Addressing The Operational Challenges For.12

ANALYSIS & PERSPECTIVE
Addressing the Operational Challenges for Outpatient

Stroke Rehabilitation
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
La’Tai Jenkins, PT, MBA, DPT, Spencer Gonzaga, PT, DPT, GCS, GTC, CSRS, Erin Jedlanek, MS, CCC-SLP, CBIS,
Gina Kim, MOT, OTL/R, CBIS, CSRS, and Preeti Raghavan, MD
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 11/03/2023
Abstract: The traditional model of rehabilitation services includes healthcare services, and finally in an outpatient rehabilitation
clear requirements for provision of services in the acute inpatient reha- setting.1 While there are relatively clear standards of care for
bilitation setting. However, there are fewer guidelines on the frequency multidisciplinary inpatient rehabilitation, there is much vari-
and duration of rehabilitation services beyond the acute setting. Re- ability in the delivery of outpatient rehabilitation services. Sev-
cent research has suggested that neurorehabilitation interventions that eral recent studies suggest that the timing and frequency of out-
are provided frequently enough upon discharge from acute inpatient patient rehabilitation are critical for long-term recovery after
rehabilitation to facilitate repeated practice and feedback improve stroke2,3 and can significantly reduce the cost of care.4
long-term stroke outcomes. However, it is challenging to provide Animal models of stroke suggest that the nervous system
high-frequency outpatient rehabilitation, as the logistics of scheduling may be particularly responsive to external stimuli during the
and insurance limitations often do not allow it. The Sheikh Khalifa period of heightened plasticity in the period immediately after
Stroke Institute at Johns Hopkins Medicine innovated a new model injury.5 However, the external stimuli must be provided at ap-
to provide the appropriate frequency of therapy for stroke rehabilita- propriate doses,6 where the timing, frequency, intensity, and
tion in the outpatient setting. This article describes the restructured op- duration of the interventions allow for repeated progressive
erational infrastructure for outpatient stroke rehabilitation to facilitate practice, preferably during a period of biologic repair. How-
high-frequency transdisciplinary stroke rehabilitation in the real world, ever, despite an emphasis on dosing in rehabilitation especially
including the development of the outpatient postacute therapy pro- in the subacute stage poststroke, little has been done to restruc-
grams and the identification of appropriate patients for each program, ture the standard of care for outpatient rehabilitation. In 2019,
the development of scheduling matrices and treating teams to deliver the Sheikh Khalifa Stroke Institute (SKSI) at Johns Hopkins
the postacute therapy programs, the implementation of transdisciplin- Medicine set out to translate the findings from research to clin-
ary neurorehabilitation, and the steps taken to empower patients to en- ical care by creating the unified SKSI model of recovery and
gage in rehabilitation at home and address barriers to accessing the rehabilitation. The goal was to create the infrastructure and op-
programs. We assessed the effect of the operational restructuring on erations that would address each patient’s rehabilitation needs
schedule utilization, no-show rates, and cancellation rates in the 3 by providing the right dose of therapy at the right time in the
mos before and after implementation of the program and show that continuum of care in a clinical setting.
it increased schedule utilization and reduced no-show rates and can- A major challenge in outpatient rehabilitation is that there
cellation rates, suggesting that it may increase compliance with reha- are typically more patients needing therapy than there are thera-
bilitation. It is possible to create the infrastructure needed to bridge pists available to provide the services. The reopening of outpatient
the continuum of care for poststroke recovery and rehabilitation. facilities after the shutdown during the COVID-19 pandemic
also increased the demand for outpatient stroke rehabilitation
Key Words: Stroke, Administration, Rehabilitation, Continuum of Care services.7 To address the growing need for multidisciplinary outpa-
(Am J Phys Med Rehabil 2023;102:S61–S67) tient rehabilitation services, without compromising the frequency
of visits, especially during the early poststroke period, we needed
to overhaul the care coordination, staffing, and patient access
(scheduling) systems. This article discusses the development
fter a stroke, a patient typically transitions through multi-
A ple care settings, starting in the emergency department,
and then in the acute stroke unit in the hospital, which may
of the outpatient postacute therapy (PATH) programs and the
identification of appropriate patients for each program, the de-
velopment of scheduling matrices and treating teams to deliver
be followed by care in an acute inpatient rehabilitation facility the PATH programs, the implementation of transdisciplinary
and/or a skilled nursing facility, then at home with home neurorehabilitation, and the steps taken to empower patients
to engage in rehabilitation at home and address barriers to
From the Department of Physical Medicine and Rehabilitation, Johns Hopkins Univer-
sity School of Medicine, Baltimore, Maryland (LJ, PR); Rehabilitation Therapy accessing the programs. We assessed the effect of the opera-
Services, Department of Physical Medicine and Rehabilitation, Johns Hopkins tional restructuring of the outpatient programs on schedule uti-
Hospital, Baltimore, Maryland (SG, EJ, GK); and Department of Neurology, Johns lization, no-show rates, and cancellation rates in the 3 mos be-
Hopkins University School of Medicine, Baltimore, Maryland (PR).
All correspondence should be addressed to: Spencer Gonzaga, PT, DPT, GCS, GTC, fore and after implementation of the program.
CSRS, Johns Hopkins Hospital, 600 N Wolf St/Meyer 1-130, Baltimore, MD 21287.
This study was funded in part by the Johns Hopkins Sheikh Khalifa Stroke Institute.
LJ and PR conceived of the manuscript. LJ, SG, GK, and EJ wrote the manuscript. DEVELOPMENT OF THE PATH PROGRAMS AND
All authors reviewed the final manuscript.
Financial disclosure statements have been obtained, and no conflicts of interest have been IDENTIFICATION OF APPROPRIATE PATIENTS
reported by the authors or by any individuals in control of the content of this article. FOR EACH PROGRAM
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115 Providing a greater total dose and frequency of stroke re-
DOI: 10.1097/PHM.0000000000002145 habilitation has been shown to be associated with improved
American Journal of Physical Medicine & Rehabilitation • Volume 102, Number 2 (Suppl), February 2023 www.ajpmr.com S61

