MS. SHEILA CULLEN
DIRECTOR, VA SIERRA PACIFIC NETWORK (VISN 21)
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE
JANUARY 7, 2010
Mr. Chairman and Members of the Committee, mahalo for the opportunity to appear before you today to discuss the state of VA health care in Maui. It is a privilege to be here in Maui to speak and answer any questions you may have pertaining to the services we provide Veterans in Maui County. I am accompanied today by Dr. James Hastings, Director of the VA Pacific Islands Health Care System (VAPIHCS), and Dr. Adam Darkins, Chief Consultant, Care Coordination, Office of Patient Care Services, Veterans Health Administration.
First, Mr. Chairman, I would like to thank you for your leadership and advocacy on behalf of our Nation’s Veterans. During your tenure as Ranking Member and Chairman of this Committee, you have consistently demonstrated your commitment to Veterans by introducing legislation designed to meet the needs of Veterans. As I will highlight later, your vision and support have led to an unprecedented level of health care services for Veterans, construction of state-of-the-art facilities here in Honolulu, and remarkable improvements in access to health care services for Veterans residing on the Hawaiian neighbor islands, American Samoa and Guam. In addition, I appreciate your interest in and support of the Department of Veterans Affairs (VA).
Today, I will briefly review the VA Sierra Pacific Network that includes Hawaii and the Pacific islands region; provide an overview of the VA Pacific Islands Health Care System (VAPIHCS); provide national and local information regarding telehealth programs; discuss the VA clinic in Maui; and highlight issues of particular interest to Veterans residing in Maui County, including capacity at the VA clinic in Maui and VA services on the nearby islands of Molokai and Lanai.
VA Sierra Pacific Network (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21) is one of 21 integrated health care networks in the Veterans Health Administration (VHA). The VA Sierra Pacific Network provides services to Veterans residing in Hawaii and the Pacific region (including the Philippines, Guam, American Samoa and Commonwealth of the Northern Marianas Islands), northern Nevada, and central/northern California. There were an estimated 1.1 million Veterans living within the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY) 2009.
The VA Sierra Pacific Network includes six major health care systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; Sacramento, CA; Fresno, CA; and Reno, NV, as well as an Independent Outpatient Clinic in Manila, PI. In FY 2009 the Network provided services to over 250,000 unique Veterans out of 350,000 enrolled Veterans. There were about 2.7 million clinic visits and 28,079 inpatient discharges. The cumulative full-time employment equivalents (FTEE) level was 9,740, and the operating budget was about $2.2 billion.
The VA Sierra Pacific Network is committed to ensuring the care Veterans receive is of the highest quality. All six health care systems within the Network have major academic affiliations. The Network hosts a significant number of Centers of Excellence in VHA and supports a large and broad research portfolio. It also has expansive and collaborative relationships with the Department of Defense (DoD). The VA Sierra Pacific Network has not only exceeded patient satisfaction goals (inpatient and outpatient), but its employee satisfaction scores are among the top five Networks for overall job satisfaction in VHA. As reflected in the most recent employee satisfaction survey, the Network had the highest scores in VHA in several categories including leadership, supervisory support, customer service, conflict resolution, praise, and rewards.
Given the large and diverse geographic nature (i.e. rural or frontier lands and remote islands) of VISN 21, access to care is a priority. In FY 2010, the Network will activate nine new sites of care including the Pacific (Hawaii and the Northern Mariana Islands), California, and Nevada. Finally, VISN 21 is proud to operate one of four Polytrauma Rehabilitation Centers in VHA dedicated to addressing the clinical needs of the most severely injured Veterans.
VA Pacific Islands Health Care System (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in VISN 21. Dr. James Hastings is the director and a practicing cardiologist at VAPIHCS. VAPIHCS is unique in several important aspects: its vast catchment area covers 2.6 million square-miles (including Hawaii, Guam, American Samoa and Commonwealth of the Northern Marianas); its remote island locations create access challenges; and it enjoys the cultural richness of the Pacific Islands with an ethnically diverse patient and staff population. In FY 2009 there were an estimated 118,000 Veterans living in Hawaii, and at least 10,000 additional Veterans located beyond Hawaii in the VAPIHCS catchment area.
