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Care Coordination in Action: Sharing Behavioral Health Patient Information November 20, 2013 Contact:
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Speakers
Michael R. Lardieri, LCSW VP, Health Information Technology & Strategic Development, National Council for Behavioral Health Allison Hamblin Vice President for Strategic Planning, Center for Health Care Strategies; David Mancuso Director of Research and Data Analytic Division Services & Enterprise Support Administration, Washington State Department of Social and Health Services;
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Information Sharing 101
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Innovations under CMS
• Payment reform; fundamental shift •
• • • •
away from fee-for-service Delivery system reform: encourage reorganization of system to take out waste and deliver high‐value care Different opportunities for providers based on readiness Strategic partnerships with data Robust quality monitoring Emphasis on multi‐payer strategies and approaches
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Jonathan Blum, CMS
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…and from a business planning perspective
• Shifts in revenue sources as more people become eligible and enroll in new insurance options • Increased competition as health providers meet new value-based purchasing standards built on health system partnerships and accountability for clinical outcomes
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Connect with other providers
Coverage expansions are ONLY sustainable with delivery system reform Collaborative Care Patient Centered Healthcare Homes Accountable Care Organizations
Accountability and quality improvement are hallmarks of the new healthcare ecosystem
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The Goal
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Challenges
Strategies
Financial Resources
Focus on Health Information Exchange
Practice Transformation
Clinical Quality Measures
Staff Training
Clinical Decision Support
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ONC’s Approach •
Interoperability is a journey, not a destination
•
Leverage government as a platform for innovation to create conditions of interoperability
•
Health information exchange is not one-size-fits-all
•
Multiple approaches will exist
•
Build in incremental steps – “don’t let the perfect be the enemy of the good”
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side-by-side
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ONC’s Role - Reduce Cost and Increase Trust and Value To Mobilize Exchange VALUE
COST Standards: identify and urge adoption of scalable, highly adoptable standards that solve core interoperability issues for full portfolio of exchange options Market: Encourage business practices and policies that allow information to follow patients to support patient care HIE Program: Jump start needed services and policies
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• • •
Payment reforms Meaningful Use Interoperability and wide-scale adoption
TRUST
•
Identify and urge adoption of policies needed for trusted information exchange
ONC’s ROLE 10
Proposed Stage Two Meaningful Use Exchange Requirements (summary)
•
Provide summary of care document for more than 65% of transitions of care and referrals with 10% sent electronically (across vendor and provider boundaries)
•
Patients can view, download or transmit their own health information
•
Successful ongoing submission of information to public health agencies (immunizations, syndromic surveillance, ELR)
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Standards & Building Blocks are in Place, with Clear Priorities to Address Missing Pieces
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ONC Made Big Strides to Enable Exchange in Stage 1
The first challenge was to make sure that information produced by every EHR was understandable by another clinician and could be incorporated into his EHR With the vocabularies, code sets and content structure standards in Stage 1 meaningful use every certified EHR can produce the standardized content needed:
Produce and consume a standardized care summary Maintain standardized medication lists Consistently report quality measures and public health results Consume structured lab results
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Additional Critical Pieces Are Now In Place
Next we needed a common approach to transport, allowing information to move from one point to another
We now have two easily adopted standards for transporting information – NwHIN Direct and the transport protocol used in NwHIN Exchange
And it was clear that we needed more highly specified standards to support care transitions and lab results delivery
For the first time in our country’s history there is a single, broadlysupported electronic data standard for patient care transitions
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There are Issues That Need to be Addressed
Privacy and Security HIPAA Not a Barrier - Allows information to flow freely for Treatment Payment, and Operations Contact:
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There are Issues That Need to be Addressed
Specific State Laws for Mental Health Many State Laws for Mental Health Mirror HIPAA so this is not a problem
Mental Health information can flow thorugh the HIE Contact:
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There are Issues That Need to be Addressed 42 CFR Part 2 – Regulations covering consent and sharing of substance use information “from a Part 2 Covered Program” are a challenge
Part 2 is more stringent than HIPAA The “To Whom” section Most HIEs do not include SU Providers due to the additional consent management requirements
Sharing SU 42 CFR Part 2 Data is still difficult but not impossible Contact:
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Types of Health Information Exchange
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Exchange Among Providers in One system Somewhat Difficult but Occurring Nationally
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Exchange Among Providers in Multiple Systems More Difficult but Occurring Nationally
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Secure Messaging Exchange Uses DIRECT Protocols Meets Meaningful Use Requirements
Easy I encourage ALL providers to obtain and DIRECT Address!! Even if you DO NOT have an EHR!!
