Status Report on Protecting Our Infants Act Implementation Plan. Recommendations Addressing Clinical Changes

02/07/2019

Recommendations addressed by the following agencies:

17. Improve and expand screening to identify women in need of brief intervention, and referral to treatment.(Data & Surveillance, Maternal)

  1. ACF/Children's Bureau, AHRQ, CDC, CMS, HRSA, IHS, NIDA, OASH/OWH, SAMHSA

18. Define and understand the elements of an effective risk-benefit assessment in order to counsel pregnant women with pain regarding their management.(Data & Surveillance, Maternal)

  1. CDC, IHS, NICHD, NIDA, OASH/OWH, SAMHSA

19. Expand the use of SBIRT to identify hazardous and harmful substance use and intervene to change behavior prior to conception. (Programs & Services, Maternal)

  1. CDC, CMS, FDA, HRSA, IHS, OASH/OWH, SAMHSA

20. Support continuation of treatment for SUD from preconception through pregnancy and one year postpartum and tailor MAT according to parental need.(Programs & Services, Maternal)

  1. CDC, CMSHRSA, OASH/OWH, SAMHSA

21. Provide easily accessible, family-friendly, SUD treatment for pregnant and parenting women.(Programs & Services, Maternal)

  1. ACF/Children's Bureau, CMS, HRSA, IHS, NIDA

22. Provide developmental assessment and early intervention services for substance-exposed children with or without a history of NAS/NOWS.(Programs & Services, Child)

  1. ACF/Children's Bureau, CDC, CMS, HRSA, IHS, SAMHSA

23. Promote training and resources for child welfare workers to effectively address SUD and prenatal substance exposure, facilitate linkages to treatment, and promote recovery for mothers with SUD.(Education, Child)

  1. ACF/Children's Bureau, CDC, CMS, HRSA, IHS

Examples of Agency activities to address recommendations:

