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Woods MHV Secure Messaging

VIEWS: 85 PAGES: 68

									My HealtheVet and Secure
       Messaging
    Patient-Centered Medical Home
             Las Vegas, NV
               April 2010
        Session Overview
•   My HealtheVet and The Medical Home
•   Patient Engagement and Online Tools
•   Secure Messaging Experience
•   Implementing Secure Messaging
My HealtheVet: A Tool to Deliver PCMH
 Engaging Patients Using Secure Messaging


            Paul Nichol, MD
         Susan Woods, MD, MPH
New Models of Care
Personal Health Records (PHR) and
Secure Messaging: Integral to PCMH
American College of Physicians Homebuilder Survey
 Uses e-mail to provide appropriate care
 Uses website that enables patients to initiate appt.
 Allows the PHR linked to the practice record
 Allows patient to import record to PHR
National Committee for Quality Assurance (NCQA)
 Advanced Electronic Communications
 Availability of interactive website
 Electronic Care Management support
                       Patient Centered Primary Care Teamlet
    Administrative                          Provider                      Veteran                        RN Care Manager                      Clinical Support
      Support                          (Physician, NP, PA)

Customer Service                    Direct Patient Care                                             Direct Patient Care                   Direct Patient Care
•Initial point of contact           •Scheduled Clinic Visits          Schedule appointments         •Scheduled Clinic Visits              •Assist with triage
•Patient Advocate                   •Walk in or Urgent Visits         As needed or requested by     •Walk in or Urgent Visits
•Address customer service                                             primary care team                                                   •Assist providers with
                                    •Group Visits                                                   •Group Visits                         exams/procedures
concerns & coordinating
solutions.                          •Telephone Visits                                               •Telephone Visits
                                    •Incoming telephone demand        Appointment check in          •Incoming telephone demand            •Perform treatments (EKGs, V/S,
•Hand-off communication                                               (including correct ID)                                              blood sugar, etc)
                                    •Pertinent Clinical Reminders                                   •Triage/place orders by protocol
Assists providers                                                     •Utilizes kiosk to check in   •Pertinent Clinical Reminders         •Administer meds, wound care
•Prepare paperwork requested                                          when available (performs                                            •Pertinent Clinical Reminders
                                    Secure Messaging                  In-Person Authentication)
by the Veteran and/or PCP           •Triaged messages from patients                                 Secure Messaging
•Specialty consult completion                                         •Updates insurance &          •Triaged messages from patients
                                    •E-mail with consultants          demographic info                                                    Secure Messaging
tracking                                                                                            •E-mail with consultants
•Coordinate information                                                                                                                   •Triage messages from patients
exchange for the co-managed         Care Management                   Face to Face Visits
patient                             •Virtual review of patients       •Arrive on time
                                                                                                    Care Management
•Manage telephone demand            including inpatients                                            •Virtual/F2F in-depth and ongoing
                                                                      •Bring medications                                                  Care Management
(receiving and documenting)         •Identify high risk for           •Required Paperwork
                                                                                                    review of patients including
•Manage appointment                 hospitalization.                                                inpatients                            •Track/administer required
scheduling including EWL &                                            •Health risk assessment       •Identify high risk for               immunizations
                                    •Appropriate for CCHT, OEF/OIF,   completion (with RN)
recall.                             HBPC                                                            hospitalization.                      •Triage phone calls for
•Pre-visit patient reminder calls                                     •Lab work completion          •Initiate appropriate consultations
                                    •Preventive care needs                                                                                appointments
Face to Face Visits                 •Non VA records                   Prepare for Primary Care
                                                                                                    for CCHT, CM, OEF/OIF, HBPC,          •Coordinate group visits
•Appointment check in               •View alerts                      Visit
                                                                                                    hospice/palliative care               •Identify additional services
•Assists w/My HealtheVet            •Diagnostic result                                              •Discuss care with specialty          needed by Veteran/Family
                                                                      •Discuss concerns and
registration                        •Discuss care with/refer to       plan of care
                                                                                                    consultants
•Performs In-Person                 specialty consultants                                           •Preventive/chronic disease care
Authentication                      •Traveling veterans               •Utilize My HealtheVet        needs
•Assists with updating and          •Medication Reconciliation        •Contact PC “teamlet”         •Triage to other team members as
verifying demographics and                                            with any
insurance information               •Refer to other team members as                                 appropriate
                                    appropriate                       problems/concerns that        •Non VA records                       Team Work
                                                                      arise during/after face to    •View alerts                          •Daily huddle
Team Work                                                             face encounter.
•Daily huddle                       Team Work                                                       •Follow-up calls                      •Team meetings
•Team Meeting                       •Daily huddle
                                    •Team Meeting                     Participate                   Team Work
                                                                      •Attend committees,                                                 Education
Clinic support                      •Midlevel Collaboration                                         •Daily huddle
•Identify & prepare required                                          patient advisory groups,                                            •New patient orientation
                                                                                                    •Team Meeting
forms, documents/records prior                                        and task forces                                                     •Assist with patient education
to clinic session                   Education
•Faxing, copying, mail mgt          •New patient orientation                                        Education
                                    •Provider CME , Grand Rounds                                    •New patient orientation              Clinic Support
•Manage clinic grids
•Manage office supplies &           •Teaching trainees                                              •Mentor/precept nurse trainees        •Daily equipment/supply checks
setup                                                                                               •Patient health                       •Keep exam rooms stocked
                                                                                                    education/coaching
What is the experience of health
 systems using patient portals
 and personal health records?
     Experience at Group Health
   Secure Email is core function of MyGroupHealth
   Dispelling Myths
       Patients respectful of clinician time
       Patient connect to clinicians as trusted source of information
       Opportunity to manage challenging patients
   Workflow efficiencies
       Triage – filter, asynchronous communication
       Time motion study suggests Secure Message/e-visit takes
        half the time of a phone visit
   Improved documentation of care

