Elaine Ellis Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?  

Elaine Ellis Center is a ambulatory FQHC located in Ward 7 in the Kenilworth Community in Northeast Washington D.C. The mission of this healthcare center is to provide affordable, quality healthcare to the underserved community which includes the Kenilworth Court public housing community and its surrounding areas regardless of their ability to pay.

What are the infrastructure characteristics of your health center (use of expanded care team, culture)?

How do interventions and/or workflows need to be adapted to ensure health equity?

Interventions and workflows need to be inclusive and adaptable to reflect the complexities and challenges that the patient population face to achieve positive outcomes to health equity. Access, communication and resources are the most important characteristics to achieve health equity.

How complex are the patient interventions to implement (e.g., perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, and number of steps required)?

Patient interventions can be complex are the patient interventions to implement due to an number of factors. This can range from patient engagement, staffing structures of the clinical care team and/or standing order policies. Patient interventions should be simple in the number of steps so everyone on the care team can follow.

What are key characteristics of the participating setting(s)?

Elaine Ellis is a small but growing organization. The care team contributes in providing care to the patients is adaptable (especially in sharing duties), diverse, responsive and motivated to provide quality healthcare to the community of patients. Other Challenges patients face range from transportation for access, medication affordability, health literacy and resources for care.

External Characteristics

What external or environmental supports or threats are there?

One of the benefits of Elaine Ellis is that it is located in a high traffic area which serves as a thoroughfare. it is accessible by Metro bus and provides free parking to the patients. It also allows a good environment to provide a good location and base for community outreach for the patients and residents in the surrounding area.

Treatment Intensification (Combination Therapy)

Plan

Treatment Intensification (Combination Therapy)

Actual

Describe Intervention Patient engagement and health literacy on importance of lower BP numbers

(Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies)

Chosen intervention: Improve patient engagement. Apply shared decision making at initiation of treatment plan and throughout therapy. Use collaborative communication skills in conversations.

Update: Hypertension self-management program for patients to set up medication combination therapy/intensification for African American patents with uncontrolled hypertension over the past year.

Target population - outreach patients that have reported BP over 160 based from their last visit.

Plan for intervention: During the visit, discuss with the patient the plan to lower blood pressure rates by having an inclusion strategy process with the patient on communicating different ways on medication therapy, small lifestyle adjustments and set up follow-up appointments before they leave the site.

Update: Reach out and schedule patients that had uncontrolled BP patients over 160 for a new visit to treat their BP on combination therapy and/or treatment intensification if needed, especially if they do have a upcoming visit scheduled or hasn’t been in the center throughout the year.    

Chosen Intervention: Improve patient engagement.

Date when implemented: October/November 2023

Updates: March 2024

The new providers in the practice has expanded their schedules to see all patients. They have begun to establish a care approach relationship and communication with the high hypertensive patients to work together to lower their blood pressure numbers. They have made suggestions in small lifestyle changes, making adjustments to their medication therapy which also includes combination medication and stress to make the follow-up before they leave the practice. The number of patients that had high systolic numbers (between 160-170) has decreased by having communication and more involvement in their follow-up process.

April 2024 Update:

All of Elaine Ellis’ providers had some a good job making sure they encourage communication with the patients by promoting recommendations for small lifestyle change ranging from diet and light exercise regimes in addition to their combination medication therapy.  

1. Strategy Name (e.g., outreach, clinical decision support, clinician education, data reports, etc.)

2. Strategy Description (including who is the focus/target of the intervention)

3. Who Enacts the Strategy? (e.g., QI staff, clinicians, health center leadership, patients/consumers, etc.)

4. What specific Actions, Steps, or Processes Need to be Enacted (e.g., provide clinical supervision, support learning)?

   1. Crystal pulling data to see patients with high numbers and if they have upcoming appointments

   2. talk with provider - feedback - e.g., if last 3 visits had a high BP but patient is combative and don’t want to do anything (i.e., is this patient able to be engaged, or do they need an additional resource first such as BH)

   3. provider forms a strategy with patient during visit, provider makes suggestions about lowering BP (diet, Rx, Rx reminders) using formation of relationship and trust

5. When is the Strategy Used? (e.g., during each patient visit, during monthly QI meetings)

6. What is the Dose of the Strategy? (e.g., one 3-hour training)

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: Update: There are four providers family medicine providers here at Elaine Ellis.

