The innovative medical legal partnership between Christiana Care and the Community Legal Aid Society, Inc (CLASI) is the first funded program through the Harrington Value Institute Community Partnership Fund. From left to right: Amy Ball, MBA, health guide; Sandra Tineo, BSW, social worker; Katelyn Lentz, JD, law clerk; Aimee Mantell, JD, paralegal; and Elsie Evans, health guide program assistant.

Harrington Value Institute Community Partnership Fund Improves Social Needs of Patients

Christiana Care Health System is moving beyond the traditional bounds of health care, this time to target social determinants of health through the recently established Harrington Value Institute Community Partnership Fund. The program was established to foster innovative partnerships between Christiana Care and the community, supporting population health research and program development to address community needs and reduce health-care disparities for underserved and disadvantaged populations.

The partnership is seeking submissions from new or existing innovative community programs that target one or more social determinants of health – factors that affect daily life and health, such as neighborhood, education, and economic stability – and include both a community focus and a clinical outcome. The community partnership will select programs annually, with awards averaging $100,000 per year that can be renewed for up to three years, depending on the previous year’s progress.

“This program is important because it directly serves our New Castle neighbors by offering innovative ways to add value to the patients in these communities,” said Value Institute Project Manager Jennifer Ostertag-Stretch, MBA.

The first initiative selected to receive funding is the Delaware Medical Legal Partnership, a collaborative effort of Christiana Care and the non-profit Community Legal Aid Society, Inc. (CLASI), which provides civil legal services to low-income, disabled, and elderly people.

Understanding that medical conditions can be aggravated by legal or social problems, the Delaware Medical Legal Partnership is designed to improve the health of low-income patients who are frequent hospital users, enhance their health care experience, and reduce health care costs by integrating lawyers into the health care team. For example, an attorney’s assistance can help ensure proper mold remediation takes place in an asthmatic resident’s rental home, or help prevent a utility company from cutting off electricity to the home of someone who requires supplemental oxygen. By addressing the social determinants of health, this program hopes to improve those individuals’ health and reduce their need to seek repeated emergency treatment at the hospital.

“Providers often don’t think about legal issues when treating patients, and the patients themselves are often not aware a legal remedy exists for their problem or they cannot afford legal representation,” said Susan Howard-Smola, J.D., MBA, senior clinical researcher, Value Institute. “Linking these typically disparate resources provides patients with more comprehensive care that benefits the patient and health system.”

Submissions to the Harrington Value Institute Community Partnership Fund are currently in review. Awardees will be announced May 2016. For more information, visit Harrington Community Partnership Fund.

Project Champions: Daniel Atkins, Esq., Executive Director; Community Legal Aid Society, Inc.; Marissa L. Band, Esq., Supervising Attorney, Community Legal Aid Society, Inc.; Brenda Pierce, Esq., R.N., Corporate Counsel, Legal and Risk Management; Julie Silverstein, M.D., FACP, Medical Director, Rocco A. Abessinio Family Wilmington Health Center; David Paul, M.D., Chair, Department of Pediatrics; Robert Locke, D.O., MPH, Director, Neonatal Research; Susan Howard-Smola, J.D., MBA, Senior Clinical Researcher, Value Institute.

In the face of a national epidemic of opioid addiction, Christiana Care’s Behavioral Health Service Line, with support from the Value Institute, is piloting a new way to identify and help patients at risk of opioid withdrawal.

Behavioral Health’s clinical pathway on opioid withdrawal begins with a new screening tool called the Opioid Withdrawal Risk Assessment Tool – a simple, two-question survey administered to admitted patients, regardless of their primary reason for presenting. This tool identifies those suffering from opioid withdrawal and provides effective, standardized treatment. The Value Institute will validate the tool and its effectiveness.

“Variations in care, as well as untreated withdrawal in patients who don’t identify themselves as opioid users, increase the number of patients who sign themselves out against medical advice,” said Terry L. Horton, M.D., FACP, chief of the Division of Addiction Medicine and medical director of Project Engage, and associate physician leader for the Behavioral Health Service Line. “Such issues also result in longer hospital stays, higher readmission rates, higher costs of care, poor patient experience, and low staff morale.”

During the pilot program, any patient who answers yes to either question on the Opioid Withdrawal Risk Assessment Tool – purposely simple and easily administered within nurses’ workflow – will be given a more detailed and proven assessment, the validated Clinical Opiate Withdrawal Scale (COWS). A standardized opioid withdrawal treatment protocol will begin for those who score above a specific threshold on the COWS test.

To evaluate the sensitivity and specificity of the Opioid Withdrawal Risk Assessment Tool, both it and COWS will be administered to 1,500 patients during the three-month pilot phase on four units at Christiana and Wilmington hospitals.

