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Oral Health Program: Teaching Caregivers on Oral

Health
Part 1
March 19, 2018
Michele Andrus, Leslie Coleman, Marisa Martin,
Haleigh Turley
NEEDS ASSESSMENT

A. General Data

1. Description of Site

Pelican Bay was opened in January 2013 and is located at 2501


South Major Drive in Beaumont, Texas. (3)"Pelican Bay is a senior living
community designed to make a positive difference in the lives of our
residents. Our team of professionals recognize and appreciate each
person's God-given potential and want each one of our residents to
maintain as much of their independence as possible." (2) It is a highly
recommended facility in the Southeast Texas area. The facility consists of
two sides: Memory Care and Assisted Living. The Assisted Living portion
of the center focuses on patients who need help with daily care but cannot
function safely on their own. The Memory care portion of the center is
designated for Alzheimer’s and Dementia patients. The entire facility is
equipped with alarms and cameras are specifically targeted to the Memory
Care section to monitor patients regularly. (4) The residents receive daily
care based on their needs from onsite caregivers. The facility accepts
mainly private pay and some military benefits. They do not accept
Medicare payments currently.

2. Description of Target Group

The residences living in Pelican Bay Assisted Living Facility are


our target population. There are approximately 70 total residents from
Memory Care and Assisted Living. The criterion for residency is based on
the activities of daily living; eating, bathing, dressing, toileting, transferring
or walking, and continence or bladder control. (2) Our focus of education
will be directed towards the caregivers so that a direct impact can be
made on their residents' oral health. The skills taught to the caregivers will
positively influence the lives of our target population.

3. Description of Staff Population

The staff population consists of a Registered Nurse, two LVNs,


nine Caregivers, and two med aides. The RN is the overseer of the
Memory Care and Assisted Living centers. There is one LVN in charge of
the Assisted Living side and one LVN Memory Care side. Jennifer Rinker,
CNA, RDH, BS started her career as a dental hygienist but later went back
to school for her CNA because she saw the need for health care providers
with oral health knowledge in long-term care facilities. (8) The caregivers
are divided into three people per shift and the site has three shifts per day.
The caregivers are the backbone of the facility and are the most
interactive with the residents. This part of the staff does laundry, cleans
residents living area, assist with activities of daily living, and provide a
sense of comfort to senior residents. There is also a Med-aide on two
shifts throughout the day who are responsible for providing proper
medications to the residents. The entire staff is responsible for planning
holiday parties and special events. (1)

4. Description of Services Provided

Cindy Dorsey is the Life Enrichment Director for the residents of


Pelican Bay. The residents have a variety of activities planned throughout
the month that they can attend. There are set activities planned for each
day of the week, which can be found on their monthly calendar. Examples
of these activities include: board games, prize bingo, outings to Wal-Mart,
exercise sessions, and social hour. The daily schedule is as follows: (1)

6:00- Wake up
7:30- Breakfast
9:00- Let's Walk or Sit and Fit
10:30- Various games depending on the day
11:30- Lunch
1:00- 3:00 Various activities and games; nap optional
5:00- Dinner
5:30- Social hour or movie/popcorn

In the future, the activities coordinator could implement our oral health
program into their set daily routine. The staff will be able to use the skills
learned during this time to implement oral cancer screenings and teach
proper denture care to the residents. These plans will promote a better
quality of life for the residents and an above average standard of care at
Pelican Bay.

5. Other Pertinent Data


The water fluoridation of the Pelican Bay facility is 0.7ppm. (1)

B. Information Related to Dental Health

Pelican Bay is a private pay facility. They do not provide any type
of preventive oral hygiene aids to their residence. Pelican Bay will provide
transportation to dental offices if needed. They also offer fluoridated water
provided by the city. The family is the sole provider of preventative care
for the residents. (1) The previous oral health program was directed
toward the residents, contributing limited benefits due to lack of
compliance. (1) There was also a mental health barrier because most of
the residents could not recall what was taught at the oral health sessions.
Due to lack of compliance from the staff, we were unable to assess the
knowledge and awareness of dental health that the staff is using daily. A
pre-test will be given at the first education session to gather initial
information and assure compliance from the staff.

C. Dental Health Status:


Describe the prevalence of dental disease & dental care for these groups
and their dental needs relative to other needs. Relate this to their SES
and ethnic/cultural group membership.

