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2005-187-Minutes for Meeting January 12,2005 Recorded 3/16/2005DESCHUTES COUNTY OFFICIAL RECORDS NANCY BLANKENSHIP, COUNTY CLERK CJ SEP COMMISSIONERS' J URNAL 11111111111111111111111 1111111 03/16/2005 10:33!44 AM 2005-1 DESCHUTES COUNTY CLERK CERTIFICATE PAGE 4 C This page must be included if document is re-recorded. Do Not remove from original document. Document Reproduces Poorly (Archived) Deschutes County Board of Commissioners 1300 NW Wall St., Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org MINUTES OF DEPARTMENT UPDATE — MENTAL HEALTH DEPARTMENT DESCHUTES COUNTY BOARD OF COMMISSIONERS WEDNESDAY, JANUARY 12, 2005 Commissioners' Conference Room - Administration Building - 1300 NW Wall St.., Bend Present were Commissioners Michael M Daly, Tom De Wolf and Dennis R. Luke. Also present were Mike Maier, County Administrator; and Scott Johnson, Mental Health Department. No representatives of the media or other citizens were present. The meeting began at 4:15p.m. A general discussion took place regarding agenda items submitted by Mr. Johnson, including an overview of the Fiscal Year 2005-06 budget for his Department. (See the attached copy of the agenda and supporting documentation) The Commissioners discussed supporting the hiring of Gary Smith (former Director ofthe Mental Health Department) to handle the Department's business plan on a consulting basis. LUKE: Move approval. DALY: Second. VOTE: LUKE: Yes. DALY: Yes. DEWOLF: Chairvotesno. (Splitvote) Being nofurther items addressed, the meeting adjourned at 4:45 p.m. Minutes of Department Update — Mental Health Department Wednesday, January 12, 2005 Page I of 2 Pages +h DATED this 12 Day of January 20 Commissioners. ATTEST: Recording Secretary I — v Ir Mi Dewolt, Chair is R. Luke, , C issioner issioner Minutes of Department Update — Mental Health Department Wednesday, January 12, 2005 Page 2 of 2 Pages 14 Deschutes County Mental Health BOCC Monthly Meeting - Proposed Agenda January 12, 2005 3 Month Progress Report - I'll provide you with a report to update you on my priorities for my first year (based on our agreement). Please let me know if you have any suggestions. 2005-2006 Bud -get Goals - Review of submitted material. ABHA Proposed Business Plan - Recommendations: develop a Business Plan, postpone decision on alternative to ABHA till summer 2005. I'll b(ing a proposal to the meeting. Becky Wanless replaces Chuck Frazier as MH, A&D Advisory Board Chair. 5. Sage Vie - open house 3:30 Jan. 21, please attend. Update on negotiations on 5 -year Service Contract and other paper to remove Deschutes County from the LLC. Critical Issue: We need to secure State indicient funds, dollars provided to other areas of Oregon to offset cost of acute care for indigent clients. We will not be able to sustain same amount of Sage View service for low income without help. Increasing costs could also impact ABHA inpatient. Nikkel meeting 2:00 January 21 at Sage View, including Commissioner if possible. 6. Evidence Based Practice (EBP) developments in the next year a. Supported Employment for people with mental illness - We are shifting one FTE (Pat Nichols) from the Clubhouse to SE. Benefit to consumers. b. Consumer led Clubhouse - email last week, update on I / I I Town Hall, next steps: research best practice, involve consumers and family members, visit other centers, and address concerns from the Town Hall. Benefit to consumers: develops skills and abilities, self esteem, supported employment. 7. Update on Strategic Plan - 46 staff to full time, opening Fridays for services to clients beginning Friday January 14, 3 work groups: Best Practice, Measuring Results, and Professional Development, Phase 11 of Plan due to BOCC Summer 2005. 8. SAHMSA grant- Judith is helping us with a federal application for methamphetamine treatment in the region - $500k / year, 3 years. 9. 0thftr- (time permitting) a. Children's System Reform - starts July 2005, OHP children, more flexibility, emphasis on Central Oregon as a region b. Clubhouse grant - $25,000 for consumer led activities; 3 lead positions; other. c. Criminal justice - continuing efforts to address people with MI in justice system; I am very supportive of anything we can do (within resources) to address this. d. Custody evaluations - working with Courts on March or April proposal e. Children's services $51,000 grant received - proposal pending. f. Givens audit. g. June 2005 Mental Health and Alcohol & Drug State Audits 2005 / BOCC monthly January To: Deschutes County Commissioners, Mike Maier From: Scott Johnson Date: January 12, 2004 Subj: Three Month Report - 2004-2005 Priorities In November, following work with my DCMH Management Team and in consultation with the Chuck Frazier, Chair of the Advisory Board, we finalized my first year priorities as DCMH Director. This Report will serve as a three month progress report. Summary: A very good first three months. We have reopened on Friday, returned 46 staff to full time status, and reinstituted all staff meetings. We have an adopted Strategic Plan (Phase 1) and a 3 -year financial plan and a financial model