The AUCD Network: Promoting Wellness for Persons with Disabilities (All Programs)

May 16, 2007

University centers on disabilities are addressing the growing demand for wellness promotion activities for persons with disabilities in their communities by bringing together research, educators, and the public in innovative programs.

This article provides brief descriptions of wellness initiatives going on across the country in 14 different UCEDDs.

Colorado

JFK Partners, University of Colorado at Denver Health Sciences Center in Aurora

JFK Partners provides primary health care, including prevention and wellness efforts, to individuals with developmental and other disabilities. They offer group and individual health promotion classes to teens and adults with developmental and other disabilities and their families or caregivers. JFK Partners provides in-service education to community center board staffs and school staffs on health promotion and wellness for people with disabilities.

JFK Partners staff members and faculty have published articles on health care (including wellness and prevention secondary conditions) for people with developmental and other disabilities, to bring these issues to a wider community (e.g. nurses, rehabilitation nurses; other health care providers). In their advanced practice nursing courses, they teach content on health promotion and wellness and the prevention of secondary conditions for people with developmental and developmental disabilities

JFK Partners also directs programs addressing the needs of individuals with particular disabilities or health conditions, such as yearly conferences and health consultation for people with Spina Bifida and Down Syndrome; also coordinates the statewide ad hoc Aging and Developmental Disabilities Group, composed of agencies concerned with both Developmental Disabilities and Aging.

District of Columbia

The Center for Child and Human Development at Georgetown University in Washington

The Georgetown University Center for Child and Human Development, University Center for Excellence in Developmental Disabilities has created a variety of products related to health and wellness:

• Family Food and Fitness: A Guide to Healthy Eating and Exercise provides families with information about healthy eating and active lifestyles. Families can use this information to help them buy fresh food, prepare nutritious meals, and have fun being active. We encourage families to include their children while they shop for food, prepare meals, and cook. Children who participate in cooking enjoy eating and make healthier food choices. The manual includes information about nutrition recommendations, food safety, meal planning and preparation, budgeting and physical activity. The guide can be downloaded at: http://gucchd.georgetown.edu/topics/special_health_needs/object_view.html?objectID=6584
• Health and Wellness for Individuals with Disabilities: An Annotated Bibliography of On-Line Resources is specifically geared for people with disabilities interested in attaining and maintaining a healthy lifestyle. Participating in physical exercise and activity, maintaining good nutrition, managing stress, and creating social supports are important to promote health and wellness. Finding appropriate activity, wellness, and health promotion information that pertains to their unique needs can be challenging for individuals with disabilities, their families, and service providers. This document can be downloaded from: http://www.gucchdgeorgetown.net/ucedd/documents/Connie%20Johnson's%20Annotated%20Bib%203-07.pdf
• The Move, Experience, Engage (M.E.E.) Calendar includes a variety of activities that will help promote health and a sense of well-being. Some of the activities promote fitness and flexibility; others increase awareness of the community or holiday traditions; and others are to help individuals with disabilities relax or socialize. There are many different types of activities such as arts and crafts, cooking, game playing, etc. Some are very easy while others may be a bit more challenging for some individuals with disabilities. One activity is listed for each day of the year. The Classification Guide describes the emphasis of each activity (movement, sensory, social, arts and crafts, and cooking). The M.E.E. Calendar is divided into three sections. Section One describes general precautions as well as a description of the symbols used on the calendar to classify the activities. Section Two is a month to month listing of the activities. Following each month there are descriptions and suggestions to adapt the activities if necessary or desired. Section Three are photos of individuals doing the exercises recommended in the calendar.
• Fit for Life: An Exercise Video. Created in partnership with George Washington University, School of Public Health and Program in Physical Therapy, Fit for Life is a 20 minute exercise video made especially for adults with developmental disabilities. The video shows four adults with various disabilities exercising under the direction of a physical therapist. The exercise program includes all elements of a comprehensive health oriented program: Warm-up, flexibility, strengthening, balance, and aerobic training. A brochure that describes each of the exercises accompanies the video.
• Exercise Fact Sheet encourages individuals to incorporate exercise into naturally occurring activities and routines. Exercise Fact Sheet can be downloaded from: http://www.dchrp.info/articles/exerciseproviders.html
• DC Health Resources Partnership is a web site that provides information to improve the health of adults with developmental disabilities. The web site promotes the goal of the project to expand the community health care capacity for individuals with intellectual and other developmental disabilities. Information on providing health and mental health services that are accessible and implementing strategies to promote quality health outcomes is on the site.
• Prevention, Assessment and Intervention for Falls in Adults with Developmental Disabilities: A Power Point Presentation explains the common risk factors for falls in the aging population, explains common screening tools used to assess fall risk in this population and provides strategies to prevent falls in the home and community.
• Physical Activity for Adults with Developmental Disabilities: A Power Point Presentation explains the importance of physical activity for individuals with developmental disabilities and provides strategies to incorporate physical activity into everyday activities and routines.