                               Dr. Matt Handley, presentation to VA Secure Messaging
                                                          Workgroup, December 2009
       Shifting Demand:
If e-mail were not available, would you...




                                MyGroupHealth Satisfaction Survey,
2004                               N=630 (2004), N=646 (2006)




                     2006
How would you rate the value of secure
 e-mail in enhancing in person visits?



                          “This is the best health care I have
                          ever had! I love the online services
                          the friendly employees and GHC's
                          overall desire to help me be
                          healthy. I'm from California and
                          GHC beats any health care they
                          had to offer.”




                                   MyGroupHealth Satisfaction Survey,
                                       N=645 (2004), N=666(2006)
 Kaiser – Patient Portal Usage

                                        49.2 Million results
6,000,000
                                       viewed (since launch)

5,000,000

                                                Registered members
4,000,000
                 3.4 Million users             Lab test results
                                               viewed online
3,000,000                                      E-mails sent to
                  19.3 Million Emails          providers
                                               Visits to past visit
2,000,000                                      information

                                               Online prescription
                                              refills
1,000,000


       0



                      From Jan Oldenburg, Kaiser Internet Services
                                                            Group
“The laying on of hands will increasingly include
the pressing of keys. This emerging model will
improve the practice of medicine but will also bring
new challenges.”
                                     - JH Stone

Communication between physicians and patients in the era of e-
medicine. New England Journal of Medicine, 2007
    Complementary Tools: EHR & PHR
VA Electronic                               My HealtheVet
Health                                      Personal
Record                                      Health
(EHR)                                       Record (PHR)


   Comprehensive record      Secure web-based portal
   At all care sites         Patient & family centered
   Decision support          Information and services
   Clinical reminders        Multiple levels of access
   Patient safety            Increasing offerings over time
 Internet Use in the U.S., 2008
• 74% of adults in U.S.
• 87% ages 18-29; 72% ages 50-64
• 41% age 65 and older
• 64% living in rural areas
• 77% white, 64% black, 58% Hispanic
• 57% if < $30,000 per year

                              Pew Internet & American Life Project
                                             www.pewinternet.org
Our Veterans and their families are
increasingly online and engaged in
     their own health and care.
   My HealtheVet Use (February 2010)

956,500 Registered

179,427 Authenticated
   Requires in-person process
   Required to use Secure Messaging

Over 14 million Rx Refills Processed
   Averaging 111,000 refills weekly in 2010
Authenticated Users Can:
• Refill Prescriptions
• View Medications
• Research Health Information
• Get Wellness Reminders
• Track & Graph Their Metrics
• Use Health Journals
• Use Self-Assessment
• See Wellness Calendar
• Access eBenefits
Manage Medications




