Case Studies in Telehealth Adoption
January 2013
Centura Health at Home: Home
Telehealth as the Standard of Care
Andrew Broderick and Valerie Steinmetz
Abstract: Building on its success using telehealth to reduce preventable readmissions
Fund is to promote a high performance
with home-based Medicare beneficiaries, Centura Health at Home (CHAH)—the home
health care system. The Fund carries
care unit of Centura Health—augmented its program by integrating its existing service
out this mandate by supporting
with a clinical call center staffed by registered nurses who provide telephonic telehealth
independent research on health care
services. Results from the year-long program demonstrated successful outcomes in terms
issues and making grants to improve
health care practice and policy. Support
of reducing 30-day rehospitalizations, increasing patients’ quality of life, improving
for this research was provided by
patients’ self-management skills and education, and reducing the frequency of home vis-
The Commonwealth Fund. The views
its from registered nurses. Centura’s experience indicates that restructuring home service
presented here are those of the authors
coordination and educating clinical call center nurses on chronic disease management are
and not necessarily those of The
key to a successful program. The successful integration of the two programs has led to the
Commonwealth Fund or its directors,
establishment of telehealth as the standard of care at CHAH.
officers, or staff. The Center for
Technology and Aging, a program of the
Public Health Institute, provided grant
funding to Centura Health at Home for
the intervention discussed in this case
study. Centura Health at Home was one
OVERVIEW
of five recipients for grant funding in the
Across the country, the average 30-day rehospitalization rate for Medicare ben-
Remote Patient Monitoring Diffusion
Grants Program.
eficiaries with chronic conditions is 20 percent. At Centura Health, the average
rate is 19 percent, of which approximately 90 percent are unplanned and prevent-
For more information about this study,
able. Centura Health has been working to reduce its 19 percent rate of readmis-
please contact:
sions, particularly among older adults struggling with chronic conditions. Centura
Andrew Broderick, M.A., M.B.A.
Health at Home (CHAH)—the organization’s home care unit—has demonstrated
Codirector, Center for Innovation
the ability of telehealth to significantly reduce readmission rates for home care-
and Technology in Public Health
Public Health Institute
based Medicare beneficiaries to 6 percent.
Building on its success with telehealth, CHAH recently completed a one-
year program to further decrease 30-day rehospitalization rates and increase qual-
ity of life among older adults by expanding its telehealth services. The project
To learn more about new publications
was funded by the Center for Technology and Aging as one of five grant projects
when they become available, visit the
in the Remote Patient Monitoring Diffusion Grants program.1 CHAH integrated
two independent, successful home health service programs, a clinical call cen-
Commonwealth Fund pub. 1655
Vol. 2
ter staffed by registered nurses (RNs) and a remote patient monitoring (RPM)
2
The Commonwealth Fund
program. The merged telehealth program expands the
living options, to more than 20,000 patients and
activities of the clinical call center to provide assis-
members of their families, many of whom are older
tance to participants in the telehealth program 24 hours
adults. CHAH serves patients and residents in their
a day, seven days a week.
own homes, nursing homes, residential centers, and
The year-long program reduced the frequency
hospitals, and employs more than 1,300 employees to
of 30-day rehospitalizations and home RN visits, while
serve communities across the state. Today, CHAH is
improving quality of life, self-management, and educa-
the largest home care provider in the state, with more
tion among patients. The program also supported advo-
than 400 clinical staff and associates, including regis-
cacy for policy change addressing payments to home
tered nurses, physical therapists, occupational thera-
care agencies for telehealth services in Colorado. The
pists, speech therapists, medical social workers, and
integration of CHAH staff into the telehealth program
chaplains.
has been essential for the program’s success and has
CHAH is the first home health agency in
led to the establishment of telehealth as a new standard
Colorado to have implemented a telehealth system.
of care at CHAH.