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Issues/Challenges:
Some HIEs cannot process only specific providers in the “To Whom” Section Is “All or Nothing” Is “All or Nothing” for “Type and Amount” of Data Data Segmentation is not available in all systems today to support Data Segmentation HIEs cannot currently process “Only providers in the HIE as of the date of signing the form” Barriers due to technology, cost & operational issues for HIEs and providers Contact:
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What Gets Exchanged
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Data Integrity Follow the Continuity of Care Document / C-CDA
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Psychotherapy Notes are not Sent
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Good Health Clinic Continuity of Care Document Created On: January 6, 2012
Patient Henry Levin , the 7th
MRN 996-756-495
Birthdate September 24, 1932
Sex Male
Guardian Kenneth Ross 17 Daws Rd. Blue Bell, MA, 02368 tel:(888)555-1212
Next of Kin Henrietta Levin tel:(999)555-1212
Table of Contents • • • • • • • • • • • •
Purpose Payers Diagnosis Allergies, Adverse Reactions, Alerts Medications Immunizations Results Treatment Plan Progress Note Suicide Risk Risk of Violence Substance Abuse
Purpose
Transfer of care Contact:
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Payers Payer name Healthy Insurance
Policy type / Coverage type Extended healthcare / Self
Covered party ID 14d4a520-7aae-11db-9fe1-0800200c9a66
Authorization(s)
Diagnosis • • • • • •
Axis I Primary : 296.21 - Major Depressive Disorder , Single Episode Axis I Secondary : 303.90 - Alcohol Dependence Axis II Primary : 301.6 - Dependent Personality Disorder Axis III : None Axis IV : Social Environment (Recently divorced), Occupational (Recently unemployed), Housing (Recently lost home to foreclosure and is homeless), Other Problems (Recent evidence of male pattern baldness) AxisV:58
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Allergies, Adverse Reactions, Alerts Substance Penicillin Aspirin Codeine
Reaction Hives Wheezing Nausea
Status Active Active Active
Medications Medication Albuterol inhalant Clopidogrel (Plavix) Metoprolol Prednisone Cephalexin (Keflex)
Instructions 2 puffs QID PRN wheezing 75mg PO daily 25mg PO BID 20mg PO daily 500mg PO QID x 7 days (for bronchitis)
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Start Date
Mar 28, 2000 Mar 28, 2000
Status Active Active Active Active No longer active
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Immunizations Vaccine Influenza virus vaccine Influenza virus vaccine Pneumococcal polysaccharide vaccine Tetanus and diphtheria toxoids
Date Nov 1999 Dec 1998 Dec 1998 1997
Status Completed Completed Completed Completed
Source of Information Immunization Tracking System Immunization Tracking System Immunization Tracking System Immunization Tracking System
Results March 23, 2011 Hematology HGB (M 13-18 g/dl; F 12-16 g/dl) WBC (4.3-10.8 10+3/ul) PLT (135-145 meq/l) Chemistry NA (135-145meq/l) K (3.5-5.0 meq/l) CL (98-106 meq/l) HCO3 (18-23 meq/l)
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April 06, 2011
13.2 6.7 123* 140 4.0 102 35*
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Treatment Plan Problem 05-Substance Abuse Goal Accept chemical dependence and begin to actively participate in a recovery program. Objective Describe childhood experience of alcohol abuse by immediate and extended family members. Goal Establish a sustained recovery, free from the use of all mood-altering substances. Objective Develop a right aftercare plan that will support the maintenance of long-term sobriety.
Progress Note 02/04/2009 Henry Levin was assessed and completed testing. He showed signs of alcohol dependence as evidenced by marked tolerance, previous attempts at abstinence, relationship problems as well as hangovers and blackouts. He also has a previous OWI and completed Level I with this program in 2007. Referred to XYZ Counseling Center for IOP. Baseline UA taken.
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Suicide Risk Suicide Thoughts?
Date of Last Suicidal Thought
Risk Factors
Previous attempts?
Date of Last Attempt
Yes
04/15/2009
Guns in house, potentially lethal medications
Yes - 1
11/27/1989
Additional Information Recently lost job, feeling despondent
Risk of Violence Threat towards others?
Existence of Plan
Plan details
Yes
Moderate Plan
Reduce the risk of domestic violence
Level of Intent Minor
History of Violence?
History details
Risk Factors
Additional Information
Yes
Assault on 1 individual with deadly weapon
Guns in house
No vehicle to carry out plan
Substance Abuse Substance Route Frequency Age of First Use Date of Last Use Primary Methamphetamine Injection 3-6 times in the past week 15 05/04/2009 Secondary Methylphenidate Oral 1-2 times in the past week 17 04/27/2009 Electronically generated by: on January 6, 2012 Contact:
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ONC’s Special Focus on Interoperability
September 9, 2013 Office of the National Coordinator (ONC) Issued: Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments
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Purpose: Guidance is meant to serve as a building block for federal agencies and stakeholders to use as they work with different communities to achieve interoperable electronic health information exchange.