VAPIHCS currently provides care in ten locations, with two more soon to be added. Our current facilities include an Ambulatory Care Center (ACC) and a Community Living Center (CLC) on the campus of the Tripler Army Medical Center (TAMC) in Honolulu; community-based outpatient clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii), Hagatna (Guam) and Pago Pago (American Samoa); and outreach clinics in Molokai and Lanai. Two new facilities planned include a new CBOC to serve Leeward Oahu Veterans (approved in FY 2008 with an expected opening in late FY 2010) and a new rural outreach clinic in Saipan set to open this winter. A mental health provider (psychologist) has begun seeing patients part-time in Saipan but the clinic has not yet been activated. The inpatient post-traumatic stress disorder (PTSD) residential rehabilitation unit is in its interim location on the campus of TAMC, pending construction and activation of a new VA-funded facility ($9.56 million), also at TAMC, during FY 2011.
VAPIHCS is also constructing a new replacement CBOC in Guam that will offer expanded capacity. It will be located along the perimeter of the Guam Naval Hospital, and we expect it to open in May 2010. VHA operates a total of six Vet Centers in Honolulu, Lihue, Wailuku, Kailua-Kona, Hilo and Guam. These facilities provide counseling, psychosocial support, and outreach. A Vet Center staff member was also added in American Samoa during FY 2008.
In FY 2009 VAPIHCS provided services to more than 24,000 Veterans, an increase of five percent from FY 2007. Of these Veterans, 19,000 reside in Hawaii. VAPIHCS provided 175,000 outpatient visits during FY 2009. The cumulative VAPIHCS FTEE in FY 2009 was 619 employees, with an operating budget increase from $139.1 million in FY 2008 to $155.1 million in FY 2009, an increase of 12 percent.
VAPIHCS provides or contracts for a comprehensive array of health care services. VAPIHCS directly provides primary care, including preventive services and health screenings, and mental health services at all locations. VAPIHCS does not operate its own acute medical-surgical hospital and as a result faces some challenges in providing specialty services. VAPIHCS has hired specialists in orthopedics, cardiology, endocrinology, ophthalmology, nephrology, infectious disease and inpatient medicine (“hospitalist”), and makes use of University of Hawaii faculty to provide specialty care services in pulmonary disease, rheumatology, allergy, and hematology in Honolulu and to a lesser extent at CBOCs. Veterans with spinal cord injuries receive care from VAPIHCS dedicated staff, which provides a multidisciplinary approach to care. The team, located on Oahu, is planning to travel and care for patients on the neighbor islands during FY 2010. Veterans requiring other specialty care continue to be referred to DoD and community facilities.
Inpatient long-term and acute rehabilitation care is available at the Community Living Center (CLC). Inpatient mental health services are provided by VA staff on a 20 bed ward within TAMC and at the 16 bed Post-traumatic Stress Disorder (PTSD) Residential Rehabilitation Program (PRRP). VAPIHCS contracts for care with DoD (at TAMC and Guam Naval Hospital) and community facilities for inpatient medical-surgical care.
National and Local Telehealth Programs
National Telehealth Programs
Telehealth involves the use of information and telecommunication technologies as a tool in providing health care services when the patient and practitioner are separated by geographical distance. The benefits of telehealth to health care systems include: improving access to care, making specialist services available in rural and remote locations, and supporting patients to live independently in their own homes and local communities. Because of the support of telehealth by VA and Congressional leadership, more Veterans are able to realize these benefits.
Over the past six years telehealth in VA has transitioned from use in a range of discrete local projects and programs toward a unified, enterprise level approach that provides routine telehealth services that are mission critical to the delivery of care to Veterans. In 2009 over 260,000 Veteran patients received care via VA’s telehealth programs. Telehealth takes many forms. VA’s enterprise telehealth programs deliver care to Veteran patients in their homes via home telehealth; telehealth care is also provided in VA medical centers (VAMCs), CBOCs and Vet Centers via clinical videoconferencing. In addition, VA routinely exchanges clinical images via “store and forward” telehealth.