that can be updated whenever needed. The management team is outstanding. They are competent, dedicated professionals who have been extraordinarily helpful in the transition. I've also met with about a third of the staff individually. I've taken a lead role in the Sage View negotiations and have a Board adopted set of principles for a final agreement. We are working regularly on the new Children's System of Care reform (scheduled to begin in July '05). Advocacy is starting on state indigent funds. Our reserves are up, new operating funds are in place and the general staff climate seems favorable. Having said all of this, many challenges remain. Long term financial projections (3-5 years out) are not favorable. The state is undertaking a reform of the children's system for high need children without additional resources. Expenses are increasing more than revenue and the state budget is not likely to provide any immediate relief. Growth in the county is stressing our capacities and the crisis with the state hospital system may affect local hospitalizations and increasing county costs in that area. Finally, we may need to enter into difficult policy discussions about our core services and our manner of operation. a. Farniliaritv with staff and the organization. Dedicate time to the management team and individual managers. Meet periodically with program teams. Individual staff meetings with staff by January 2005. Learn systems and processes. Progress: On Track, this will be an ongoing process. Meeting weekly with Management Team and individual managers. Held Management Team retreat. Attended one or more meetings of all program teams. Individual meetings offered to all staff and held with about 30 to date. Learning systems and processes will be ongoing. b. Strategic Plan. Complete preliminary plan by December 2004 with service benefits, better public access and increased hours. Complete a full plan (including program priorities and a business plan) for adoption by Summer 2005. Include work on evidence based practice, staff development and performance measures. Progress: On Track. Phase 1 Plan adopted by Commissioners, Planning Committee, and Advisory Board. Plan contains a 3 -year financial plan including use of new equity funds. 46 staff returning to full-time status in January. Leadership named for 3 work groups (measuring S:\Menta1_Hea1th\Scott\Scott1s Priorities 3 -month rpt.doc 1/12/2005 results, evidence based practice, professional development) - Phase 2 Plan priorities have been identified. Phase 2 Plan is tentatively scheduled for completion in the summer of 2005. c. Sa e View. Provide support for January 2005 opening of the crisis resolution center. q_ Complete negotiations to consider alternative to LLC, including CHC ownership of facility, management of program and DC investment in services. Progress: On Track. Sage View opens January 31. Completed negotiations in priinciple with Commissioners adopting the principles. 5 -Year service contract and other legal documents under development. Adoption of documents may or may not occur prior to opening. We continue to make this a priority with excellent support from Mark Pilliod. We are also creating an Acute Care Reserve including $290,000 (repayment) and $400,000 (capital repayment). d. Children's "S stem of Care " (SOC) Prepare for 2005 (kick-off) implementation as well as a general plan through 2008 (with Suzanne Donovan, region, mho). Resolve how best to manage risk and responsibility. Emphasize evidence -based practice. Progress: On Track, at least four year reform. This reform is scheduled for kick-off July 2005. It will affect services for high need OHP children and families, eventually other children as well. Participating actively (with Suzanne Donovan) in planning and preparation. Likely to propose concept of ��entral _®re on �re i�on for design of services, planning and placement decisions. Challenges include the typical development and uncertainty of a reform effort, the complete lack of new resources, risk management considerations and the need to stabilize existing programs. e. Manaaed Care. Review our involvement in ABHA; assess benefits. Consider other mho options, benefits and risks. Work with leadership to determine our best managed care option and what changes, if any, we might want to propose. Progress: On Track. We are processing the Gary Smith White Paper; awaiting February response(s) from ABHA and /or member counties. I am recommending proceeding with the Business Plan to a) complete this process in a thorough manner, b) help us fundamentally resolve the question of ABHA membership and the best Mental Health Organization for Deschutes County and to c) provide us with a development "road map" if and when we make a change at some point in the future. I do not recommend making any change at this time. While a business plan should be development, any change should be postponed at least until Summer 2005. f. Mental Health,, Alcohol & Druci Advisory Board. Create significant role for the MHADAB in guiding the organization, developing policy and advising both the County commissioners and the Director. Progress: On Track, this