Recommendation Agency Action Funding Milestones/Status
17. Improve and expand screening to identify women in need of brief intervention, and referral to treatment.(Data & Surveillance, Maternal) ACF (move to next ACF)
Children's Bureau (move to next CB)
  • Funded
  • Ongoing
AHRQ (move to next AHRQ)
  • USPSTF is undertaking an evidence review to update clinical recommendations on "Screening for Illicit Drug Use in Adults and Adolescents." This review includes pregnant women.
  • Funded
  • Ongoing
CDC (move to next CDC)
  • Funds PQCs which are networks of perinatal care providers and public health professionals working to improve pregnancy outcomes for women and newborns in states and nationally. Efforts include: improve identification of and care for infants with NAS.
  • Funded
  • Ongoing through 2022
  • Provided grant funds for a research project to compare and validate screening tools for substance use among women. CDC has also contracted with ACOG to survey members about screening, referral, and treatment of maternal opioid use and will produce a research report on survey results.
  • Grant funded
  • Ongoing
  • Continue efforts to provide ready access to parental support and early intervention services through the PQC.
  • Funded
  • Ongoing 2022
CMS (move to next CMS)
  • As a part of a multi-pronged strategy to combat the opioid crisis, some CMMI models being considered for potential development explore opportunities to improve and expand screening to identify women with SUD and provide relevant referral to treatment.
  • Potentially funded through Section 3021 (of the Affordable Care Act) Appropriation
  • 10-12 months
HRSA (move to next HRSA)
  • Provided funds for the Bright Futures Pediatric Implementation Program.
  • Funded
  • Ongoing
  • AIMS and SUD-MH expand access to SBIRT and mental health screening at health centers.
  • Funded
  • Ongoing
  • Specifically for PPW grantees in programs such as Healthy Start and Home Visiting, uses evidence-based approaches to screen, intervene, and refer perinatal women and parents of young children to treatment and recovery support services. Frontline staff provide health education and guidance for parents of young children, including caring for babies born with NAS.
  • Funded
  • Ongoing
  • Supports the development of clinical guidelines such as Bright Futures Health Supervision Guidelines for pediatric practice and the AIM initiative, which developed best practices for hospitals on the obstetric management of women with opioid dependence.
  • Funded
  • Ongoing
  • Provides all states with Title V funds that may be used to implement screening for substance use among pregnant women.
  • Funded
  • Ongoing
  • Funds Healthy Start whose community health workers use standardized screening tools to screen and refer perinatal women for substance use.
  • Funded
  • Ongoing
IHS (move to next IHS)
  • Collaborates with the ACOG's Committee on AI/AN Women's Health to develop and expand clinical practice guidelines to routinely screen women for SUDs and facilitate early referral to treatment.
  • Funded
  • All activities will be completed in 10-12 months
  • Collaborates with the AAP CONACH to develop standardized screening guidelines based on the IHS Best Practice Guidelines: NOWS.
  • Funded
  • Ongoing
  • Plans to implement approved guidelines and publish best practices recommendations on the IHS Opioid Dependence Management and Maternal Child Health webpages.
  • Funding TBD
  • 12 months
  • Plans to identify training needs to support implementation of guideline recommendations.
  • Funding TBD
  • 12 months
  • Plans to create and release outcomes measures to track implementation progress.
  • Funding TBD
  • 12 months
NIDA (move to next NIDA)
  • Funded research in the development of screeners to assess prescription drug abuse and other illicit drug use among pregnant women and identifying risk factors for prenatal substance and polysubstance use.
  • Funded
  • Results published 2018
  • Plans to develop research in this area.
  • Funding TBD
  • TBD
OASH (move to next OASH)
OWH (move to next OWH)
  • Through OWHPA grants, awarded 6 out of the 20 grants to organizations training health professionals in using SBIRT. Grantees are in Regions 1, 2, 4, 5, and 7.
  • Funded via cooperative agreement for FY 17-FY19
  • Ongoing
  • In March 2017, initiated a 1-year partnership with IHS to address the problem of opioid misuse among women of reproductive age in AI/AN communities, including PPW. Specifically, the IAA supports national training, education, and guidance through development of written recommendations on the screening, diagnosis, and management of opioid dependence among AI/AN women of reproductive age and AI/AN newborns. These documents are being developed through work with ACOG and AAP.
  • Funded via IAA and contract in FY17
  • Written recommendations will be released later in 2018 and will then be disseminated throughout the IHS system (partnership with IHS and OASH/OWH)
  • Through the same IAA with IHS, OASH/OWH supported the development of a structured, comprehensive approach to prenatal care and SUD treatment in the Billings, MT, an area of particularly high need. This process has included extensive process mapping, and data collection has been conducted at two clinical sites (Lame Deer and Crow).