Update: Based on the end of June 2023 there were 77 of the African American patients that has high blood pressure that requires treatment protocol or an updated change in their current treatment protocol.

Reach of implementers/providers?

Actual:

Elaine Ellis has has new providers to the organization. They are now seeing patients which has expanded to the patients that does not have controlled blood pressure numbers or have not been in the practice in some time that need some updated care and medication protocol.

April 2024 Update:

The new providers are now seeing all adult patients, which has expanded to the total number of patients seen. Due to this increase in patients, it does increase the total number of patients this could affect the total number of patents that does not have controlled blood pressure numbers.

Reach of patients (# of patients receiving treatment intensification)? The goal is to reach 50 of the African American patients in this group that has high blood pressure that requires an updated treatment protocol.

Planned:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 87

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 10

Reach of patients (# of patients receiving treatment intensification)?

Actual:

As of the end of November, the center has been able to reach some patients and get them on a combination therapy regime.

The number of patients in this cohort that has received treatment is 17/45 patients.

Reach of implementers/providers?

November 2023: As of the end of November, the center has been able to reach some patients and get them on a combination therapy regime.

Update March 2024: The number of patients in the cohort has improved slightly. The number of patient has gone up to 28/50 patients that has lowered BP number based on a updated regime and more emphasis on follow-up visits.

April 2024 Update:

# AA pts. w/uncontrolled HTN on no therapy (as of 3/31/2024):72

# AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2024): 10

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Update: Pull hypertension data from EMR and chart reviews to see if the number/percentage of patients that made it to their appointment and have medication intensification changes in their therapy.  

Were you able to accurately measure how your intervention was working?

To analyze if this is working, puling and updated hypertension report in the EMR and still have access to the old data pulled and then compare the old data that was pulled at the beginning of this measure. There was a chart audit completed with these patients to review the provider’s notes and the medication updates in the patient’s chart.

April 2024 Update:

The process of reviewing hypertension data and reviewing the changes from the previous month’s data has shown small improvement with patient engagement. 

What outcomes do you expect?

Update: We expect some improvement with the number of patients now since there are more providers that can assist with these patients. 

What outcomes have you seen?

A slow process, however there were some patients that started to “buy-in” with the new provider in the patient-care relationship for them to come to their follow-up appointments so they can manage their blood pressure rates.

How will you ensure your intervention will be effective for your target population?

This will be completed by chart audits on those patients, monitor their appointments and work with the clinical team (including the Case worker) on negating challenges in their care and lower their hypertension rates.

Update: Monthly chart audits on patients, monitor their appointments and work with the clinical team (including the Case worker) on negating challenges in their care and lower their hypertension rates.

Did your intervention reach the target population?

As mentioned above, this is a slow process. Not all of the patients are participating in their follow-up care however the target population is getting care.

April 2024 Update:

As mentioned above, this is a slow process. Not all of the patients are participating in their follow-up care however the target population is receiving care.

What unintended consequences or outcomes might there be?

Non-compliance from the patients is the largest hurdle.

What unintended outcomes did you experience?

So far none. Elaine Ellis as an organization still have an issue with no-shows. No-show non-compliance was anticipated to be a hurdle or issue with this intervention, so it is going to take some time.

April 2024 Update:

So far none. Elaine Ellis as an organization still have an issue with no-shows. No-show and non-compliance patients was an anticipated to be a hurdle or issue with this intervention, so it is going to take some time.

Adoption (#/% and representativeness of staff and sites who implemented the intervention) Three primary care providers at location.

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

The intervention will be delivered by the clinical staff, first by the provider discussing the BP reading taken by the medical assistant. Once the patient/provider discuss more in depth about medication therapy regimen and other care education items, they will set up the follow-up appointment and/or refer to LCSW to coordinate for more resource assistance.

Update: The clinical staff, first by the provider discussing the BP reading taken by the medical assistant, will deliver the intervention. Once the patient/provider discuss more in depth about medication intensification regimen, they will set up the follow-up appointment and/or refer to LCSW to coordinate for more resource assistance.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

The intervention was delivered by the provider discussing the BP reading taken by the medical assistant. The providers here at Elaine Ellis are more than competent to discuss the importance of controlling hypertension rates and failure or non-compliance of medication adherence. Each visit there are education material given to the patient with a patient reminder placed in chart for follow-up appointments and other care appointments. When necessary or needed, they were referred to LCSW to coordinate for more resource assistance.

