Research

Collaborative to Reduce the Use of Substances, HIV and Hepatitis-CRUSHH

Honoring the remarkable, brave youth whom I had the privilege to meet and work with as part of "The White House Office of National HIV/AIDS Policy Meeting on Youth and HIV/AIDS". This meeting’s purpose was to gain input into the development of the National HIV/AIDS Strategy on 1) reducing HIV incidence among youth, 2) increasing access to care and optimizing health outcomes for youth, and 3) reducing HIV-related health disparities. Check out the final 2010 report here.

HIV community planning is an ongoing and ever evolving process whereby state and local HIV prevention and care organizations share responsibilities for developing a comprehensive HIV prevention and care plan with other state and local agencies, community based organizations and representatives of communities and groups at risk for or affected by HIV.

The Broward Collaborative to Reduce the Use of Substances, HIV and Hepatitis (CRUSHH) is a unique partnership of individuals selected from several local community based organizations that have proven successful in serving various target populations. Broward's CRUSHH has carefully considered the cultural make-up of the community, identified a realistic project target population based on the Substance Abuse and Mental Health Administration’s objectives, corroborated by community needs assessments and focus group results. Using countywide analyses and reports Broward CRUSHH is able to adequately assess the magnitude of substance use and or abuse, HIV, and hepatitis in the catchment area. Extensive planning occurred, engaging stakeholders, policy makers, funders, consumers and included consultation with evaluators throughout the application development process. As a result, Broward CRUSHH has adopted a four-prong prevention approach, focusing on outreach, training and technical assistance, cultural diversity, and prevention. As the first step in the development of Broward's Strategic Community Framework, a workgroup of providers, stakeholders, and policy makers, advocates and funders will convene. The strategic planning framework (SPF) for implementing culturally appropriate services to the target population will be based on documented needs; evidence-based practice for minority and reentry populations; resources and strengths of the community; measurable objectives; baseline data, and; enhancing hepatitis screening and linkages to services that provide immunizations for hepatitis A and/or B. The ICHP at NSU serves as the evaluator for this 5-year Substance Abuse and Mental Health Administration grant project.

Cost Utilization Analysis of a Pediatric Emergency Department Diversion Project

Collaboration between Florida’s Agency for Health Care Administration, Pediatric Associates, Inc., Broward Regional Health Planning Council and the Institute for Child Health Policy at Nova Southeastern University.

States are struggling to find effective means to decrease Medicaid costs. State Medicaid and SCHIP initiatives face challenges in attracting health plans and providers to participate in their programs. Ensuring a medical home and good continuity of care is contingent upon building and retaining a strong provider network. It is stated that about one-half of Medicaid and SCHIP health plans report difficulties in negotiating contracts with primary care providers.

In addition, states are facing enormous fiscal pressures. Some of the states’ efforts to control costs are directed toward SCHIP, where children with special health care needs may comprise 20% or more of the enrollee pools. Cross-sectional studies have consistently shown that a small percentage of children consume a large percentage of the health care dollar. Understanding health care expenditures could help the development of reimbursement strategies for health plans and providers that mitigate the financial consequences associated with high-cost enrollees. Financing strategies that redistribute limited resources according to children’s health status may be appealing to states as they address their fiscal constraints. Problems in contract negotiations may be mitigated if reimbursement and financing strategies afford health plans and health care providers greater protection against financial risk.

Managed Care and market competition have fundamentally changed the structure of the US healthcare system and the referral relationships between physicians, mental health providers and other support service providers, such as case managers. Managed care has many desirable qualities. It can help overcome barriers to care through a unified administrative structure and by making use of private sector management technology. Capitation arrangements allow for flexibility and promote the development of comprehensive continuum of services.

However, there is a risk when individuals with complex clinical needs, such as children with asthma and other chronic diseases or mental health needs, are enrolled in a managed care program designed for those with less complex needs. Children with special health care or behavioral health needs often have ongoing long term needs. For that reason, they are the focus of this study and are compared with other children who are only in need of preventive services.

The objective of this pilot study was to compare emergency department (ED) cost and utilization by members enrolled in a pilot program (designed to reduce the use of hospital emergency departments) with the costs and utilization incurred by a control group.

