Neighborhoods Matter

State: WA Type: Model Practice Year: 2012

A 2008 report A Healthy Start: Spokane’s Future Maternal and Infant Health (MCH Report), demonstrated that Spokane County had significant maternal and infant health (MIH) issues, many of which were disproportionately worse for those on Medicaid and racial minorities, especially African Americans and Native Americans. This is especially concerning because of Spokane County’s 471,221 residents 86.7% are non-Hispanic white. Key findings included: • In 2006 35.4 % of births were to unmarried women compared to 31.7% for Washington State. This rate is higher for Blacks/NH (57.8%), Native Americans/Alaska Natives (NAAN) (72%) and Hispanics (48.2%) compared to the White/NH population (33.4%). • 46.2% of births were to women on Medicaid compared to Washington State’s 39.1%. • Smoking rate among pregnant women was 20.1%, approximately twice Washington State’s rate of 10.3%. This is disproportionately higher for women on Medicaid (31.7%) compared to women not on Medicaid (10%). This rate is also disproportionately higher for Black and NAAN at 25.3% and 36.2% respectively, compared to Whites at 19.5%. • One in ten births was pre-term. This is disproportionately higher in Black and NAAN women at 14.8% and 14.3% respectively compared to 10.7% in White women. To impact these trends, the Community and Family Services Division of the Spokane Regional Health District (SRHD) shifted our existing paradigm for developing interventions from addressing a problem’s symptoms to its root causes. Furthermore, we changed our approach from individual service delivery to population based, emphasizing policy development and focusing on reducing health disparities in vulnerable populations. We centered our attention on a specific neighborhood and worked in concert with community partners and neighborhood residents. We called the program Neighborhoods Matter. Neighborhoods Matter (NM) was launched in January 2010 with the selection of a neighborhood. It is led by an intra-divisional team that includes a public health nurse, a community organizer, an epidemiologist, an environmental public health staff and a program manager. The selection process included: the establishment of an Advisory Board consisting of key leaders in Spokane who made the final decision regarding the neighborhood; key informant interviews; focus groups; and a Request for Information and Intent (RFII). The selection process utilized quantitative and qualitative data using indicators from the MCH Report and other indicators regarding undeserved populations, poverty, and chronic disease for quantitative measurements. The RFII provided the qualitative data. The Advisory Board reviewed and scored applications and the East Central neighborhood of Spokane was subsequently chosen. East Central has a population of 11,800. A community health assessment of the neighborhood found that 52% of residents over the age of 18 live at or below 200% of the federal poverty level (FPL); 32.5% of residents were on food assistance; and nearly 72% of elementary school children were enrolled in the free/reduced school lunch program. From 2007-2009, 65.6% of births in East Central were paid for by Medicaid. Yet East Central has many community assets including a community center, a library, several churches, two elementary schools, active business associations, a Neighborhood Council, and many residents who are committed to improving the neighborhood. The goal is to reduce health disparities impacting maternal, child and family health by improving parental protective factors. Our objectives include: 1. Expand neighborhood capacity to address root causes of health issues 2. Create connectivity among residents 3. Create sustainability A Governance Council composed of residents and key stakeholders began meeting monthly as soon as the neighborhood was selected. They identified issues and concerns in the following categories: nutrition and physical activity; housing; safety; and, maternal-child health. The Governance Council utilized the SMART criteria to determine potential solutions to meet our goal and objectives. We decided on the following: Community Kitchens, Urban Fruit Tree Harvest, Community Garden, and Play and Learn. The budget for Neighborhoods Matter is approximately $400,000 per year, the majority of which is from local capacity development funds. To date, NM held two 6-week Community Kitchens, distributed over 1000 pounds of fresh fruits and vegetables, was a key player in the establishment of a community garden in a city park, and recently launched weekly Play and Learn sessions. In addition, we successfully kept open the neighborhood library branch. We have also created evaluation tools to measure the parental protective factors. Lessons we have learned thus far include: • The program resonates with residents since they are involved in the process. • It takes time to build trust, implement interventions, and see the outcomes. • Developing the leadership capacity of residents should be a component of all the interventions.