Jenkins et al. Volume 102, Number 2 (Suppl), February 2023
FIGURE 1. Depiction of the Sheikh Khalifa Stroke Institute PATH Programs: high frequency (PATH A), intermediate frequency (PATH B), and low
frequency (PATH C). In addition, patients may join the precision rehabilitation study where data collected from assessments facilitates long term
monitoring of recovery by a dedicated team.
outcomes for both upper and lower limb impairment and Inpatient Integrated Rehabilitation Program at Johns Hopkins
function.8–11 However, not all patients can tolerate high-dose Hospital. The initial SKSI intake algorithm provided a numer-
rehabilitation or have the resources to make it to the therapy ical rating for six determinants that were factored into the de-
visits. Therefore, it is necessary to be able to tailor the fre- cision making and referral process. These included the acuity
quency of visits to the patient’s needs. Hence, we developed of stroke (chronic = 1, acute = 2), level of impairment (mild = 1,
tiered PATH programs to accommodate patients with differing moderate = 2, severe = 3), degree of family support (poor = 1,
needs (Fig. 1). The high frequency PATH A program provided moderate = 2, high = 3), activity tolerance (low = 1, moder-
up to 3 hrs of multidisciplinary rehabilitation (i.e., occupational ate = 2, high = 3), level of patient insight into their impairments
therapy [OT], physical therapy [PT], and speech and language (low = 1, moderate = 2, high = 3), and transportation chal-
therapy [SLP]) per day, for 4–5 days a week for 4 wks. The lenges (high = 1, moderate = 2, low = 3). If the patient scored
PATH A program was designed to extend the dose of therapy more than 11/17 points, they were deemed appropriate for re-
that is typically received in an inpatient rehabilitation setting ferral to PATH A, pending insurance clearance. We found that
to the outpatient setting for multidisciplinary rehabilitation. most patients met the threshold for PATH A and demonstrated
The intermediate frequency PATH B program provided the interest in the program. However, even though the algorithm
more traditional twice per week frequency of therapy for factored in psychosocial factors such as level of support
4–8 wks and was intended for patients who either could not tol- and transportation challenges, as well as individual factors
erate or did not need PATH A. The PATH C provided therapy such as insight and activity tolerance, many eligible pa-
once a week for up to 12 wks and was designed for individuals tients still found the logistics of coming for therapy daily
with mild impairment who received early supported discharge, to be too demanding to make it to the scheduled therapy ap-
but still had rehabilitation needs, or for those who were pointments consistently. This negatively impacted operations
transitioning from the PATH B program and needed skilled and productivity and prevented the delivery of the desired
therapy to facilitate carry over. high-frequency multidisciplinary rehabilitation. The numerical
To identify the right patient for the right PATH program, algorithm was subsequently replaced by a decision tree to
particularly immediately after inpatient rehabilitation, an algo- match the patients to the programs more precisely (Fig. 2). This
rithm was developed in collaboration with the Comprehensive new algorithm also referred patients to home care, PATH B and
FIGURE 2. The Sheikh Khalifa Stroke Institute PATH program intake algorithm.
S62 www.ajpmr.com © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Volume 102, Number 2 (Suppl), February 2023 Operational Restructuring in Stroke Rehabilitation
C programs, case management/social work, and courtesy trans- scheduling model could be described as “chaotic,” in that
portation programs, if needed. All referrals then went through patients were scheduled whenever there was an opening in
insurance clearance before scheduling. therapists’ schedules, which was not at a consistent time of
A more in-depth decision tree was required to identify ap- day or time block for multiple disciplines, nor with the same
propriate patients to the PATH programs after discharge di- therapist, making planning difficult for patients and their
rectly from the acute hospital service or the brain recovery unit caregivers. The lack of a consistent schedule and carryover