will be an ongoing process. I am seeking a larger Board role but need to recognize people were not recruited with this in mind. With your support, you'll see decision making involvement in department policy development, finances and program priorities. This will take time and will take more than a year to complete to my own satisfaction. g. Evidence -Based Practice. Identify our current strengths and accomplishments in this area. Identify and begin implementing program development priorities for evidence -based practice, including associated training and development. S:\Menta1_Hea1th\Scott\Scott!s Priorities 3 -month rpt.doc 1/12/2005 Progress: On Track. Assigned to Lori Hill and Kathy Drew as lead managers with opportunities for staff involvement. This will affect program development, priorities and also training costs. It is natural that it will also cause some concern for staff, consumers and possibly the Advisory Board because it is about change and priorities. I am confident it is the right thing to do. It will also keep us in compliance with state law (SB 267). 1 will ask for BOCC approval of our EBP priorities as part of Phase 11 of the Strategic Plan. h. Accountability / Quality Improvement. 1. DCMH Results: Emphasize service quality and high utilization. Clarify and strengthen functions, processes and reports. Progress: Underway. Referenced in Strategic Plan with leadership assigned to our Quality Assurance staff, Sheryl Hogan and Virginia Mayhill 2. Audit: Work with County Internal Auditor on analysis and improvements, as needed, in business practices including finance systems and procurement process. Progress: Underway. Dave Givans is currently auditing our department. We are very supportive of this project and looking forward to his report. 3. Staff Development: Work to achieve consistent and beneficial performance reviews with attention to staff development and performance concerns, if any. Progress: Underway. Referenced in the Strategic Plan as "professional development" with leadership for offering recommendations assigned to Suzanne Donovan and Karen Tamminga. 4. DCMH Results: Work with Sheryl Hogan to develop a community report card; work with Kathe Hirschman and others on Annual Report by fall, 2005. Progress: Underway. Coordination is occurring through Sheryl and Virginia Mayhill. i. State Relations: Develop / sustain working relationships with state officials. Participate actively in the 2005 legislative process. Priority issues will include equity (both alcohol/drug and mental health) and Children's System of Care. Progress: Under way; this will be an ongoing process. Completed Salem day -long orientation at OMHAS. First time this was requested by a County Director and first time completed. Several contacts with Bob Nikkel, OMHAS Director as well as our Central Oregon legislators. Attendance at periodic AOCMHP meetings (County mh directors) and ABHA Board and planning meetings. Cc Becky Wanless, Chair, Deschutes County Mental Health, Alcohol & Drug Advisory Board DCMH Management Team: Canfield, Donovan, Drew, Hill, Hirschman S:\Menta1_Hea1th\5cott\Scott's Priorities 3 -month rpt.doc 1/12/2005 w 9 LO CD CD cm LL 0 0 w 0 0 0 CD z (1) cn E 0 (D co E 0 3s� Pit 17- , jj� 30) S 4�K J, JL' "M Z' %) '79" "o, 'T'k, V TC;' 3s� Pit 4�K 6� d. Es Mi (D CA U) 0 0 M CD 0 rot& G) 0 2) CA cn CD CL 0 CD Es Mi (D CA U) 0 0 M CD 0 rot& G) 0 2) CA CD CI) o Es Mi (D CA U) 0 0 M CD 0 rot& G) 0 2) CA Deschutes County Mental Health Proposed Business Plan for a Deschutes County Mental Health Organization By Scott Johnson Recommendations: 1. Continue full participation in ABHA for the foreseeable future including an active role in its success and activities for both the good of all county members and the greatest possible benefit for residents of Deschutes County. 2. Receive and fully consider ABHA and member county responses to the Gary Smith White Paper titled "The ABHA Question". March - May 200-& Q%L �A, 3. Develop a Business Plan for a Deschutes C feasibility of alternative arrangements and 4. Employ Gary Smith as a temporary, part time and others to develop a Deschutes MHO Busi a. Compensation: same rate as 2004; Revenue and details to be worked b. Deliverables: 1) Written Report and prese representative and_DCM 2) Seven EssentiqLEffnents J0ftvequestions about the s, S, d benefits. June 2005. to work M&the DCMH Director ounty in er t not to exceed $ 5,000. ji� County Administrator. lknsult( tri o Nn bmmissioners, Advisory Board Report Due: June 1, 2005. 