Health Issues Neighborhoods Matter seeks to reduce health disparities impacting maternal, child and family health in the East Central neighborhood of Spokane. The interventions that were identified and developed involved collaborative engagements with neighborhood residents and were guided by the 5 protective factors needed to strengthen families and communities: nurturing and attachment; knowledge of parenting and child and youth development; parental resilience; social connections;  concrete supports for families. When the East Central neighborhood was selected as the pilot site for Neighborhoods Matter, a Governance Council composed of neighborhood residents and key stakeholders began meeting monthly to identify issues and concerns within the neighborhood and their potential solutions. In addition, we conducted "man on the street" interviews, held focus groups, and reviewed neighborhood data. At that time staff began to regularly attend neighborhood meetings including those hosted by the neighborhood council, business associations, and church-led programs. Issues and concerns identified by the residents fell under the following categories: nutrition and physical activity; housing; safety;  maternal –child health. Over a period of three months, the Governance Council met twice per month to identify possible interventions to implement. We utilized the SMART (specific, measurable, achievable, realistic, and time bound) criteria to determine which interventions would best address maternal and child health. Through this process, we decided on the following: Community Kitchens, Urban Fruit Tree Harvest, Community Garden, and Play and Learn. Furthermore, we have utilized Community Cafés to gain input from residents regarding safety concerns and identify measures that can be taken to address those. Neighborhoods Matter’s interventions empower residents of East Central to address issues affecting maternal, child and family health. Examples include: • Community Kitchens is a model that fosters community connectivity while promoting nutritious food by bringing neighborhood residents together to cook and discuss nutrition and other issues. Participants have identified the opportunity to get to know their neighbors as a component that is valued. For low-income families, this model builds the social connections necessary to build resiliency. Also, as a train-the-trainer model, residents are encouraged to lead sessions, which addresses the sustainability of the activity. • The Urban Fruit Tree Harvest is led by two refugees who view it as powerful medicine against the isolation that many refugees experience when they settle in Spokane. They are able to meet other neighborhood residents who volunteer to share fruits from their trees. At the same time, they share the harvested fruits with other neighbors allowing the refugees to give back. As one of the refugee coordinators stated,” the urban fruit tree harvest is better than the medicine you get from the doctor.” • Play and Learn, our newest intervention, encourages parents to play with their children. Through this activity they learn developmentally appropriate parenting which helps increase attachment and bonding. In addition, they build social connections with other parents in their neighborhood and are provided references for concrete services. As Play and Learn progresses, we plan to create a parent advisory board to provide guidance for the project as well as assist in identifying parents who will eventually take over the weekly Play and Learn sessions. Innovation Population-based interventions are not new to public health. Within SRHD, our Health Promotion division successfully worked with the City’s Planning Department on a proposal for Complete Streets. The primary difference with Neighborhoods Matter is our focus on a specific neighborhood and the intention of involving community residents in the program. In the process of designing Neighborhoods Matter, we reviewed two categories of literature: articles on population level approaches, both theoretical and practical, and existing guides and toolkits on community engagement. For the first category, we especially took note of Whatever It Takes: A White Paper on the Harlem Children’s Zone, which provided an example of a comprehensive approach to changing the outcomes for children and youth living within a specific geographical boundary. Adopting a Population-Level Approach to Parenting and Family Support Interventions by Ronald J. Prinz and Matthew R. Sanders (Clinical Psychology Review) looked at how parenting interventions can be implemented at the community level to reach a broader audience. Developing Population Health Competencies Among Public Health Nurses in Georgia by Jakeway, Cantrell, Cason and Talley (Public Health Nursing) and Transforming Elements of Public Health Practice: Preliminary Considerations by Hofrichter (Tackling Health Inequities Through Public Health Practice: A Handbook for Action) helped in the decision to create a multi-disciplinary team that includes a public health nurse and a community organizer. The second category of literature provided tools that we used including Mapping the Assets of your Community: A Key Component for Building Local Capacity and the Healthy Communities Toolkit. Utilizing insights from the literature review, we designed Neighborhoods Matter to be a community-driven, community-based program. As was previously mentioned a neighborhood was selected based on several indicators impacting maternal and child health. The traditional approach to improving maternal and child health utilizes homevisits with individual parents. Even though homevisitation remains an important and integral intervention that has a proven record of success, we wanted to focus on the root causes of the problem and to involve the broader community in identifying and solving problems. We view community members as assets and acknowledge that the health of a mother and her child is impacted by biological, social, environmental, and economic factors. Thus, we need to look not only at affecting individual behavior but also on systemic changes. A mother who lives in an area considered to be a food desert has difficulty shopping for nutritious food. She relies on what the corner store has available. When looking at interventions, we may consider working with the corner store to provide fruits and vegetables. We could also talk with neighborhood residents to see if they are interested in starting a community garden. At the policy level, we may work with the city to provide tax incentives for a grocery store to open in the neighborhood. This multi-level approach is required to make lasting change on the mother’s behavior regarding what she feeds her child.
