www.ortelehealth.org

IMPROVING ACCESS TO BEHAVIORAL HEALTH & ADDICTIONS TREATMENT IN A RURAL CRITICAL ACCESS HOSPITAL DISTRICT THROUGH COMMUNITY-ACADEMIC PARTNERSHIPS Telehealth Alliance of Oregon 2019 Summit Program (Portland, OR) May 14, 2019 Wayne Pollard MSW LICSW Ryan Kimmel MD, Shane McGuire, CEO Matt Iles-Shih, MD, MPH Anna Ratzliff MD, PhD Cara Towle RN MSN MA

DISCLOSURES No conflict of interest/disclosures LEARNING OBJECTIVES Using the Columbia County Health Systems experience, this presentation explores: 1. An approach to envisioning & planning for systems change 2. Several options for integrating behavioral health & addictions treatment (BHAT) into general medical settings 3. Key components of & considerations in cross-system implementation of BHAT 4. How this systems experience with multilevel integration might inform your own efforts.

PRESENTATION OUTLINE Background: Behavioral health & addictions treatment in rural settings Columbia County Health System, a case study Pragmatic Innovation: Developing a Vision, Identifying Needs & Service Goals Inventory of local capacity, augmenting through partnership Designing and implementing a program: Inpatient Outpatient BACKGROUND Good News! Accessing behavioral health & addictions services improves

many general health & mental health outcomes Integrating these services into general medical settings improves access and utilization Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54(3):216-26. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-20. BACKGROUND A Challenge: Access to Behav. & addictions services especially limited in rural areas

75% WAs counties & majority of its landmass is rural Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323-8. Andrilla CHA, Garberson LA, Paterson DG, Larson EH. The Supply and Distribution of the Behavioral Health Workforce in America: A State-Level Analysis. Data Brief #163. WWAMI Rural Health Research Center, UW, July 2017. CASE STUDY COLUMBIA COUNTY HEALTH SYSTEM (CCHS) Overview of CCHS Service Area Region: Dayton, Waitsburg, Starbuck, & surrounding areas Catchment : ~5,600 residents

Demographics: Older (median age = 50) Rural (3rd least populated county in WA, 4.7 people/ sq-mile) CASE STUDY COLUMBIA COUNTY HEALTH SYSTEM (CCHS) Overview of CCHS Service Area Columbia Countys Health Ranking (out of 39 counties): 37th for longevity 22nd for aggregate health factors (e.g., tobacco, diet, exercise, health care access & quality) 14th for social and economic health 2nd for physical environment

Mental/Behavioral Health: 4.2% describe MBH as poor (state ave = 3.8%) 29% of Medicare patients depressed, 14% dealing with anxiety MBH provider-to-pt ratio = 440:1 (state ave = 330:1) CASE STUDY COLUMBIA COUNTY HEALTH SYSTEM (CCHS) Dayton General Hospital Critical Access Hospital Level V Trauma Center Level III Cardiac & Stroke Center Booker Nursing Home On Dayton Gen Hosps Cam

Primary Care Clinics Dayton Waitsburg CASE STUDY (CCHS) OPPORTUNITIES System: Strong Leadership Dedicated & skilled clinical staff

Multiple care settings EHRs (inpt/outpt) Behavioral Health Care Two MSWs LICSWs No Psych ARNP or MD/DO CASE STUDY (CCHS) OPPORTUNITIES Addictions Treatment: No specialists 2 Buprenorphine-naloxone waivered providers Option for outpt psychosocial SUDs treatment at Blue Mountain Counseling

Community/Pt Needs Hosp-to-hosp transfers for multi-week IV abx (often due to IVSU) Under-treated depression, bipolar, anxiety, OCD, PTSD, schizophrenia, addictions DEVELOPING A VISION & PLAN FOR INTEGRATED CARE CCHS VISION: REINFORCING GOALS GOALS Now Future

+/- + +/- + - + + -

+ +/- + Which patient populations are we targeting? Patients in crisis and distress Patients with common chronic mental illnesses such as depression and anxiety. Patients needing support to manage serious, chronic and persistent mental illness. Patients in the Inpatient Setting What capacities do we have and need to develop? Measurement-based treatment to target Commitment to population-level outcome improvement

www.safetynetmedicalhome.org/sites/default/files/GROW-Pathway-Planning-Worksheet.doc RESOURCES What resources does CCHS have? Geography Physical space Support of leadership CCHS (hosp, rehab, ED, PC, palliative care, PCBH), Blue Mt Counseling, hospice, referral to Tri-Cities PC clinic, nursing home, ED, Hosp on same campus; distant satellite PC clinic Engaged, willing to innovate/experiment