Participants in the program were Medicaid recipients under 18 years of age. Enrollment in the program was either through patient self-selection or mandatory assignment by the state Medicaid agency. 17,382 children enrolled in the enhanced access program (intervention group), and 26,066 Medicaid eligible children received services from other local community primary care providers (control group). Children with chronic health conditions receiving Supplemental Security Income (SSI) benefits were excluded from this analysis.

Regression analyses were applied to analyze the claim data collected for this project.

Three variables were used as dependent variables to measure different aspects of the ED cost and utilization: per member per month cost, per thousand member per month encounter frequency, and per encounter cost. These variables were used to compare the intervention group with the control group for ED claims, as well as for the overall cost of care during the study period.

In the initial 12-month period after program initiation, average per member per month cost for ED utilization in the intervention group was $1.36 less than that of the control group. However, there was no significant difference in terms of per-visit cost related to ED utilization. Therefore, the savings seemed to come as a result of a reduction in ED visits, not from reduced cost per visit. Subsequent regression analyses for ED visits revealed that, on average, children in the intervention group visited the ED eight fewer times per thousand members per month than the control group. Yet there was no significant difference in the overall cost of care between the intervention and control groups.

Analysis from the first year of this pilot program demonstrates that by providing enhanced, coordinated primary care access to Medicaid children, the utilization of the emergency department was significantly lowered among healthy children, while the overall cost of care remained the same.

Disaster Medicine

Family/Community Special Concerns in a Disaster

Numerous natural and “man-made” disasters have challenged our country’s experts. In a disaster environment, children sustain specific patterns of physical injury as well as profound psychosocial ills.

Disasters frequently threaten or destroy the effectiveness of the family as the primary child-protective unit, and put children in a position where their survival and well-being are temporarily in the hands of local health care and social personnel.

Epidemiologists working in the field of disaster medicine have clearly documented the vulnerability of children over any other age group to injury and disease as a result of disasters. Changes in routine, diet, environment, and the close quarters of temporary housing contribute to injury and illness.

While Hurricane Katrina highlighted the need for improved disaster planning, especially for children, a recent survey of licensed U.S. prehospital emergency medical service agencies revealed that most are significantly unprepared to appropriately care for pediatric patients in a disaster. In the study, "Prehospital Preparedness for Pediatric Mass-Casualty Events," researchers surveyed 1,932 emergency medical service agencies. While most agencies (72.9 percent) reported having a written response plan for mass-casualty Events (MCS), only 13.3 percent included pediatric-specific procedures. Most (69 percent) did not have a specific plan for responding to a mass-casualty event at a school, and only 19.2 percent had pediatric triage protocol. And while nearly 70 percent of the agencies reported participation in a regional disaster drill during the past year, less than half of the drills included pediatric victims. The study authors recommend child- specific disaster planning throughout the United States.

With the potential for traditional Emergency Medical Service agencies to be overburdened when disaster first strikes, the initial emergency response falls on the shoulders of the family and neighborhood community. We also know that the family unit is a primary factor in contributing to good long-term health outcome in times of disaster.

Endorsed by the American Academy of Pediatrics and Federal Emergency Management Agency (FEMA), product development of the Family Readiness Kit: Preparing to Handle Disasters was supported through a Department of Health and Human Services Emergency Medical Services Corporation federal grant and a State of Florida Department of Health Bureau of Emergency Medical Services Matching Grant. The aim of the product is to ensure that the family receives the information they require to effectively prepare for disaster and to deal with the calamity once it has struck. For the first time, the Family Readiness Kit: Preparing to Handle Disasters put kids into the disaster plan.

Immediately following Hurricane Katrina the American Academy of Pediatrics Mississippi Chapter received a Children’s Defense Fund award for purposes of translating the Family Readiness Kit: Preparing to Handle Disasters into the Spanish language.

Part of the public domain, any private organization or foundation can print the product. The only requirement is that the content cannot be changed. The sponsor can place their organization’s logo on the back cover white space. Go to: www.aap.org/family/frk/frkit.htm to access the full version in both English and Spanish.