1. Dental Caries
Prevalence
1. 93% of seniors 65 and older have had dental caries on permanent
teeth.
1. White seniors, higher income families, and individuals with higher
education portray more decay.

Characteristic Percent with decay, missing, or


filled permanent teeth
Age
65 to 74 years 93.25
75 years or more 92.70
Sex
Male 93.64
Female 92.49
Race and Ethnicity
White, non-Hispanic 94.86
Black, non-Hispanic 80.20
Mexican American 83.82
Poverty Status (Income
compared to Federal Poverty
Level)
Less than 100% 83.47
100% to 199% 90.92
Greater than 200% 95.53
Education
Less than High School 83.73
High School 94.27
More than High School 97.04
Smoking History
Current Smoker 89.28
Former Smoker 93.48
Never Smoked 93.01
Overall 93.00
(10)

Unmet Needs
1. 18% of seniors 65 and older have untreated decay.
2. Black seniors, Hispanic seniors, lower income individuals, and less
educated individuals have more untreated decay.

Age
65 to 74 years 17.07
75 years or more 19.52
Sex
Male 20.42
Female 16.43
Race and Ethnicity
White, non-Hispanic 15.92
Black, non-Hispanic 36.78
Mexican American 41.19
Poverty Status (Income
compared to Federal Poverty
Level)
Less than 100% 33.22
100% to 199% 23.82
Greater than 200% 14.22
Education
Less than High School 26.16
High School 17.68
More than High School 14.30
Smoking History
Current Smoker 27.28
Former Smoker 18.74
Never Smoked 16.58
Overall 18.18
(10)

Severity
1. Seniors 65+ have an average of 9.24 decayed or missing
permanent teeth as well as 43.02 decayed and missing permanent
surfaces.
2. Hispanic subgroups and those with lower incomes present with
more severe decay on permanent teeth.
3. Black/Hispanic subgroups and those with lower incomes have more
untreated decay on permanent teeth.
Characteristi Decayed Missing Filled Total decayed,
c permanen permanent permanent missing, or
t teeth teeth (MT) teeth (FT) filled
(DT) permanent
teeth (DMFT)
Age
65 to 74 0.39 8.32 8.96 17.68
years
75 years or 0.47 9.41 8.42 18.30
more
Sex
Male 0.53 8.67 8.37 17.57
Female 0.35 8.96 8.99 18.30
Race and
Ethnicity
White, non- 0.36 8.30 9.57 18.23
Hispanic
Black, non- 1.04 12.61 3.25 16.90
Hispanic
Mexican 1.10 9.74 4.26 15.11
American
Poverty
Status
(Income
compared to
Federal
Poverty
Level)
Less than 1.01 12.19 4.10 17.30
100%
100% to 0.58 10.79 6.84 18.21
199%
Greater than 0.29 7.61 10.24 18.15
200%
Education
Less than 0.77 11.99 4.92 17.68
High School
High School 0.38 9.58 8.39 18.35
More than 0.28 6.71 10.91 17.90
High School
Smoking
History
Current 0.82 12.45 5.68 18.95
Smoker
Former 0.42 9.58 8.41 18.40
Smoker
Never 0.39 7.76 9.31 17.46
Smoked
Overall 0.43 8.81 8.71 17.96
(10)

2.Periodontal Disease
1. 10.20-11.03% of seniors age 65 and over have periodontal
disease. Of this group, 10.58% are categorized as having
moderate to severe periodontal disease.
2. Older seniors, Black/Hispanic seniors, current smokers, those from
a lower income, and less educated individuals are more likely to
have periodontal disease. This group is also more likely to have
moderate/severe periodontal disease.