What resource challenges need to be addressed? Limited access to other specialty care No concerns/new space requirements Continued support ($, messaging, coordinating process changes) Training & incorporation of any new approaches, staff Care team and workforce development Stable, dedicated teams Shared workflows

Inpt (limited BH workflow); PC (screening, PCBH) Depends upon mix of BH approaches Available technology/ HIT 2 EHRs, small onsite IT dept Possible telehealth, registry functions Financial resources Some support from ACO, ACH, WRHAP; prior budget for co-located psychiatrist

Financial Plan for (1) program devel. & then (2) ongoing clinical care RESOURCES (CONTINUED): PRIOR & CURRENT SERVICES Existing & Previous Behavioral Health & Addictions Treatment Co-located outpatient psychiatrist Long-term Psychiatric Care (2016-2018) Co-located outpatient MSW LCSW - Brief Interventions & Longer-term Therapy (9/2017-Present)

Dedicated inpatient and outpatient clinical staff, without specialty training A local community behavioral health service, providing primarily psychotherapy RESOURCES (CONTINUED): NEEDS Needs Identified (by patients, clinical staff, administration): Support for Addictions Treatment (Inpatient and Outpatient) PCP access to consultation regarding management of psychiatric disorders Patient interest in direct access to both therapist & psychiatrist Managing no only acute events but treating a population over

time Integrating care across clinical settings (inpatient, outpatient, residential/nursing home) OPTIONS Potential strategies & their challenges: Facilitated referrals Patients access a challenge Optimize use of existing local resources Largely optimized Develop local resources, de novo Expensive, logistically challenging

Hire new on-site providers Historically, a significant challenge (for psychiatric ARNPs, MDs, psychologists), +/- cost-effective Find an External Partner: Limited local partners No established model for integrated services across the inpatient consult and outpatient within a Critical Access Rural Hosp District OPTIONS: EXPLORING APPROACHES TO INTEGRATION Building a Community-Academic Partnership CCHS reached out to & partnered with University of Washington Collaborative Exploration: What approaches exist & which facilitate: Rapid access to assessment & short-term management of acute issues

Longitudinal care Population-based care Which are evidence-based? Which are viable in the CCHS contexts? Inpatient vs. Outpatient APPROACHES TO INTEGRATION: INPATIENT APPROACHES TO INTEGRATION: OUTPATIENT OPTIONS: EXPLORING APPROACHES TO INTEGRATION Collaborative Exploration: What mix of approaches would be feasible, efficacious, cost-effective?

and in which contexts? Inpatient psychiatric & addictions needs Telepsychiatry Clinical Peer-to-Peer (zoom, phone, email) Outpatient psychiatric & addictions needs: Continued PCBH functions Collaborative care Telepsychiatry Clinical Peer-to-Peer (phone, email)

Other: Booker Nursing Home: access to PC services plus psychotropic review WORKFLOW Identifying changes needed in order to deliver integrated behavioral health Does staff need to be hired? What types of staff? Do existing or new staff need to be trained? Training for CoCM; 1 new BHC What facilities, HIT, and other resources are required to implement the integrated workflow? TM hardware, Zoom, Patient Registry

What internal communication materials and protocols, and practice-specific guidelines and protocols for psychiatric emergencies do we need? Protocols for patient screening, enrollment, scheduling, conducting visits; clarify protocols for psych emergencies How will our physical space foster collaboration? What materials do we need to introduce the new care delivery pathway to patients and practice clinicians and staff? No concerns/needs identified Fliers for staff and patients; Staff/provider meeting with UW partners (site visits)

New schedule for BHCs (controlled by BHCs), with changes in appnt/blocks distribution How will we schedule visits? Will we schedule follow-ups interspersed with open access appointments to facilitate time for just-in-time consultations and warm handoffs? When and how will we evaluate our progress? What would be the next step if we dont reach our goal? How will we know we are not just going through the motions? New quality metrics, patient symptoms and outcome tracking through outpt registry ADMINISTRATIVE & TECHNICAL Credentialing & Privileging

With direct pt care (i.e., telemedicine), full credentialing & privileging for all CCHS sites where pts where seen. Liability Covered by UW (CCHS sites designated site of practice HIT 2 EHRs (hospital & clinic) - Consultants trained, granted remote access EHR privileges: Unrestricted read capacity Ability to generate documents within medical record No orders, prescribing New HIT Registry (Patient Tracker), Zoom, TM Laptop & Cart