  • Funded via IAA and contract in FY17
  • Report will be released later in 2018 and will then be disseminated throughout the IHS system (partnership with IHS and OASH/OWH).
  • In FY 2018, OASH/OWH is partnering with the HRSA Office of Women's Health on an initiative to produce a care coordination model for women impacted by opioids who receive healthcare services via HRSA-administered programs. This 2-year initiative will involve a two-phase series of working consultation meetings leading to the development of a final guide that will include care coordination and implementation resources. Meetings will be held with stakeholders from all 10 HHS regions. OASH/OWH and HRSA will engage with regional staff to assist with follow-up consultation and plans to develop and disseminate the care coordination models and resources.
  • Funded via AA in FY18, FY19 funding TBD
  • FY18-FY20 (partnership between HRSA and OASH/OWH)
SAMHSA (move to next SAMHSA)
  • Working with ACOG and AAP to improve screening and care for women with OUD who are pregnant. ACOG issued guidance that all pregnant women be screened for SUD.
  • New initiatives funding TBD
  • Conversations/ collaboration initiated
  • · Collaborated with the SAMHSA/HRSA Center for Integrated Health Solutions in the development of a webinar, "Screening Pregnant Women for SUD."
  • Funded
  • January 2018
  • Project LAUNCH grant program: one core component of the LAUNCH model is to promote screening for children and their caregivers. Especially screening for behavioral health issues. LAUNCH grantees partner with existing systems that serve women and women with young children (home visiting; MCH; primary care/OB care; women, infants, and children; early intervention) and create mechanisms and opportunities to embed behavioral health screening and referral in those systems.
  • Grant funded
  • Ongoing; first cohort awarded in FY08; new cohort targeting AIAN communities will be awarded in FY18, date TBD
Recommendation Agency Action Funding Milestones/Status
18. Define and understand the elements of an effective risk-benefit assessment in order to counsel pregnant women with pain regarding their management. (Data & Surveillance, Maternal) CDC (move to next CDC)
  • Leading the Treating for Two initiative to identify the safest treatment options for the management of common conditions before and during pregnancy and to improve the availability and quality of data to help inform clinical management decisions for pregnant and reproductive aged women and their healthcare providers. Treating for Two also conducts ongoing research and surveillance of medications commonly used to manage health conditions during pregnancy and associated adverse outcomes including structural birth defects.
  • Unfunded
  • Ongoing
  • Published guidelines related to prescribing opioids for chronic pain, which included counseling pregnant women on opioid. (Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016. MMWR Recomm Rep 2016; 65(No. RR-1):1-49. DOI: dx.doi.org/10.15585/mmwr.rr6501e1 )
  • Funded
  • Published March 2016
  • Has developed an online training for healthcare providers on opioids and pregnancy.
  • Funded
  • Ongoing
  • Developing a module specific to pregnancy from the CDC Guideline for Prescribing Opioids for Chronic Pain to be released summer/fall 2018
  • Funded
  • Summer/Fall 2018
IHS (move to next IHS)
  • Has instituted formal training in opioid prescribing for all physician staff prescribing narcotic pain medications.
  • Funded
  • 10-12 months
  • With AAP, CONACH, and ACOG, revises guidelines for managing addiction in pregnant women.
  • Funded
  • Ongoing
  • Creates a training platform to educate providers on comprehensive pain assessment and treatment strategies in special populations to reduce NOWS risk
  • Funding TBD
  • Ongoing
NIDA (move to next NIDA)
NICHD (move to next NICHD)
  • Addresses opioid use in pregnancy, NAS, and childhood outcomes.
  • Ongoing
  • April 2016 meeting convened
  • Published an executive summary on the research agenda in Obstetrics and Gynecology in June 2017.
  • Funded
  • Completed; summary/research agenda published June 2017
OASH (move to next OASH)
OWH (move to next OWH)
  • Focuses several OWHPA grants on risk-benefit assessment and counseling pregnant women on pain management. These grants are in Regions 1, 4, and 5.
  • Funded via cooperative agreement for FY 17-FY19
  • Ongoing
SAMHSA (move to next SAMHSA)
  • Will convene an expert panel to discuss the available evidence on the long-term impact of in utero opioid exposure and the role of illicit or prescribed opioid exposure on child development.
  • Contract funding
  • April 2018
  • Will develop a product that summarizes the literature and recommendations.
  • Contract funding
  • September 2018
Recommendation Agency Action Funding Milestones/Status
19. Expand the use of SBIRT to identify hazardous and harmful substance use and intervene to change behavior prior to conception.(Programs & Services, Maternal) CDC (move to next CDC)