For more information about these resources, please contact Toby Long, PhD, PT, Director of Training, Georgetown University Center for Child and Human Development at 202-687-8899 or by emailing [email protected]

Iowa

Center for Disabilities and Development, University of Iowa in Iowa City

Through its CDC-funded Secondary Conditions Interventions grant, the Center for Disabilities and Development (CDD) has offered "Living Well with a Disability" (LWD), a health promotion/wellness program, to over 500 individuals with disabilities in 10 Iowa communities over the past six years. Developed by researchers at the University of Montana's Rural Institute on Disabilities, LWD consists of eight weekly two-hour training sessions and covers such topics as goal-setting, healthy reactions, nutrition, physical activity, and systems advocacy. Because peer support is a key program component, most training facilitators are individuals with disabilities. To build on an already strong peer support model, CDD staff developed and successfully piloted a four-week "refresher course" to LWD entitled "Continuing to Live Well with a Disability." Preliminary findings from a five year outcomes evaluation of LWD suggest that program participants have fewer hospitalizations, less pain and fatigue, fewer secondary conditions including significantly less depression, and fewer limitations in walking and moderate physical activity. In addition, participants report they are able to do more and have experienced an improvement in their overall health.

CDD staff has also developed "Staying Healthy and Living Well," a 10-lesson health promotion course targeting high school students with disabilities who are expected to make independent life decisions as adults. "Staying Healthy and Living Well" uses key concepts from the LWD curriculum and provides an experiential learning opportunity for students. CDD staff have collaborated with Iowa school districts to offer approximately 15 Staying Healthy courses. Preliminary results, primarily gleaned through student and teacher satisfaction surveys, are encouraging. The curriculum will be advertised and made available to all Iowa high schools. In 2006, the project launched a comprehensive website, found at www.livingwelliowa.org. The site offers resources for individuals with disabilities, training facilitators, and LWD training site coordinators. LWD graduates and other individuals with disabilities are encouraged to join the project's listserv, where they are free to exchange resources and suggestions for healthy living.

Through its Secondary Conditions Interventions grant, CDD has entered the pre-service education arena through partnerships with the University of Iowa Physician Assistant Training Program and College of Medicine. Staff and consultants with disabilities developed a series of vignettes to instruct students on the appropriate treatment of patients with disabilities. The training has been offered to students in the Physician Assistant Training program since 2005 and for first year students in the College of Medicine since 2006. It has yielded extremely positive feedback. Evaluations showed that students appreciated the "true to life" experience of learning directly from individuals with disabilities and their families In April of this year, we expanded our collaboration with the College of Medicine by incorporating simulated examinations of children and adults with disabilities to be conducted by third year medical students.

Illinois

Institute on Disability and Human Development, University of Illinois in Chicago

The Rehabilitation Research and Training Center on Aging with Developmental Disabilities (RRTCADD) is providing training to hundreds of staff working in community-based organizations across the United States and internationally, (including California, Colorado, Georgia, Illinois, Michigan, Minnesota, Indiana, Louisiana, New York, Nebraska, Maryland, New Mexico, North Carolina, Iowa, Ohio, Wisconsin, and Taiwan) to develop and implement health promotion programs for individuals with I/DD. This Train-the-Trainer training builds on the RRTCADD's successful curriculum "Exercise and Nutrition Health Education Curriculum for Adults with Developmental Disabilities."