FINANCES - BILLING CCHS payers/insurance UW consultants needed to be credentialed with insurers Telepsychiatry: G-codes Collaborative Care Fee for Service CoCM G-codes (not used to date) UW CCHS Administrative (Devel / Implementation Support): Clinical: Inpatient Clinician-to-Clinician & Telemedicine:

Fee for service hourly rate Collaborative Care: based on panel size and number of BHCs 1 full panel (30-80pt), 1 BHC = 3hrs of CoCM plus 1 hr of telepsychiatry per week 4 hr at standard hourly rate CCHS INPATIENT INTEGRATED CARE APPROACH INPATIENT CONSULTATION Access: M-F, 9AM-5PM Contact: 1hr/day Hospitalist-toConsultant curbside (9AM5PM) 1hr/day Direct Pt-toconsultant Telemedicine

Visit INPATIENT TELEMEDICINE Equipment: UW Consultant: desktop computer Logitech C920 camera/microphones Zoom software Dayton Gen. Hosp: Laptop computer with builtin camera & microphone Zoom software Mobile cart

INPATIENT TELEMEDICINE Process: Pt ID-ed by Hospital Team Hospitalist & Psychiatrist discuss case (phone) confirm plan for TM visit Appnt sched by Hosp staff RN & psychiatrist join secured Zoom meeting INPATIENT TELEMEDICINE Process (continued): RN:

Moves TM cart to patient room Provides intro Remains present for clinical encounter Psychiatrist: Conducts assessment, discusses dx impressions & treatment recs w/pt before visit ends Contacts Hospitalist to discuss dx & treatment recs, completes noted in EHR CCHS OUTPATIENT INTEGRATED CARE APPROACH

PHQ-9 SCREENING WORK FLOW - EXAMPLE Patient checks-in for PC or BH related appointment. Initial identification: Universal screening (PHQ9) Targeted screening Clinical presentation Front Desk Staff Hands out PHQ9 form to patients 18 and older Nurse/Medical Assistant Collects, scores, and data enters the PHQ-9 and GAD scores Score is: 0-9

Score is: 10+ Nurse/Medical Assistant Nurse/Medical Assistant If patient interested in IBH services, give PHQ-9 to BH care manager and have patient schedule appt. put PHQ-9 in BHCs inbox If patient not interested, give PHQ-9 to PCP to review MA contacts BHC for a team hand-off if pt interested If BHCM is available, give PHQ-9 to BHC, BHC to enter special populations patients into registry

If BHCM is not available, give PHQ-9 to PCP to review and have patient schedule f/u with BHC if interested. BHC is available. BHC is not available. PCP Behavioral Health Consultant (BHC) Adds patient to their schedule & completes BH visit Adds patient to registry and has patient schedule follow up appointment as needed

Reviews the form with patient Assesses for suicidality and recommends follow-up appointment with BHCM PRINCIPLE: POPULATION-BASED CARE Caseload Overview Utilizing a Registry University of Washington Free UW AIMS Registry: (https://aims.uw.edu/resource-library/patient-tracking-spreadsheet-example-data) Proactive monitoring & engagement (no one falls through the cracks)

Shows who needs attention, prompting treatment adjustment Facilitates communication among team 34 PRINCIPLE: MEASUREMENT-BASED TREATMENT TO TARGET Regular use of behavioral health measures to track response to

treatment Use of psychiatrists to help intensify treatment Stepped care makes efficient use of behavioral health resources WHY TRACK OUTCOMES Proactive treatment adjustment Avoid Patients staying on ineffective treatments for too long Treatment plan shelf life = 10-12 weeks max Full, partial, no response Know when to refer for consultation/get help 36

PATIENT-CENTERED COLLABORATIVE TEAM Telemedicine PCP / MAT Prescriber Core Program New Roles Beh. Health Consultant / Care Manager Patient Additional Clinic

Resources Other Community Resources Psych & Addictions Consultant PATIENT-CENTERED TEAM PRIMARY CARE PROVIDER Primary treatment relationship Prescribes medication (including MAT) Monitors medication management, together with care manager Supports treatment plan

Consults with Collaborative Care team Supports system change 38 PATIENT-CENTERED TEAM BEHAVIORAL HEALTH CONSULTANT Assesses & addresses urgent issues Facilitates patient engagement Performs systematic initial and follow-up assessments Evidence-based psychotherapy