Medical Special Needs Shelters

Texas Department of State Health Services Regions 6/5 South was awarded discretionary funds to develop a multi-jurisdictional Medical Special Needs Shelter Operation for Adult and Pediatric Clients, to include the purchase of supplies. Florida is the most vulnerable state in the nation to hurricanes, and has the highest predicted storm surges in the world. With the help of a multidisciplinary team of disaster medicine experts a joint collaboration was engineered among partners representing:

  • University of Texas Health Science Center Houston
  • Texas Children's Hospital (Baylor College of Medicine)
  • UTMB (University of Texas Medical Branch, Galveston)
  • Texas Institute of Research and Rehabilitation
  • NSU (Nova Southeastern University) Institute for Child Health Policy
  • California Office of Governor Arnold Schwarzenegger Special Advisor to the Director Office on Access and Functional Needs, Governor's Office of Emergency Services
  • City of Houston Emergency Management, Catastrophic Medical Operations Center
  • Florida Department of Health Public Health Nursing Executive Leadership and Consultants
  • Texas Department of State Health Services- Region 6/5 South, and the City of Port Arthur Health Department
  • American Academy of Pediatrics
  • Florida Medical Association Public Health Council

Reference

Drowning Prevention

The Institute for Child Health Policy (ICHP) at Nova Southeastern University (NSU) acknowledges that drowning prevention planning and emergency readiness is a complex issue. Different types of unintentional injury prevention efforts and emergency response may require qualitatively different knowledge and skills. Different family structures require different approaches to readiness, effective networks, and community resources that allow families to interface with the development of drowning prevention strategies and preparedness to manage emergency response. Since families are the first line of response it is important that parents, caregivers, and children alike are provided with information that will guide their actions.

Nationwide, drowning is the leading cause of injury-related death of children 4-years-old and younger with a mortality rate of 557, which represents 20% of all deaths in this age group (National Center for Health Statistics [NCHS], 2005; National Vital Statistic Reports, 2007). In 2006, an estimated 3,134 children between the ages of 1 and 4-years-old were treated in emergency departments for near-drowning (National Electronic Injury Surveillance System [NEISS], 2006). Children between the ages of 1 and 4 years are most likely to drown in pools and spas (58% and 51% of children 1 to 2 years and 3 to 4 years, respectively; Brenner, Trumble, Smith, Kessler, & Overpeck, 2001).

To address the complex issue of drowning prevention, researchers at the ICHP are conducting a thorough assessment for community services and needs surrounding drowning prevention to identify gaps in existing services. Through the use of well-planned research methods and procedures, an inventory will be created of all  Emergency Medical Services (EMS) drowning prevention programs or training services available throughout the state of Florida. With this information, a report highlighting the gaps in current drowning prevention efforts will serve as a mechanism for program improvement. The researchers at ICHP will create a state of the art training guide for EMS workers and prevention guides for residents in the state of Florida.

To address the complex issue of drowning prevention, researchers at the Institute for Child Health Policy are conducting a thorough assessment for community services and needs surrounding drowning prevention to identify gaps in existing services. Through the use of well-planned research methods and procedures, an inventory will be created of all EMS drowning prevention programs or training services available throughout the state of Florida. With this information, a report highlighting the gaps in current drowning prevention efforts will serve as a mechanism for program improvement. The Institute for Child Health Policy will create a state of the art training guide for EMS workers and prevention guides for residents in the state of Florida.

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EnhanceFitness

EnhanceFitness© is an evidence-based best practice model in physical activity programming for older adults (http://projectenhance.org). The EnhanceFitness © was designed by researchers and specialists in aging at the University of Washington in Seattle as an easy-to-implement community based ethnically diverse fitness program aimed directly at older adults. The program has received the US Health and Human Services Innovation in Prevention Award; US Administration on Aging You Can! Program Champion and National Council on Aging One of the Ten Exemplary Physical Activity Programs for Older Adults in USA. A typical EnhanceFitness© class of 15-20 participants' experience: a 5-minute warm-up; 20-minute cardiovascular workout; 5-minute cool-down; 20-minute strength-training workout with soft ankle and wrist weights followed by a 10-minute stretch/balance session. In addition, participants are able to follow their own progress through instructor administered functional fitness testing and self-administered quality of life evaluations. Presently, we have received funding from the EnhanceFitness© program from the Health Foundation of South Florida and the Florida State Department of Health Bureau of Chronic Disease Prevention and Health Promotion. Our partners and collaborators include the Broward Regional Health Planning Council, Broward Health System (NBHD) and the Memorial Health System (SBHD). Presently, we are coordinating eight classes in Broward and Miami-Dade counties.