Primary Stakeholders The primary stakeholders in Neighborhoods Matter include residents of the East Central neighborhood, existing neighborhood groups, coalitions and organizations serving Spokane County, churches, local government, and the Spokane Regional Health District. Stakeholders/Partners Role The role of stakeholders/partners in the planning and implementation of the practice include: • Identify issues: As was mentioned above, neighborhood residents identified nutrition and physical activity, safety, housing, and maternal and child health as important issues affecting them. Specifically they talked about limited access to fresh fruits and vegetables especially for low income families, not feeling safe because of speeding cars or not having enough street lights, limitations in availability of affordable housing, and diminishing resources for low-income parents. • Identify interventions: The Neighborhoods Matter Governance Council identified interventions including Community Kitchens and Grant Park Community Garden. A smaller workgroup of neighborhood residents have been meeting regularly to identify how to improve safety in their part of the neighborhood. They drafted a letter to the Neighborhood Council urging them to ask the City of Spokane to examine ways to slow down vehicles on two streets that are highly utilized by children and seniors. • Lead the interventions: Neighborhood residents are the key players in leading interventions. For example, two refugees are spearheading the Urban Fruit Tree Harvest which is an idea that they proposed to the Governance Council. They recruited homeowners to donate fruits from backyard trees, harvested the fruits, and distributed them to low-income residents of East Central. • Evaluate the interventions: The Governance Council conducts regular evaluations of Neighborhoods Matter activities. The goal is to identify which activities are going well and improvements that can be made. LHD Role SRHD staffs Neighborhoods Matter. The staff convenes meetings, implements identified interventions, interfaces with the community and partner organizations, recruits neighborhood residents for different activities, identifies and strengthens the leadership capacity of individual neighborhood residents, and evaluates the outcomes of each intervention. Furthermore, staff brings forth policy proposals to both the Advisory Board and the Governance Council. For example, we are currently working with neighborhood residents to enact an Alcohol Impact Area (AIA) for the East Central neighborhood, which has seen an increase in public drunkenness. The AIA will ban the sale of inexpensive high alcohol content beer at area stores. Members of the Advisory Board and Governance Council wrote a joint letter that they submitted to the City Council supporting the AIA as well as testifying at a City Council meeting. Staff is also providing support to resident led activities to document the adverse impact these beverages have on the neighborhood. Since our focus on the East Central neighborhood of Spokane is limited to 3 years, staff is also tasked with ensuring that the program successfully transitions to a neighborhood-based organization. Neighborhoods Matter strongly believes that lasting change to maternal and child health in the East Central neighborhood of Spokane is dependent on the active involvement of its residents. When staff interacts with residents, they are partners, not experts. We let residents know that they are the experts because it is their community. In the way that Neighborhoods Matter is structured, the Governance Council is the driver of the bus. It identifies issues of concerns and, with assistance from staff, determines and implements interventions. Since the Advisory Board consists of key leaders in the broader community including elected officials, it works with the Governance Council on promoting policy changes such as opposing the closure of the East Side Library and supporting the implementation of an Alcohol Impact Area. Outside of those two bodies, Neighborhoods Matter also interacts with neighborhood residents who attend our activities. Staff identifies and works with residents to take leadership roles whether by joining the Governance Council, by leading Community Kitchens, or by testifying before the City Council. Lessons Learned During the course of implementing Neighborhoods Matter, we have learned several lessons including: • Neighborhoods Matter resonates with residents because they are part of the process. • It takes time to implement interventions and have the data needed to measure their effectiveness. • Developing the leadership capacity of community residents has to be systematic and take into account their skills and personalities. • Going into a neighborhood with assets is important. We need to be able to build on existing relationships and structures in order for the effort to be sustained. • Developing relationships with different stakeholders and residents is necessary to build trust. • We have to be willing to make mistakes on the interventions and either modify them or move on to another intervention. For example, traditional parenting classes do not work for low-income parents who view them as punitive. Thus, we implemented Play and Learn which focuses on the importance of play in the relationship between a parent and her child. • Evaluation is important and must be done both quantitatively and qualitatively. This is sometimes hampered by the lack of evaluation tools for community connectedness or effective