Individual Other functions Behavioral health interventions focused on health behaviors Addressing substance use Coord of psychosocial services/interventions Systematically tracks treatment response Supports treatment plan with PCP Reviews patients with the psychiatric consultant weekly 39 PATIENT-CENTERED TEAM PSYCHIATRIC CONSULTANT Engage & Support PCP and Team Review cases with BHC using

registry Scheduled (ideally weekly) Prioritize patients that are not improving Consult urgently (as needed) with PCP or BHC Educational Components 40 OUTPATIENT TELEMEDICINE Two hours per week (M/ Th) Shared with inpt addictionfocused telemedicine Can be (1) Pt-to-Psych or

(2) PCP-to-Pysch Complex diagnostic or treatment OUTPATIENT TELEMEDICINE Prior to visit Pt Identification & Prioritization BHC, PCP, Pt referral BHC controls schedule Pt consented & appnt set by BHC Day of Visit: BHC & Consultant open Zoom Meeting

BHC greets, rooms, & introduces pt & consultant Consultant consents pt to use of telemedicine, conducts assessment (45min) BHC joins final 10-15min; reviews dx, treatments recs Consultant enters note in EHR INTERLUDE: INTEGRATED ADDICTIONS TREATING PEOPLE WHERE THEYRE AT BARRIERS TO ADDRESSING SUDS Resource Limitations: Time (e.g., not enough of it)

Other: treatment availability Comfort with Asking about SU: Stigma (ours &/or out pts) Itll undermine our relationship Treating SU (greatnow what do I do?) Opening Pandoras Box Assumptions: Theres no way Jennys an addict Addiction is a personal failing, not a medical problem My pts not ready/able to change; my doctor will judge/misunderstand/be

disappointed HARM REDUCTION Abstinence only approaches dont reach everyone (probably a minority) HR Goals: Reduce harm from high-risk behaviors Improve quality of life ETOH: ALCOHOL WITHDRAWAL MANAGEMENT & Withdrawal Management: Does pt need med-managed withdrawal? Currently has/likely to develop w/d syndrome If yes, which setting?

Hx of complicated w/d, hx of recent use, CIWA, comorbidity If ambulatory withdrawal rx appropriate, which rxs, follow-up? Then what? Develop and enact a recovery plan (psychosocial, MAT) OUD TREATMENT: Where To Begin? Indications & Conditions for Rx: Screen & dx opioid use disorder Pts preferences & engagement Clinical factors ID-ed in Evaluation Rxs (MAT): Buprenorphine Methadone XR-Naltrexone

Potential treatment contexts: Hospital Residential Treatment Specialty outpt addictions Primary Care / general MH Psychosocial Tx: MET, CMT, CBT, NA & Rescue Kits: Naloxone kits (Prescribe them!) PATIENT-CENTERED TEAM HOLISTIC CARE PLAN

Whole person treatment BioPsychoSocial The treatment that WORKS is the best one Review all evidence-based tx options Weigh pros & cons Create shared care plan Clear goals, roles, priorities 48 TYPICAL DURATION OF CARE MANAGEMENT 6 Months (average)

50%-70% of patients need at least one change in treatment to improve Only 30-50% patients respond fully to first treatment Each change of treatment moves an additional ~20% of patients into response or remission 49 LESSONS FROM AN EXPERIMENT IN WHOLE SYSTEM INTEGRATION OUTCOMES PRIMARY CARE CoCM:

Caseloads: 2 BHCs sharing 112 pts Early & Sustained Engagement: ~80% returning for f/u care, >90% in-clinic visits Symptom Response (Dep/Anxiety, snapshot of the active panel): 40%-50% Psychiatric Caseload Consultation: 1hr per BHC per week (7-12 pts/wk) Telepsychiatry: Access: 2 hours per week (2pts/wk) Booker Nursing Home: Monthly 1-hour team-based psychotropic review (5-6pts) PCP-to-Psychiatrist Consultation:

Earlier, several calls per week; once CoCM and TM established, now every other wk CHALLENGES & OPPORTUNITIES: OUTPATIENT Facilitating pt engagement/outreach Phone visits, home visits Psychosocial Interventions: Linking to community services Additional training in psychotherapy modalities Optimize utility of TM time Office hours with providers? Monitoring: Treatment plan implementation & adherence