at Johns Hopkins Hospital, due to the medical complexity of with a therapist team was reported by both patients and staff
these patients. Factors such as mental health, substance abuse as a barrier to attaining patient goals. Furthermore, each
disorder, health literacy, and medical stability needed to be time a new therapist worked with a patient, additional time
considered in addition to the factors identified previously. Of- was spent in chart review, getting to know the patient and
ten, these medically complex patients declined acute inpatient family, and objective testing.
rehabilitation. While offering high-frequency multidisciplinary The role of a stroke program navigator was created to de-
therapy services in an outpatient setting may seem like an ade- velop the operational structure to support the PATH programs.
quate solution, the medical complexity led to reduced compliance The initial solution was to create scheduling blocks in each
and increased the no-show or cancellation rate to the outpatient SKSI therapist’s day to ensure therapist availability for newly
therapy visits. This underscored the need for a collaborative ap- discharged stroke patients from inpatient rehabilitation. How-
proach with case management and social work to facilitate re- ever, scheduling blocks are a risk to ambulatory operations, es-
habilitation across the care continuum for these patients.12 Thus, pecially in urban settings where no-show rates are high. To ad-
the intake algorithms helped determine and inform scheduling dress the challenge of high no-show rates, Lotfi and Torres13
decisions for patients transitioning to outpatient rehabilitation, performed decision-tree analysis to develop a predictive model
facilitated care coordination for multidisciplinary rehabilitation that provided the likelihood of patients’ missing scheduled ap-
across the levels of care within and outside the institution, and pointments. Common reasons for no show included lack of
enabled the appropriate frequency of therapy visits to be deliv- transportation, a sick household member, or lack of financial
ered within the critical period of recovery. resources, as well as cognitive or emotional barriers such as
perceived disrespect and not understanding the scheduling sys-
tem. Therefore, we surmised that scheduling blocks were still
DEVELOPMENT OF A SCHEDULING MATRIX the best solution to provide patients with a consistent schedule
AND THERAPY TEAMS FOR DELIVERY OF THE and demonstrated respect for their time and commitment and
PATH PROGRAMS that they could also assist the patient and caregivers to plan
A key challenge in determining the feasibility of the tiered and integrate rehabilitation into their lives.
PATH programs was creating a scheduling matrix that en- The next challenge was to find the right scheduling matrix
abled existing therapists to balance the needs of providing for each therapist’s blocked versus available time during the
high-frequency rehabilitation for patients with stroke, while day to allow for provider consistency for returning patients,
also providing neurorehabilitation for other neurologic condi- while not restricting access for new patients. The use of sched-
tions. Long wait times and reduced access to the programs not uling blocks and adjusting parameters such as frequency and
only were detrimental to productivity but also prevented early duration for each PATH program led to a nominal improvement
and high-frequency rehabilitation that has been shown to be in access to high-frequency multidisciplinary therapy. How-
critical for poststroke recovery. Furthermore, the incumbent ever, it did not address the need for continuity with a consistent
FIGURE 3. Scheduling blocks are shown for therapy team #1, consisting of occupational therapist (OT-1), physical therapist (PT-1), and speech and
language therapist (SLP-1) for two new PATH A patients (patient #1, light pink and patient #2, purple) who can receive PT, OT, and SLP consecutively
and then transition to PATH B with the same team as they transition to the team block (team #1, dark pink). The team #1 block can accommodate two
PATH B patients, and one PATH C patient over the course of the week. The team #1 therapists may also belong to other therapy teams treating patient
#3 and patient #4.
© 2023 Wolters Kluwer Health, Inc. All rights reserved. www.ajpmr.com S63

