shift project – salford’s health investment for tomorrow
DESCRIPTION
SHIFT Project – Salford’s Health Investment For Tomorrow Whole system pathways and commissioning as a dynamic approach Janet Roberts, Sylvain Laxade, Janelle Homes, Richard Freeman. What we are going to cover. Making it Real What have we done? Were there problems? What are we doing now? - PowerPoint PPT PresentationTRANSCRIPT
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
SHIFT Project –
Salford’s Health
Investment For
TomorrowWhole system pathways and
commissioning as a dynamic
approachJanet Roberts, Sylvain Laxade, Janelle Homes, Richard Freeman
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
What we are going to coverWhat we are going to cover
• Making it Real
• What have we done?
• Were there problems?
• What are we doing now?
• How will we make change stick?
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Where have we come from Where have we come from and what have we done?and what have we done?
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
History of the ProjectHistory of the Project
• Strategic Outline Case
• Initial hospital focus
• Victorian ward blocks
• Salford’s health status
• Other organisations
• LIFT
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Features of the new systemsFeatures of the new systems
• Integration of health and social care
• Planned or elective care
• Unplanned or emergency care
• New intermediate level services
• New ways of managing out patients and
chronic diseases
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
How services will change…..How services will change…..
Acute
Intermediate
Primary / community
Old = organisational focus New = Pathway focus
10 20
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Service Design GroupsService Design Groups
Emergency
Elective Chronic Disease
Management
Diagnostic & Therapies
Intermediate Care
ElderlyPrimary
Care
Childrens Interface
Group
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
User / public involvementUser / public involvement
• Early principle of project
• Public consultation
• Patient focus
• Get it right!
• Requirement for planning services
• Methodologies
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Care Pathways & Service RedesignCare Pathways & Service Redesign
• Integrated Care Pathways are one way of implementing protocols. They express locally agreed, multidisciplinary practice, based on guidelines and evidence, where available, for a specific patient group.They form all or part of the clinical record, document the care given and facilitate evaluation of outcomes for quality improvement purposes (Modernisation Agency, 2002)
• The first stage of an Integrated Care Pathway development relates to the provision or mapping of the patient’s journey, what is to happen , where, when and by whom.This is often referred to as the ‘High Level Care Pathways’ (Modernisation Agency 2002)
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Accessing the detailAccessing the detail
• Identified a range of
diseases / patient
presentations &
services
• Clinical leads
• Events - Energise
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Getting StartedGetting Started
• Clear methodology for the redesign processClear methodology for the redesign process• Identification of the key stakeholdersIdentification of the key stakeholders• Selection of case types based on pre set criteriaSelection of case types based on pre set criteria• Development of a project planDevelopment of a project plan• Inclusion and exclusion criteriaInclusion and exclusion criteria• Strategies for managing the redesign processStrategies for managing the redesign process• Reporting mechanismsReporting mechanisms
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
A Sample Project PlanA Sample Project Plan
• Part 1: Part 1: Process Map of current patient’s journey and SWOT analysis against NHS PAF
• Part 2:Part 2: Process Map of future journey, Key proposals and the resource implications
• Part 3: Part 3: Potential Opportunities and Health Impact- access, outcomes, efficiency, effectiveness, patient’s experience. Key protocols and guidelines supporting the new journey
• Part 4: Part 4: Health and Social interventions and goals along the patient’s journey and manpower/skill mix identification
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Outline Template for Pathways TIME
Primary
Prevention Early
Detection Assessment Primary Care
Management Intermediate
Treatment Secondary
Care Management
Tertiary Intermediate Recovery
Continuing Care/ Follow
up
WHO
WHAT
WHERE
HEALTH WHEN
WHO
WHAT
WHERE
SOCIAL WHEN
WHO
WHAT
WHERE
O T H E R
AGE NC Y
WHEN
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Primary Care Model A&E
Model
Emergency Model
Theatre Model
Specialty Model
Intermediate Care Model
Chronic Disease Model
OBC Model
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Dependence Continuum
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Dependence Continuum
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Procurement• Commissioning, LDPs
• Modernisation Development Agenda
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Dependence Continuum
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Technology Development• PACS – Remote Health Management – ICRS – telemedicine & telemonitoring- Diagnostics & Lab
Procurement• Commissioning, LDPs
• Modernisation & Development Agenda
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Dependence Continuum
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Human Resource Management
• Recruiting, rewarding, retaining
• New roles, new ways of working, whole system working
Technology Development• Integrated patient record, PACS – Remote Health
• Management – ICRS – telemedicine & telemonitoring
Procurement• Commissioning, LDPs
• Modernisation Development Agenda
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Dependence Continuum
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Health Care Infrastructure
Human Resource Management
• Recruiting, rewarding, retaining
• New roles, new ways of working, whole system working
Technology Development• Integrated patient record, PACS – Remote Health
• Management – ICRS – telemedicine & telemonitoring
• SHIFT / LIFT / Health & Social Care Partnership
Procurement• Commissioning, LDPs
• Modernisation Development Agenda
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
Social Services City Council Life Events Life Event & Life Cycle
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Care Continuu
m
OBC Model
Social Model
Support Activities
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value
system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Health Care Infrastructure
Human Resource Management
• Recruiting, rewarding, retaining
• New roles, new ways of working, whole system working
Technology Development• Integrated patient record, PACS – Remote Health
• Management – ICRS – telemedicine & telemonitoring
• SHIFT / LIFT / Health & Social Care Partnership
Procurement• Commissioning, LDPs
• Modernisation Development Agenda
Management Systems• Systems of planning, finance, quality control, etc.