1 n: (work to begin January 2005) tions ailed list of essential MHO duties (verified by OMHAS). an ions needed to assure MHO requirements are met incl. minim alifi s and integration within DCMH (with Scott Johnson) + Compard bud ifh Greg Canfield and Marty Wynne). Revenue and expense s ules (p o rata share of ABHA expense vis a vis Deschutes County opti ). Special note: include projection of capitation for next 3 years and reco nclations on DCMH actions to increase available capitation. * Compara. Analysis - Comparable MHO models in Oregon (includes site L, visits an I itten summary) (with Scott Johnson) qWH 0 ideration - A specific look at how this action would intersect with responsibilities; comment on the benefit of any integration (with H reps) * Risk Management considerations (with Marty Wynne and Scott Johnson) * Timeline and activities required to establish an MHO (with OMHAS officials) - Listing of all primary tasks; in consecutive order where applicable. Provide a conservative estimate of the time required for each task. 5. Maintain communication with C.O. Counties. To date, Jefferson and Crook appear to prefer continuation of ABHA in its present form. We should remain open (as much as possible) to administrative models that can benefit OHP residents of those two counties. No work on Jefferson and Crook considerations unless requested by those counties. I May be extended if developments in Oregon Legislature affect MHOs and this project. MHO Business Plan Recommended 1/11/2005 ADULT TREATMENT PROGRAM DEVELOPMENTS Discussion: The Adult Treatment Program is currently undergoing several changes to remain current with evidence -based practices and to better serve our clients. Changes In Our Community Support Services Team: The Community Support Services team (CSS) is one of the teams within the"Adult Treatment Program and provides services to consumers with a serious. mental illness. This team in particular has been evolving and enduring significant changes as we move more in the direction of evidence -based practices and struggle with the challenges of providing services in a climate of limited resources. The focus of services is increasingly moving to an environment of recovery—assisting consumers to develop lives in the community, learning the skills needed to manage illnesses as independently as possible and decreasing dependence on the mental health system. There are several evidence -based practices that have been identified as priorities for the Community Support Services team: dual diagnosis treatment, supported employment and intensive case management/assertive community treatment. Dual diagnosis is one area in which we have a significant advantage in that our mental health and alcohol & drug treatment services have been integrated for a number of years. The challenges in this area are to assure that we are providing adequate content and curriculum in our services to consumers with dual issues and to assure that all our staff has adequate training in both areas. In regards to intensive case management, some of the additional funding that was recently provided by the state has been designated to enhance services in this area. We have recently hired two additional positions —'intensive case managers who will share a low caseload of high -need clients at risk of hospitalization and who also rotate weekend hours so that we are able to provide services seven days a week. The Clubhouse program is one component of the Community Support Services team that has been going through continuous development in recent years and has been significantly impacted by the move to evidence -based practices. About five years ago, we made the transition from a traditional day treatment program to a clubhouse model. This model has been a significant improvement, with an increased focus on consumer involvement and direction. While this model has been much more consumer -driven, it has also continued to use fairly intense staff resources. It has been an ongoing challenge to operate this program effectively while still meeting the needs of consumers who do not attend the Clubhouse. Currently we have approximately 25-30 consumers who attend the Clubhouse on a regular basis (defined as at least once a wee . k). There are approximately 200 consumers currently being served by the Community Support Services team. This means that there at 170-175 consumers who do not attend Clubhouse and who need other services. Approximately nine months ago, in an effort to move towards being even more consumer driven as well as to distribute resources better to meet the needs of a variety of clients, the number of staff in Clubhouse was decreased from three to two. During the fall, members of the CSS team attended several trainings on evidence -based practices, with a particular focus on supported employment. During trainings, the issue of looking at reallocating existing . resources to provide services such as supported employment was openly discussed, including the trend of diverting resources from day programs such as clubhouses. The expectation from the state was clear, as well as thevalue of being able to offer these services to consumers who want them as an important part of the recovery process. It was during this time that we decided to make a strong commitment to develop support employment services as part of the CSS program. A way to do this would be to continue to help the Clubhouse move to a more consumer -driven model with the ultimate goal being a completely consumer -run program that is still supported by DCMH. At the beginning of this year, one additional staff made the transition from the Clubhouse program and has begun to develop supported employment services. There is currently one staff person working in the Clubhouse program, and discussions