The agency’s integrated clinical call center-telehealth
program represents a culmination of efforts that origi-
BACKGROUND
nally began in 2004 with video-based interventions for
As the largest integrated health care system in
a small population of high-acuity patients enrolled in a
Colorado, Centura Health serves communities in
managed Medicare plan. Telehealth has enabled CHAH
Boulder county, the metro Denver area, Colorado
to visit with patients in between scheduled in-person
Springs, Pueblo, Cañon City, and rural and mountain
home visits to reinforce the education process and to
communities. The integrated delivery system encom-
maintain closer contact with patients. Traditionally, eli-
passes a network of 13 hospitals, four freestanding
gible participants meet the Medicare home health ben-
emergency departments, seven senior living com-
efit and for these patients there has been no program
munities, and home health and hospice services.
cost for participation.2
Approximately 14,500 employees, including more
than 6,000 physician partners, deliver advanced care to
INTEGRATION OF THE CLINICAL CALL
more than half a million people annually.
CENTER AND TELEHEALTH PROGRAMS
The deployment of information systems is a
The integrated program broadens the clinical call cen-
core tenet in Centura Health’s systemwide strategic
ter’s capabilities to include telehealth assistance and
2020 plan to improve the quality, consistency, avail-
coordinated care. This clinical call center also extends
ability, and affordability of health care to communities
the reach of telehealth-enabled care to include patient
throughout Colorado. This also aligns operationally
populations who would otherwise not be eligible for
with the evolution of the Centura model from centers
home care services under the Medicare homebound
of care (i.e., individual hospitals) to a complete system
benefit. The evaluation criteria used for inclusion in
of care. Establishing electronic health records linking
the telehealth program has been broadened to include
physicians, clinics, hospitals, long-term care facilities,
all patients readying for discharge from the hospital,
and home care services has been central to Centura’s
regardless of their eligibility under Medicare for home
strategic investments in information technology.
care services. The program extends the continuity of
Centura Health at Home (CHAH) was founded
care on a 24/7 basis, more effectively uses existing
in 1997. It is a division of Centura Health and a non-
health care resources, and extends the reach of a lim-
profit, faith-based, home health care organization
ited nursing staff to manage a larger number of patients
that provides a broad continuum of services, includ-
on a daily basis (Exhibit 1).
ing home care, rehabilitation therapies, and senior
Centura Health at Home: Home Telehealth as the Standard of Care
3
Exhibit 1. Centura Health at Home Integrated Telehealth Program
• Remote monitoring of patients by registered nurses and augmented with 24/7 clinical call center and telehealth services
• Patients identified for and introduced to the program during a hospital admission or upon enrollment in CHAH
•
“Real-time” patient education, lifestyle management, and medication adjustments
Who is eligible?
Who is not eligible?
• Patients who have any of the following:
• Active substance abusers
°°
chronic disease (e.g., congestive heart failure, chronic
• Unsafe home environment
obstructive pulmonary disease, hypertension, diabetes)
• Pest control problems
°°
fall risk factors
°°
age 80 or older
• Patients with documented violence/aggression
°°
two or more hospitalizations in past six months
• Patients with advanced dementia, unless they have a
°°
two or more emergency room visits in past six months
competent caregiver
°°
taking five or more medications
• Patients with low functional vision, unless they have a
°°
documented history of nonadherence to prescribed regimen
competent caregiver
°°
any other indicator that they may return to the hospital in 30
days or less
• For telephonic telehealth-only program: patient does not qualify
for Medicare homebound benefit
• Patients covered by Medicare, Medicare Advantage plans, and
Medicaid
Source: Centura Health at Home.
Initially, CHAH sought to enroll at least 200
daily measurement of patient indicators, including
patients eligible for home care, and to increase the
vital signs, weight, and behavioral health, with remote
number of patients served in the program by a mini-
monitoring of data conducted by RNs. The clinical call
mum of 200 per year. Of CHAH’s Medicare patients,
center-based program, which has been in existence
70 percent require home care. One-third of these
for more than 20 years, broadens the traditional clini-
patients are using telehealth and this proportion is con-
cal call center’s capabilities to now include telehealth
tinuously growing. On average, a home care nurse can
assistance and coordination of care for patients utiliz-
see five to seven patients a day during in-person home
ing remote patient monitoring, while also generat-
visits, whereas a telehealth nurse can monitor 60 to 70
ing a telephonic telehealth-only treatment group that
patients a day. The increase in the monitoring casel-
extends the reach of care to patient populations not
oad managed by telehealth nurses has been gradual as
meeting the Medicare home health benefit. Integrating
Centura has refined processes, developed the skills of
the clinical call center with the telehealth program has
monitoring nurses, and transitioned to a new monitor-
also allowed CHAH to adapt the traditional clinical
ing platform. The number of patients a telehealth nurse
call center’s business marketing model to a clinical
can manage in a day is expected to continue to increase
business model to support a more robust telehealth
to close to 100 patients in the future.
program.