• Scheduling, access, outcomes, user experience, efficiency, effectiveness
INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCESEMI - DEPENDENCE
Primary prevention
- Osteoporosis
- Falls managementEarly recognition
- call for help
- initial management
Primary Care Model A&E
Model
Emergency Model
Emergency model management
72hr stay
Operation time according to condition
Recovery
Theatre Model
Specialty Model
Specialty bed
Length of stay < 6 days
Intermediate Care Model
Intermediate Care
e.g. virtual, transitional, therapy beds
Chronic Disease Model
Secondary prevention & chronic disease management
A&E management
RCP guidelines
Fast track
Quality &
Cost
-
effective care
Acce
ss Effi
ciency
Patie
nt / U
ser
Experie
nce
Outco
mes E
ffectiv
eness
Equity
Care Continuu
m
OBC Model
Dependence Continuum
Support Activities
Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive
advantage, creating and sustaining superior performance – the value system
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
START Patient consults General Practitioner
GP assesses needs
Hernia diagnosed / suspected
GP sends referral letter to hospital
Consultant triages patient and informs appointments
Hospital sends appointment to patient
Initial outpatient consultation. Consent given. Patient put on
waiting list
Hospital pre-operative assessment
… six, nine, twelve months later
Patient attends Day Case Unit - Operation - Home on
day of surgery unless clinically contra indicated
Review in outpatient 4-6 weeks later, discharge to
GP. Audit completedEND
YES
Refer to appropriate agency
NO
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
START
• Patient consults GP with hernia
• GP assesses condition and suitability for day case hernia according to anaesthetic and surgical protocol
• Investigations and test if necessary
• GP books patient into Day Case Unit operating list via direct booking on line according to the patients preference
• GP emails referral letter and Day Case suitability pro forma to hospital- Consent in principle
• Patient attends Day Case Unit Seen by Surgeon and Anaesthetist
• Written consent
• Operation if appropriate and fit- Same day discharge
• Review appointment with GP / a Nurse in Primary Care
• On line audit form completed and emailed to hospital
END
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Goal achieved
GP level. Patient presents
with hip pain
GP assessmen
t using joint
protocol
Serious pathology suspected
Refer to orthopaedic consultant
immediately
END
Refer to appropriate
agency
END
Hip problem suspected
NOYES
YES
Refer to PCT Central Booking System for
physio triage. Commence pain
management
Triage in primary /
secondary care
Patient <50 years Vascular necrosis
suspected,significant hip pain
Refer to orthopaedic
surgeonIdentify cause Treat
accordingly
Patient appropriate for
surgery
P1
Refer to orthopaedic consultant
Outpatient appointment
within 4 weeks
Listed for surgery via
booking system
Outpatient appointment via central booking
system
PC Stage 1 Pre-operative assessment
within 2/52 of listing
New Zealand score. Priority assessment/
Health Management Hip assessment. Wish
for surgery
YES
MDT assessmen
t Goal setting
Identify address All home
alterations/ modifications
Surgical consent
Back to primary care for goal management
Admit on day of surgery, subject to anaesthetic
criteria. Surgery 3/12
NO
Hospitalisation. Length of stay 3/5
days unless clinically indicated
Hospitalisation goals achieved
Discharge home6 weeks review ? P Care
12 weeks reviewYES
NO
YES2nd pre-op
assessment + Anaesthetic assessment
Treat as P3
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Intermediate Care needed
YESIdentify
package of care
setting, etc.