SUDs screening and monitoring CHALLENGES & OPPORTUNITIES: OUTPATIENT Struggling Patients: Early ID, more aggressive monitoring, treatment escalation for pts w/more severe symptoms/conditions Clearer pathways & thresholds for referral to specialty care More innovative approaches to enhancing provider skills Further increasing capacity in CoCM? Closer work with community partners, relationships/coordination with non-CCHS specialist OUTCOMES INPATIENT Direct to Patient Telemedicine

More freq over time (1/mo 5/mo) Reasons for Consult: initially SUDs-focused, increasing general psychiatric Hospitalist-to-Psychiatrist Consultation: Frequency: variable Training/Education Annual site visits CHALLENGES & OPPORTUNITIES: INPATIENT Defining optimal use of inpatient consultation: Conditions/severity Direct pt eval vs. peer-to-peer

Monitoring inpt treatment plan implementation & adherence Ensuring smooth transitions in care; full system integration Need new approaches to supporting providers Targeted education Finer gradation of clinical support (brief calls, email) Development of resource libraries Annual Site Visits quarterly video conf WHAT QUESTIONS DOES THIS RAISE FOR YOU? What has been your experience with integration? Where might you go from here? THANK YOU!

(and our colleagues at CCHS and UW) Ryan Kimmel MD, Shane McGuire, CEO Anna Ratzliff MD, PhD Cara Towle RN MSN MA ... RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM INTEGRATION 1. Planning for Integrating Behavioral Health Develop a shared vision for integrating behavioral health & addictions care across the organization. Establish an integration planning and implementation team.

Develop an integrated care implementation plan. Goals, Resources, Options, Workflow (GROW) planning process 2. Establish Operational Systems to Support Integration Define types of patients who will receive integrated care. Define roles for clinicians and staff in integrated care team. Foster ongoing administrative support to integration. Establish clear mechanisms for regular and effective communication among team members. Design workspaces that maximize contact between behavioral health providers and medical clinicians. Ensure appointment scheduling system allows patients to see integrated care team in timely manner. Ensure a common medical record for behavioral health and medical care. Begin to develop quality measures. RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM

INTEGRATION Plan for Financial Sustainability Ensure billing tools, payment systems in place for reimbursement. Develop plan for sustained financing of integrated care. Obtain Behavioral Health Expertise and Build a Culture of Integration Identify type of behavioral health services needed. Identify skill sets and personnel needs and ensure these are met (e.g., training or new hires/contracts) in a timely manner. Train primary care and behavioral health providers to work as a team to provide integrated care. Develop and maintain a culture of collaboration and teamwork. Tailor the Care Team to Meet the Needs of Patients Identified for Integrated Care Develop an integrated care team designed to match the patients needs (composition and process.) Identify supervision and training needs and develop plan for meeting these.

RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM INTEGRATION Establish Protocols to Identify Patients Who Could Benefit from Integrated Care Develop and use a protocol (validated screening and initial diagnostic assessment) to identify patients who could benefit from integrated care. Develop Shared Care Plans for Patients in Need of Integrated Care Develop protocol for creating shared care plans with & for patients in need of integrated care. Ensure shared care plan is located in a single medical record. Ensure processes are in place to primary care and behavioral health providers both work from the shared care plan. Educate Patients and Families about Integrated Services Develop and rollout plan to educate all patients in need of integrated care (and their family members, where appropriate) integrated behavioral health

care services. RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM INTEGRATION Provide Patient-centered Integrated Care to Identified Patients Perform behavioral health assessment Provide caseload-focused psychiatric consultation Provide in-person psychiatric assessment of complex patients Patient education about symptoms & treatment options Collaboratively develop, execute, & update Behavioral Health Treatment Plan Brief Counseling, Activity Scheduling, Behavioral Activation Evidence-based Psychotherapy (e.g.,PST, CBT, IPT) Prescribe Psychotropic Medications

RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM INTEGRATION Track Patients Identified for Integrated Care and Monitor Their Outcomes Develop & utilize protocol to quickly identify patients not improving with treatment. Develop & utilize protocol to adjust the care plan for patients who are not improving. Develop & utilize protocol to identify patients who are struggling to engage or follow treatment plan. Reach out to Patients who are Non-adherent or Disengaged Track Patients Symptoms (e.g., PHQ-9) Track Medication Side Effects & Concerns Track Outcome of Referrals & Other Treatments

Develop process for educating patients who have improved to recognize risk factors for and signs/symptoms of relapse as well as strategies to address these. Develop criteria and process for program completion and mechanisms for monitoring post-discharge status. RESOURCES AN OUTLINE FOR IMPLEMENTING WHOLE SYSTEM INTEGRATION Collect and Use Data for Quality Improvement Systematically collect & track data on all patients identified to receive integrated care services. Systematically track health outcomes for all patients receiving integrated care services. Use collected data to improve workflow, processes, treatment approaches, to enhance quality of care provided to all patients in integrated care.