The telehealth component of the program
Patients were recruited in the Denver Metro
uses remote patient monitoring technology for the
area at two Centura Hospitals, St. Anthony’s Central
4
The Commonwealth Fund
and Porter Adventist Hospital. The typical participant
current health status, and educational needs. Patients
was an older adult (average age of 76), living in his or
are given peripheral devices, including a scale, blood
her own home, managing comorbid conditions, and
pressure cuff, pulse oximeter, and thermometer. They
had recently experienced a hospitalization related to
are monitored on a daily basis and transmit data
an exacerbation of a chronic health condition. Among
through the phone line at least once daily, and more if
patients, 44 percent were diagnosed with conges-
the condition requires it. Within 48 hours of discharge,
tive heart failure, 34 percent had chronic obstructive
home care field nurses visit and conduct health and
pulmonary disease, and 17 percent were diabetic.3
environmental risk assessments. In the following 24
Because nurses at the clinical call center were familiar
hours, a telehealth technician visits the patient at home
with the use of telephonic technology but lacked train-
to install and familiarize patients with the remote mon-
ing on information technology, the program empha-
itoring technology. Nurses and installers are trained
sized support for nurse training and education in infor-
to use the teach-back technique to assess the patient
mation technology.
and family’s level of understanding and commitment.
Patients participating in the project were strati-
At the same time, primary care physicians write up
fied into two categories. The first group used remote
PRN orders (i.e., “as needed” orders that nurses can
patient monitoring technologies and had access to the
modify), which allow the monitoring nurses to react to
24/7 clinical call center. A second tier of patients who
trending and monitoring data within a specified set of
did not qualify for the Medicare homebound benefit
parameters.
and tended to be more physically capable of caring for
Once operational, dedicated telehealth nurs-
themselves received telephonic telehealth care through
ing staff monitor patient data from the remote devices
the clinical call center. On average, the patients in the
and call the patient if there are significant vital sign or
first group are enrolled in the program for 60 days.
health status changes. Patients are also able to contact
Patients transmit monitoring data on a daily basis, or
the clinical call center with questions 24/7. When tele-
more often if the condition requires close monitoring.
health patients call, call center RNs can review patient
For patients in the second group, clinical call center
data, provide assistance, and escalate the alert to a phy-
RNs set up weekly calls over a three-week timeframe
sician, if needed. Primary care physicians are closely
after discharge to review medication lists and manage-
involved in the program and monitor patients’ progress
ment, compare medications to discharge orders, and
by reviewing weekly reports containing the patients’
educate patients using a teach-back technique that
current medication list, vital sign and symptom read-
highlights patients’ level of understanding regarding
ings, and nursing notes. For patients in the second
their condition and lifestyle behaviors. Upon comple-
group who are solely using the clinical call center as
tion of the project, the duration of the telephonic care
their telehealth strategy, clinical call center RNs set
intervention was extended to four weeks. During each
up a series of weekly follow-up calls after discharge
call, nurses identified potential medical issues and
to review care management plans and issues related to
decided which follow-up interventions were needed.
patient self-efficacy.
Under the new integrated program, the first
Patients can be discharged from the remote
group of patients using RPM received a base station
patient monitoring program when they no longer meet
that displays and collects behavioral and general health
home care criteria. Patients in the telephonic telehealth
questions, as well as vital sign data from peripheral
intervention are discharged when the three weekly calls
devices. Baseline parameters are set using input from
are complete or the patient self-discharges from the tel-
primary care physicians, as well as a telehealth algo-
ephonic component. The program prepares patients for
rithm, which is customized for each patient using 2,000
eventual discharge by teaching them how to indepen-
different elements, based on patient health history,
dently monitor core health indicators and to identify
red flags so they know when to contact their clinicians.