The health promotion curriculum is an innovative interactive twelve-week program where participants are encouraged to examine their attitudes toward health, food, and exercise; gain skills and knowledge about healthy eating and exercising; participate in and identify their preferences in each activity; and locate places in the community where they can exercise. The curriculum incorporates opportunities for making choices, self-determination, self-advocacy, and problem solving techniques. The study is one of the first to examine the effectiveness of a community-based health promotion program to improve the health and well-being of adults with I/DD. A primary aim of the training is to teach staff strategies for implementing health promotion programs for adults with I/DD and to support adults with I/DD in developing goals to increase healthy behaviors. Currently, the training encourages the development of peer co-facilitators. Future modules will incorporate peer leadership sessions to increase long-term lifestyle changes.

Training has a wider and more cost-effective dissemination as more persons can be trained with less staff time and agency resources. The training is currently being beta tested as a web-based curriculum. This will allow additional modules to be developed and will assist with wider dissemination of the curriculum. The web-based curriculum may allow participants to feel less anxious about making mistakes when they complete the exercises through on-line simulations. Varying skill levels and topics can also be covered by having participants work at their own pace in on-line session that focus on a variety of applications; and participants can work on the topic and tutorial skill level that best suit their needs which can result in greater learning gains. Lastly, training is easier to systematically replicate.

The research project and trainings have had many positive outcomes. Compared to the lag group, participants in the exercise group reported several areas of improvement including the following: general health status, reports of pain, self-efficacy to exercise, increased SES for exercise, balance, and flexibility immediately following the exercise program (p < .05). Results from preliminary analysis found that 45% of the participants consume less than two servings of fruits and vegetables per day, 64% had little or no involvement in food preparation, shopping, and meal planning, 33% reported that the food they eat is not healthy, and 11% reported that they do not like the food that they eat. Immediately after the 12-week program, nutrition and activity knowledge increased significantly for participants in intervention group compared to the lag group.

Kansas

Life Span Institute, University of Kansas in Lawrence

Dr. Muriel Saunders (Assistant Research Professor in the Life Span Institute at the University of Kansas) and Dr. Richard Saunders (Senior Scientist, LSI at KU, and Training Advisor in the UCD), have a grant (2006-2009) from the Kansas Council on DD to explore the efficacy of a particular diet, and approach to dieting, to assist adults with DD in KS to lose weight and increase exercise. We also recently received a grant from Special Olympics (2007-2008) to follow 450 special athletes attending games in North and South America who will receive advice on hearing, vision, and oral health at Healthy Athletes screenings at major Special Olympics events this summer. Dr. Saunders is also the coordinator of a grant from the REACH foundation in the Kansas City area (awarded to a local service delivery agency from 2005-2007) to conduct oral health screenings of adults with DD and to refer and pay for assessments from local dentists and to help defray costs of emergency and essential dental work.

Faculty and staff also recently participated in an application, via the Research and Training Center on Independent Living in the Lifespan Institute and our State Department of Health and Environment, to the CDCs, to fund nutrition and weight-loss promotion to persons with physical, intellectual, and other disabilities statewide from 2007-2012. Current awards follow recent pilot research (funded by the University of Kansas and a local DD service agency) to address ergonomic and positioning issues for adults in sheltered workshops and also dietary intake of adults living in group homes. Additional grants to NIDDK and other agencies are in preparation.

Our other funded work is from NICHD (2007-2012) to research innovative approaches to establishing effective and functional communication by infants, children, and adults at risk for, or with, the most severe multiple impairments. This work is in collaboration with the Department of Speech and Hearing Sciences, University of Washington.

Kentucky

Interdisciplinary Human Development Institute at the University of Kentucky in Lexington

A key wellness project of the Interdisciplinary Human Development Institute is the Preservice Health Training Project, funded by the Kentucky Council on Developmental Disabilities, to provide training to medical, nursing, physician assistant, and dental students in communicating and caring for their patients via an interactive "virtual patient" case study approach. We have completed a set of seven modules, and our effectiveness studies on these modules (measuring both knowledge and attitudinal changes) have appeared in such peer-reviewed journals as the Journal of Dental Education (February 2007), Journal of Physician Education (in press), and Journal of Nursing Education (in press). To date, over 1,000 students have participated in the modules across these various disciplines, and we are preparing to do a study with 450 medical, dental, and nursing students across 15 university programs in Great Britain this summer.

Though we designed these modules for the Preservice level, we have also found that they have strong continuing education merit. To date, Preservice Health Training modules have been accepted for CME credit by the American Dental Association (the dental modules are in final stages of being placed on the ADA's website), American Academy of Physician Assistants, American Academy of Nurse Practitioners, and the American Osteopathic Association. We are currently working to determine the most effective methods for disseminating these modules for CMEs through these professional organizations.