parenting. Implementation Strategy The goal of Neighborhoods Matter is to reduce the health disparities impacting maternal, child, and family health in the East Central neighborhood of Spokane. Specific objectives and corresponding tasks are as follows: Objective 1: Expand the neighborhood capacity to address root causes of health issues. Tasks for this objective included hosting Community Cafes which brought neighborhood residents together to discuss safety concerns and determine solutions. Residents recognized that speeding cars and lack of street lights hinder their ability to engage in physical activity such as walking. Another is promoting policies to improve the well-being of neighborhood children. This includes opposing the closure of the neighborhood library which provides a safe space for children after school. We also supported the establishment of an Alcohol Impact Area in the neighborhood. The AIA bans inexpensive high content beer particularly in corner stores located near an elementary school and a park. Objective 2: Create connectivity among neighborhood residents. All of our activities are designed to increase community connectivity. Specific examples are: Community Kitchens, which enables residents to cook together and discuss nutrition issues; Grant Park Community Garden, which not only provided nutritious food but also built relationships among neighbors; and, the Urban Fruit Tree Harvest, which allowed refugees to connect with other residents in their neighborhood and, at the same time, give back to the community. Objective 3: Create sustainability To create sustainability, Neighborhoods Matter has been intentional in designing activities that allow for training neighborhood residents on the activities implemented. The Community Kitchens is a train-the-trainer model as is Play and Learn. The Urban Fruit Tree Harvest was developed and implemented by refugees who will continue with the project in the coming years. With the Grant Park Community Garden, we provided some funds to assist in the creation of a governing body. The time frame for Neighborhoods Matter is 3 years (2010-2012). We spent the first six months selecting the neighborhood. During the subsequent six months, we worked with neighborhood residents to identify issues and concerns and appropriate interventions. In 2011, we were able to implement the interventions. Timelines for specific tasks are as follows: • Community Kitchens were implemented twice in 2011 – one in the Spring and another in the Fall. • The Grant Park Community Garden was approved in the first quarter of 2011 and the garden broke ground in May. By June, 40 plots have been built with limited resources. By the end of the growing season in November, 90% of the plots were rented. • The Urban Fruit Tree Harvest got off the ground in June and harvests took place from August to November. • Community Cafes focusing on neighborhood safety were held every three weeks starting in July. • Play and Learn was launched in October of 2011 and is being held every week. For 2012, our goal is to expand the interventions to cover different areas of the neighborhood and to work with the Governance Council to transition the oversight of these activities to them.
Process & Outcome Identify high need areas in Spokane County pertaining to maternal and child health: Thirty-eight neighborhoods were identified in Spokane County using designated boundaries established by the City of Spokane, Office of Neighborhood Services. Within the boundaries, block groups were identified and collapsed together to determine a neighborhood. Selected indicators were utilized to determine Spokane County neighborhoods that require high need maternal and child health interventions. The methodology included the collection and analysis of eight indicators from birth certificate data that correlate to each of 38 neighborhoods in the county. The indicators included the proportion of: teenage pregnancies, maternal smokers, unmarried mothers, births paid by Medicaid, pregnancies with late/no pre-natal care, pregnancies with short-inter-pregnancy intervals, births with low-birth weight, and pre-term births. They were selected because these indicators could determine the future health of a neighborhood, and were risk factors that greatly affected the health and well-being of mothers and infants. Neighborhoods were compared to one another based on the proportion of the female population that was observed for the desired indicators. Neighborhoods having the lowest proportion ranked highest and neighborhoods with the highest proportion ranked lowest. Each neighborhood was given a score of one, two, three, or four which corresponded to their percentile ranking. Spokane County averages for the indicators served as the benchmark. Neighborhoods with a score of a one were in the upper 75th percentile and were ranked highest for the specified indicator. Neighborhoods with a score of a two were in the 50th to 74th percentile and were ranked in the middle but their scores were higher than county’s score for the specified indicator. Neighborhoods with a score of a three were in the 25th to 49th percentile and were ranked in the middle but their scores were lower than the county’s score for the specified indicator. Neighborhoods with a score of a four were in the zero to 24th percentile and were ranked lowest for the specified indicator. After a score was determined for each of the eight indicators for each neighborhood and for the county, an overall average score was calculated for