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Supports The Triple Aim BETTER HEALTH
Care Coordination
Clinical Care
BETTER CARE
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Population & Community Health
Efficiency & Cost Reduction
Safety Person / Caregiver Centered
LOWER COSTS
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Strategies to Position Yourself to Effectively Share Information and Use Data
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Focus on Interoperability Obtain a DIRECT Secure Messaging Address Speak to your vendor about compatibility with the C-CDA Select Clinical Quality Measures that the rest of health care is using Then add your own Begin sharing data with your health care partners
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Michael R. Lardieri, LCSW Vice President, HIT & Strategic Development
[email protected]
• • • • •
Website: www.thenationalcouncil.org CIHS: www.integration.samhsa.gov Blog: www.MentalHealthcareReform.org Twitter: @nationalcouncil Facebook: www.facebook.com/TheNationalCouncil
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Integrating Health Data to Identify Super Utilizers and Support Care Intervention Strategies Presented at the
NGA Super Utilizer Policy Academy Meeting David Mancuso, PhD
Chief, Program Research and Evaluation Section Research and Data Analysis Division Washington State Department of Social and Health Services
November, 20 2013
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What does a Medicaid “Super-Utilizer” look like? Top 10 most frequent ED utilizers in WA State in past 15 months: 1.
ED visits in past 15 months range from 78 to 134
2.
IP admissions range from 0 to 22 (average of 7)
3.
9 out of 10 have an indication of a current substance abuse problem
4.
10 of 10 have an indication of mental illness
5.
2 of 10 are currently homeless
6.
3 of 10 are currently or have recently been living in a group care setting
7.
1 of 10 is currently receiving in-home personal care
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Patient number 10 • 54-year-old male on SSI • Currently homeless following release from jail 12 months ago • Applied for personal care but never received assistance • In the personal care assessment process, reported losing recently losing section 8 housing assistance • 78 ED visits and 1 IP admission in past 15 months • Co-occurring SMI and substance abuse • Most recent ED visits have been to treat problems with a catheter and chronic UTI Contact:
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Patient number 10: “Super Utilizer” risk profile Disease Category
Most recent Drug or Diagnosis
Risk Factor
Renal Skeletal CNS Pulmonary Psychiatric Hematological Cardiovascular Metabolic Diabetes Substance abuse Infectious CNS Infectious Cerebrovascular Eye Renal Psychiatric Skeletal Pulmonary Cardiovascular CNS Psychiatric Psychiatric
OTHER CYSTOSTOMY PYOGEN ARTHRITIS-UNSPEC SPINAL CORD INJURY NOS FOOD/VOMIT PNEUMONITIS PARANOID SCHIZO-UNSPEC THROMBOCYTOPENIA NOS COMPLICATIONS/AUTO CARDIAC DEFIBRILLATOR HYPOPOTASSEMIA DIABETES W/O COMPLICATION ALCOHOL ABUSE-UNSPEC CEFPODOXIME PROXETIL TAB 200 MG METHOCARBAMOL TAB 500 MG SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG UNSPECIFIED HEMIPLEGIA/HEMIPARESIS CATARACT NOS RETENTION OF URINE, UNSPECIFIED CHRONIC FACTITIOUS ILLNESS JT CONTRACTURE-HAND PNEUMONIA, ORGANISM NOS HYPERTENSION NOS BRACHIAL PLEXUS LESIONS UNSPECIFIED EPISODIC MOOD DISORDER PSYCHOSIS NOS
Renal, medium Skeletal, medium CNS, medium Pulmonary, medium Psychiatric, high Hematological, low Cardiovascular, low Metabolic, very low Diabetes, type 2 low Substance abuse, very low Infections, medium -Rx Multiple Sclerosis/Paralysis-Rx Infections, low -Rx Cerebrovascular, low Eye, very low Renal, low Psychiatric, low Skeletal, low Pulmonary, low Cardiovascular, extra low CNS, low Psychiatric, medium low Psychiatric, medium
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Claims
9 1 2 1 92 7 11 5 3 73 1 5 3 2 1 27 3 4 4 16 3 2 7
Last Date Risk Score
Aug 26, 2012 Dec 21, 2011 Sep 7, 2012 Apr 11, 2012 Nov 26, 2012 Apr 17, 2012 June 8, 2012 Apr 11, 2012 Mar 1, 2012 Nov 26, 2012 Feb 24, 2012 Jan 31, 2012 July 20, 2012 Oct 30, 2011 May 25, 2012 Oct 26, 2012 Mar 1, 2012 Apr 9, 2012 Apr 22, 2012 Sep 7, 2012 May 23, 2012 Oct 27, 2011 Sep 7, 2012
0.93 0.42 0.41 0.32 0.27 0.26 0.25 0.19 0.10 0.09 0.06 0.04 0.01 0 0 0 0 0 0 0 0 0 0
• Nurse care manager to client ratio 1:50 – Primarily face-to-face – Telephone support as needed
Intervention strategy: health home interventions focused on management of high-risk patients
• Evidence-based protocols including: – – – – – –
Diabetes management Pain management Fall assessment and prevention planning Medication management Health Action Planning Coaching for Activation™
• Comprehensive Assessment including Patient Activation Measure (PAM™) • Client-centered Health Action Plan and Goal Setting Worksheet – Set goals with client according to activation level – Education towards self-management of chronic illness Contact:
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Risk determinants for targeting Health service encounter risk criteria • Predictive modeling (PRISM) – Past 15 months of integrated health care claims determine future medical cost and inpatient risk scores – High frequency conditions: diabetes, cardiovascular disease, mental health and substance abuse – Minimum risk score in top 20% of expected future medical costs for SSIrelated population