Characteristic Percent with Percentage with


periodontal moderate or severe
disease* periodontal disease*
Age
65 to 74 years 10.20 14.26
75 years and over 11.03 20.75

Sex
Male 12.97 20.61
Female 8.56 14.40

Race and Ethnicity


White, non-Hispanic 8.99 15.47
Black, non-Hispanic 23.92 24.47
Mexican American 17.23 24.20

Poverty Status
(Income compared
to Federal Poverty
Level)
Less than 100% 17.49 31.96
100% to 199% 11.59 18.75
Greater than 200% 8.62 13.91

Education
Less than High 16.56 28.24
School
High School 8.30 15.51
More than High 8.90 12.38
School

Smoking History
Current Smoker 13.80 32.01
Former Smoker 9.20 19.25
Never Smoked 11.12 14.08

Overall 10.58 17.20


(10)

3.Oral Hygiene
Perceived Condition of Teeth and Mouth
1. 24% of Seniors 65+ report the condition of their teeth/mouth as very
good or excellent.
2. 16% of all Seniors 65+ report the condition of their teeth/mouth as
poor.
3. Black/Hispanic Seniors, those with lower incomes, and individuals
with less education report the condition of their teeth/mouth as
poor.
1. Seniors with higher incomes and higher education have a greater
likelihood of reporting the condition of their teeth/mouth as very
good or excellent.

This information comes from the perceived (self-reported) condition


of teeth and mouth among Seniors Age 65 and older.

(10)

4.Oral Cancer

Oral Cancer Prevalence


1. Oral cancer is more prevalent in older age groups, with males at a
higher percentage than females.

Age Sex Oral Cancer


Cases
60-69 Male 40,095
60-69 Female 18,110
70+ Male 60,638
70+ Female 39,446

Oral Cancer Incidence


1. 10.5 adults per 100,000 will develop oral cancer.
1. Oral cancer rates are higher for males than females.
2. Oral cancer rates increase with age. This increase becomes more
rapid after age 50 and peaks between the ages of 60 and 70.

Age Sex Race Oral Cancer


Incidence
50-59 Male All 51.9
50-59 Female All 17.9
60-69 Male All 58.9
60-69 Female All 26.0
70-79 Male All 59.4
70-79 Female All 29.4
80+ Male and All 40.0
Female

1. Oral cancer rates are higher in Hispanic and Black males.

Age Sex Race Oral Cancer


Incidence
60-69 Male Black 61.0
60-69 Female Black 16.2
60-69 Male Hispanic 32.9
60-69 Female Hispanic 9.2
60-69 Male Caucasian 52.7
60-69 Female Caucasian 18.4
60-69 Male Asian 34.4
60-69 Female Asian 14.2
70-79 Male Black 61.6
70-79 Female Black 20.5
70-79 Male Hispanic 38.7
70-79 Female Hispanic 15.6
70-79 Male Caucasian 60.7
70-79 Female Caucasian 27.0
70-79 Male Asian 36.0
70-79 Female Asian 17.2
80+ Male Black 43.4
80+ Female Black 19.5
80+ Male Hispanic 39.7
80+ Female Hispanic 20.9
80+ Male Caucasian 62.0
80+ Female Caucasian 30.0
80+ Male Asian 35.6
80+ Female Asian 28.2

Notes About Oral Cancer Incidence Statistics:


1. Statistics were generated from malignant cases only.
1. Rates are expressed as cases per 100,000.
2. Statistics are provided by the SEER Program for research purposes
only
3. Due to the impact of Hurricane Katrina on Louisiana's population for
the July - December 2005 time period, Louisiana cases diagnosed
for that six-month time period have been excluded from these
statistics.

(10)

5. Utilization of Dental services

Time Since Last Dental Visit


1. 23% of Seniors 65 and older have not been to the dentist in the last
5 years.
2. About half of all Seniors 65 and older have been to the dentist
within the past year.
3. More Black and Hispanic Seniors and those with lower incomes
and less education have not been to the dentist in the past 5 years.
4. Seniors with higher incomes and more education are much more
likely to have seen a dentist within the past year.