                     23
Track Health Data

                Vitals &
                Readings
                Labs & Tests
                Health History
                Family Health
                History
                Military History
                Allergies
                Immunizations
                Journals
                Personal Health
                Summary
1. Hypertension
2. Influenza Vaccine
3. Pneumococcal Vaccine
4. Colorectal Cancer Screening
5. Lipid Measurement
6. LDL Target
7. Body Mass Index (BMI)>25.0
8. Diabetes Foot Exam
9. Diabetes Hemoglobin A1C
10. Diabetes Retinal Exam
11. Mammography Screening
12. Cervical Cancer Screening
My HealtheVet Website Survey

 • 96% login from home
 • 1 out of 2 login monthly
 • 1 out of 4 login weekly or more
 • 3 out of 4 login for Rx refill
 • 64% would like to securely email their provider

                         American Customer Satisfaction Survey (ASCI)
                                 October 2007 – October 2009
What is Secure Messaging?
 Secure, encrypted within My HealtheVet
 Electronic, bi-directional communication
 Asynchronous (not at same time)
 For enrolled participants only
 For non-urgent issues
 Can triage messages across a team
 Can save messages saved to CPRS
                  VA Secure Messaging Pilot Sites
                                                       BEDFORD
                                       ERIE            HC Team 11
   PUGET SOUND                         HC Team    29   Patients 116
   HC Team 37                          Patients   62
   Patients 330                                              BOSTON
                                                             HC Team 60
PORTLAND
                                                             Patients 479
HC Team 56
Patients 380
                                                        WASHINGTON DC
                                                        HC Team  65
                                                        Patients 767
MARTINEZ
HC Team  25
Patients 357




                   ALASKA
                   HC Team    18
                   Patients   85
    Effective Messaging
 Respond within 3 business days
 Triage to appropriate person
 Simple, conversational language
 Higher level of care if appropriate
 Use surrogates as needed
 Dr. Woods –
Hello. I just received a new bottle of
 You told me at the clinic yesterday
  the blood pressure medicine. It’s
 that I should get the shot for
the same name but the pill doesn’t
  My back is really hurting bad. I run
 shingles. But I didn’t getIthe shot.
   look the same. Should take it?
  out of pain meds in about 3 days.
 Should I wait or do I need to come
 back in?
VA Secure Messaging Experience
  Is patient centered
   o   Patients find it convenient and personal

  Takes a healthcare team
   o   Triage model = specific team roles

  Offers efficiencies of care
   o   With positive patient feedback

  Is used as intended
Meeting My HealtheVet Goals
• Improving Access to Services
• Enhancing Health Literacy
• Improving Communication
• Increasing Satisfaction

           “This is a great thing for us. I
           love being able to refill
           prescriptions.”
Veteran-Provider Interaction
with My HealtheVet Secure
        Messaging