  • Supported FASD Practice and Implementation Centers (PICs) and National Partners to prevent FASDs by improving healthcare practice, education, and awareness among healthcare professionals through use of evidence-based practices, including alcohol screening and brief intervention. The PICs and National Partners worked with six health disciplines -- family medicine, medical assisting, nursing, obstetrics and gynecology, pediatrics, and social work. The goal of ongoing efforts is to impact healthcare practice at the systems level and enhance FASD prevention opportunities nationally for women of childbearing age and their support networks.
  • Funded co-agreement
  • Completed co-agreement: 2014-2018
  • Ongoing co-agreement: 2018-2022
  • CDC and SAMHSA, in collaboration with the National Committee for Quality Assurance, are working to improve quality of care through alcohol screening and brief intervention and its reporting in electronic clinical data systems. This effort will promote a newly approved Healthcare Effectiveness Data and Information Set (HEDIS) performance measure, Unhealthy Alcohol Use Screening and Follow-Up. This work will be done through a quality improvement learning collaborative that will help health plans use and report the HEDIS measure in order to improve quality of care and health outcomes of individuals with unhealthy alcohol use.
  • Interagency agreement/ contract
  • 2017-2020
CMS (move to next CMS)
  • Funded
  • Completed
  • Funded
  • Completed
  • Providing TA to states as requested.
  • Funded
  • Ongoing
HRSA (move to next HRSA) Achieves this recommendation through health centers and other primary care settings. Examples include:
  • AIMS and SUD-MH expand access to SBIRT and mental health screening at health centers.
  • Funds support testing evidence-informed interventions for integrating behavioral health with primary medical care for people living with HIV and using an implementation science model to develop tools and resources to guide implementation locally at Ryan White HIV/AIDS Program provider sites.
  • Funded
  • Ongoing
IHS (move to next IHS)
  • Plans to consider wide adoption of a Centering Pregnancy® program, which provides group prenatal care facilitated by a nurse midwife.
  • Funding TBD
  • 10-12 months
  • Captures screening and SBIRT initiatives in planned guidelines.
  • Funded
  • Ongoing
  • Released GPRA SBIRT logic in baseline year; limitation is that this is captured for behavioral health patients.
  • Funded
  • Ongoing
OASH (move to next OASH)
OWH (move to next OWH)
  • A potential element of the OASH/OWH and HRSA Office of Women's Health initiative to produce a care coordination model for women impacted by opioids who receive healthcare services via HRSA-administered programs.
  • Funded via IAA in FY18, FY19 funding TBD
  • FY18-FY20
SAMHSA (move to next SAMHSA)
  • Increased SBIRT use in the 2017 PPW cohort and other programs serving women of childbearing age and PPW populations.
  • Funded
  • Ongoing grant funded: 2017-2020
  • · Cross-agency collaboration with CDC, HRSA, to expand SBIRT in women's healthcare settings. Quarterly calls to provide updates on programming.
  • New initiatives funding TBD
  • Ongoing
  • Project LAUNCH states and communities promote and expand use of SBIRT, focusing on systems that serve pregnant women and parents of young children. Many grantees provide trainings on SBIRT and incorporate SBIRT into the array of services being provided through the grant
  • Grant funded
  • Ongoing; first cohort awarded in FY08; new cohort targeting AIAN communities will be awarded in FY18, date TBD
Recommendation Agency Action Funding Milestones/Status
20. Support continuation of treatment for SUD from preconception through pregnancy and one year postpartum and tailor MAT according to parental need.(Programs & Services, Maternal) CDC (move to next CDC)
  • Has been working to improve the assessment of opioid and other SUD as a contributing factor in maternal deaths. State and local Maternal Mortality Review Committees (MMRCs) comprehensively assess maternal deaths and identify opportunities for prevention. To strengthen this work, CDC has partnered with the CDC Foundation and the Association of Maternal and Child Health Programs. MMRCs are in a unique position to identify and document the contribution of mental health conditions and substance use disorders (including opioid use disorders) to pregnancy-related mortality, because of their comprehensive and interdisciplinary approach. CDC is working with representatives of 25 MMRCs (AK, AZ, CO, DE, FL, GA, HI, IL, LA, MA, MS, MO, NH, NM, NYC, NC, OH, SC, TN, UT, VA, WA, WV, WI), to strengthen the capture of data related to substance use, including screening, diagnosis, referral, treatment, adherence, and the committees' determination of whether substance use disorder contributed to the death.
  • External funding (CDC Foundation from Merck for Mothers)
  • End date March 2019
  • Build capacity of MMRCs in other states to improve data quality and data capture of the contribution of mental health and substance use disorders to maternal mortality.
  • External funding (CDC Foundation from Merck for Mothers)
  • End date March 2019
CMS (move to next CMS)
  • See responses to #5. CMS makes information available on broad Medicaid coverage categories; states determine how to implement them consistent with Medicaid law and regulation and CMS approval when applicable.
  • Funded
  • Ongoing
  • Provides TA to states as requested.
  • Funded
  • Ongoing