Charact Never 1 Year 1 to 2 2 to 3 3 to 5 More


eristic or Less Years Years Years than 5
Years
Age
65 to 74 * 56.90 8.78 6.04 6.67 21.23
years
75 or * 51.64 9.28 6.01 7.37 25.52
more
years
Sex
Male * 56.15 8.40 5.71 6.37 23.04
Female * 53.56 9.33 6.21 7.41 23.24
Race
and
Ethnicit
y
White, * 57.96 8.35 5.63 6.10 21.85
non-
Hispani
c
Black, * 37.99 13.45 5.59 11.28 30.59
non-
Hispani
c
Mexica 4.12 38.31 9.92 9.25 9.32 29.08
n
Americ
an
Poverty
Status
(Incom
e
compar
ed to
Federal
Poverty
Level)
Less * 30.23 9.39 7.48 13.14 38.82
than
100%
FPL*
100% to * 42.19 9.56 6.88 7.59 33.51
199%
FPL
More * 67.08 8.86 4.49 4.85 14.22
than
100%
FPL
Educati
on
Less * 35.28 10.61 6.90 9.99 36.43
than
High
School
High * 53.63 7.79 6.44 7.25 24.82
School
More * 71.47 8.68 4.96 4.07 10.77
than
High
School
Smokin
g
Status
Current * 33.91 8.86 4.17 13.15 39.00
Smoker
Former * 54.91 8.46 6.81 6.20 23.42
Smoker
Never * 57.75 9.70 5.72 6.56 19.97
Smoke
d
Overall * 54.52 9.01 6.03 6.99 23.18
(10)

6. Additional Information
Tooth Loss
Number of Teeth Remaining
1. Seniors over age 65 have an average of 18.90 remaining teeth.
2. Black seniors, current smokers, and those with lower incomes and
less education have fewer remaining teeth.

Characteristic Mean Number of Permanent


Teeth
Age
65 to 74 years 19.34
75 years or more 18.36

Sex
Male 19.03
Female 18.77

Race and Ethnicity


White, non-Hispanic 19.39
Black, non-Hispanic 15.19
Mexican American 18.15

Poverty Status (Income


compared to Federal
Poverty Level)
Less than 100% 15.58
100% to 199% 16.99
Greater than 200% 20.08

Education
Less than High School 15.86
High School 18.10
More than High School 20.96

Smoking History
Current Smoker 15.39
Former Smoker 18.16
Never Smoked 19.91

Overall 18.90
(10)

Number of Adults with Total Tooth Loss


1. 27.27% of seniors over age 65 have no remaining teeth
2. Older seniors, women, Black seniors, current smokers, and those
with lower incomes and less education are more likely to have no
remaining teeth.

Characteristic Percentage with no Remaining


Teeth
Age
65 to 74 years 23.93
75 years or more 31.30

Sex
Male 24.42
Female 29.30

Race and Ethnicity


White, non-Hispanic 26.12
Black, non-Hispanic 32.81
Mexican American 23.90

Poverty Status (Income


compared to Federal
Poverty Level)
Less than 100% 44.19
100% to 199% 36.61
Greater than 200% 17.25

Education
Less than High School 43.32
High School 28.28
More than High School 13.65

Smoking History
Current Smoker 49.69
Former Smoker 28.69
Never Smoked 21.72

Overall 27.27
(10)

Goal and Objectives

Goal: The primary goal for this program is to increase the staff's
knowledge of oral health care by 20% to prevent and control oral diseases
in the care facility.

Objectives: Directed towards the staff of Pelican Bay


1. Teach common oral conditions found in elderly and denture
patients
1. Demonstrate the proper method for an oral cancer screening
2. Teach proper denture care
3. Teach proper oral hygiene care methods
4. Increase the oral health knowledge of the staff at Pelican Bay by
10%.

Rationale for Program

Beyond dentistry, there is a significant lack of oral health care


knowledge among health care providers. This lack of knowledge
includes caregivers that work at long-term care facilities such as
Pelican Bay. (9) Daily oral hygiene is an activity that many of these
residents have difficulty with. Educating those who help with this
task is vital in maintaining the resident's oral health. The World
Health Organization (WHO) has recognized the need to incorporate
oral health services into existing health care systems. (9) The older
adult population has the highest percentage of dentures due to the
prevalence of tooth loss in this age group. (10) Although dentures
decrease masticatory function by up to 1/7 of natural teeth, they
improve the quality of life for the edentulous population. (7)
Dentures are also costly, creating a barrier to care for this age
group due to lack of dental coverage through medicare. (6) Health
care providers with very little knowledge of oral health create a
problem in long-term care facilities. In this type of facility, it is the
caregiver's responsibility to assist residents with their daily oral
hygiene care. (1) This includes brushing, flossing, rinsing, cleaning
dentures/partials, and assuring that these things are done properly
without damage or loss of oral care aids and dentures.