I would like to briefly highlight some of the direct benefits these services are providing to Veterans. More than 40,000 Veterans are receiving home-telehealth-based care that supports care delivery to them in their own homes. These care coordination/home telehealth (CCHT) services have reduced hospital admissions by 25 percent, hospital stays by 25 percent, and have high levels of patient satisfaction (86 percent mean score). In 2009 more than 58,000 Veterans received care via clinical videoconferencing, the majority receiving mental health care services that reduced hospital admissions by 24 percent. In 2009 almost 150,000 Veterans were screened to prevent avoidable blindness by VA’s teleretinal imaging programs (CCSF).
The successful implementation of robust and sustainable telehealth services that VA entrusts to provide care to Veteran patients must satisfy stringent clinical, technological and business requirements that ensure they are appropriate, effective and cost-effective. These requirements include acceptance by patients and practitioners as well as staff training and quality management systems. Mr. Chairman, you and the Committee understand how the geography of Hawaii and the Pacific region poses particular challenges in implementing telehealth that are not encountered on the U.S. mainland. Services to Guam and American Samoa not only need to bridge a physical distance of 3,820 and 2,300 miles respectively, they also need to bridge between patients and clinical communities that are distant and distinct from one another. Bridging these distances and linking these communities to enable them to integrate requires telecommunications bandwidth. VA is currently seeking to embrace Hawaii and the Pacific region within its clinical enterprise video conferencing network (CEVN) and in doing simplify the linkage to specialist services from medical center assets on the U.S. mainland.
VA recognizes the pioneering role that Hawaii and the Pacific region have played in the development of telehealth solutions that range from teleretinal imaging to home telehealth. These innovations have included partnerships with DoD and the University of Hawaii within the collaborative framework of the Pacific Telehealth and Technology Hui. VA appreciates the support of Congress in supporting rural health initiatives that enable us to focus on extending current enterprise telehealth solutions as well as developing new telehealth solutions to serve Veterans, not only those in Hawaii and the Pacific region Islands, but also Veterans elsewhere in the nation for whom geographical distance from VA’s physical health care assets presents a challenge to receiving care. In considering future innovation for local and enterprise portfolios of telehealth services, VA is looking toward new iterations of a familiar technology—the telephone. Currently the telephone has meant that eight patients a month from Hawaii and the Pacific region have been able to access VA’s suicide hotline and receive support from Canandaigua, New York. The transition of health applications onto mobile technologies such as cell phones promises to further revolutionize how telehealth can serve Veterans in areas such as Hawaii and the Pacific region.
Mr. Chairman, I used the word Hui earlier. As you know, Hui describes a partnership, a union or a gathering. All health care is ultimately local, and my discussion so far has focused on the clinical, technological and business issues of implementing telehealth across the VA health care system. My attention will now turn to local telehealth initiatives that support Hawaiian Veterans and those living on other Pacific Islands.
Local Telehealth Programs
In partnership with DoD, specifically TAMC, VAPIHCS began to develop this capability in 2001 with the support of Senator Daniel K. Inouye. The Hui allows joint development of telemedicine technologies for both organizations in the Pacific. This partnership has fielded many demonstration projects that have enabled both Departments to develop ongoing telehealth activity for our beneficiaries.
For VAPIHCS, this partnership allowed us to begin developing telemedicine capabilities in collaboration with the local information technology (IT) department that developed the telecommunications network infrastructure and supported the deployment of video teleconferencing to VA CBOCs on the islands of Hawaii, Maui, Kauai, Guam, and American Samoa. Connectivity to Molokai and Lanai is also available, and we are presently studying connectivity for our newly approved Outreach Clinic in Saipan. Additionally, this initial investment allowed the development of procedures, practices, and protocols to support video teleconference clinical visits for primary care, mental health, and subspecialty care. Funds were provided for purchasing telemedicine "carts" that allow the use of peripheral medical equipment (stethoscopes, otoscopes, cameras and other attachments), as well as teleretinal imaging equipment to permit screening for diabetic eye disease. Automated Drug Dispensing System (ADDS) machines were installed in CBOCs in 2003 allowing pharmacists in Honolulu to dispense medications and, through the use of video conferencing, to provide medication counseling to Veterans at the time of their clinic visits. The VAPIHCS also began tele-home care projects in 2003 by deploying home telemedicine units. This partnership and initial funding has helped us establish a foundation of experience upon which we continue to build to enhance the medical care provided in our facilities throughout the Pacific Region. Additionally, this early experience has allowed our facilities to compete for research dollars to further develop telemedicine and tele-mental health activities.