  U.S. Army Veteran Devin Nuszbaum
  David M. Douglas, MD
                               The dreaded phone tree???
                                                                                            2: Directory
                                                                         0: Operator          XXXXX
                                                                                                                                               AudioCare
                                                                                             3: Enrollment/                                    Application
                                                                                                                                                                                                           Pharmacy CSS
                                                                       1: Direct Transfer       Eligibility
                                                                                                                                                                                                              X 50810
                                                                                              DID x 55069
                                                                                                                                                                                                         (pm: Dayton 51850)
                               0                                                            (pm: voicemail)
                               1
                               2                                                                                          AudioInquiry                       Order Refills
                               3
Start                          4                                                                                         Appt Reminders
             Main Greeting     5                                                             4. AudioCare       1          for 45 days
                53651                                                                                                                      9
                               6                                                              Automated         2                                             Check on the
                               7                                                                Services                                                     Status of Refills
                                                                                                                                           1
                                                                                             DID x 55201                                   2
                                all others                                                                                 AudioCare
                                star                                                                                                       4                   Request a                                             Primary Care
                                                                   1                                                    Pharmacy options
                                                                                                                                                               Renewal                                         Pt’s directed to call team
                                                 Incorrect entry   2                                                                       8
                                                                                                                                                                                                                extension via DID line
                                                    YYYYY          0
                                                                   9
                                                                                            5. Scheduling Agents                                                                                                        Portland 1
                                                                                                DID & x 53494                                                      1                                                   DID x 51495
                                                                                               (after 8-4:30: VM                                MPC Portland       2                                                (pm: Dayton 51850
                                               Voicemail Access                                                                                                    3
                                                                                                   message)                                       x 50960
                                                                                                                                                                   4
                                                                                                                                                (pm: Dayton
                                                                                                                                                  51850)                                                                Portland 2
                                                                                                                                                                                    Vancouver 1                       DID x 51497
        PDX VA Phone Tree – v1.0 rev 2.1.08                                                                         1                                              1
                                                                                                                                                                                       x 31665
                                                                                                                                                                                 (pm: Dayton 51850)
                                                                                                                                                                                                                   (pm: Dayton 51850)
                                                                                                                    2                          MPC Vancouver       2
         Themes                                                                               6: Primary Care       3                             x 50970
                                                                                                                    4                           (pm: Dayton                         Vancouver 2                         Portland 3
                                                                                                  x 50980           5
         ·     Patient and caller self management                                                                   6
                                                                                                                                                  51850)                               x 31901                        DID x 51496
                                                                                                                                                                                 (pm: Dayton 51850)                (pm: Dayton 51850)
         ·     Simple, clear menus
         ·     Pleasant, calm, consistent voice                                                                                                     PC Salem
                                                                                                                                                  DID x 51499
         ·     Fail safe loops for incorrect actions – no dead                                                                                                                                                          Portland 4
                                                                                                                                               (pm: Dayton 51850)
               ends for caller                                                                                                                                                                                        DID x 51498
                                                                                             7: Specialty Clinics
                                                                                                                                                                                                                   (pm: Dayton 51850)
                                                                                                  x 50820
                                                                                            (pm: Dayton 51850)                                      PC Bend
                             2008 QWEST phone book                                                                                                DID x 51494
                             numbers grossly incorrect                                                                                         (pm: Dayton 51850)                     East Portland 1
                             Eligibility and Information                                                                                                                               DID x 51007
                                    503-273-5289                                                                                                                                    (pm: Dayton 51850)
                                                                                                                                                 PC North Coast
                                                                                                                                                     x 52593
                             Currently AudioCare appt                                                                                          (pm: Dayton 51850)                    East Portland 2
                              pressing 9 goes to 50950                                                                                                                                DID x 51008
                             chg to 53494. At times this                                                                                                                           (pm: Dayton 51850)
                                                                                                                                                                       1
                                 also cycles back to                                                                                                                   2
                                                                                                                                                PC East Portland
                                  Audiocare 55201!                                                                                                                     3
                                                                                                                                                     x 50960           4             East Portland 3
                                                                                                                                               (pm: Dayton 51850)                     DID x 51009
                                                                                                                                                                                   (pm: Dayton 51850)


                                                                                                                                                                                     East Portland 4
                                                                                                                                                                                      DID x 51010
                                                                                                                                                                                   (pm: Dayton 51850)
I’m out of refills. Now what?
Hmm, maybe Secure Messaging?
“Doc I am out of refills”
Meanwhile back at the clinic…
De-identified notification
Same username and password
The Secure Message
The Doctor replies
The Veteran’s de-identified notification
No problem; Your Rx is on its way
Secure Messaging
 Best Practices
     Tracey Martin, RN
      Nurse Manager
VA Boston Healthcare System

                              46
  Marketing SM Perks to the Team

          Telephone                       Secure Messaging
• Tag, you’re it!                    • No phone tag.
• Leave a message? Not               • Message goes to the
  sure who will hear it                person it was intended for
• The waiting is the hardest         • Resolve message in real
  part                                 time or when you have
                                       time
• “While I have you on the
                                     • Less rambling/ focused
  phone….”
                                       discussion
• Release of information
                                     • MHV release resolves the
  issues
                                       ROI issues
VA World: Postal distress (packaging, addressing, transporting)
     Map the Triage Process


Look at how your TEAM manages “demand” care

Plan and appoint members of the care TEAM to
      receive the initial Secure Messages.