The 65+ population has the highest amount of oral cancer cases
compared to all other population groups. (10) Healthcare
personnel, specifically at long-term care facilities for 65+, have little
knowledge on how to perform an oral cancer screening. (12) Oral
cancer screenings can be easily done by looking in one's mouth
with some form of light source. (11) If done correctly, oral cancer
screening can help detect cancerous lesions at the earliest stages
and increase chances of survival. (11)

Educating the caregivers at Pelican Bay on oral cancer screenings,


denture care, and overall oral health will have a positive impact on
their facility and improve the quality of life for their residents.

Program Design

A. Activities
1. Session One (February 6th, 2018)
a. Life Enrichment Director and LVN for Assisted Living Side
Present oral health care program to caregivers to improve oral health of
residents
Discuss the need to teach caregivers to clean and care for dentures and
do oral cancer screenings Discuss the best time to work with caregivers
Pre-test
Give flyer with oral health program times and dates
This session will take 30 minutes and we will need the Life Enrichment
Director and the Resident Care Director.
2. Session Two (March 27th, 2018)
a. Caregivers
Presentation of general oral health conditions and how to implement oral
cancer screening.
i. Use brochures on Oral Cancer screening to explain the procedure
for an oral cancer screening and to provide examples of irregular
tissue.
ii. Demonstrate how to evaluate a patient's oral cavity using a light
source (pen light, or loupes), tongue depressor and gauze.
This session will take an hour and we will need the caregivers to attend.
3. Session Three (April 3rd, 2018)
a. Caregivers
Presentation of proper denture cleaning and why it is important for healthy
oral tissues. Relation of improper denture cleaning and candidiasis
infection.
i. Demonstrate how to clean a denture with a denture brush, while
explaining the procedure and reasoning for overnight soaking.
ii. Define candidiasis and use flip book to show pictures that provide a
visual aid of oral tissues and tissues affected by candidiasis.
iii. Acknowledge the staff's concern about the high incidence of
dentures that are thrown away in the trash or lost by residents by
giving donated cases with chains.
This session will take an hour and we will need the caregivers to attend.
4. Session Four (April 10th, 2018)
a. Caregivers
Assessment of the oral health program. Caregivers will give a
demonstration and relay what they have learned to other providers in the
Pelican Bay facility.
i. Evaluate the caregivers' ability to implement the program.
ii. Post-test
iii. Have caregivers demonstrate how to clean dentures and evaluate
their ability to recall the reasoning for the soaking technique and
leaving dentures out overnight.
iv. Have caregivers identify pictures of normal and abnormal tissue
using visual aids from a flip book.
v. Address the staff's concern about residents losing dentures and
evaluate how donated cases are helping.
This session will take an hour and we will need the caregivers to attend.

B. Constraints and Alternative Strategies


1. Caregivers may have a lack of interest in the program
a. Use visual aids
b. Ask open ended questions
c. Involve caregivers in the presentation
2. There may only be partial attendance
a. Free t-shirt for attending program presentations
b. Whitening strips door prize at last session
3. Not able to get pre-test completed/returned
a. Give pre-test at beginning of 2nd session

C. Resources
The following are the resources required to implement the Oral Health
Program
1. Personnel
a. Life Enrichment Director and Resident Care Director (first and last
sessions only)
b. Caregivers (Sessions 2-4)
c. As many of the staff as possible (session 4)
2. Visual Aids
a. Flipbook with pictures of different pre-cancerous lesions (Made by
Clinicians)
b. Flipbook with pictures of common denture lesions (Made by
clinicians)
c. Typodont with toothbrush (Provided by clinicians)
d. Denture model (Provided by LIT)
e. Brochures; The Oral Cancer Exam, Older Adults and Oral Health,
Daily oral care guide for caregivers, Dry Mouth
3. Supplies
a. Denture Cleaner, Denture toothbrush, Polident tabs, gauze, tongue
depressors, mouth mirrors (donated by LIT)
b. Gloves, masks, loupes (supplied by clinician)
4. Evaluation Material
a. Pre-test
b. Post-test: same as pre-test
c. Administrator Evaluation
5. Supplements
a. Cases for dentures/partials (donated by Dr. Williams D.D.S)
b. Chains for cases (donated by clinicians)
c. Outline of the program plan (supplied by clinicians)
d. Incentive T-Shirts (donated by clinicians)
e. Incentive Whitening Stripes (donated by clinicians)
f. Flyer to put near time clock for staff to be aware of program dates
and time (created by clinicians)
g. List of dental providers for low cost in the area (made by clinicians)

