care providers, understand the life of the patient, but alsohelping the patient to deal with micro issues like housing or family violence, things likethat that clearly affect people's health,
but they are not within the purview of theclinical provider like a physician or nurse. it's a very important distinction. it's oneof the reasons why it's not necessary for chw's to be licensed. it's also not necessaryfor them to have professional liability or malpractice coverage because they are notconducting activities that are subject to those kinds of standards. okay, thank you. i think this next questionis for katie, but if others have anything to share, feel free to chime in after katie.for individuals who are now taking chw training, whether online or in a classroom setting,will certification be available as an option for them? is it available statewide or isit only available to michw and has it been
decided or is it in discussion for now? isit up to providers and employers to decide? it's a long question. i can chime in a little bit on that, but iwelcome the other panelists to also share. currently, in michigan, certification doesnot formally exist yet. michw will lunch our certification process later this year, butit's not up and running yet. right now, options for community health worker training in michiganinclude our core competency based curriculum, which is being implemented across the statein various parts. to date, we have over 75 chw's who have completed with several morein process. we also have a history of training in this state. there will be several dozen,if not hundreds of chw's who will be eligible
for grandparenting. we have not finalizedthose criteria yet, but there will chw's who have previous training experience whetherit be electronic or in person, as long as it hits on some of our core competencies.as part of grandparenting, there will be a provision where the chw will have to verifythat they have met those core competencies and that we are still figuring out the detailsof the extent to which an employer can sign off on that versus previous training experienceand documentation needing to be provided for this is gail and i will jump in for massachusetts.the way it will work here, we believe, it hasn't been finalized yet, is that any communityhealth worker in massachusetts can apply to become certified. if they are going throughthe training and work experience pathway,
they will need to submit evidence that theyhave successfully completed an approved training program. otherwise, as they go through thework experience pathway, they won't. all chw applicants will need to submit three referencesattesting to their proficiency in the core competencies. again, as katie says, the devilis in the details. how we are going to do that? again, we are trying to adhere to theprinciples of not creating barriers to community health workers who are successfully workingnow. i think that probably answers the question from our perspective. yeah, if i could just add very quickly, innew york, our recommendations are really centered around credentialing training programs ratherthan credentialing individuals. a number of
reasons for that there were many members ofour leadership advisory group that were either academic training institutions or proprietarytraining institutions. this whole, in new york, at least, these concepts of either creditfor life experience or college credit bearing training programs, are very, very complexissues. evaluating life experience for credit is really, really difficult and complex accordingto these educational experts and institutions. rather than put that onus on the individual,we chose to credential training programs that were responsible to the scope of practiceand that applied appropriate pedagogies. okay, thank you. so this next question isn'tdirected towards any of our speakers, but maybe we can start with carl and then if otherspeakers could chime in. is there any realistic
chance of moving beyond grant based fundingfor chw, eg and integrated care teams without chw certification in the context of changingpayments models under aca? sure, and i will say that's a very importantquestion, maybe a little beyond the scope of this particular webinar. i am hoping wewill get back to one later. i will just say very briefly that while as sergio said thatthe financing question is not dependent on certification, certainly. that some agreementon qualifications is going to be important. there are a lot of different pathways to sustainablefunding. grant funding, by definition is pretty much out of the question as a sustainablestrategy. i will just saw a couple of things. one is that, of course, we are talking mainlyabout medicaid since the major area of effectiveness
of community health workers is with low incomepopulations, but that there are plenty of things in those states which have a managedcare model that health plans have a lot of latitude to do things with chw's now withno additional authorization from the state. secondly, that a lot of states are movingtowards some form of value based payment for healthcare and that the opportunity to persuadethem to integrate community health workers into those strategies can really make a lotof sense. i think that is really where the strategies like that make the most sense ratherthan pursuing dedicated funding streams for chw's as a workforce. i would say that the answer to that questionat least from new york is absolutely, yes.
chw's are being built into district modelsand integrated into healthcare teams quite extensively across all of our district recipients.some of these district models are really quite extensive. some of them are even called medicalvillages. so yeah, chw's are being integrated as part of those teams without credentialing. gail or katie, do you want to weigh in onthat? okay, i am mindful of our time. we are about five minutes before our planned endingtime, so maybe this next one may be the last question. it's up to you, kristen, but it'slooking that way. yeah, i think that sounds great, carl. this question will be for sergioand also for gail, if you both have remarks. in terms of the chw advisory boards, whatwere lessons learned, if any, in terms of
maintaining self-determination and makingsure that voice of chw's is heard in the process? you want to go with that, gail? sure, it's sort of to the effect of what iwas saying before. i mean i think that we have dedicated resources and staff time toactually ensuring that there be a community health worker association with voice at thetable and with support to speak up. i think people need to be mindful of that. they needto understand what the specific challenges are that community health workers face inparticipating in these conversations and actually make active attempts to get past them so thatcommunity health workers feel ownership and otherwise there is no point in doing this.i guess i would just leave it at that.
yeah, i would say that it was really laborintensive for us. we really had to go throughout the state and beat the bushes and find smallgroups of people that wanted to organize and then really worked to help them not only becomeorganized, but to become literate and intelligent about the salient issues so that people werereally able to consider what are their potentials and consequences of certification, not justto meet just the hopes or the dreams , but what is the reality and what is the nationalexperience today so they can be, like i said, deliberately intelligent about it. that wasnot an easy thing to do. it took us quite a bit of time traveling across the state doingthat, but i will say that it's chw's are typically not in a position of power in their work experience.so bringing them to a table to leaders and
asking them to contribute to that needs support.that is not a normal posture or position for them to be in. they really need a lot of encouragementand support in order to be able to contribute their wisdom to a discussion of a group inwhich there are power dynamics that are working against us. kristen, you have some comments to make inwrap up? yes, so thank you so much to our panel andour speakers today for the engaging discussion. i just wanted to mention that we have a coupleof slides here with different references and also resources that will be available to everyonewhen the slide deck is posted on astho's web page. i just wanted to thank everyone forjoining us today and as mentioned earlier,
you will be immediately directed to an evaluationat the conclusion of today's webinar. so please take a few minutes to complete our surveythat provides with useful information for our future projects. it also has questionsrelated to the work you are doing around community health workers in your state. we really wantto hear about the work that you are doing and how it may inform our future projects.i would like to thank hrsa for sponsoring this webinar and i would also like to thankour speakers, kt kramer, carl rush, gail hirsh, katie miller, and sergio matos. a recordingof today's webinar will be available on our website within the next few days and the webaddress is on your screen now. as carl mentioned, we will also post the answers to some of theq&a questions that we weren't able to get
to during the discussion this afternoon. wehope that you will be able to use this webinar as a resource and will share the link withothers once it is available. also, please visit astho's website to access the numberof chw resources, along with the other resources that our presenters shared with us today.information about the next webinar in this community health worker call series will beavailable soon. if you have any questions about today's webinar, please feel free tocontact me at krego@astho.org. thank you so much and enjoy the rest of your day. [end of audio]
Demikianlah Artikel Florida Department Of Health License Verification
Anda sekarang membaca artikel Florida Department Of Health License Verification dengan alamat link https://yanderatjen.blogspot.com/2017/05/florida-department-of-health-license_23.html
0 Response to "Florida Department Of Health License Verification"
Posting Komentar