*No one team member works in isolation!
     Primary Roles in SM triage
• Medical Support Assistant, Program
  Support Assistant, Clerical staff
• Clinical Associates: Health Technician,
  Nursing Assistant, Pharmacy Technician
• Nurses: LPN, RN

• Can these staff members be the triage
  team?
    Tertiary Roles in SM Management
•   Clinical Pharmacy
•   Dietitian
•   Social Worker
•   Mental Health Provider
•   Primary Care Provider
•   Other members of the multi-disciplinary
    team
             Example of a SM Team
  The triage team receives the message, troubleshoots
    the concern and forwards or assigns to another team
    member only if needed

    Veteran                Provider_PrimaryCare_Site
1. IPA’d
2. Enrolled into
Secure Messaging
                       Triage Team                       Provider
                     Health Technician
                           LPN
                            RN                           Social
                                                         Worker
                                                     Mental Health
                                                       Provider
                     MSA


       Pharmacist
                                         Dietitian
  Traditional Secure Messaging


Requests driven by PATIENT
• Administrative Question
• Appointment Request
• Change of Address Request
• Health Information Question
• Lab or Test Results Question
• Medication Prescription Question
             Best Practices
• Secure Messaging is currently being
  utilized in various VA clinical settings
  across the nation.
• Some examples:
       Audiology
       Mental Health
       HBPC
       Tele-health
 *******Primary Care*******
    Primary Care Pre-planning
•   Arrive early
•   Bring updated medication list
•   Communicate concerns
•   Do labs
•   Ensure updated shared care info is received
•   Fax number
•   Give administrative staff updated
    demographics/insurance/community provider
    list.
Utility: Using Secure Messaging for
         Anticoagulation Clinic
     SM SENT TO PT W/ HEALTH QUESTIONS

PT RESPONDS BACK TO PROVIDER W/I 24 HOURS
OF ANTICOAGULATION APPOINTMENT

IF RESPONSES ARE BENIGN, PT COMES TO CLINIC
FOR BLOODWORK ONLY    & THEN GOES HOME!
INR RESULTS ARE REVIEWED BY CLINIC
PROVIDER

SM SENT BACK TO PT WITH RESULTS, DOSING
INSTRUCTIONS & EXPECTED RETURN DATE

PT RESPONDS BY SM THAT        RESULTS     AND
INSTRUCTIONS WERE RECEIVED
            MOVE! Clinics
• Utilize for patients who are unable to
  attend face-to-face appointments

• Goal setting/sharing

• Problem solving

• MOVE! Along….. Virtual MOVE!
              Other PCMH Uses
• Announce special clinics i.e. seasonal flu,
  H1N1, special educational programs…

• Post-visit follow-up:
  – labs/discussion, exam results, procedure education
  – interim communication


• CaSe or CaRe management

• Caregiver communication/support.
Roll Out of Secure Messaging
      The VISN 5 Experience
          Kate Andrews, MD
         Quality Management Officer
         Primary Care Lead Physician



                                       58
VISN 5




         59
                   VISN 5

                     Enrollment
                    Based Market
                       Share            Active Patients
   Enrollees
                    (Enrollees to
                      Veteran
                     Population)
    193,174               25%               107,305



     Enrollees                        Patients

Urban     Rural    % Rural   Urban      Rural    % Rural
146,054   48,042    25%      77,482     29,773    28%
   Roll Out of Secure Messaging
• Partner with the
  National
  MyHealtheVet and
  Secure Messaging
  Teams
  – Weekly Conference
    Calls
  – SharePoint
  – Implementation Check
    List
  – Make Connections


                           61
Roll Out of Secure Messaging
        • Solicit Leadership Support
          – Sell SM by presenting to
            Leadership at key committee
            meetings and through personal
            contact
          – Make SM a component of your
            operational plan
          – VISN 5  roll out of SM is a 2010
            VISN-wide performance measure
             • 60% of Primary Care Providers will
               be participating as part of a three-
               level triage team by end of Q4


                                        62
   Roll Out of Secure Messaging
• Determine the Method of Roll Out
  – VISN 5  SM Collaborative
  – Teams
     • Each MC developed an Implementation Team
     • Each Implementation team is part of the VISN-wide
       Collaborative
  – Meetings
     • Each MC Team meets every two weeks
     • The VISN-wide Collaborative meets by conference call
       every two weeks to discuss progress, successes, barriers
       and national issues
     • Every Quarter meet face-to-face