Finally, the project was recognized by our University's President, Dr. Lee T. Todd, as one of a select set of Commonwealth Collaboratives. Commonwealth Collaborative Projects are designated by the University as those which have the greatest potential to impact the lives of the citizens of our state.

Maine

Interdisciplinary Disability Studies Center for Community Inclusion and Disability Studies at the University of Maine in Orono

The Prevention Center of Excellence (PCoE), a collaborative effort directed by Stephen Gilson, Ph.D., is devoted to advancing universally accessible prevention throughout Maine and beyond. The Center conducts research, policy analysis, teaching, and technical assistance to align inclusive substance abuse prevention with the state's larger public health agenda. The PCoE has also developed initiatives in obesity prevention, domestic violence prevention and tobacco cessation which reflect the principles of full access and inclusion espoused by the Center for Community Inclusion and Disability Studies.

Elizabeth DePoy, Ph.D. at the Center for Community Inclusion and Disability Studies collaborates with the Maine Title V office as the evaluator on the Healthy and Ready to Work National Center. This national project provides health related organization, information and technical assistance to national Healthy and Ready to Work projects, Title V state agencies, and other health and wellness efforts focusing on youth with disabilities and chronic health care conditions who are transitioning to adulthood.

The modular Long term care Project, directed and authored by Elizabeth DePoy, Ph.D. and Stephen Gilson, Ph.D., prepared and nationally disseminated universally accessible, multi-media interactive long term care educational modules.

Funded by the Office of Women's Health, Stephen Gilson, Ph.D, and Elizabeth DePoy, Ph.D. with Liz Cramer, Ph.D, co-authored a universally accessible domestic violence prevention social work education module on CD ROM entitled Domestic violence and women with disabilities, a curriculum training module for schools of social work.

Montana

University of Montana Rural Institute: Center for Excellence in Disability, Education, Research & Service in Missoula

The University of Montana Rural Institute on Disabilities has conducted research into the health and wellness of adults with disabilities since 1988. We have developed two secondary conditions surveillance instruments that have been widely used. In addition, based on data from these instruments, we have developed and tested several interventions. The Secondary Conditions Screening Instrument (SCSI) addresses secondary conditions experienced by adults with mobility impairments. Applications of this instrument suggest that adults with mobility impairments experience an average of 14 secondary conditions annually that interfere with their ability to participate in community life. A similar instrument, Health and Secondary Conditions Surveillance Instrument for Adults with Developmental Disabilities, targets adults with intellectual and developmental disabilities.

We have also developed the Living Well with a Disability program for adults with mobility impairments. Since then, it has been adopted and implemented by over 120 organizations in 32 states. Living Well with a Disability is typically delivered as an 8-week workshop to groups of 8-10 participants that are facilitated by staff from a center for independent living (CIL) 2 hours per week. The facilitator guides the group through 10 chapters of a self-help workbook. CIL facilitators are trained in either a 2-day experiential training seminar or via internet. Living Well provides a process for setting, clarifying, monitoring and attaining self-selected goals. It also provides participants with tools to manage their health, make healthy lifestyle changes, increase physical activity, develop and maintain healthy relationships, avoid depression and frustration, and improve eating habits. This program has been shown to improve health and reduce medical service utilization in controlled field trials in 9 states. We are currently developing and testing interventions (i.e., The Health Club, MENU-AIDDS, and Have Healthy Teeth) for adults with intellectual and developmental disabilities.

Now, the Montana Disability and Health Program has published Community Activated Living Well: A Guide for Implementing the Living Well with a Disability Health Promotion Workshop for Community Members who have Disabilities. This guide includes ideas, agendas and procedures that community members can use to organize and conduct Living Well workshops. For more information, please visit: mtdh.ruralinstitute.umt.edu/Publications/COALW.htm.