Criteria based on long-term care assessment data – – – – –
Client lives alone High risk moods/behaviors (agitation/irritable) Self-reported health rating is “fair” or “poor” Overall self-sufficiency declined in last 90 days Medication management risk
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Findings to date • Chronic Care Management evaluation – – – –
Modest net savings Driven by reduced IP and SNF costs Reduced mortality Increased patient satisfaction
• Other interventions – Housing support – Substance abuse treatment
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Targeting approaches • Extreme ER/ED utilization • Expected future medical costs • Prospective inpatient risk • Care gaps and quality indicators [less well targeted for high ROI]
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Prospective Inpatient Admission Risk Model Example condition within risk group
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Prospective Inpatient Admission Risk Model continued Hospital Admission Impact . . .
Outpatient Emergency Room Utilization Impact . . .
Patient Example
Jane Doe has been diagnosed with congestive heart failure (9.4%), poorly controlled type 1 diabetes (6.0%), and chronic obstructive asthma (5.3%). She was hospitalized once in the prior 31-90 days (5.8%), and twice in the prior 183-365 days (2 x 2.1% = 4.2%). She has been to the ED twice in the past month without being admitted to the hospital (2 x 1.7% = 3.4%). Her risk of an inpatient admission in the next 6 months is 28.3%. Contact:
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State Medicaid Agency role • Work collaboratively with plans and providers to build shared commitment to improve outcomes for highest-risk patients • Support multi-system data integration and analytics • Recognize impact of social and behavioral risk on medical utilization Patient
Rx/Dx
ED
Analyze
Q
Risk Model
Review
Invest
Team Provider Review Contact:
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Contact:
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Contact:
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Contact:
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Contact:
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Contact:
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CLOSE-UP
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Drug Adherence
CLOSE-UP
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Contact:
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Case Studies
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Case Study #1 A CMHC develops a partnership with one or more local primary care practices to improve care coordination. What options might exist for sharing relevant individual-level clinical information between sites, particularly without consent? Contact:
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Case Study #2 An SUD treatment provider develops a similar partnership with local primary care providers. How are its options the same or different?
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Case Study #3 A state Medicaid program implements a health home model in primary care practices, and would like to provide primary care providers with access to BH information to support care coordination. What information can be shared by the state to PCPs in the absence of consent? Contact:
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Case Study #4 A state Medicaid program implements a health home model within the community mental health system. Health homes are required to partner with local hospitals to receive referrals of eligible members. What options exist for sharing this information between hospitals and mental health providers? Where would consent be required? Contact:
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Case Study #5 A Medicaid program provides behavioral health services through a “carve-out” managed behavioral health organization. What behavioral health information can the carve-out share with physical health managed care plans without consent? Contact:
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Case Study #6 A health plan develops a web-based portal to provide its primary care network with access to consolidated health care utilization/diagnostic information for its members. What type of behavioral health information can be included in the absence of consent? Contact:
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Case Study #7 An accountable care organization is created, including a hospital, primary care clinics, mental health and SUD treatment providers, and a care management provider. What patient-level information can be exchanged across this group of affiliated providers in the absence of consent? What is a possible role for QSOs here, and can the ACO be considered a QSO? Contact:
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Case Study #8 A state is building an all-payer claims database. Can the legislature require that Part II providers submit claims information to the allpayer claims database? If so, are there limitations on what the data can be used for? Contact:
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Mike Lardieri –
[email protected] David Mancuso -
[email protected] Allison Hamblin -
[email protected]
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