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2012 Model Practice Application (Public)Application Name: 2012 Model Practice Application (Public) : LA County Department of Public Health - Emergency Preparedness and Response Program : Los Angeles County Department of Public Health - Community Partner Assessment Toolkit (cPAT) Applicant Name: Mr. Sinan Khan, MPH, MA Application Title: Los Angeles County Department of Public Health - Community Partner Assessment Toolkit (cPAT) Please enter email addresses you would like your confirmation to be sent to. sikhan@ph.lacounty.gov Practice Title Community Partner Assessment Toolkit (cPAT) Submitting LHD/Agency/Organization Los Angeles County Department of Public Health - Emergency Preparedness and Response Program Head of LHD/Agency/Organization Dr. Alonzo Plough Street Address 600 S. Commonwealth Ave, Suite 700 Practice Contact Person Sinan Khan Submitting LHD/Agency/Organization Web Address (if applicable) www.lapublichealth.org/eprp Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice Emergency planners at local health departments (LHDs) continue to develop mass prophylaxis plans to prophylax entire populations within forty eight hours in order to reduce mortality after a bioterrorist attack. Although, Points of Dispensing (PODs) serve as cornerstones for mass prophylaxis many LHDs find it extremely difficult to prophylax their entire population within forty eight hours using only their PODs because of staffing, security and site availability concerns. Several LHDs are therefore beginning to explore the possibility of utilizing alternate modes of dispensing to assist with mass prophylaxis.
Los Angeles County (LAC) spans across 4,752 square miles with eighty-eight incorporated cities and several unincorporated areas. The population of the county of 10 million people is extremely diverse due to a high rate of immigration, with people representing more than a 140 nations and speaking over 100 languages. In addition, the County has several high priority terrorist targets, is a large tourist destination, neighbors a larger tourist destination, has a large daytime population influx, and also has a large sheltered-in population. The Los Angeles County Department of Public Health must therefore plan to mass prophylax up to 12 million people within 48 hours of a bioterrorist attack to prevent loss of lives and reduce widespread panic.
There are several alternate modes of dispensing available for mass prophylaxis beyond the use of PODs. However, until the development of this toolkit, there was no formal method to analyze and compare these alternatives. Since the speed of dispensing or total number reached, staffing requirements, and security needs for the various mode of dispensing are different, it is difficult to quantitatively estimate the advantages offered by one mode of dispensing over another.
The Los Angeles County Department of Public Health (LACDPH) working with the Naval Postgraduate School (NPS) and the Centers for Disease Control and Prevention (CDC) developed a Microsoft Excel based multi-criteria decision support toolkit that would assist the County and other LHDs analyze the effectiveness of various alternate modes of dispensing within their jurisdiction. Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. The toolkit took into account the number of individuals that can be reached, the staffing requirement (clinical and non-clinical) as well as security requirements (site security and transportation security) for each alternate mode of dispensing and creates an objectives hierarchy that is used to measure the overall effectiveness of each alternate mode of dispensing and the trade-offs a decision-maker is willing to make between them. Finally, the toolkit provides a simple graphical output detailing optimal alternate modes of dispensing for the jurisdiction as well as a one-way and two-way sensitivity analysis of the results.
This toolkit dubbed ‘Community Partner Assessment Toolkit (cPAT) was presented as a part of a SNS Webinar hosted by the CDC in February 2011 and applied by the Los Angeles County Department of Public Health to develop its alternate dispensing strategy. The primary audiences of this toolkit are local and state SNS and Mass Prophylaxis coordinators as well as SNS reviewers/advisors at the CDC and DHHS. Describe the public health issue that this practice addresses. (350 word limit)
Emergency planners at local health departments (LHDs) continue to develop mass prophylaxis plans to prophylax entire populations within forty eight hours in order to reduce mortality after a bioterrorist attack. Although, Points of Dispensing (PODs) serve as cornerstones for mass prophylaxis many LHDs find it extremely difficult to prophylax their entire population within forty eight hours using only their PODs because of staffing, security and site availability concerns. Several LHDs are therefore beginning to explore the possibility of utilizing alternate modes of dispensing to assist with mass prophylaxis.