New York

Westchester Institute for Human Development in affiliation with New York Medical College in Valhalla

Westchester Institute for Human Development has just published a curriculum called "My Health, My Choice, My Responsibility" designed to teach adults with Developmental Disabilities to advocate for themselves for a healthier lifestyle. The curriculum is designed to be used by two trainers (one of whom is a self-advocate) over multiple sessions. It was done with the NYS Self-Advocacy Association and the DD Council. The Institute is also implementing an electronic medical record system and is working on a patient portal so that patients, families and support staff can access info from their own medical record. For agencies, that is a huge deal given the info they are required to have. They can also use it to make appointments, communicate with their primary care provider or other physician, etc. We are serving about 3000 adults with Developmental Disabilities - primary care, subspecialty care, dental, behavioral health, etc., and we are doing about 15,000 visits per year, just in the adult health care area.

Oregon

Oregon Institute on Disability and Development at Oregon Health and Science University in Portland

Healthy Lifestyles (HL) is a free 3-day, health promotion intervention offered by the Oregon Office on Disability and Health (OODH) at Oregon Health & Sciences University (OHSU). HL is designed for people with disabilities to develop confidence and skills to stay on a journey toward a healthy and happy life. This workshop is facilitated by trainers with and without disabilities, and is appropriate for people with all types of disabilities, including people with mild to moderate cognitive abilities. To date, over 450 people with disabilities in Oregon and SW Washington have participated in HL workshops.

Healthy Lifestyles uses an integrated wellness and empowerment approach and provides participants with knowledge and skills to adopt healthier behaviors. The curriculum covers all aspects e.g., social health, physical health, emotional health, spiritual health, and health through meaningful activities. After completion of the workshop, HL support groups meet once a month for six months. During these meetings, participants share their successes and challenges in meeting their self-identified goals and a guest speaker leads a discussion on a health-related topic.

Celebrate Wellness (CW) is an annual conference (2006 was our seventh annual) promoting health, fitness, social inclusion, consumer awareness, youth transition and overall wellness for people with disabilities. Conference attendees include, people with disabilities and their family members as well as service providers, researchers, educators and businesses that serve people with disabilities. Celebrate Wellness addresses the substantial need for participatory and educational opportunities that specifically target people with disabilities, and influence current health practices. The conference is based on an integrated paradigm incorporating medical, functional, and social approaches to disability. This premise supports the need for educational interventions that promote the following: 1) a positive and accurate depiction of disability and its dimensions; 2) the idea that people with disabilities should not be considered "sick" or "unhealthy;" 3) that everyone, with or without a disability, can choose to lead a healthy lifestyle; and 4) that a healthy lifestyle means being proactive and participating in health and wellness efforts that best suit personal needs, interests, and abilities. The conference supports these assumptions by providing conference participants with the opportunity to develop the necessary skills and knowledge to lead a healthy lifestyle. It also provides a much needed opportunity for a diverse group of individuals to come together and share their knowledge, expertise, and experiences in health and wellness for the benefit of people with disabilities.

South Dakota

Center for Disabilities at the Sanford School of Medicine of The University of South Dakota in Sioux Falls

The South Dakota UCEDD, Center for Disabilities (CD), has made concentrated efforts to improve the health and wellness of South Dakotans with disabilities. CD operates the state's only Dietetic Internship Program, one that is unique in the nation as it is the only dietetic internship, approved by the American Dietetics Association, with a focus on individuals with disabilities and/or special health care needs. CD's staff has assisted the South Dakota Department of Health in the development of the State Plan for Nutrition and Physical Activity To Prevent Obesity and Other Chronic Diseases, a plan that focuses on all South Dakotan's including those with disabilities. Recently, CD began working with three community-based service organizations to develop nutrition educational materials with appropriate readability and literacy levels for individuals with disabilities to enable them to make healthy food choices assisting with effectively managing their diabetes and weight. Along with the development of educational materials, the project is providing extensive nutrition education to the target population, along with their family members and direct support workers. By addressing these health literacy issues, the target population, with assistance from their service providers, families and community members, will be able to improve their overall health outcomes over the long term.

Utah

Center for Persons with Disabilities at Utah State University in Logan

The Utah UCEDD partnered with the Utah Department of Health two years ago to develop and implement a statewide health promotion and wellness initiative for the exploding population of Utah Latinos. We conducted focus groups with over 200 Utah Latino adults with disabilities and family members of Latinos with disabilities to better understand the complex relationships between health, disability and Latino culture. The result was a Latino State Plan for Disability and Health and the development of the Utah Center for Disability and Health with a targeted focus on Latino issues. We've translated standard health promotion curricula into linguistic and culturally appropriate Spanish; partnered with the Mexican Consulate, Utah Governor's Office and other community groups to increase awareness of health and disability issues faced by Latinos in the United States; and, are providing targeted health promotion training to Latino adults with disabilities (in collaboration with the state independent living program) and to Latino families who have children with disabilities.