April 2024 Update:

The providers have shown their level of competency and care to discuss the importance of controlling hypertension rates and failure or non-compliance of medication adherence. Each visit there are education material given to the patient with a patient reminder placed in chart for follow-up appointments and other care appointments. When necessary or needed, there is follow up from the LCSW to coordinate for more resource assistance.

How will you know if clinicians/care teams/sites used the intervention?

Periodic chart reviews from data pull from the EMR on HTN patients.

Update: Periodic chart reviews from data pull from the EMR on hypertension patients.

What proportion of the planned staff/sites implemented the intervention? Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

There are four providers that treat the internal/family medicine patients and three of them are new to the practice. All three providers work at both center locations and they were all able to implement the intervention. There were slight differences between the care teams due to a couple of reasons which range from location, culture, and provider schedules.

April 2024 Update:

There are Four Family Medicine Providers and three of them have been in the practice less than one year. All were able to implement the intervention into their daily practice. There are slight challenges they face in their care due to a couple of reasons, ranging from patient culture beliefs/ culture trust, language barriers, and health literacy of patients.

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention? Periodic chart reviews from data pull from the EMR on HTN patients. Deeper dive from the patient’s previous visit and conduct an audit to see any differences, trends and improvements.

Update: Chart reviews from data pull from the EMR on uncontrolled hypertension patients.

How did you track modifications during the intervention?

Periodic chart reviews from data pull from the EMR on HTN patients.

What might be some of the possible obstacles to consistent implementation?

Patient cultural attitudes towards care which includes no-show for their appointments, other SDOH which can prevent access in health equity.

Update: Patient cultural attitudes towards care that includes no-show for their appointments, other SDOH that can prevent access in health equity.

What were the barriers to consistent intervention implementation?

Patient cultural attitudes towards their health care. This has impact the patient no-show rates for their appointments. There were other social determinants of health (SDOH) that may have affected patient outcomes.

What costs and resources (including time and burden, not just money) need to be considered? The amount of time needed to spend with each patient for their engagement which could impact patient flow in the center. In addition, since EECH does not have nurses on site, may need more involvement from both NP’s and clinical MA’s to work with patients.

Update: The amount of time needed to spend with each patient for his or her engagement, which could affect patient flow in the center. In addition, since EECH does not have nurses on site, may need more involvement from both NP’s and clinical MA’s to work with patients.

What costs and resources (including time and burden, not just money) need to be considered?

The resource to be considered is the amount of time spent with these patients that are not consistent in showing for their appointments and get them to engage in their care. This can impact patient flow in the center. The providers also serve as nurses since there are no nurses on site which requires more involvement for engagement to work with patients.

April 2024 Update:

The resource considered is the amount of time spent with these patients that are not consistent in showing for their appointments and get them to engage in their care.  If the patient has low health literacy, this can affect patient flow in the center. Since there are no nurses (RN) on site, providers also serve the role of the nurse. This can require more involvement for engagement to work with patients.

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain: Reminders during in-service meetings

How will you spread your intervention and lessons learned?

There will be periodic meetings with the team to share data. This time will also be used to brainstorm ideas from the clinical team to possibly put into practice.

How will you spread your intervention and lessons learned?

Meetings.

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention Improve Medication Adherence

(Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies)

Chosen intervention: Expand care team encounters to include medication education and adherence coaching.

Update: Improve patient engagement. Apply shared decision making at initiation of treatment plan and throughout therapy. Use collaborative communication skills in conversations.

Plan for intervention: Set up a series of follow-up appointments to monitor High HTN numbers and during the follow-up appointment provide more coaching and education.

Update: During the visit, discuss with the patient the plan to lower blood pressure rates by having an inclusion strategy process with the patient on communicating different ways on medication therapy, small lifestyle adjustments and set up follow-up appointments before they leave the site.

Chosen Intervention: Expand care team encounters to include medication education and adherence coaching.

Date when implemented: October 2023/November 2023

Updates:

Patients have follow-up appointments set up the provider’s schedule.