  • Church of the Ascension
  • James E. Scott Community Association of Richmond Heights
  • Austin Hepburn Center
  • City of Miramar Satellite Senior Center
  • Noble A. McArtor Senior Day Center
  • Hillmont Gardens Senior Housing Facility
  • Memorial Senior Partners
  • Nova Southeastern University-Lifetime Learning Institute

Over and above coordinating program implementation, administration and evaluation at the current sites, we are in the process of identifying additional new locations, training additional EnhanceFitness© instructors; identifying additional master trainers, providimg technical assistance and guidance to others who are interested in expanding EnhanceFitness© classes in Florida.

Appleseed Workshop: Falls Prevention

 

Fitness and Nutrition

Funded by the Health Foundation of South Florida and the Broward Regional Health Planning Council (BRHCP) (2006), the Institute for Child Health Policy (ICHP) at NSU conducted a Broward County study to address: community need, current services, and gaps in existing services as they relate to fitness and nutrition. Along with the needs assessment quantitative surveys were conducted with community members as well as exploratory focus groups. The focus groups and surveys delved into the perceived risks and concerns associated with nutrition and fitness issues. The information gathered from the preliminary study provided a richer understanding of the target populations’ perspectives on what services and resources were available giving insight as to resources that the community felt was missing. The information collected assists community stakeholders in developing fitness and nutrition programs to better serve the needs of Broward County residents in the future.

Global Health

Global Child Health Educational Models Project
(GCHEM) ICHP Director is a member of the Advisory Council.

  • This project will develop a series of peer-reviewed, problem-based, high-caliber, case-driven, on-line teaching modules covering key topic areas in pediatric global health directed to UK/US/Canadian medical residents as well as faculty, community physicians, and fellows.
  • This modules series will cover a set of core topic areas otherwise difficult for a single program to address, and will be aligned with the GH learning objectives developed through the AAP-SOICH workgroup on residency education with National Children’s.
  • These modules may be used by residency programs in a customized, Lego-block fashion whereby specific modules may be used to fill in gaps within a GH program curriculum; or alternatively the entire series may be used to supplement its existing GH curriculum
  • These modules will aim to prepare residents for work with vulnerable populations in low-income settings, and through clinical cases which will draw the learner into developing a deeper and more broad understanding of the social/economic/political setting in which disease/illness/injury occurs as well as to appreciate the public health measures to prevent and control these conditions at the community, regional, and country level.

"From Mobile Surgery to Human Development"
Presentation by Edgar Rodas MD FACS
Dean of the Medical School University of Azuay
Cuenca, Ecuador
2009 American College of Surgeons Humanitarian of the Year

Florida College of Emergency Physicians EMPulse:
Special Edition on Human Trafficking  August 2010

American Public Health Association 138th Annual Meeting Theme:  Social Justice
November 6-10, 2010 in Denver, CO.

March of Dimes

A Mixed-Methods Study to Examine the Attitudes, Beliefs, and Practices Regarding Healthy Eating and Physical Activity Among Black Women in Broward County

The goal of this ICHP at NSU investigation, supported in part by the March of Dimes of Broward County, is to increase our understanding of the attitudes and behaviors of black women in Broward County regarding healthy eating and physical activity. The data provided will serve as a needs assessment that can be utilized by the March of Dimes to develop a lifestyle enhancement health program for black women of child bearing age living in Broward County, Florida. The mission of the March of Dimes is to improve the health of babies by preventing birth defects, premature birth and infant mortality. Thus, this needs assessment will provide the March of Dimes with a better understanding of the pre-pregnancy outcomes of child-bearing women. Ultimately, programs that use the target population in their program design will have a better chance of ensuring that the women served will have healthier babies and attain longer healthier lives with their children and families.

NCPIC/CDC Appleseed Project

The Appleseed Project was created by the Injury Response Division of the NCIPC/CDC to promote this idea and improve practice. The goal is to spread the seeds of collaboration state to state and community to community by inviting local EMS and public health workers, leaders, and champions to a one-day learning and action planning workshop. Florida has the unique opportunity of hosting an Appleseed Workshop.