Centura Health at Home: Home Telehealth as the Standard of Care
5
EVIDENCE OF OUTCOMES
period using the SF-36 scale that examines health and
Prior to the implementation of the integrated program,
wellbeing across eight physical, mental and social
the telehealth program at CHAH demonstrated a
aspects, showed a statistically significant increase for
reduction in hospital readmissions to 6 percent, from
patients receiving home telehealth care in specific age
the average 19 percent rate at Centura Health. The
groups and sexes with comparatively greater increases
goal of the merged telehealth program was to expand
for women compared with men, but did not present a
access to the telehealth program for a broader popula-
statistically significant increase in overall quality of
tion of older adults in Centura’s hospital system most
life. Patient satisfaction and self-management, mea-
responsible for the systemwide 19 percent readmis-
sured on a monthly basis using Centura’s telehealth
sion rate. Specific goals were to enroll at least 200
patient satisfaction tool, showed positive perceptions
patients, decrease 30-day readmission rates related to
and beliefs about health technology, patient satisfaction
congestive heart failure, chronic obstructive pulmonary
with the technology, and self-management. The fre-
failure, and diabetes at participating Centura hospitals
quency of RN visits was reduced from the traditional
by 2 percentage points, and measurably increase par-
two to three visits per week over a 60-day episode
ticipants’ quality of life. About one-quarter of the 200
of care to approximately three visits over the entire
patients used telephonic telehealth, while the major-
60-day telehealth care management period. The result-
ity used remote patient monitoring with access to the
ing cost savings is between $1,000 and $1,500 of total
clinical call center.
costs per patient.4
Results from the program show that 30-day
Over the course of the year-long program,
rehospitalizations related to congestive heart failure,
there were seven readmissions for 87 patients with
chronic obstructive pulmonary failure, and diabetes
congestive heart failure, three for 67 patients with
were reduced by 62 percent, and rehospitalization rates
chronic obstructive pulmonary disorder, and no read-
for patients receiving telehealth home care (6.3%) were
missions for the 34 patients with diabetes (Exhibit 2).
significantly lower than those for traditional home care
Quality of life was measured at baseline and at
patients (18%). Emergency department use decreased
the end of the study period using the SF-36 scale that
from 283 visits in the year preceding the study to 21
examines health and well-being across eight physical,
visits during the year-long study. Quality of life, which
mental and social aspects. An increase of five points is
was measured at baseline and at the end of the study
statistically significant. The project found that quality
Exhibit 2. Program Readmission Rates: Centura Health at Home Remote Patient Monitoring
Pre-intervention
Post-intervention readmission
Facility and condition:
readmission rates
rates (n=200)
St. Anthony’s Central
• Congestive heart failure
13.8%
4.2%
• Chronic obstructive pulmonary disease
14.1%
6.7%
• Diabetes
14.7%
0.0%
Porter Adventist Hospital
• Congestive heart failure
17.7%
9.5%
• Chronic obstructive pulmonary disease
12.5%
2.7%
• Diabetes
9.5%
0.0%
Source: Data provided by Centura Health at Home, reporting outcomes to the Center for Technology and Aging.
6
The Commonwealth Fund
of life increased for patients receiving home telehealth
subsequent Center for Technology and Aging grant-
care, averaging a 4.8 point increase in both the physical
ees. In reviewing surveys about older adults' percep-
and mental health components (Exhibit 3). While these
tions and beliefs about health technology, several
results were not statistically significant overall, specific
key points were addressed, such as privacy concerns,
components of the quality-of-life survey demonstrated
time of use, involvement in one’s health care (patient
statistically significant changes in all ages and sexes:
self-management), and quality of care (Exhibit 4).
physical functioning, role limitation due to physical
The survey was created on a five-point Likert scale
problems, social functioning, and role limitation due to
taken from the Coleman Care Transitions Survey that
emotional problems. There were statistically significant
was developed and tested for use with older adults.5
improvements for 45-to-54-year-olds, 65-to-74-year-
Satisfaction scores were not assessed for statistical sig-
olds, and individuals 75 and older.
nificance; rather they were viewed in aggregate form
Patient satisfaction and self-management was
only for Centura’s own knowledge, as opposed to indi-
measured with the Centura telehealth patient satisfac-
vidual patients’ pre- and post-study. Exhibit 3 shows
tion tool, which was developed specifically for this
the monthly patient satisfaction and self-management
project and has received a large uptake of use from
scores of all patients using telehealth.