  • As a part of a multi-pronged strategy to combat the opioid crisis, some CMMI models being considered for potential development explore opportunities to support continuation of treatment for SUD throughout pregnancy and the postpartum period.
  • Potentially funded through Section 3021 (of the Affordable Care Act) Appropriation
  • Ongoing
FDA (move to next FDA)
  • Labeling for MAT products notes the benefits of MAT treatment in pregnancy.
  • Funded
  • Ongoing
HRSA (move to next HRSA) Achieves this recommendation through health centers and other primary care settings. Examples include:
  • The AIMS and SUD-MH supplemental funding for health centers.
  • RHOP.
  • Testing evidence-informed interventions for integrating behavioral health with primary medical care for people living with HIV.
  • Funded
  • Ongoing
OASH (move to next OASH)
OWH (move to next OWH)
  • A potential element of the OASH/OWH and HRSA Office of Women's Health initiative to produce a care coordination model for women impacted by opioids who receive healthcare services via HRSA-administered programs.
  • Funded via IAA in FY18, FY19 funding TBD
  • FY18-FY19
SAMHSA (move to next SAMHSA)
  • Convened a Technical Expert Panel: Developmental Impacts on Children of Opioid Use During Pregnancy: Pragmatic Approaches to Supporting Children and Families. Will result in a product that describes the scientific literature on the impact of opioids in pregnancy, on the fetus/child, gaps future research should address, pragmatic approaches to supporting children/families impacted by opioid use in pregnancy.
  • Contract funding
  • April 2018
Recommendation Agency Action Funding Milestones/Status
21. Provide easily accessible, family-friendly, SUD treatment for pregnant and parenting women.(Programs & Services, Maternal) ACF (move to next ACF)
Children's Bureau (move to next CB)
  • See response to recommendation #3 regarding the Children Bureau's funding of the Regional Partnership Grant Program.
  • Grant funded
  • Ongoing; to be completed by 2022
CMS (move to next CMS)
  • Works with states on section 1115 demonstrations to improve SUD treatment as well as use of the health homes authority to coordinate care for Medicaid beneficiaries with substance use disorder, which often include improving access to treatment in outpatient settings that are generally more accessible and family friendly.
  • Funded
  • Ongoing
  • Provides TA to states as requested.
  • Funded
  • Ongoing
  • As a part of a multi-pronged strategy to combat the opioid crisis, some CMMI models being considered for potential development explore opportunities to provide easily accessible, family-friendly, SUD treatment for pregnant and parenting women.
  • Potentially funded through Section 3021 (of the Affordable Care Act) Appropriation
  • 10-12 months
HRSA (move to next HRSA)
  • Achieves this recommendation through health centers and other primary care settings. Examples include: The AIMS and SUD-MH supplemental funding for health centers. The AIM initiative.
  • Ongoing
  • Ongoing
IHS (move to next IHS)
  • Provides tobacco cessation training for various healthcare disciplines (e.g., pharmacists, nurses) on universal tobacco use screening (Ask-Advise-Refer).
  • Funded
  • Ongoing
  • Makes tobacco treatment services available in outpatient clinics with expanded access to OTC and prescription treatments for nicotine dependence.
  • Funded
  • Ongoing
  • Makes available counseling and support services for pregnant women in conjunction with tribal programs.
  • Funded
  • Ongoing
  • Creates best practices recommendations to build treatment capacity and assist with early intervention and referral to treatment for OUD.
  • Funded
  • Ongoing
  • Creates a series of webinars focused trauma-informed care principles.
  • Funded
  • Ongoing
  • Provides webinars on illicit substance use in pregnancy, opioid maintenance, and prevention strategies (to be revised to support new guideline implementation).
  • Funding TBD
  • 12 months
  • Publishes on the Opioid Dependence Management public domain page and provides trainings through the IHS TeleBehavioral Health Center of Excellence.
  • Funded
  • Ongoing
NIDA (move to next NIDA)
  • Funded research on improving access to treatment for women with OUD and risk assessment of NOWS.
  • Funded
  • Ongoing
  • Continues funding for this research to increase available data and form recommendations.
  • Funded
  • Ongoing
Recommendation Agency Action Funding Milestones/Status
22. Provide developmental assessment and early intervention services for substance-exposed children with or without a history of NAS/NOWS. (Programs & Services, Child) ACF (move to next ACF)
Officeof Head Start
  • Early Head Start and Early Head Start-Child Care Partnerships
  • Funded
  • Ongoing
  • Funded
  • Ongoing
CDC (move to next CDC)
  • CDC's Learn the Signs. Act Early. program aims to improve early identification of developmental delays and disabilities, so children and families can access early intervention and other support they need. The program offers free tools to help all parents and other caregivers learn the signs of healthy development, track their young child's developmental milestones, and act early if there is ever a developmental concern.
  • Funded
  • Ongoing
CMS (move to next CMS)