The Injury Response Division of the National Center for Injury Prevention and Control of the Centers for Disease Control (NCIPC/CDC), in collaboration with the Florida Department of Health, Florida Department of Elder Affairs, NOVA Southeastern University (NSU) and the American College of Emergency Physicians sponsored The Appleseed Workshop: Elderly Falls Prevention on Tuesday, September 15, 2009. This one-day bi-directional videoconference workshop was held at two locations: NSU Ft. Lauderdale campus and NSU Tampa Educational Center. The purpose of this workshop is to foster stronger working relationships towards elderly fall prevention. In Florida, falls are the leading cause of injury death and hospitalizations for residents 65 and over. As the "Baby Boomer" generation ages, or the "Silver Tsunami" begins, the number of seniors is expected to double by 2040. This means more falls, more injuries, and more traumatic deaths unless we make a major effort to prevent these falls. Enhanced collaboration between all components of the medical, public health and public safety communities is critical.

Appleseed Workshop: Falls Prevention

One Community Partnership

One Community: Working Together For Our Children
A System of care for children with serious emotional disturbances

With the Division of Collaborative Program Development playing a crucial role, Broward County joined Hillsborough and Palm Beach counties as Florida’s Substance Abuse and Mental Health Services Administration (SAMHSA) “One Community” federal grant recipients. By collaborating with several community-oriented organizations, Collaborative Program Development will provide its research and evaluation expertise to help develop a healthcare system that will provide children with serious emotional disturbance (SED) and their families with a positive, encouraging, and caring environment.

A SAMHSA Excellence in Community Communications and Outreach (ECCO) Gold award recipient, One Community Partnership is a six-year project to evaluate and redesign the existing array of children's mental health services in Broward County into a comprehensive, coordinated system of care. The project vision is to develop a system of care driven by family voices that will sustain and support SED children in the least restrictive and most clinically appropriate environment. This initiative will serve as a pilot project that will stimulate system reform initiatives across other social services networks within the county and ultimately across the state.

The ICHP researchers contributed toward the One Community project goal of improving data collection; implementing science-based evaluation to monitor service improvements and needs; and enhancing cultural proficiency within the system.

http://www.broward.org/onecommunity/welcome.htm

Prevention Quality Indicators Initiative (PQI)

The PQI is a program developed under the leadership of Broward Regional Health Planning Council (BRHPC) to help reduce avoidable hospital admissions. Congestive heart failure, hypertension and diabetes are among the 14 avoidable admissions analyzed. Initially, The Health Foundation of South Florida funded this Broward County based program. From the second year, The PQI Initiative became a statewide pilot made possible through an award by the Blues Foundation.

With the expansion of the program, BRHPC developed a web-based data warehouse and analytic engine which includes the following query module functions: Prevention Quality Indicators/Avoidable Admission, Chronic Conditions (ICD-9), Suicide Incidence, ED Acuity Stratification (CPT) and NYU Algorithm ED Preventable/Avoidable can also be generated. To access this additional information, please log in to the Health Data Warehouse located on BRHPC’s website (www.brhpc.org) at the following link http://healthdata.brhpc.org/Index.aspx. Through the Health Data Warehouse, a variety of reports can be generated, including PQIs by gender, age group, race/ethnicity and payer source. The information contained in the Health Data Warehouse can be a valuable community planning tool which BRHPC encourages organizations to utilize.

The purpose of the PQI Project is to:

  • Examine avoidable admissions data;
  • Develop intervention strategies to prevent these admissions;
  • Evaluate emergency department and hospital inpatient admission data across the state to determine which hospital and/or emergency department admissions could have been prevented had quality primary care and preventative services been accessible;
  • Gather information on Chronic Conditions and Suicide Incidence; and
  • Trend detecting on Healthcare data.

Project partners include BRHPC and 10 other Florida Local Health Planning Councils, the Institute for Child Health Policy at Nova Southeastern University, Memorial Healthcare System, Broward Health (North Broward Hospital District), and NEX Consulting, LLC..

Traumatic Brain Injury

Outpatient Multidisciplinary Traumatic Brain Injury Rehabilitation Center

The creation of a multidisciplinary outpatient rehabilitation center at Nova Southeastern University (NSU) in partnership with Broward General Medical Center Trauma Service provides much needed services to children, youth and adults in the community who have sustained a mild to moderate traumatic brain injury (TBI). Research into Florida’s needs indicates that our geographic location is comprised of the largest TBI population in the state. Multidisciplinary services are needed in order to effectively promote recovery for those who have sustained a TBI. Additionally, with hundreds of veterans returning from war with brain injuries, NSU has the opportunity to reach out to those who are defending our country by providing them with services that will complement those they receive from Veteran’s Affairs.