therapy team. Continuity of care with a consistent team of ther- participate in their own rehabilitation at home. To truly be
apists’ (i.e., the same physical therapist, occupational therapist, able to extend rehabilitation immediately after inpatient reha-
and speech and language therapist) was possible early in a pa- bilitation, the scheduling matrix had to be structured enough
tients’ treatment course, but as the patient progressed, for ex- to provide access to patients soon after discharge from inpa-
ample from PATH A to PATH B, the therapy team changed tient rehabilitation but also nimble enough to enable continu-
as the primary team moved on to the next new patient. ity of therapy for those who need it.
Therefore, we created “therapy teams” to facilitate conti-
nuity of care with a consistent set of multidisciplinary thera-
pists across the patients’ journey through the PATH programs, IMPLEMENTATION OF TRANSDISCIPLINARY
NEUROREHABILITATION
provided there was staff availability. The scheduling block ma-

trix with therapy team #1, consisting of OT-1, PT-1, and SLP-1 The team structure facilitated the implementation of a co-
is shown in Figure 3. Note that this team of therapists can see hesive, transdisciplinary treatment model where each clinician
two patients for multidisciplinary PATH A 5 days a week: pa- was encouraged to share findings from their individual treat-
tient #1 (light pink receives PT at 1:00 PM, OT at 2:00 PM, ment visits. Recommendations were made to the entire clinical
and SLP at 3:00 PM), and patient #2 (purple, receives SLP at team, including treating therapists from other therapy disci-
1:00 PM, PT at 2:00 PM, and OT at 3:00 PM). In addition, this plines (i.e., PT, OT, SLP), physicians, psychologists, and re-
team of therapists also has an additional hour blocked on their searchers to provide a holistic treatment program to optimize
schedule consistently (dark pink, team #1) for potentially an- patient outcomes.14
other new PATH A patient or for the current patients who Transdisciplinary communication occurred through struc-
may be transitioning to PATH B and would like to continue tured neuro rounds, which were scheduled twice a month on a
to be treated by the same team. Team #1 can accommodate routine basis. In preparation for neuro rounds, treating clini-
two PATH B patients (who would be seen twice a week) and cians were encouraged to share key information on a secure in-
one PATH C patient (who would be seen once a week). OT-1 formation sharing platform including information about the
may also be part of another team of therapists (e.g., team #2) patients’ functional mobility status, level of support to com-
who will see patient #3 (blue), while PT-1 and SLP-1 may be plete transfers, upper extremity function, visual skills, dyspha-
part of team #3 who will see patient #4 (yellow), who are also gia diets (type of diet/liquid intake), communication skills,
shown in this scheduling matrix. cognitive skills, safety awareness, and barriers that needed to
It is important to note that patients may begin with any be overcome to optimize recovery. During neuro rounds, team
PATH program and transition to any other. For example, a pa- members had the opportunity to learn from each discipline’s
tient may only tolerate PATH C or B at first because of re- experience, brainstorm to bridge gaps in care, refer patients
duced endurance but may progress to PATH A once endur- for specialty treatments such as spasticity management or to
ance increases. Alternatively, a patient may begin with PATH neuropsychology and/or ongoing research projects, and set ex-
A and progress to PATH B as they gain skills and the ability to pectations for the patient’s transition to the next tier of care.
FIGURE 4. Home exercise program kits: (A) PT mobility kit, (B) OT GRASP Kit, (C) OT vision kit, (D) SLP dysphagia kit, and (E) SLP dysarthria kit.