There are several alternate modes of dispensing available for mass prophylaxis beyond the use of PODs. However, until the development of this toolkit, there was no formal method to analyze and compare these alternatives. Since the speed of dispensing or total number reached, staffing requirements, and security needs for the various mode of dispensing are different, it is difficult to quantitatively estimate the advantages offered by one mode of dispensing over another. Therefore there was no simple way for emergency planners to determine which alternate mode of dispensing would be the most effective in their jurisdiction. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) There several formally written literature on alternate modes of dispensing. However, most studies are jurisdiction specific and qualitatively indicate the advantages and challenges of an alternate mode of dispensing for that specific jurisdiction. The most important resource to find alternate modes of dispensing being considered or tested by other jurisdictions has been the SNS List Serve, an online discussion forum where individuals working closely with SNS issues post their thoughts and comments as well as questions.
One frequent problem was that there was no specific guideline listed by any jurisdiction to formally evaluate the effectiveness of their alternate mode of dispensing and the ability to compare a portfolio of alternate modes of dispensing across various attributes. The most that is analyzed is how many people are processed through the system within a given time frame. This information is quite important but so are other attributes such as staffing (both clinical and non clinical) as well as security (site and transportation).
LACDPH therefore launched forward to develop an innovative approach of evaluating the effectiveness of alternate modes of dispensing and being able to compare their strengths and weaknesses across various attributes in a uniform manner. LACDPH wanted the process to be applicable to all alternate modes of dispensing and in any jurisdiction. How does the practice address the issue? The toolkit runs on Microsoft Excel and contains all Multi Attribute Value Function (MAVF) calculations pre programmed into relevant cells on the spreadsheet. In addition, the toolkit is includes directions, examples and messages for each cell where data must be entered by the users (including potential sources of data). There are several alternate modes of dispensing available for mass prophylaxis beyond the use of PODs. The toolkit takes into account 8 alternate modes of dispensing considered best practices by the CDC:
- Prepositioning of medication:
o for government employees and their families
o hospital patients, staff and staff families
- Dispensing of medication to
o Critical Infrastructure employees and their families
o Sheltered in Populations
o Tourists, Travelers, Hotel Employees and Families
o Large Private Sector Employers
o Students and Faculty at Colleges and Universities
o Tribal Nations
and allows planners to include up to three additional community partners that may be unique to their jurisdiction. Planners are required to provide basic information each of three criteria: Maximum Number of Individuals that can be reached, clinical/non-clinical staffing requirements and site/transportation security rating for each alternate mode of dispensing as well as basic POD information. Finally, the planner must provide their preference for each of the three attributes – thus representing the trade offs they are willing to make. Once information is entered the toolkit provides a graphical output of the efficiency of each community partner as well as a one way and two way sensitivity analysis of the results that can be understood by decision makers from non-statistical backgrounds.
This process reveals and documents decision maker’s preferences. It also highlights areas where different decision makers may have points of disagreement. Finally, since the analysis is quantitative, it permits marginal and sensitivity analysis to be rapidly performed for a variety of scenarios. This toolkit offers several advantages as it considers each alternative independently, it provides a good approximation in practice, can be easily explained, and can be understood by decision makers from non-statistical backgrounds. Is the practice new to the field of public health? If so, answer the following questions. Yes What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. Based on our literature review, a comparative analysis was performed to understand how involving business in dispensing of drugs during a mass prophylaxis event would reduce the stress on PODs. The paper compared the use of business PODs, regular PODs, USPS and a combination of all three options using the strategy canvas developed by W. Chan Kim and Renee Mauborgne in Blue Ocean Strategies, which allows decision makers to understand “current status of activities to be captured against a range of factors associated with performance within a given industry” visually represented by a value curve (Smith, 2007). This curve shows the relative performance of an option based on the selected factors (Chan and Mauborgne, 2007). However, there were no concrete overarching studies that analyze speed of dispensing, staffing requirements (clinical and non-clinical), and security (transportation and site) for various alternate mode of dispensing through formal statistical analysis. LACDPH was first to employ a multi-objective decision analysis, a well established tool in decision analysis and operations research, to analyze which alternate mode of dispensing would be the most valuable during a mass prophylaxis event and develop a toolkit that any LHD could use to develop their alternate dispensing strategy. How does this practice differ from other approaches used to address the public health issue? Although there is formal literature on alternate modes of dispensing available online, most literature focuses on a specific alternate mode of dispensing and spells out its advantages and disadvantages. One frequent problem is that there are no specific guidelines listed by any jurisdiction to formally evaluate the effectiveness of their alternate mode of dispensing. The most that is analyzed is how many people are processed through the system within a given time frame. This information is quite important, but so is evaluating the staffing and security needs and any added benefit the alternate provides the jurisdiction over other modes of alternate dispensing. The cPAT toolkit is the first such toolkit that allows local health departments to analyze the effectiveness of alternate modes of dispensing by comparing them to each other by implementing a proven mathematical model. The toolkit is easy to use and provides a graphical output detailing optimal alternate modes of dispensing for the jurisdiction as well as a one-way and two-way sensitivity analysis of the results. The graphical results can easily be understood by decision makers without a statistical background. Is the practice a creative use of an existing tool or practice? If so, answer the following questions. No What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?