Exhibit 3. Quality of Life SF-36 Results:
Centura Health at Home Remote Patient Monitoring
QM SF-36 Scores for Study Population
60
50
40
Pre
30
Post
Variance
20
10
0
PCS MCS PF RP BP GH VT SF RE MH
Dimension
Code key:
PCS = Physical Component Summary
GH = General health
MCS = Mental Component Summary
VT = Vitality
PF = Physical Functioning
SF = Social Functioning
RP = Role-Physical
RE = Role-Emotional
BP = Bodily Pain
MH = Mental Health
Centura Health at Home: Home Telehealth as the Standard of Care
7
Exhibit 4. Telehealth Patient Satisfaction Survey Results:
Centura Health at Home Remote Patient Monitoring
5=completely agree
0=completely disagree
Mean score
5
4
3
2
1
0
Area of inquiry
LESSONS LEARNED
nursing staff can demonstrate the value of the inter-
Lessons learned at CHAH from the integration of
vention without negatively affecting the workflow of
telephonic telehealth with home telehealth highlight
clinicians. As a result of the improved chronic disease
several critical program areas for the successful imple-
management in the program, field nurses were able
mentation of telehealth at scale and on a sustained
to focus their time and attention on visits dictated by
basis: staff engagement; training and support; working
urgent health circumstances, rather than regular assess-
with vendors to select solutions that scale while meet-
ments, which can be routinely conducted via telehealth
ing the broader patient population’s needs; and modi-
equipment.
fying care management practices to reflect telehealth-
Effective nurse communication training is
enabled efficiencies.
vital to patient enrollment and engagement. Home
Staff engagement and buy-in are critical to
Service Coordination Nurses—the nursing staff who
program success. For the program to be successful,
introduced patients to the program during their hos-
home care nurses and clinicians must see value in the
pital stay—required additional training for effective
telehealth intervention for patients, nurses, and physi-
communication, particularly to emphasize the value
cians. One potential strategy is hosting an open house
of the program to patients. Clinical call center nurses
for the home care nurses to interact with the telehealth
also benefited from effective communication training
technology and ask questions. Key discussion points
to bolster confidence in decision-making processes to
used during such events should demonstrate the value
actively manage patients in response to issues raised
of the telehealth intervention to patients, nurses, and
during calls. Training focused on key words and
clinicians by focusing on outcomes, visits/episode,
phrases that are simple yet effective in describing the
rehospitalization rate, as well as patient satisfaction
program and on the intended outcomes for the patient.
data. Discussing how the program can improve chronic
There was also some scripting of the initial RN call to
disease management by extending the reach of the
the patients after the technology installation, as well as
8
The Commonwealth Fund
key elements for the installers in teaching patients and
increasing the volume of patients served through the
families.
integrated telehealth program, CHAH made a decision
Traditional clinical call center nurses
to change vendors to support more cost-effective scal-
require additional disease management education.
ing of the program while meeting the broader patient
Clinical call center nurses also underwent specific dis-
population’s needs. In particular, the new platform
ease management education that improved their prob-
offers the ability to only monitor those patients who
lem-solving and critical-thinking skills while fostering
fall outside established parameters, thereby placing
confidence. Among the challenges encountered, clini-
the emphasis on those patients needing immediate
cal call center nurses who were previously accustomed
attention.
to directing patients with symptoms to emergency
Establish physician PRN orders for tele-
rooms required training on the new paradigm, which
health patients to maximize efficiency. Monitoring
emphasizes chronic disease management at home.
nurses are able to react to trending and monitoring data
Streamline the discharge planning process
more quickly by utilizing physician PRN orders. To
to incorporate enrollment into the telehealth pro-
operate on a larger scale, physicians should establish
gram. Centura’s experience indicates that attention to
the orders when patients are initially enrolled into the
coordinating home care services is a key factor to pro-
program.
gram success. As part of the program, the home service
Provide real-time education to patients to
coordination discharge planning process was restruc-
increase patient self-management. The monitoring
tured in the hospital. Case managers were trained to
nurses can connect with patients in real time, helping
identify patient eligibility and enrollment criteria for
patients understand the relationship between cause
patients discharged without home care. Before dis-
and effect of lifestyle-related behaviors. For example,
charge, patients are introduced to the telehealth inter-
if nurses observe data such as missed medications or
vention in the hospital. Within 48 hours of discharge,
meals high in salt, they have the opportunity to educate
a personalized telehealth algorithm is created and tele-
the patient and make the correlation between actions
health technicians install devices and train patients on
and outcome.
how to use them. This streamlined process encourages
patient and caregiver engagement as they begin to fol-
DISCUSSION
low their treatment plan at home.