#AA of patients BP over 160 Dec 2023: 15/67

April 2024 Update:

The number of patients that have high systolic BP (over160-170) has reduced. More emphasis is still needed to reduce the BP numbers for patients  

The Admin team has reached out and schedule patients that had uncontrolled BP patients over 160 for a new visit to treat their BP on combination therapy and/or treatment intensification if needed, especially if they do have a upcoming visit scheduled or hasn’t been in the center throughout the year.    

 #AA pts with BP over160: 22/68

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: There are three(3) primary providers. Monitor and work with them to make sure that there are follow-up appointments set for those patients with high HTN numbers especially those that had a intensification to their therapy regime.

Update: Based on the end of June 2023 there were 77 of the African American patients that has uncontrolled high blood pressure that requires treatment protocol or an updated change in their current treatment protocol. At that time, Elaine Ellis is in staffing transition with the clinical staff.

Reach of implementers/providers?

Actual:

There are four primary providers, with one also treats behavioral health. Two of them just expanded their schedules and trained with the other two to make sure that there are follow-up appointments set for those patients with high HTN numbers especially those that had a intensification to their therapy regime.

Reach of patients (# of patients receiving treatment intensification)? The goal is to reach 50 patients that are African American patients that has high blood pressure that requires treatment protocol.

Update: The goal is to reach 50 patients that are African American patients and have uncontrolled high blood pressure (over 150) that requires consistent treatment protocol.

Planned:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 77

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):8

Update

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 77/305

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):10/24

Reach of patients (# of patients receiving treatment intensification)?

Actual:

17/50 as of November 2023.

2/15 - Crystal will pull new numbers.

April 2024 Update:

# AA pts. w/uncontrolled HTN on no therapy (as of 3/30/2024): 96/343

# AA pts. w/uncontrolled HTN on monotherapy (as of 3/30/2023): 5/14

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Continue to pull HTN data from EMR and chart reviews to see if the number/percentage of patients lowers due to more patient engagement and education.

Update: Pull hypertension data from EMR and chart reviews to see if the number/percentage of patients that made it to their appointment and have medication intensification changes in their therapy.  

Were you able to accurately measure how your intervention was working?

To analyze if this is working, puling and updated hypertension report in the EMR and still have access to the old data pulled and then compare the old data that was pulled at the beginning of this measure. There was a chart audit completed with these patients to review the provider’s notes and the medication updates in the patient’s chart.

What outcomes do you expect? The expectation of this protocol is that the follow-up appointment will become more routine in care and establish an importance in the patient/provider relationship. With more trust in the relationship, this will promote lower high blood pressure rates with African-American patients.

Update: The expectation of this protocol is that the follow-up appointment will become more routine in care and establish an importance in the patient/provider relationship. With more trust in the relationship, this will promote lower high blood pressure rates with African-American patients.

What outcomes have you seen?

Update: The expectation of this protocol is that the follow-up appointment will become routine in care and establish an importance in the patient/provider relationship. With more trust in the relationship, this will promote lower high blood pressure rates with African-American patients.

No-shows is still an issue at the center.

April 2024 Update:

There are some small progresses with patients controlling BP.  An issue that still ongoing are the no shows, which affects the consistency of progress.

How will you ensure your intervention will be effective for your target population?

Monthly chart audits on those patients, monitor their appointments and work with the clinical team (including the Case worker) on negating challenges in their care and lower their hypertension rates.

Did your intervention reach the target population?

So far the intervention is showing some progress.

April 2024 Update:

There has been some success with some patients working on improving their BP numbers but challenges listed above affect the consistency progress.

What unintended consequences or outcomes might there be?

Lack of trust of the new providers from the patients.

What unintended outcomes did you experience?

So far none. The challenge is the no-show appointments.

April 2024 Update:

The challenge is the no-show appointments. Many of the patients have started to gain trust with the new providers, which is promoting engagement between provider-patient

Adoption (#/% and representativeness of staff and sites who implemented the intervention)

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

The intervention will be delivered by the clinical staff, first by the provider discussing the BP reading taken by the medical assistant. Once the patient/provider discuss more in depth about medication therapy regimen and other care education items, they will set up the follow-up appointment and/or refer to LCSW to coordinate for additional resource assistance.