have begun with consumers about how to move to fully consumer run. Understandably, this has been met with many questions as well as concerns and fears among both consumers and staff. For this reason, the current plan is to move slowly and thoughtfully. There is no date set as to when the remaining staff will be removed from Clubhouse. Rather, over the coming six months to a year, the focus will be on the process of what needs to happen for a consumer -run program to be successful, for example, generating a list of questions regarding how to operate a consumer program, visiting a variety of other programs to see how they operate, getting consumer focused trainings, addressing safety and transportation issues, etc. The goal is to provide the support that is needed for a successful program. Change can be difficult and challenging, yet also very rewarding. We look forward to your thoughts and input to help guide us through this process. Contacts for more information: Lod Hill, Adult Treatment Program Manager, lori—hill@co.deschutes.or.us, 322-7535 Elisabeth Huyck, CSS Supervisor, elisabeih—fincher-huyck@co.deschutes.or.us, 330-4633 Ih XXZEUSXKatheH\My Documents\ADULnChanges In Our Community Support Services Team.doc IT supported Employment Implementation Resource Kit '71 DRMT VERSION 2002 Information for Practitioners and Clinical. Supervisors People with mental illness have many talents and abilities that are often overlooked, including the ability andmotivation to work. Work has become an important part of the recovery Pr . ocess for many con . sumers . Research has shown that: 70% of adults with a severe mental, illness desire work. 60% or more -of adults with mental illness can be successful at working when using supported employment. The following section answers some common questions regarding supported employment. What are the principles of supported employment? Supported employment is based on six principles. Eligibility is based on consumer choice. No one is excluded who wants to �'Participate. DRAMM INFORMAMN FOR PRAUMOMRS A CLINICAL SUPERVSOiR-S I I Supported employment is integrated with treatment. Employment specialists coordinate plans with the treatment team: the case manager, therapist, psychiatrist, etc. Competitive employment is the goal. The focus is community,jobs anyone can apply for that pay at least minimum wage, including part-time and full-time jobs. job search starts. soon after a consumer expresses interest in working. There are no requirements for completing extensive pre-employment assessment and training, or intermediate work experiences ([ike prevocational work units, transitional employment, or sheltered .workshops). 0- Follow -along supports I are continuous. Individualized supports to maintain employment continue as Ion g as consumers want the. assistance. Consumer preferences are important. Choices and decisions about work and support are individualized based on the persores preferences, strengths, experiences. Work is stressful. Will. consumers experience increased symptoms if they obtain a competitive- job 70. Generally. speaking, people who work do not experience symptoms at any higher rate than'people who do not work. In fact, for many consumers, symptoms improve through the planned, purposeful activity of work. In supported employment, the assessment of an individual's strengths, copmg strategies, and symptoms helps identify a good job and work environment for each person. It should also be remembered that not working is also stressful, often more stressful than working. Case managers are already overworked. How will they have time to support this employment effort? The work of e mployment specialists provides an additional resource for c ase managers and consumers in supporting consumer goals. Over time, DRAFr2OO2 NmRPAMN FoR RA cnTUN—ERS AND CUNICAL SUPERVISORS 2 consumers depend less on case . Managers and the mental health system as they Progress in their recovery process. How will colleagues be convinced thats'Upported emplovment w orks? Everyone will need education and training on how to carry out their part in supporting a consumer's efforts to work. Managers and supervisors help Practitioners follow the Principles and practices of supported'employment in their daily work. More and more, practitioners who have seen how people grow when they are working have become convinced that work can be part of the recovery process. The people I work with are too disabled to hold jobs. What does supported emplo yment have to offer people. with the most severe dis Abilities? The evidence shows that even people with the- most severe mental illnesses can work. In supported employment, job selection i�s tailored to individuals- An important part of the recovery Process is hope. Supported employment Provides all consumers a chance to succeed at employment. For some people, the opportunity to work a few hours a week is a symbol of hope. If consumers start going to work, will they still be able to attend groups and a c-tivities and keep appointments with doctors and p I ractitioners? Agencies have restructured their resource allocations ,cheduling as more cons