  • Under the EPSDT benefit, Medicaid covers regular screening services for children under age 21 in order to identify health and developmental issues as early as possible. States must provide or arrange for screening services both at established times and on an as-needed basis. Covered screening services are medical, mental health, vision, hearing and dental. The medical screenings include, among other things, a comprehensive health and developmental history that assesses for both physical and mental health, as well as for substance use disorders.
  • Funded
  • Ongoing
  • Funded
  • Completed 2016
  • Core Set of Children's Health Care Quality Measures for Medicaid and CHIP (Child Core Set) includes the quality measure "Developmental Screening in the First Three Years of Life (DEV-CH). Results publicly reported for the first time for FFY 2016 and 27 states reported on the measure for FFY 2017.
  • Funded
  • Ongoing
HRSA (move to next HRSA)
ACF (move to next ACF)
  • Direct services programs such as Home Visiting and Healthy Start grant programs.
  • Funded
  • Ongoing
HRSA (move to next HRSA)
ACF (move to next ACF)
  • Jointly administer the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program to support parents of young children in at-risk communities. The program helps parents tap the resources and hone the skills they need to raise children who are physically, socially, and emotionally healthy and ready to learn.
  • Funded
  • Ongoing
HRSA (move to next HRSA)
  • Provides funding to the Bright Futures Pediatric Implementation Program, which promotes developmental screenings at certain well-child visits (9 Month, 18 Month, and 2½ Year) and at other times at which concerns are identified.
  • Funded through cooperative agreement
  • Ongoing
SAMHSA (move to next SAMHSA)
  • One of the core strategies of Project LAUNCH is to increase and improve access to developmental and social emotional screening for young children ages 0-8.
  • Grant funded
  • Ongoing; first cohort awarded in FY08; new cohort targeting AIAN communities will be awarded in FY18, date TBD
Recommendation Agency Action Funding Milestones/Status
23. Promote training and resources for child welfare workers to effectively address SUD and prenatal substance exposure, facilitate linkages to treatment, and promote recovery for mothers with SUD. (Education, Child) ACF (move to next ACF)
Children's Bureau (move to next CB)
  • See response to recommendations #7, #8, and #16 as it relates to the on-going work of NCSACW. Through this work, ACF is providing on-going TA to communities to promote and facilitate and strengthen collaboration between child welfare workers, facilitate linkages to treatment and promote recovery for mothers with SUD. NCSACW provides TA and four different levels to achieve these goals, in addition to the development of on-line training (which offers CEUs), curricula, webinars and other products to support our work in this area.
  • Contract funding
  • Ongoing
  • Also see response to recommendations #3 as it relates to the work of the Regional Partnership Grant Program which specifically mentions the importance of cross-training and staff development as part of the work of these grants. Many of ACF's grantees include training child welfare staff as a part of their grant funded activities.
  • Grant funded
  • Ongoing; to be completed by 2022
CDC (move to next CDC)
  • CDC is working with ACF to improve the health and developmental outcomes of children with prenatal substance exposures in the child welfare system by promoting appropriate identification, referrals, interventions and education. Working towards this objective will also 1) reduce the risk of repeated cycles of abuse/neglect and 2) build an infrastructure for monitoring the magnitude and resource needs for this population. The National Center on Substance Abuse and Child Welfare handles linking parents with child welfare involvement to treatment.
  • Interagency agreement
  • 2016-2019
CMS (move to next CMS)
  • As a part of a multi-pronged strategy to combat the opioid crisis, some CMMI models being considered for potential development explore opportunities to support community-level investments in improved infrastructure and resources to effectively address SUD and prenatal substance exposure, facilitate linkages to treatment, and promote recovery for mothers with SUD.
  • Potentially funded through Section 3021 (of the Affordable Care Act) Appropriation
  • 10-12 months
HRSA (move to next HRSA)
  • Funds Evidence-Informed Practices in Home Visiting: Prevention, Identification, and Treatment of Substance Abuse in Families evaluation project. The goal is to develop a conceptual model for how MIECHV grantees can engage and support families at risk for, recovering from, or currently misusing substances, including opioids. If funded, a second phase will develop study design options to build out the model.
  • Funded
  • Ongoing
IHS (move to next IHS)
  • Has developed a brochure on management of NOWS that has been used to educate child welfare workers on NOWS.
  • Funded
  • Ongoing
  • Will support/augment training needs for tribal child welfare workers through development of a standardized curriculum (dependent on funding and available resources).
  • Funded
  • To be implemented in 10-12 months