Update: The clinical staff, first by the provider discussing the BP reading taken by the medical assistant, will deliver the intervention. Once the patient/provider discuss more in depth about medication intensification regimen, they will set up the follow-up appointment and/or refer to LCSW to coordinate for more resource assistance.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

Just like the intervention above, The intervention was delivered by the provider discussing the BP reading taken by the medical assistant. The providers here at Elaine Ellis are more than competent to discuss the importance of controlling hypertension rates and failure or non-compliance of medication adherence. Each visit there are education material given to the patient with a patient reminder placed in chart for follow-up appointments and other care appointments. When necessary or needed, they were referred to LCSW to coordinate for more resource assistance.

April 2024 Update

Just like the intervention above, the providers here at Elaine Ellis are more have shown that they are competent with patient care to discuss the importance of controlling hypertension rates and failure or non-compliance of medication adherence. Each visit there are education material given to the patient with a patient reminder placed in chart for follow-up appointments and other care appointments. When barriers have been identified, patients are referred to LCSW to coordinate for more resource assistance.

How will you know if clinicians/care teams/sites used the intervention?

The Quality department will pull hypertension data from EMR and chart reviews to see if the number/percentage of patients lowers due to more patient engagement and education.

Update: Chart pull review audits for hypertension patients to see if the number/percentage of patients are lower and reviewing patient schedules sixty days out to see if they have follow-up appointments.

What proportion of the planned staff/sites implemented the intervention?

There are four providers that treat the internal/family medicine patients and three of them are new to the practice. All three providers work at both center locations and they were all able to implement the intervention. There were slight differences between the care teams due to a couple of reasons which range from location, culture, and provider schedules.

April 2024 Update:

There are Four Family Medicine Providers and three of them have been in the practice less than one year. All were able to implement the intervention into their daily practice. There are slight challenges they face in their care due to a couple of reasons, ranging from patient culture beliefs/ culture trust, language barriers, and health literacy of patients.

Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

There are four providers that treat the internal/family medicine patients and three of them are new to the practice. All three providers work at both center locations and they were all able to implement the intervention. There were slight differences between the care teams due to a couple of reasons which range from location, culture, and provider schedules.

April 2024 Update:

There were slight differences between the care teams due to a couple of reasons ranging from patient culture, expertise, etc. however, all were able to follow the intervention.

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention?

Chart pull review audits for hypertension patients to see if the number/percentage of patients are lowered.

Update: Chart pull review audits for hypertension patients to see if the number/percentage of patients are lower and reviewing patient schedules sixty days out to see if they have follow-up appointments.

How did you track modifications during the intervention?

Periodic chart reviews from data pulled from the EMR on Hypertension patients.

What might be some of the possible obstacles to consistent implementation?

No-Show rates continue to be an issue for the site.

Update: Non-compliant patients that do not come to come to their appointment (no-show) can be an issue for the site.

What were the barriers to consistent intervention implementation?

No-Show rates continue to be an issue for the site along with some culture non-compliance.

What costs and resources (including time and burden, not just money) need to be considered? The amount of time needed to spend with each patient for their engagement which could impact patient flow in the center. In addition, since EECH does not have nurses or a patient navigator on site, may need more involvement from both NP’s and clinical MA’s to work with patients.

Update: The amount of time needed for the front desk staff and clinical support to spend reaching out to these patients to get them in the practice. The clinical team spend extra time with each patient to engage could impact patient flow in the center. In addition, since EECH does not have nurses or a patient navigator on site, may need more involvement from both NP’s and clinical MA’s to work with patients.

What costs and resources (including time and burden, not just money) need to be considered?

The resource to be considered is the amount of time spent with these patients that are not consistent in showing for their appointments and get them to engage in their care. This can impact patient flow in the center. The providers also serve as nurses since there are no nurses on site which requires more involvement for engagement to work with patients.

April 2024 Update:

The resource considered is the amount of time spent with these patients that are not consistent in showing for their appointments and get them to engage in their care.  If the patient has low health literacy, this can affect patient flow in the center. Since there are no nurses (RN) on site, providers also serve the role of the nurse. This can require more involvement for engagement to work with patients.

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

How will you spread your intervention and lessons learned?

Periodic meetings to inform protocol progress.

How will you spread your intervention and lessons learned?

Periodic meetings to inform protocol progress.

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?

Continuous review of the protocol to alter for changes.

Re-fresher training for the clinical support staff.