What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. How does this practice differ from other approaches used to address the public health issue? Who were the primary stakeholders in the practice? Los Angeles County - Department of Public Health Emergency Preparedness and Response Program What is the LHD's role in this practice? The Los Angeles County Department of Public Health’s (LACDPH) Emergency Preparedness Program (EPRP) operates as a first line of defense to prevent, protect against, quickly respond to, and recover from health emergencies, including natural, biological, chemical and radiological incidents. EPRP also provides strategic direction, support, and coordination for LACDPH preparedness and emergency response activities. As a part of its emergency planning, EPRP is responsible for mass prophylaxis planning and would therefore be required to prophylax up to 12 million people within 48 hours of a biological attack. Given the geographic size of the County, the number of PODs required, the number of staff and security requirements EPRP choose to explore various alternate modes of dispensing. EPRP thus became the primary facilitator of the development of Community Partner Assessment Toolkit (cPAT) as a whole. What is the role of stakeholders/partners in the planning and implementation of the practice? Several local partner agencies within the County of Los Angeles, such local law enforcement, fire departments and emergency medical services agency provide their input in order to make the toolkit’s functionality viable. In addition, LACDPH partnered with the Center for Homeland Defense and Security at the Naval Postgraduate School and the Centers for Disease Control and Prevention’s Division of Strategic National Stockpile in the development of the toolkit. LACDPH considers all local public health jurisdictions that must assess the viability of alternate modes of dispensing within their jurisdiction as stakeholders. Based on LACDPH’s application of the toolkit – emergency planners found that LACDPH could prophylax 53% of its population outside of PODs via the implantation of four alternate modes of dispensing:
- Prepositioning of Medication for Government employees and their families (Covers 15 % of the population)
- Dispensing of medication to Critical Infrastructure employees and their families (Covers 8% of the population)
- Dispensing of medication to the Veterans Administration (Covers 15% of the population)
- Dispensing of medication by partnering with a local HMO (Covers 15% of the population)
Based on the analysis LACDPH began building partnerships with these community partners. LACDPH now has Memorandum of Agreement with major critical infrastructure partners in Los Angeles, and is currently working on agreements with the Veterans Administration and a major local HMO’s.
What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. The LAC Force Protection Committee (FPC) was established in 2002 to discuss and provide expert advice on all issues concerning the Strategic National Stockpile and Points of Dispensing. The committee is made up of representatives from local, state and federal levels of the government and represents disciplines of Public Health, EMS, Law Enforcement, Fire Department and the Military. This committee has performed extensive work dealing with SNS and Mass Prophylaxis Planning in LAC and the members of this committee are familiar with the security, staffing and logistic environment in LAC. For this reason, they were included as stakeholders in the development of the toolkit.
Once LACDPH had applied the toolkit to its jurisdiction – LACDPH found that joint mass dispensing ventures with local HMOs, the Veterans Administration and Critical Infrastructure Partners would significantly reduce the burden on PODs. Based on the analysis LACDPH began building partnerships with these community partners. LACDPH now has Memorandum of Agreement with major critical infrastructure partners in Los Angeles, and is currently working on agreements with the Veterans Administration and a major local HMO’s. Describe lessons learned and barriers to developing collaborations Once a LACDPH had established which alternate modes of dispensing will best serve the needs of their jurisdiction, based on the cPAT Toolkit it faced a new challenge regarding implementing its findings.
LACDPH faced two major hurdles:
Cognitive Hurdle: Making Stakeholders aware of the issues that the traditional POD approach would not suffice in LAC during a mass prophylaxis emergency where the entire residential population of the County must be prophylaxed within 48 hours.
Motivational Hurdle: Mobilizing stakeholders to act and become a part of the alternate dispensing strategy. LACDPH had to approach each community partner identified as an efficient mode of dispensing by the toolkit in order to partner up with them. Convincing these community partners to act was very difficult given the bureaucratic nature of private sector businesses and the County.