Options
Transitional home/
Intermediate Care/ Hospital Intermediate
Care
Goals met
1 year review Indefinite review via THR system
DischargeGo to review system Chronic
D Mang
END
Outcome of New Zealand Hip Score
Patient improving
Review management
Treat as P3
Priority classification. Care for all
Refer to community
physio and OT via booking
system
Pain management according to
pain guidelines
Review New Zealand hip
score in primary care 3/12
P3
Manage according to P2
Refer to Orthopaedic Surgeon
Continue P3 programme
Outpatient physio GP
managementReview 3 to 6 months
Pain management
if required
New Zealand Score P3
P2
NO
P3
P1
P2
Remain at P2 Continue programme
Review in 3/12
Refer to Orthopaedic
Surgeon
P1Surgical
management
DISCHARGE Review system
END
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Future underpinning of Elective CareFuture underpinning of Elective Care
Application of the 72 hour principleAn amalgam of service models as identified in OBCFocus on length of Stay underpinned by outcomes and coordinationUse of a range Intermediate Care facilitiesDependence on IM&TSupported by new roles and functionsHigh S Care acuity and turnover leading to quicker access Redefinition of purpose of Secondary and Primary CareClinical Governance across whole systemPost-op review in Primary Care Linked to Social Services and City Council Life Event Model
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Planned Care…………….Planned Care…………….
Key Change Principles emerging from the Redesign
Primary Prevention and Early Detection StrategyManagement in Primary Care via Joint Protocol Development and Clinical NetworkInformal access to Surgeons and Physicians if requiredReferral according to pre set criteria via Central Booking SystemNot all Patents need to go to OutpatientInvestigations and Diagnostics in Primary Care prior to referralSurgery in an appropriate location based on Risk criteriaPre-op location based on Anaesthetic RiskAdmission on day of Surgery
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Integrating the Redesign into the Integrating the Redesign into the Commissioning ProcessCommissioning Process
The Logical StepsThe Logical StepsProcess map of current serviceProcess map of current serviceSWOT Analysis/NHS PAFSWOT Analysis/NHS PAFFuture DesignFuture DesignResource Implications and Economic ModelResource Implications and Economic ModelClinical Governance - Guidelines/ProtocolsClinical Governance - Guidelines/ProtocolsMedicine Management CommitteeMedicine Management CommitteeProfessional Executive CommitteeProfessional Executive CommitteeIntegration into LDPs/Financial FlowsIntegration into LDPs/Financial FlowsDirectorate’s agendaDirectorate’s agendaMonitoring by ExceptionMonitoring by Exception
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Resource ImplicationsResource Implications
• PeoplePeople• TimeTime• User InvolvementUser Involvement• SupportSupport• PlanningPlanning• Specific Needs client / patient groupsSpecific Needs client / patient groups
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
BarriersBarriers
• Time » Right people – right time» Short term delivery targets v long term improvements
• Culture» Bureaucracy & Institutional loyalties» Adversarial approach between primary & secondary care» Silo thinking & working» Risk aversion» Professional & inter professional tension & rivalry» Limited ownership locally of overall strategy
• People» Resistance to change – suspicion, fatigue, cynicism, apathy» Self preservation, empire building» Fear – involving patients & carers
• Information» Lack of good quality / whole system information & data» Lack of shared information
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Overcoming barriersOvercoming barriers
• Skills– Energiser– Barometer– Programme Manager– Facilitator– Translator– Communicator
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Strengths of the processStrengths of the process
• Relationship changes• Energy & Enthusiasm• Mutual understanding and agreements• Communication & networking
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
What are we doing now? What are we doing now? How will How will we make the change stick?we make the change stick?
• Created SHIFT vision, service principles and sample
care pathways
• Directorate / service level planning
• Core organisational focus
• Early wins
• Tier 2 / Collaboratives / NSFs / etc.
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
The challenge for The challenge for commissioningcommissioning
How can commissioning makeservice redesign work?
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
How can commissioning help?How can commissioning help?
• Costs & activity• Financial flows• Local Delivery Plans• Ongoing quality & activity monitoring
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Pathways & commissioningPathways & commissioning
• Translate pathways into separate elements with:– Costs– Locations– Expected activity– Quality measures– Quantified impact on existing services
• This will be the basis for commissioning redesigned services
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Financial flowsFinancial flows
• Payments linked to activity• National tariff price for each HRG• Full cost implications of activity changes• Regime is still developing• Issue of currency & tariff for:
– Mental health services– Community services
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Using financial flowsUsing financial flows
Financial flows means• Moving activity at full cost• Patient choice is reflected in payments
But…• Need to develop mechanisms for pathways to
cross between primary & secondary care
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Local Delivery PlanningLocal Delivery Planning
• Sets out actions to meet key deliverables• Prioritisation process for schemes
So…• Actions arising from service design must be
reflected in the LDP• Service design resource requirement must be
subject to appropriate scrutiny and prioritisation
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow
Ongoing monitoringOngoing monitoring
• Develop mechanisms and indicators to monitor:– Quality of service provided– Activity delivered– Access to services
• The above will be required for each part of the pathway
Project
alford’s HHealth IInvestment FFor TTomorrow
Project
alford’s HHealth IInvestment FFor TTomorrow