The Hui also provided support for TAMC projects, including support for “store and forward” telemedicine for adult and pediatric care to the Western Pacific, cardiac sonography from TAMC to Guam and Japan, intensive care unit telemetry and consultation from TAMC to Guam Naval Hospital and Korea, speech therapy and other projects.
Beyond the Hui, VAPIHCS and TAMC are working together to develop joint telemedicine capabilities in American Samoa to support co-location of TAMC personnel at a VA CBOC. This arrangement would extend clinical expertise from TAMC to American Samoa to serve Veterans and active duty service members, as well as members of the National Guard and Reserve who have experienced a traumatic brain injury (TBI).
Recently, VA expanded mental health programs, including significant growth in tele-mental health activities. VA recruited a clinical psychologist to fill a new position for a dedicated tele-mental health coordinator based in Maui. This new position expanded tele-psychology services equitably throughout the CBOC. Additionally, VA has begun conducting tele-mental health Compensation and Pension (C&P) examinations to expedite the assessment of Veterans for appropriate benefits.
During fiscal year (FY) 2009, telehealth has been extremely helpful in delivering mental health services and dispensing medications to Veterans. A snapshot of relevant data, current through September 2009, includes:
• Over 2,500 telehealth patient encounters in VAPIHCS, 1,500 of which were for mental health and 52 of which were for mental health C&P evaluations for patients in Guam or the Commonwealth of the Northern Mariana Islands; and
• Over 12,500 prescriptions filled at CBOCs on Kauai, Maui, Hilo, Kona, American Samoa and Guam using Automatic Drug Dispensing System (ADDS) machines.
VAPIHCS has other Telehealth services that are available to Veterans, including:
• Clinical Video Telehealth clinics (CVT), which offer
o Individual and group psychology and psychiatry support;
o PTSD group research clinic;
o Individual and family nutrition information;
o Mental health C&P examinations;
o Geriatric psychiatry;
o General surgery and neurosurgery through the San Francisco VAMC;
o Treatment for spinal cord injury through the Palo Alto VAMC;
o Wound care;
o Nephrology care; and
o Participation in VA’s ‘MOVE!’ (weight loss) program;
• Care Coordinated Store Forward clinics (CCSF):
o Teledermatology through the San Francisco VAMC;
o Teleretinal Imaging; and
o Care Coordination Home Telehealth, utilizing home telehealth devices to support the care of Veteran patients in their own homes on Oahu, Maui and Hilo.
Our expanding and diverse experience with telehealth has provided many “lessons learned” to further shape the development of our VAPIHCS Telehealth Program. For example, numbers (i.e. encounters) alone do not tell the complete story of how technologies may be used to improve the health care of Veterans. In addition to increasing access to specialty services for Veterans, VAPIHCS has found telehealth technologies also allow CBOC providers to learn from telemedicine experiences (with distant providers), which can improve the skills of local physicians. VAPIHCS continually evaluates the use of telehealth services that are provided to Veterans within our service area and changes the program as necessary to meet the needs of the Veterans we serve. There is a new opportunity to expand the use of telehealth as we develop new outreach clinics to meet the needs of Veterans in highly rural areas.
This increased "hands-on" care allows us to pursue new telehealth opportunities in even more remote locations to benefit Veterans. We are providing more care in the home, using VA's Care Coordination Home Telehealth (CCHT) protocols. This will provide us with patient data and information from the home that can be used to maximize our ability to manage medically complex patients in conjunction with our chronic disease team to improve the quality of life for Veterans.
There are some local challenges with telehealth. We are adding additional staff, including telehealth nurses, to our sites so our clinics can both provide direct patient care and staff telehealth clinics as well. We anticipate that by this fall, we will have sufficient support for telehealth activities at each CBOC in the area.