                                                     63
    Secure Messaging SUPERSTARS!                            DC                      MT                          VAMCHS
                                                     2nd and 4th Tues @
                                                    1pm, 1D141 (Center for 1st and 3rd Weds at   1st and 3rd Tues @
                                                      Performance Conf     3:30pm, 54261# and 9:30am, 60222# and MC
                Meeting Details                            Room)                 3C-134               Conf room
                                                                                                         Site Managers: Fname Lname
Secure Messaging Facility Champion                       Fname Lname            Fname Lname
Secure Messaging Clinical Champion                       Fname Lname            Fname Lname                    Fname Lname
System Redesign Representative                           Fname Lname            Fname Lname                    Fname Lname
Nursing Representative                                   Fname Lname            Fname Lname                    Fname Lname
Primary Care Physician or Nurse Practitioner             Fname Lname            Fname Lname                    Fname Lname
Lab Representative                                           N/A                Fname Lname                    Fname Lname
Pharmacy Representative                                  Fname Lname            Fname Lname                    Fname Lname
Clinical Application Coordinator                         Fname Lname            Fname Lname                    Fname Lname
Administrative Assistant                                     TBD                Fname Lname                    Fname Lname
IT Representative                                        Fname Lname            Fname Lname                    Fname Lname
MAS/Business Representative                              Fname Lname            Fname Lname                    Fname Lname
Education or Academic Affiliations Representative            N/A                Fname Lname                    Fname Lname
My HealtheVet Point of Contact                           Fname Lname            Fname Lname                    Fname Lname
                                                                                                               Fname Lname
Secure Messaging Clinical Coordinator                        TBD         pending clarification of role         (Social Work)
Public Affairs Office                                    Fname Lname           Fname Lname                     Fname Lname
Planetree POC or Facilitator                             Fname Lname           Fname Lname                     Fname Lname
Other - DC - RN, Chief, Patient Service Center           Fname Lname                xxxxx                          xxxxx
Other - DC - PharmD, Chief, Pharmacy Service             Fname Lname                xxxxx                          xxxxx
Other - DC - Supervisory Patient Advocate                Fname Lname                xxxxx                          xxxxx
Other - MT - Managed Care CNE                               xxxxx              John Goldizen                       xxxxx
Other - VAMHCS - Dep Dir Managed Care                       xxxxx                   xxxxx                      Fname Lname
Other - VAMHCS - BT Lead MD                                 xxxxx                   xxxxx                      Fname Lname
Other - VAMHCS - RN Nurse Manager                           xxxxx                   xxxxx                      Fname Lname
Other - VAMHCS - RN Nurse Manager                           xxxxx                   xxxxx                      Fname Lname
Other - VAMHCS - MAS                                        xxxxx                   xxxxx                64    Fname Lname
     Using a Collaborative Model
– LS1  AP1  LS2  AP2  LS3  AP3  LS4 
  AP4
– Nov 2009 LS1
– Nov - Dec 2009 AP1
  • Develop additional AIM statements
  • Develop and submit action plan for implementation of SM
– Jan 2010 LS2
  • Didactic Session – presentations on flow mapping to look for
    barriers, look and feel of SM, how to create teams using the
    Admin Portal
  • Break Out Groups to identify each MC’s 1) SM Administrator(s),
    2) monthly % goals for PCC providers as part of a three level
    triage team and 3) next three steps when they got “home”


                                                      65
Using a Collaborative Model
        – Jan – April 2010 AP2
          • Implementation of Action Plans and
            development of Teamlets
          • Enhancing IPA capabilities
        – April 2010 LS3
          • National Training of Teamlets and
            Administrators
        – May – July 2010 AP3
          • Expansion of Teamlet training
          • Patient education and staggered notification
        – July 2010 LS4
          • Identify best practices, provide MC updates
        – Aug – Sept 2010 AP4
          • Expansion beyond PCC
                                       66
  VAMC and VISN MHV Program
• Resources allocated to each Network
   – VISN MHV Coordinator
   – VAMC MHV Coordinator
• VAMC MHV Program Coordinator
   – Planning, Organizing, Directing, Evaluating and Reporting on local
     MHV-related actions/activities
• AND…VAMC MHV facility coordinator is responsible for
   – Leading and coordinating secure messaging implementation and
     administration
   – Coordinating related PCMH activities for MHV implementation
   – Training
   – Communications, Outreach and Support




                                                             67
Questions?

								
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