In addition to meeting an important community need, development of a TBI rehabilitation center provides significant and direct benefits to graduate education. Serving as a practicum training site, the center will offer cutting-edge interdisciplinary training opportunities for students and faculty. This type of training is rarely available at other institutions of higher education. Research shows that interdisciplinary training prepares students to thrive in the professional world by increasing knowledge in areas outside one’s discipline, as well as promoting teamwork, communication and confidence.

Statewide Needs Assessment Data & Implications for Broward County

Youth Suicide Prevention

In 2005, the Institute for Child Health Policy (ICHP) at Nova Southeastern University (NSU) led a pilot project for the Development of the Youth Suicide and Intentional Self-harm Surveillance System. This project used existing data sources (i.e., record systems from medical examiners, hospital emergency departments, EMS providers, crisis hot lines, physicians’ offices, and schools) to collect information on youth suicide and self-harming behavior. Where possible, information was collected on victim characteristics, mechanisms used, incident circumstances, and services providers. Using this data enabled local leaders and policy makers to better identify trends in suicidal or self-harming behaviors at the county-level.

Youth Suicide Prevention School-Based Guide: In a collaborative with the University of South Florida and funded by the ICHP at NSU through a Drug Free Communities Program Award, this Guide provides a framework for schools to assess their existing or proposed suicide prevention efforts (through a series of checklists) and provides resources and information that school staff can use to enhance or add to their existing programs. The Guide can be used by school administrators, counselors, teachers; youth outreach programs, family and community partnerships, and caring adults. It is based on review of the current literature and exemplary programs and is produced in relatively short, separate Issue Briefs combined into a pocket folder. The Guide includes 7 topic-specific Checklists (Information Dissemination in Schools, School Climate, Administrative Issues, Suicide Prevention Guidelines, Intervention Strategies, Preparing For and Responding to Death by Suicide, Culturally and Linguistically Diverse Populations) that can be completed to help evaluate the adequacy of the school’s suicide prevention programs, ability to deal with a suicidal youth, and ability to respond to a suicide or suicide attempt. It also includes 13 Issue Briefs with topic-specific references that offer a rational for the importance of the topic with an overview of proven effective strategies:

  • Information Dissemination
  • School Climate
  • Risk Factors: Risk and Protective Factors and Warning Signs
  • Risk Factors: How Can a School Identify a Student At-Risk for Suicide
  • Administrative Issues
  • Suicide Prevention Guideline
  • Intervention Strategies: Establishing a Community Response
  • Intervention Strategies: Crisis Intervention Teams
  • Intervention Strategies: Responding to a Student Crisis
  • Preparing for and Responding to a Death by Suicide: Steps for Responding
  • Preparing for and Responding to a Death by Suicide: Responding to and Working With the Media
  • Family Partnerships
  • Culturally and Linguistically Diverse Populations

References for each topic include helpful links for further investigation into the specific topics. In addition, a sample of school-based suicide prevention programs, additional resources and links, statistics from the American Association of Suicidology, a true/false test about the myths of youth suicide, and sample school forms are included.

The Guide was completed in 2003 and released nationally at the December 2003 Suicide Prevention Resource Center Conference in New Orleans and is in use across the nation as well as in Florida. The Florida Department of Education is strongly encouraging schools to use this Guide. Initially 600-700 copies were distributed at no charge to Florida schools. Another 600-700 copies were purchased by Florida schools or school systems. It was put on-line in January 2004 and currently can also be obtained on CD. In 2005 a flier was prepared and sent with the overview of the Guide to school superintendents and secondary school teachers. In addition, a number of presentations as well as workshops have been made at statewide education and school health conferences. The Florida Department of Education SAFE Schools program developed a virtual teacher continuing education program on the topic of Youth Suicide Prevention showcasing the Guide and offered through PBS statewide. There are links to the website from several Florida suicide prevention websites as well as being listed in the Suicide Resource Center Library. There is also a reference to this Guide and its website in the National Governor’s Association Issue Brief on “Youth Suicide Prevention: Strengthening State Policies and School-Based Strategies.”

Aditional Resources