FIGURE 5. The goal of the PATH programs and the transdisciplinary approach to treatment is patient empowerment to engage fully in their
rehabilitation.
Another type of structured communication included fam- for carryover outside the treatment setting. The principles of
ily conferences. In preparation for the family conference, the high-frequency training, task-specific practice, and goal-oriented
primary treating therapists from each discipline met separately practice were imparted to patients through education, home ex-
to identify the goals of the meeting, prepare data on the pa- ercise programs (HEP), and community integration. In addi-
tient’s progress from the time of admission, find consistency tion, we created SKSI HEP kits that were adapted from the
in concerns or successes to share with the patient, and decide telerehabilitation kits created during the COVID-19 pan-
on a collaborative plan to prepare the patient for a successful demic17 and customized to patients’ rehabilitation needs
discharge. One team member was appointed to act as the liai- (Fig. 4). The five kits were discipline and task specific and in-
son between the patient, family, and therapists to build a stron- cluded the PT mobility kit, the OT GRASP (Graded Repetitive
ger therapeutic relationship and develop trust. The liaison Arm Supplementary Program) kit, the OT vision kit, the SLP
scheduled, organized, and facilitated the family conference. dysphagia kit, and the SLP dysarthria kit. Links to online
This enabled follow-up and continued collaboration between videos demonstrated how the home exercise program could
the patient, family, and treating team. be safely performed at home. The goal of providing the infor-
However, given the complexity of the dynamic neurologic mation and kits was to empower patients by giving them the
rehabilitation process, communication extended beyond struc- tools needed to supplement their therapy and to facilitate main-
tured meetings. Unstructured communication included discus- tenance and carryover of the skills gained after discharge from
sion of patient concerns, scheduling needs, insurance authoriza- therapy.18,19 As patients progressed through their rehabilita-
tion, emergent issues such as family crises, patient advocacy, tion, the gap between treatment and community reintegration
and information sharing for community-based resources. Some was bridged with the introduction of community-based re-
patients felt more comfortable discussing details regarding psy- sources, such as group therapy for technology-facilitated reha-
chosocial support, falls, emotional status, family dynamics, etc. bilitation (e.g., for aerobic exercise, upper limb rehabilitation,
with certain providers during one-on-one visits rather than dur- and/or task-specific gait training) and self-efficacy training to
ing structured family meetings. In other cases, the clinical team increase patient autonomy. The transdisciplinary approach to
worked together to identify strategies to target motivation, com- neurorehabilitation facilitated collaborative education and
pliance, and evolving clinical concerns outside of formal struc-
tured team meetings. The implementation of transdisciplinary
neurorehabilitation facilitated patient engagement. TABLE 1. Comparison of scheduling metrics before and after
implementation of the scheduling matrix with the therapy
team model
EMPOWERING PATIENTS TO ENGAGE IN
REHABILITATION AT HOME Preimplementation Postimplementation
Studies have shown that patients with stroke need both Schedule utilization OT: 61% OT: 80%
high-frequency rehabilitation early on during the critical pe- PT: 79% PT: 83%
riod,2 as well as high-intensity long-dose rehabilitation8–11; SLP: N/A SLP: 81%
the greater the severity of impairment, the longer the duration No-show rate OT: 4.1% OT: 3.5%
of rehabilitation needed for recovery. Hence, it is imperative PT: 8.3% PT: 5.5%
that the duration of rehabilitation is tailored to the degree of SLP: N/A SLP: 4.3%
impairment and that rehabilitation is continued by the patient Cancellation rate OT: 31% OT: 29%
at home beyond one-on-one therapy sessions. Educating pa- PT: 38.2% PT: 31%
tients and caregivers on the use of strategies and cues that SLP: N/A SLP: 33%
were effective during treatment sessions may enhance carry- Schedule utilization is an indicator of the efficiency of appointment sched-
over outside the treatment setting in the home and in the com- uling processes, no-show rate reflects the percentage of appointment time lost
munity.15 For example, multisensory stimulation (i.e., visual, because patients do not show up or cancel after the appointment time, and can-
auditory, and tactile cues) and rhythmic cueing may be used to cellation rate reflects the percentage of appointments canceled within 24 hours
stimulate an intrinsic motor response.16 We developed a of the appointment.
stroke education booklet to collaboratively and interactively N/A, not available.
document such patient-specific strategies that would be useful