The current program was designed to demonstrate
Patient telehealth program enrollment is
the impact of a telehealth-based program on 30-day
most effective when introduced by a trusted clini-
readmissions, particularly in light of looming policy
cian. Patients were most likely to enroll in the tele-
changes that will penalize hospitals for what are
health program when they were introduced to the
deemed to be excessive rates of avoidable readmis-
program during the hospital stay by a home care nurse
sions for congestive heart failure and other conditions.
or physician or by a primary care physician after dis-
The project demonstrated that the use of remote patient
charge. Once patients were enrolled, repeat visits from
monitoring technologies combined with a 24/7 tele-
the telehealth device installer were required to train
health clinical call center benefited older adults’ health
elderly adults on using the technology.
while making more effective use of existing health care
Select a technology that will work in the
resources and extending the reach of nursing staff. The
long term. The original program design involved use
results support the sustainability of the intervention,
of either two-way video technology, to meet the needs
with plans to extend the telehealth component within
of patients’ with a very high acuity level, or remote
CHAH and to senior living communities to reach 1,000
patient monitoring technology, to more routinely moni-
adults by 2012 and 2,000 patients by 2013. At the state
tor patients with chronic conditions. As a result of
level, CHAH used the emerging evidence base in its
Centura Health at Home: Home Telehealth as the Standard of Care
9
work with the Home Care Association of Colorado to
CHAH, and not the exception, aligns with Centura’s
pass Telehealth Rule 8.520. The law now allows direct
2020 strategic plan, which expects changes to payment
payment for Medicaid patients in the remote patient
systems to support how, where, and when a hospital
monitoring intervention receiving home care telehealth
provides care.
services. Making telehealth the standard of care at
How This Case Study Was Conducted
This case study was developed through interviews with staff from Centura Health at Home (CHAH) and quar-
terly reports from the Center for Technology and Aging’s CHAH Remote Patient Monitoring Program. In partic-
ular, we would like to acknowledge Erin Denholm, CEO; Ellery Aiken, former director of Telehealth and Disease
Management; and Melody Wright, vice president of Patient Care Services, for their assistance in preparing this
case study.
The other organizations profiled in our Case Studies in Telehealth Adoption series are the Veterans Health
10
The Commonwealth Fund
Notes
1
2
The Medicare home health benefit pays a 60-day
episodic rate for home health care, including remote
patient monitoring, when four criteria are met: the
older adult is homebound, requires skilled care
on an intermittent basis, a physician signs a home
health certification, and the patient receives care
from a Medicare-certified home health agency.
3
Every participating patient has comorbidities and
the numbers reflect this overlap.
4
Centura Health at Home, reporting outcomes to the
Center for Technology and Aging.
5
Centura Health at Home: Home Telehealth as the Standard of Care
11
About the Authors
Andrew Broderick, M.A., M.B.A., is codirector, Center for Innovation and Technology in Public Health, at the
Public Health Institute. Mr. Broderick’s research focuses on the adoption and appropriate use of technology to
address vital and pressing challenges in public health, including efforts to enhance linkages between the public
health and health care delivery systems. Mr. Broderick previously managed research activity at HealthTech, including
work in cardiovascular disease, remote health services, and technologies for independent living. Mr. Broderick
holds a master of arts in economics and geography from Trinity College, in Dublin, Ireland, and a master of
business administration from San Francisco State University. He can be emailed at abroderick@phi.org .
Valerie Steinmetz, program director for the Center for Technology and Aging at the Public Health Institute, leads
the Remote Patient Monitoring and mHealth Diffusion Grants Programs. These programs focus on the acceler-
ated adoption and diffusion of technology-enabled chronic disease care that benefits older adults and is patient-
centered, coordinated, efficient, and effective. Ms. Steinmetz previously coordinated research in key clinical
areas at The Health Technology Center. Ms. Steinmetz graduated from the University of California, Berkeley,
and is currently enrolled in Emory University’s M.P.H. program in applied epidemiology.
Editorial support was provided by Deborah Lorber.
These case studies were based on publicly available information and self-reported data provided by the case study institutions. The
Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study
series is not an endorsement by the Fund for receipt of health care from the institution.