This table provides data about telehealth usage in the following facilities:
Number of Unique Patients by Site (VA Pacific Islands Health Care System)
Facility FY 2008 FY 2009
Honolulu 74 159
Maui 153 287
Molokai 6 17
Kauai 96 124
Hilo 66 62
Guam 58 143
Kona 17 43
American Samoa 14 8
TOTAL 425 669
The total numbers of VA’s patients using telehealth increased in FY 2009 over FY 2008. Some of this change is attributed to additional telehealth nurse positions added in FY 2009, and a telehealth Psychologist who serves veterans throughout the VA Pacific Islands locations. We anticipate further growth in telehealth in FY 2010 as additional VA specialty care visits, such as Nephrology, make greater use of the capability.
VA operates a CBOC located in Kahului (203 Ho’ohana, Suite 303, Kahului, HI, 96732) and expanded the clinic’s space by an additional 4,400 square feet during FY 2008 to a total of 9,700 square feet. The building that currently houses the Clinic cannot be certified as having met federal seismic structural requirements. If the current building cannot be modified to meet these requirements, as required by the renewal lease process, we will need to identify a new location. VISN 21 and VAPIHCS have requested VA Central Office approval to seek an alternate location as a contingency should the modifications not be feasible.
In addition to the CBOC, VA operates on Maui a Vet Center, which is located in nearby Wailuku.
In FY 2009, the Maui CBOC served an estimated island Veteran population of 9,900 Veterans. Approximately 2,400 Veterans residing on Maui were enrolled for care, and 1,749 Veterans received VA care. This is a 21 percent increase over FY 2007. The market penetration rates for enrollees and users within the Veteran population are 24 percent and 17 percent, respectively. These rates are lower than rates elsewhere in Hawaii. In FY 2009 the Maui CBOC recorded 9,976 clinic visits, which represent an increasing trend largely attributed to increased capacity and enhanced services.
At the time of the hearing here in August 2007, the Maui CBOC was authorized to have 15 FTEE; the Maui CBOC has recently increased its staffing and currently is authorized to have 25 staff at the clinic. This includes two full time primary care physicians, a physician assistant and a social worker to support primary care services, two psychiatrists, two psychologists (one of whom provides tele-mental health services to other CBOCs), one social worker, one clinical nurse specialist, one substance abuse counselor, and one telehealth technician and one administrative officer are also available to address Veterans’ mental health needs. This staff provides a broad range of primary care and mental health services. In FY 2008 the clinic also implemented a Home-Based Primary Care (HBPC) program supported by a nurse practitioner. During FY 2010, HBPC will be initiated this month on Molokai, and we expect to activate Lanai’s HBPC program later this year.
The size of the Veteran population and the number of VA patients in Maui limit the feasibility of having a large number of medical and surgical specialists based in the Maui CBOC. Nonetheless, VA recognizes that some Veterans in Maui County have needs beyond primary care and mental health. VAPIHCS provides specialty care services at the clinic by sending VA staff from Honolulu and other VA facilities in California to the CBOC. Services provided by clinicians traveling to Maui include cardiology, gastroenterology, geriatrics, nephrology, neurology, orthopedics and rheumatology. If Veterans require services not available at the Ambulatory Care Center (ACC) or CLC, VAPIHCS arranges and pays for care at TAMC, local community providers, or VA facilities in California; for those referred to a facility in California, VA can cover the costs of transportation if the veteran is eligible for beneficiary travel. In FY 2009, VA spent over $4 million for non-VA care in the private sector (i.e. not including costs at other VA or DoD facilities) for residents of Maui. Treatment of many non service-connected Veterans requiring off island referrals continues to be a challenge, because VA Beneficiary Travel support is unavailable for these patients. The Maui CBOC also utilizes telehealth technologies to provide specialty services, as described above.
Capacity at Maui CBOC. As noted earlier, in FY 2009 VA provided health care services to 1,749 Veterans who reside in Maui. However, market penetration rates for enrollees and users suggest there is additional demand for VA health care. VAPIHCS has significantly increased the authorized staffing at the Maui CBOC to keep pace with the growth in numbers of Veterans seeking care, in particular Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. This population increased from 56 in FY 07 to a cumulative total of 270 unique Veterans at the close of FY 09. The Clinic’s two full time VA primary care physicians and one full time physician assistant, based upon VA primary care panel size criteria, gives the clinic a potential capacity for over 3,000 primary care patients (i.e. 1,200 patients for each full-time physician and 800 for each physician assistant). Even considering the special circumstances at the Maui CBOC (e.g., lack of VA inpatient facility and limited community health care resources on the island), the VA clinic will be able to provide high quality and accessible primary care to more than 2,000 patients.