carryover of functional skills learned during therapy sessions scheduling model. Retrospective data compared schedule utili-
to the home environment. The goal of the PATH programs zation, no-show rate, and cancellation rate for outpatient SKSI
was to empower patients to engage in their rehabilitation to neuro therapists 3 mos before and after implementation (Table 1).
lead to a progressive gain in independence (Fig. 5). Note that in the 3 mos after implementation, schedule utiliza-
tion increased across disciplines, while the no-show and can-
ADDRESSING BARRIERS TO ACCESSING cellation rates decreased. Many patients and family expressed
THE PROGRAMS their appreciation for a consistent therapy schedule, which en-
abled transportation arrangements and reorganization of work
The most prevalent barrier to accessing the PATH pro-
and family obligations to make rehabilitation more accessible.
grams was transportation to and from therapy appointments.
The new scheduling matrix and operational model may in-

At the inception of the SKSI PATH programs, services were
crease compliance with rehabilitation.
only offered at the Johns Hopkins Hospital outpatient rehabil-
itation clinic. This presented a barrier for patients who did not
reside close to Baltimore city and/or did not have a caregiver CONCLUSIONS AND FUTURE DIRECTIONS
that could provide consistent transportation for the frequent This article describes the restructured operational model
outpatient visits. Associated with transportation were the for outpatient stroke rehabilitation to facilitate high-frequency
challenges of parking and navigating a large institution. Many transdisciplinary stroke rehabilitation in the real world, particu-
caregivers reported that their own health or mobility impair- larly after discharge from inpatient rehabilitation. We have
ments restricted their ability to transfer the patient in and learned that it is possible to create the infrastructure needed
out of a car and limited their ability to ambulate from the to bridge the continuum of care after stroke.
parking garage to the outpatient clinic. To address this barrier, Our next step is to demonstrate the effectiveness of this
we created an SKSI fund to provide courtesy transportation to model in reducing impairment across multiple domains, miti-
eligible patients. gating disability, and reducing the cost of care. The operational
The next important barrier was cost. When a referral was model will support further refinement of the dose of therapy in-
placed for the SKSI PATH programs, the first order of action cluding measurement of time-on-task, number of repetitions,
was to request preauthorization from the patient’s insurance and task difficulty. We are also working on providing long-dose
carrier. After the referral was placed, and when the patient technology-assisted therapy for individuals with significant
was still on the inpatient rehabilitation unit, the stroke naviga- impairments as well as providing cardiac rehabilitation poststroke
tor facilitated the verification of insurance eligibility, visit to increase cardiovascular capacity and reduce risks for secondary
limits, and copays and indicated when the next opening for stroke prevention. We anticipate that this novel operational in-
the most appropriate PATH program for the patient was. The frastructure will enable us to deliver precision rehabilitation,
care coordinators then discussed the PATH option, as well as where the timing, frequency, duration, intensity, and content
other viable options, with the patient and family. If insurance of rehabilitation will be tailored to the individual to optimize
coverage, cost and/or logistics of transportation and time were poststroke recovery.
barriers, patients were unable to participate in the PATH pro-
grams and had to avail of other options for continuity of care.
The third barrier to the PATH programs was wait times. REFERENCES
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ANALYSIS & PERSPECTIVE

Addressing the Operational Challenges for Outpatient

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

provided there was staff availability. The scheduling block ma-

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

The new scheduling matrix and operational model may in-

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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