LACDPH eventually over came both hurdles by actively empowering the community partners showing them various cost benefit analyses of the shared responsibility. Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
Objective 1: Conduct a wide literature review and compile a list of the most viable alternate modes of dispensing
Objective 2: Developing a toolkit to quantitatively analyze the effectiveness of alternate modes of dispensing that is applicable by all LHDs
Objective 3: Implement viable mass dispensing strategies based on the analysis
• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
Objective 1: Conduct a wide literature review and compile a list of the most viable alternate modes of dispensing LACDPH conducted a detailed literature review on all alternate modes of dispensing considered best practices by the CDC. LACDPH followed up with jurisdictions via phone interviews and emails to understand the basic layout of the alternate dispensing strategy in that jurisdiction. LACDPH only choose eight alternate dispensing practices that employed the push strategy for the toolkit but also left the option for end user's to enter up to three more alternate modes of dispensing that may be unique to their jurisdiction. Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Objective 2: Developing a toolkit to quantitatively analyze the effectiveness of alternate modes of dispensing that is applicable by all LHDs
Based on our literature review, a comparative analysis was performed to understand how involving business in dispensing of drugs during a mass prophylaxis event would reduce the stress on PODs. The paper compared the use of business PODs, regular PODs, USPS and a combination of all three options using the strategy canvas developed by W. Chan Kim and Renee Mauborgne in Blue Ocean Strategies, which allows decision makers to understand “current status of activities to be captured against a range of factors associated with performance within a given industry” visually represented by a value curve (Smith, 2007). This curve shows the relative performance of an option based on the selected factors (Chan and Mauborgne, 2007). However, There were no concrete overarching studies that analyze speed of dispensing, staffing requirements (clinical and non-clinical), and security (transportation and site) for various alternate mode of dispensing through formal statistical analysis. LACDPH was first to employ a multi-objective decision analysis, a well established tool in decision analysis and operations research, to analyze which alternate mode of dispensing would be the most valuable during a mass prophylaxis event and develop a toolkit that any LHD could use to develop their alternate dispensing strategy.
The cPAT toolkit is the first such toolkit that allows local health departments to analyze the effectiveness of alternate modes of dispensing by comparing them to each other by implementing a proven mathematical model. The toolkit is easy to use and provides a graphical output detailing optimal alternate modes of dispensing for the jurisdiction as well as a one-way and two-way sensitivity analysis of the results. The graphical results can easily be understood by decision makers without a statistical background. The toolkit was presented to LHDs on a CDC hosted webinar and is now accessible to all LHDs through the DSNS website. Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Objective 3: Objective 3: Implement viable mass dispensing strategies based on the analysis
Given that there were over 5 million people in Los Angeles County that fell into one of the five established priority groups for H1N1 vaccination, if LACDPH’s mass vaccination campaign relied on PODs alone, it would have been extremely burdensome on the department’s resources in terms of staff, sites, supplies, and security. LACDPH could have established additional PODs but this would not have resolved the issue because the number of PODs directly correlated to the requisite allotment of resources. LACDPH could have increased the throughput at each site, but this would have had the same limitation, as the throughput is directly correlated to the amount of resources allocated. Since resources were scarce, it became necessary for LACDPH to consider alternate modes of dispensing as a way to complement PODs.
LACDPH evaluated various alternate modes of dispensing to analyze their reach (number of people vaccinated)into the community, staffing requirements and security requirements and built partnerships with these community partners. Kaiser Permanente turned out to be the largest push partner. As seen during H1N1, leveraging private sector resources enabled Los Angeles County to vaccinate a far greater number of individuals than it could with PODs alone, as well as build strategies that could assist the department during any future emergencies, whether due to bioterrorism, naturally-occurring disease outbreaks, or natural disasters.
LACDPH also based it's mass antibiotic dispensing on plans on the output of this toolkit. Once LACDPH had applied the toolkit to its jurisdiction – LACDPH found that joint mass dispensing ventures with local HMOs, the Veterans Administration and Critical Infrastructure Partners would significantly reduce the burden on PODs. Based on the analysis LACDPH began building partnerships with these community partners. LACDPH now has Memorandum of Agreement with major critical infrastructure partners in Los Angeles, and is currently working on agreements with the Veterans Administration and a major local HMO’s. Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. What are the specific tasks taken that achieve each goal and objective of the practice? LACDPH conducted a thorough literature review based on publications and interviews with emergency planners in other LHDs that were planning alternate modes of dispensing in their jurisdiction. However, the single most important resource to find alternate modes of dispensing being considered or tested by other jurisdictions was the SNS List Serve, an online discussion forum where individuals working closely with SNS issues post their thoughts and comments as well as questions.