FINANCES: SUSTAINABILITY OF INTEGRATE CARE PROGRAM Full financial assessment complex & needs to be individualized: What mix of services offered? What mix of payers and payment arrangements? Fee for service, case rate, fully capitated? What reimbursement for which services requiring what clinical credentials? Phases of Development/Service: Startup Costs: existing vs. required resources, infrastructure, personnel, etc? Ongoing care delivery costs Differences in cost/benefit from using different combinations of professionals, partners/consultant? How is team time and effort allocated; what are the programs visit statisics?

Myriad possible indirect costs and benefits? FINANCES: BILLING FOR TELEMEDICINE Key variables of payer policies include: Telehealth modality (i.e. audio, video, store and forward, etc.) Originating site/location of patient (i.e. healthcare facility or clinic, rural, in home, etc.) Provider type (i.e. physician, nurse practitioner, clinical social worker, genetic counselor, etc.) Type of service in some cases only certain CPT codes are allowed Location of the provider (office, clinic, etc.) Individuals plan (e.g., Private, Medicare, Medicaid) FINANCES: BILLING FOR COLLABORATIVE CARE

Primary Funding Mechanisms Traditional CPT Codes Psychiatry, Psychotherapy, Health and Behavior, Screening, SBIRT All require specific credentialing, licensure, and setting (varies by service and insurance) Value based payments and pay for based payments and pay for performance contracting with health plans Accountability to metrics Bundled Payment Models Medicare and WA Medicaid CMS Payments for Psychiatric Collaborative Care (CoCM)

Differences in licensure, tx setting, & other billing requirement among payers 67

Recently Viewed Presentations

  • Biometrics Kayla Burke Overview  Basic Authentication   Biometrics  Why

    Biometrics Kayla Burke Overview Basic Authentication Biometrics Why

    Computer science courses in biometrics are starting to be taught in schools around the United States. There are many ways that computer science can be applied to biometrics. The algorithms that are used to find matches and to get relevant...
  • Diapositive 1

    Diapositive 1

    Les quatre saluts : 1 - Naissance de l'homme à la vérité 2 - Découverte de la splendeur et de la perfection de la création 3 - Ravissement se transformant en amour pour le Dieu unique qui l'emporte sur la...
  • ISO/TS 19218 WHO Informal Consultation on Nomenclatures for

    ISO/TS 19218 WHO Informal Consultation on Nomenclatures for

    472,000 (158,000 e-sub) Australia TGA 2005 174 3,000 Health Canada TPD Drugs, 2005. Devices 2002 730 6500 Note: Over 60% of FDA's 2005 device submissions utilized alternative summary reporting (ASR) Device Code Hierarchy. Device Issue .
  • Chapter 42 Ecosystems

    Chapter 42 Ecosystems

    Land Food Web in Colorado. Figure 42.4 Computer model for a land food web in East River Valley, Colorado. Balls signify species. Their colors identify trophic levels, with producers (coded red) at the bottom and top predators (yellow) at top.
  • Pale Blue Dot is a photograph of planet

    Pale Blue Dot is a photograph of planet

    Presently, the earliest known archaeological evidence of any form of writing or counting are scratch marks on a bone from 150,000 years ago. But the first really solid evidence of counting, In the form of the number one, is from...
  • The Periodic Table and Periodic Law

    The Periodic Table and Periodic Law

    6.2 Assigning oxidation numbers for individual atoms of monatomic and polyatomic ions. Formation of an Ionic Bond. Define "ionic bond". Answer: the electrostatic force that holds . oppositely charged particles . ... ion can only take 1 of calcium's electrons,...
  • Use of OMS in among - fac.ksu.edu.sa

    Use of OMS in among - fac.ksu.edu.sa

    Performance based OMs are frequently used in physical therapy. These measures test the clients' actual performance at given point in time, whether it is walking 30meters on in indoor uncarpeted surface or a more complex task of standing up, walking...
  • Decade : 1980-1989

    Decade : 1980-1989

    1982 - Pioneers in Quantum Computing. Richard Feynmancreates the field of quantum computing in 1982. While conventional computers use electronic circuits to store information (in a form known as 'bits'), a quantum computer relies on 'qubits', which use subatomic particles...