each neighborhood and for Spokane County. The overall average score for each neighborhood and for the county was calculated by summing the scores received for each indicator and dividing by the total number of indicators. Neighborhoods were then ranked against one another using their overall average score based on the eight indicators and then compared to Spokane County’s overall average score. Neighborhoods whose overall average score was above the county’s overall average score were characterized as low need areas in Spokane County with regard to maternal and child health. Neighborhoods whose overall average score was below the county’s overall average score were characterized as high need areas in Spokane County with regard to maternal and child health. After concluding the assessment of neighborhoods for maternal and child health concerns using the above mentioned methodology, 17 neighborhoods in Spokane County were identified as being high need areas. Results were shared with Neighborhoods Matter's Advisory Board, its Steering Committee, which consists of SRHD’s Health Officer and Directors of Divisions contributing staff to the program, and with the staff. The extensive review and analysis that went into this part of the neighborhood selection process allowed SRHD to educate everyone involved but particularly those on the Advisory Board who are from the community on the impact of the various indicators. We have since shared this particular methodology with other local health jurisdictions at the Annual Joint Conference on Health in Washington State, and have received positive responses. Identify neighborhoods with desired community assets: As an asset based program, Neighborhoods Matter focuses on strengths that are pre-existing in the neighborhood rather than weaknesses. To strategically address maternal and child health issues, the high need neighborhood also had to contain multiple assets that could be expanded upon. To begin, staff compiled a list of desired assets that they felt would serve as a foundation to build off of when entering into a neighborhood. The list included: a community center, organizations, social service agencies, neighborhood council, clinics, schools, transportation, COP (Community Oriented Policing) shops, etc. We felt that with these assets present, we would be able to have a platform for engaging the community in a discussion around maternal and child health issues, listen to their ideas, and assist with implementing their proposed solutions. The asset identifying process was crucial in narrowing the number of neighborhoods under consideration for the Neighborhoods Matter program. After a review of the desired community assets for the 17 neighborhoods, 3 neighborhoods were identified as possible sites for the program. The three neighborhoods identified in Spokane County as being asset rich and high need were: East Central, West Central, and Hillyard. The result of this process was presented to the Advisory Board. There was no surprise regarding the three neighborhoods that emerged. All have been considered high need neighborhoods for many years. However, by examining neighborhoods through an asset lens, Advisory Board members gained a new appreciation for the efforts that are already ongoing in these neighborhoods. Select neighborhood for Neighborhoods Matter program: The selection process of the neighborhood for Neighborhoods Matter consisted of collecting, analyzing, and presenting qualitative and quantitative data for the three neighborhoods identified as having desired community assets. A methodology with a transparent selection process was developed for the final phase. The concluding step in the selection process began by incorporating quantitative and qualitative data to determine a final score that reflects the overall need of the remaining neighborhoods. The quantitative data constituted 40% of a neighborhood’s overall final score while the qualitative data constituted 60% of the overall final score. The quantitative data consisted of 21 indicators and were separated into four factors: Demographic, Poverty, Health, and Maternal and Infant factors. Quantitative data was collected for each indicator, for each factor, for each neighborhood. Factor 1: Demographic (5% of overall score) Indicators (Each contributed 25% to the overall score of the demographic factor): • Proportion of ethnic/racial minorities • Proportion of 0-4 year olds • Proportion of 15-34 year olds • Proportion of single parents Factor 2: Poverty (10% of overall score) Indicators (Each contributed 33.3% to overall score of the poverty factor) • Proportion of adults with a high school education or less • Proportion of residents utilizing food stamps • Proportion of elementary students participating in the free/reduced lunch program Factor 3: Health (10% of overall score) Indicators (Each of these are weighted differently as indicated by the percentages below. The indicators that were weighted more could be directly influenced by interventions.) • Life expectancy (15%) • Overall mortality rate (15%) • Sexually transmitted disease (STD) infection rate (35%) • Proportion of adults with chronic disease such as asthma, diabetes and obesity (35%) Factor 4: Maternal and Infant Health (15% of the overall score) Indicators (Each contributed 12.5% to the overall score of the maternal and infant factor) • Teen pregnancies • Maternal smokers • Unmarried mothers • Medicaid births • Late/no prenatal care • Short inter-pregnancy interval • Low birth weight • Pre-term births