In addition, during FY 2008, the Maui CBOC began delivering HBPC services for Veterans residing in Maui. HBPC is also delivered by VA in Oahu, Kauai and the Big Island. HBPC is an important component of VA’s non-institutional long-term care program designed to provide care in the least restrictive setting for Veterans. Earlier this year, VAPIHCS was approved for $256,000 in rural health funding to expand the Maui HBPC program and to begin providing homecare services on the islands of Lanai and Molokai. VA will add staff to serve these islands, with service delivery anticipated this month on Molokai and later this year in Lanai.
There is also a significant demand for mental health services at the Maui CBOC. About 32 percent of all patients currently seen at the clinic have a documented mental health illness (compared to 19 percent for VHA). This includes a high prevalence of PTSD. In response to this need, VA has substantially increased its authorized mental health capacity at the Maui CBOC. As you know, Mr. Chairman, Congress has provided several hundred million dollars to VA to specifically enhance mental health services. Since FY 2006, and each subsequent year thereafter, VAPIHCS has received nearly $3 million of these funds. These funds have been used to hire about 35 new mental health staff in VA facilities across Hawaii and the Pacific region, including seven staff here at the Maui CBOC. In addition, the Maui Vet Center also successfully recruited another psychologist.
Molokai and Lanai. The islands of Molokai and Lanai are part of Maui County. VA provides limited services (i.e. part-time outreach clinics) on these islands with permanent staff (on Molokai) and visiting VA staff (to both islands). VAPIHCS is assessing options to enhance services in both locations.
Molokai. VA estimates the Veteran population on Molokai to be 649, with 203 Veterans from Molokai enrolled for VA care and 150 Veterans receiving VA services. VA formally established an outreach clinic on Molokai in FY 2005 with the assistance of you and your staff, Mr. Chairman. The VA clinic on Molokai is located in shared space near Molokai General Hospital and operates two half-day primary care clinics per week. The clinic is staffed with a part-time VA physician and contract support staff. VA has access to videoconferencing equipment at this facility. VA also sends mental health staff from the Maui CBOC to Molokai to provide care. The Clinic’s psychologist travels twice a month and the psychiatrist once a month. In addition, VA purchases non-VA care in the community (e.g., Molokai General Hospital) for eligible Veterans residing in Molokai. Veterans residing in Molokai also are seen at DoD and VA facilities in other locations. VA pays for travel expenses for those Veterans eligible for beneficiary travel.
Lanai. VA estimates the Veteran population on Lanai to be 229, with 57 Veterans enrolled for VA care, and 30 Veterans receiving VA services. Since June 2007, a VA primary care provider from Maui travels to Lanai once a month to provide needed primary care services. Additionally, in FY 2009 a Mental Health Clinical Nurse Specialist began accompanying the primary care provider. VA has used space adjacent to the Lanai Community Hospital, and most recently finalized an agreement with Straub Outpatient Clinic for visiting VA providers to use space and support the Clinic. In addition, VA purchases non-VA care in the community and pays beneficiary travel for eligible Veterans. VA is continually exploring other options to improve access...
In summary, with your support, Mr. Chairman, and with the support of other members of Congress, VA is providing an unprecedented level of health care services to Veterans residing in Hawaii and here in Maui. We look forward to a growth of new patients at the Maui CBOC and will meet the expectations of Veterans for quality and timeliness.
VAPIHCS still faces several challenges, in part due to the topography of its catchment area, the lack of an acute medical-surgical hospital, limited community resources in rural areas, and difficulties recruiting staff. VAPIHCS will meet these challenges by utilizing telehealth technologies, hiring specialists, working with community partners and developing new delivery models. I am proud of the improvements in VA services in Hawaii, but recognize that our job is not done.
Again, Mr. Chairman, mahalo for the opportunity to testify at this hearing. My colleagues and I would be delighted to address any questions you may have for us.
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