Once LACDPH had chosen the top eight alternate modes of dispensing LACDPH began to explore various methodologies to quantitatively assess the overall (and categorical) effectiveness of each alternate mode of dispensing. LACDPH partnered with the CDC Division of SNS and the Naval Postgraduate school to explore various possibilities of creating such a mathematical model. Eventually, Multi Attribute Value Function methodology, an operations research strategy, was chosen due to its ability of taking into account the trade-offs a decision maker is willing to make between attributes. LACDPH worked with local community partners and determined that the most important attributes for analyzing alternate dispensing strategies were the number of people reached, staffing (clinical and non-clinical) and security (site and transportation). The toolkit was developed around these attributes.
The toolkit was applied to Los Angeles County and the most efficient alternate modes of dispensing were prepositioning options, dispensing of medication to Critical Infrastructure, dispensing of medications through the Veteran's Administration and dispensing of medications through the largest HMO (Kaiser Permanente) in the County. LACDPH staff aggressively pursued these partners and obtained MOUs with several agencies.
LACDPH wanted the toolkit to be useful for all LHDs - therefore emergency planners began developing a simple MS excel based toolkit that included all directions that emergency planners may need to use it. LACDPH also provided the option for LHDs to enter their own/new alternate modes of dispensing into the toolkit. The output of the toolkit was a simple and graphical and also provided sensitivity analysis of the output.
This toolkit was eventually demonstrated during a national CDC DSNS hosted webinar. What was the timeframe for carrying out these tasks? The time frame for carrying out the tasks can be broken down into three phases:
Development: LACDPH spent close to six months refining the mathematical basis of the toolkit. However, other LHDs choosing to utilize LACDPH's methodology need not spend time on the development. The toolkit has already been developed, is in the public domain and is therefore available to all LHDs at no cost.
Analysis: LACDPH spent approximately 2 weeks in the analytical phase with the toolkit. LACDPH convened meetings with several stakeholders to collect the data points required for each of the three attributes across all alternate modes of dispensing. Since the toolkit has been developed - entering raw data into the toolkit will yield an output of the most efficient alternate modes of dispensing.
Implementation: LACDPH spent a significant amount time in the implementation phase of this project. Based on the analysis LACDPH targeted critical infrastructure partners, Department of Veteran's Affairs and a large local HMO. Although informal agreements were easy to create - formal Memorandum of Understanding were harder. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. Los Angeles County regularly convenes meetings with stakeholders to ensure commitment to the alternate dispensing process that will support mass prophylaxis occurring at PODs. Given that the stakeholders were a part of the process in the development of the mathematical model in the toolkit as well as during analysis and implementation they were given every opportunity to collaborate on the project. Based on LACDPH’s application of the toolkit – emergency planners found that LACDPH could prophylax 53% of its population outside of PODs via the implantation of four alternate modes of dispensing: - Prepositioning of Medication for Government employees and their families (Covers 15 % of the population) - Dispensing of medication to Critical Infrastructure employees and their families (Covers 8% of the population) - Dispensing of medication to the Veterans Administration (Covers 15% of the population) - Dispensing of medication by partnering with a local HMO (Covers 15% of the population) Given that this toolkit was the first of its kind to quantitatively compare the effectiveness of alternate modes of dispensing and its output enabled LACDPH to develop a concrete mitigation plan that would reduce the number of PODs by 50% there is sufficient commitment to sustain the practice. Describe plans to sustain the practice over time and leverage resources. LACDPH conducts regular meetings with the community partners selected as being the most efficient alternate modes of dispensing. These meetings are to engage and update the community partners of the process, and empower them to act. As seen during H1N1, leveraging private sector resources enabled Los Angeles County to vaccinate a far greater number of individuals than it could with PODs alone, as well as build strategies that could assist the department during any future emergencies, whether due to bioterrorism, naturally-occurring disease outbreaks, or natural disasters. Practice Category Choice 1: Emergency Preparedness Practice Category Choice 1, Part 2: Quality Improvement Practice Category Choice 2: Emergency Preparedness Practice Category Choice 2, Part 2: Organizational Practices Practice Category Choice 3: Emergency Preparedness Practice Category Choice 3, Part 2 Workforce Development Check all that apply. I am a previous Model Practice Applicant |
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