programming, and 6, u1ners work. While most consumers, are not taking full-time jobs, some may need evening appointments. ty What is the role of. psychiatrists in supported employment? In supported employment, employment specialists work closely with the treatment team to support the goals of.c.onsumers. As clinical leaders, psychiatrists convey positive messages about work to consumers, family members, and the whole team. Psychiatrists make treatment recommendations based in part on how a person is functioning at work . Limited resources are available to pay for needed case managers. Employment* specialists seem like a luxury. How can an agency -afford emplo* yment specialist positions? Agencies continually make decisions about how to use their limited resources. As more consumers express a desire to work, providing supported employment is becoming an increasing priority. Leaders of numerous agencies and systems have established ways to fund supported employment programs. Some agencies, for example, have converted day program staff to employment specialists. In some states, the public mental health authority has worked out mechanisms with the Division of Vocational Rehabilitation and Medicaid office. Available financing mechanisms for such services vary from state to state and agenc . y to agency - How many employment specialists are needed for a program? Employment specialists can manage caseloads of 20 to 25 people. While some case managers learn to support a consumer's work efforts, many consumers benefit -most from employment specialists who are solely devoted to supportedemployment, in addition to their case managers. DRAYr= INFORMATION FOR FRA CnTUNERS AND CLINICAL SUPERV19ORS 4 How can we make time to talk about vocational issues when we have crises that need our attention? Programs that have implemented evidence -based supported employment find that fewer crises occur because people are interested in developing their lives in the community and managing their illness more . independently. Comprehensive and coordinated planning that occurs with supported. employment leads to fewer crises, less chaos, and more structure. Whatelements of supported employment are most critic*al? CWrently, some of the elements of supported employment have more supporting evidence than others. The following components are predictive of better employment outcomes: focus on competitive employment rapid job searches jobs tailored to individuals 100- . time -unlimited f.ollow-along supports 00� integration of supported employment and mental health services 10- zero exclusion criteria (that is, no one is screened out because they are not ready) How will we know which consumers are ready for supported employment? Research has suggested that even pe I ople who are assumed unlikely to succeed Mi employment can improve their employment outcomes with the help of supported employment. When an agency.develops a culture of' work. and encourages people to consider employment options, the number of people who go to, work increases. Giving people the choice to decide whether or not to participate in supported employment is consistent with the recovery philosophy. Many consumers in agencies with supported DRA" 2MM02 ITIIF �PUVIAn�ON INEFSANDCLINICAL fpERVMig-5 employment programs identify themselves as wanting to work in competitive jobs. Why should mental health- -agencies provide supported employment when consumers can access services. at the Division of Vocational. Rehabilitation? The evidence shows that consumers achieve better employment outcomes with the support of programs that integrate employment support services and mental health treatment. Increasingly, mental health agencies are working.closely with the Division of Vocational Rehabilitation to establish higher quahty supported employment programs with demonstrated effectiveness for people with severemental illness. For more information: Supported employment services are provided by- numerous agencies across the country. If you are interested in knowing more about these services�. contact staff at your local mental health or vocational agency. Information about supported employment, as. well as other evidence - based practices for the treatment of mental illness in the community, can be found at www.mentalhealthpractices.org. The Supported Employment Implementation Resource Kit contains copies of research articles and an annotated bibliography in the User's Guide. Some of these materials are referenced on the website:' www.mentalhealthpractices.org. This document is part of an evidence -based practice implementation resource kit developed through a contract (no. 280-00-8049) from the Substance Abuse and Mental Health Services Administration's (SANEHSA) Center for Mental Health Services (CMHS) and a grant from The Robert Wood Johnson Foundation (RWJF). These materials are in draft form for use in a pilot study. No one may reproduce', reprint, or distribute this publication for a fee without specific authorization from SAMI�SA. 1HE UJL UWARVAM (W 11W"MM BLUM WXVIM FPffMVVXD A— C�f.MMd&"S�A_ JOHNSON W ... DRAFT MM MORMATION FOR PRA Crrr]DNERS MD CLINICAL SUPERVISORS 6