Wisconsin

Waisman Center on Mental Retardation and Human Development at the University of Wisconsin-Madison

The Waisman Center assumed the lead to convene a statewide invitational conference to develop a Wisconsin Blueprint to reduce health disparities of people with developmental disabilities. While that effort was focused specifically on people with developmental disabilities, all of our discussions focused on health issues of the broader group of individuals with disabilities. This report set the foundation for our continuing work in the health area. Out of this this effort:

• A statewide set of recommendations have been developed to address issues in the following areas: (1) attitudes and assumptions about disability and health, (2) organization and financing, (3) training of health care providers,
  (4) Information, assistance and advocacy.
• In-state regional conferences have been held to apply the statewide recommendations to multi-county areas.
• Local and regional trainings on various aspects of health care have been held...both for individuals with disabilities themselves, as well as for health care and other service providers.
• Wisconsin is moving towards a managed care model for long term support, and
  we are part of the statewide group that is meeting with each of the care management organizations to specifically discuss steps they should be taking to address health for individuals disabilities.
• We are actively involved in promoting the concept of "medical home" (which has been championed by MCHB as well as the American Academy of Pediatrics and American Academy of Family Physicians) as an ideal method to promote comprehensive health care for individuals with disabilities and other special health care needs.
• The Waisman Center holds nine specialty clinics within which it provides diagnostic and follow along services for specific disability areas.
• The Waisman Center has an MCH LEND program, focused on preparing the next generation of health care providers, serving those with neurodevelopmental and other disabilities.

Wyoming

Wyoming Institute for Disabilities at the University of Wyoming in Laramie

The Wyoming Early Childhood Vision Project has developed a readily replicable model for early childhood vision screening, including the use of a Photoscreener, for children with and without disabilities who are between six months and five years of age. The Vision Project provides training and materials to developmental preschool programs to facilitate competency in four areas of vision screening - 1. Intake of family background and identification of risk factors; 2. Physical screening procedures including tracking, fixation, and appearance of eyes; 3. Use of the Photoscreener; and 4. Reliable interpretation of screening results including competency testing of interpreting photos with not less than 85% inter-rater reliability using the standards established for interpretation. The Vision Project tracks the results of the vision screening to assure children referred receive professional eye examinations.

Wyoming AgrAbility is a program designed to assist farmers and ranchers with disabilities or other limitations to be able to continue to farm and ranch. The mission of Wyoming AgrAbility is to provide education, networking and assistance to ranchers, farmers, agricultural workers and their families with disabilities who are engaged in production agriculture and want to continue ranching or farming. Ranching and farming are physically demanding and hazardous jobs. Even when proper precautions are taken, disabling accidents may still occur. When a rancher or farmer acquires a disability either from an accident or due to aging, the compensatory steps taken by the individual may also place them at risk for secondary injuries or death.

As part of the educational component, Wyoming AgrAbility has increased the project focus to include injury prevention (whether it be primary injury or secondary injury prevention if a disability injury has occurred). Staff members began writing articles for general release in state and regional print media. These articles focus on things such as every day assistive technology (emphasizing universal design), working safely with children, working with large equipment and other similar information. The purpose of this education is not to detract from disabilities which may already be present, but rather to educate those who have the potential to reduce or eliminate the chance of acquiring a disability from injury.

Through the legislative activities of the Wyoming Oral Health Coalition (funded by a State Oral Health Collaborative Systems grant through HRSA) adults with disabilities who are EqualityCare eligible have received improved oral health coverage. Previous to the 2006 legislative session, individuals with developmental disabilities (who were not residents of the state school) were not eligible for any dental coverage other than emergency visits and extractions. The coalition activities during that session resulted in the approval of an adult Medicaid dental program.

During the 2007 legislative session the Oral Health Coalition requested the reimbursement of Services for Developmentally Disabled individuals in Wyoming (not already receiving this benefit by being residents at the state school) to cover 100% of necessary oral health services. Legislators did not approve the request but passed an amendment to remove the $400 cap for oral health services covered by the adult Medicaid program. This change will result in improved oral health care coverage through providing some additional services.