D. Budget
The estimated cost of the oral health program is as follows:
Denture brushes (donated by LIT Dental Hygiene for use)
Denture cleaner (donated by LIT Dental Hygiene for use)
Polident tablets (donated by LIT Dental Hygiene for use)
Partial cases (donated by Dr. Williams D.D.S for use)
Chains for partial cases (donated by clinicians)
Oral Cancer screening brochures (supplied by NIH)
Gloves (supplied by clinician)
Mask (supplied by clinician)
Gauze (donated by LIT Dental Hygiene for use)
Tongue Depressors (donated by LIT Dental Hygiene for use)
Loupes (supplied by clinician)
T-Shirts (donated by clinicians)
Whitening Strips (donated by clinicians)

E. Timetable
There will be a total of four sessions between February and April. The
schedule is as follows:
Session 1: February 6, 2018
Session 2: March 27, 2018
Session 3: April 3, 2018
Session 4: April 10, 2018
Evaluation
A. Formative
1. Weekly review of oral cancer screening, have caregivers
demonstrate
2. Weekly review of denture care, caregivers demonstrate
3. Weekly meeting with Resident Care Director and/or Memory Care
Director to evaluate the program
4. Weekly review of all general health care knowledge to help the
knowledge to be remembered
B. Summative
1. A pre-test and post–test will be given to the caregivers and then
compared to assess the growth in their oral healthcare knowledge.
2. An ending questionnaire will be given to the Life Enrichment
Director, Resident Care Director, and the Memory Care Director to
assess the effectiveness and what accomplishments came from the
oral health program.
3. A written instruction manual will be provided by the clinicians to
Pelican Bay to have as a reference to train future caregivers and
employees.
4. An annual check with the administrators will bring in long term data
on the successful utilization of the oral cancer screenings and care
of dentures for the residents

References
1. Cindy Dorsey and Tameka Wycoff, LVN. Personal Interview
February 7, 2018. 409-860-1672
2. http://www.pelicanbayassistedliving.org/ Retrieved February
13, 2018
3. https://www.bbb.org/southeast-texas/business-
reviews/assisted-living-facilities/pelican-bay-assisted-living-
community-in-beaumont-tx-90055035
4. https://www.beaumontenterprise.com/news/article/New-senior-
living-center-opens-in-Beaumont-4187673.php
5. Investapedia.com/terms/a/adl
6. Gnjato, S. (2016). Impact of Dentures on Oral Health-Related
Quality of Life. Medicinski Pregled / Medical Review, 69(7/8),
203-211. doi:10.2298/MPNS1608203G
7. Kaur Shergill, D. (2017). A Question to Denture Wearers- Does
it Improve the Quality of Life? International Journal of
Community Health & Medical Research, 3(1), 55-58.
doi:10.21276/ijchmr.2017.3.1.12
8. Rinker, J. (2015). Denture Care and Nursing Home Residents.
Rdh, 35(6), 26-30. http://www.rdhmag.com/articles/print/volume-
35/issue-6/features/denture-care-and-nursing-home-residents.html
Retrieved March 8, 2018.
9. World Health Organization (WHO)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247544/
10. https://www.nidcr.nih.gov/research/data-statistics
11. Gomes, M. S., Bonan, P. F., Ferreira, V. N., de Lucena Pereira, L.,
Correia, R. C., da Silva Teixeira, H. B., & ... Bonan, P. (2017).
Development of a mobile application for oral cancer screening.
Technology & Health Care, 25(2), 187-195. doi:10.3233/THC-
161259
12. Baumann, E., Koller, M., Wiltfang, J., Wenz, H., Möller, B., &
Hertrampf, K. (2016). Challenges of early detection of oral cancer:
Raising awareness as a first step to successful campaigning.
Health Education Research, 31(2), 136-145.
doi:10.1093/her/cyv099

Appendix+
1. Pretest/posttest
2. List of low cost dental care providers in the area
3. Brochures from NIH:
1. The Oral Cancer Exam
2. Older Adults and Oral Health
1. Daily oral care guide for caregivers
2. Dry Mouth
1. Assisted Living & Memory Care Rates 2018
2. Pelican Bay Assisted Living Community February 2018 Newsletter
3. Program evaluation