Once data was collected for each indicator for each of the three neighborhoods, they were compared to one another and given a score of one, two, or three. A three reflected that the neighborhood had the highest need for intervention for that indicator and a one reflected that the neighborhood had the lowest need for intervention for that indicator. An overall score was then calculated for each neighborhood by summing the weighted score for each quantitative factor. The data collected for the qualitative portion came from a Request for Information and Intent (RFII) and consisted of six questions. As with the quantitative data, responses to the RFII questions were separated into four factors: Protective, Stabilizing, Willingness to Partner, and Resident Involvement. Each factor had corresponding indicators. Factor 1: Protective (15% of the overall score) Indicators (Each contributed 20% to the score for protective factor) • Nurturing and attachment • Child development • Parental resilience • Social connections • Concrete support Factor 2: Stabilizing (10% of the overall score) Indicators (Each contributed 50% to the score for stabilizing factor) • Agencies that support families and children • Current major activities that support health of families Factor 3: Willingness to Partner (25% of the overall score) Indicators (Each contributed 50% to the score for willingness to partner) • Interests in partnering with Neighborhoods Matter • Letters of recommendation Factor 4: Resident involvement (15% of the overall score) Indicator (100% of the score for resident involvement) • How are residents involved in creating change in their neighborhood The qualitative data gave the neighborhoods the opportunity to express their interest in working with SRHD and explain why Neighborhoods Matter would benefit them. Completed applications were reviewed independently by seven members of the Advisory Board. The neighborhood who answered the question the best received a score of three and the neighborhood with the least best answer received a score of one. An overall score was then calculated for each factor for each neighborhood by summing the weighted score for each qualitative factor. The quantitative and qualitative scores were then combined and an overall final score for each neighborhood was determined. A discussion of the neighborhoods with the top two scores ensued and their needs for the services that Neighborhoods Matter would provide was assessed. The neighborhood selected was East Central.
There are currently commitments for the sustainability of several of the activities. The Urban Fruit Tree Harvest will be transitioned to Refugee Connections Spokane in the summer of 2012. The Grant Park Community Garden is already part of the South Perry Business and Neighborhood Association. It was understood that our assistance in establishing a governing body for the community garden would end in December 2011. We are currently working to imbed Play and Learn in one of the low-income housing complexes in the neighborhood. In the next few months we will be establishing a Parent Advisory Board to identify and work with parents from the apartment complex to continue offering Play and Learn past 2012. With the Community Kitchens, we have a cadre of four community members who have been trained to facilitate them. Our goal in 2012 is to take Community Kitchens to various parts of the neighborhood and identify additional residents who will lead them. We are also looking into working with local churches and the community center to host Community Kitchens. This will allow the practice to be institutionalized within existing organizations in the community. The Governance Council is currently working on creating Bylaws and having conversations with two existing organizations within East Central that could serve as the fiscal agent for Neighborhoods Matter East Central in the future. When Neighborhoods Matter began, SRHD made a three-year commitment to the program. It has become evident that in order to make the systemic changes desired, it will require more than three years. Similar programs in other parts of the country, like the Harlem Children's Zone, took at least 10 years to show results. Lower state and local budget projections have put into question how long SRHD can maintain the program, and if it does, whether it would choose to remain in the current neighborhood or transition into another. We are actively applying for private funding and applied for a grant from HRSA, but were unfortunately denied. We recently submitted a proposal to the City of Spokane and are awaiting the decision. We are partnering with other organizations such as Catholic Charities and Washington State University to submit joint funding applications particularly around parental protective factors and maternal-child health. In spite of these fiscal challenges, residents and staff remain enthusiastic and committed to sustaining the efforts of the previous two years. Members of the Governance Council have expressed interest in actively seeking grants and learning how to write grants. Furthermore, as was mentioned earlier, a couple of the activities are being transitioned to other entities in 2012. This will enable staff to focus on taking the remaining activities to scale and assuring that their effectiveness is evaluated. We are confident that Neighborhoods Matter is on the right path since we are being used as a model by other health jurisdictions in Washington State.
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