“We hope this screening tool will be highly sensitive so we can minimize false negatives – patients who answer no to the two questions but who are, in fact, at risk of withdrawal,” said Claudine Jurkovitz, M.D., MPH, Value Institute senior physician scientist.

In addition, the Value Institute will survey nursing staff about their attitudes and perceptions of working with patients in opioid withdrawal, both before and after the pilot program and a preceding educational session.

Project Champions: Linda Lang, M.D. Chair, Department of Psychiatry, Medical Director, Behavioral Health, Terry Horton, M.D., FACP, FASM, Chief, Division of Addiction Medicine, Medical Director, Project Engage, Value Institute Scholar; Beverly Wilson, M.S., Program Manager; Jo Melson, MSN, RN, FNP-BC, Wilmington Hospital Palliative Care, Nurse Practitioner; James Ruether, M.D., FACP, Internal Medicine; Aliesha Rivera, MSN, RN-BC, SDS, Staff Development Specialist; Bonnie Osgood, MSN, RN-BC, NE-BC, Nurse Manager; Claudine Jurkovitz, M.D., MPH, Senior Physician Scientist, Value Institute; Kimberly Williams, MPH, Research Associate, Value Institute; Rick Caplan, PhD, Senior Biostatistician, Value Institute.

Through Christiana Care's embedded trauma hospitalist program, hospitalist Erin M. Meyer, D.O., FAWM, FAAP, FACP, SFHM, sees a trauma patient at Christiana Hospital's Transitional Care Unit.

According to recent statistical analysis by the Value Institute, an innovative Christiana Care Health System program that embeds hospitalists in the trauma department is associated with reduced patient mortality and 30-day readmissions.

The program, started in 2013, uses a team of hospitalists to co-manage care with trauma surgeons. While the surgeons manage a patient’s pain and injury-related care, the hospitalists are active in attending to other complex medical issues facing the patient, such as diabetes, hypertension, or heart disease, explained Mark D. Cipolle, M.D., Ph.D., FACS, FCCM, the director of Outcomes Research for the Surgical Service Line, Value Institute scholar, and the former medical director of the Trauma Program.

“Our evidence suggests that hospitalists offer a great deal of value when embedded in a surgical service to co-manage patients with multiple comorbidities,” said Dr. Cipolle of the results, which were well received at the Eastern Association for the Surgery of Trauma (EAST) held in January in San Antonio.

The retrospective study included 469 trauma patients who were co-managed by a hospitalist and 938 matched controls that did not have a hospitalist as part of their trauma team.

“The proposed mechanisms for these results are increased patient vigilance with another pair of eyes, better-managed comorbid conditions, and education that helps keep patients from being readmitted to the hospital,” said Value Institute biostatistician Bailey Ingraham, M.S., who worked on the analysis with research associate Kim Williams, MPH, and the late Seema Sonnad, Ph.D., the inaugural director of Health Services Research at the Value Institute.

Specifically, the analysis determined that patients co-managed by hospitalists had fewer trauma-related hospital readmissions and lower mortality rates than those who did not. Patients in the hospitalist group had longer hospital stays and were more frequently upgraded to the intensive care unit than the control group.


Hospitalist Erin M. Meyer, D.O., FAWM, FAAP, FACP, SFHM, said many trauma admissions involve elderly people who arrive after a fall but have other chronic medical issues that the hospitalist can address during their stay, allowing them to be discharged with those complex conditions addressed, and sometimes better managed, for long-term health.

Project Champions: Mark D. Cipolle, M.D., Ph.D., FACS, FCCM, Director of Outcomes Research, Surgical Service Line, Trauma Program; Erin M. Meyer, D.O., FAWM, FAAP, FACP, SFHM, Med-Peds Hospitalist, Christiana Care Hospitalist Partners; Bailey Ingraham, M.S., Biostatistician, Value Institute; Kim Williams, MPH, Research Associate, Value Institute; Seema Sonnad, Ph.D., Inaugural Director, Health Services Research, Value Institute.

Liz Brown, M.D., MSHP, Harrington Clinician scholar for the Value Institute and Department of Family & Community Medicine physician, cares for a patient with the help of Leidy Acero-Luna, Spanish medical interpreter. A student researcher from the Value Institute captures data during the interaction as part of a time and motion study, a partnership between the Value Institute and Language Services.

Ensuring that all Christiana Care Health System patients receive quality care and can be active participants in their treatment, regardless of what language they speak, is at the heart of a study being conducted by the Value Institute and the Learning Institute’s Language Services department.

Communication/Language is Key, or CLIK, is tackling the challenge of guaranteeing interpreters’ availability for any patient by developing a staffing optimization model and cost analysis to address difficult-to-predict needs.

“Unlike guidelines for nurse-to-patient ratios, there are no ‘industry guidelines’ for interpreter-to-patient ratios, despite a federal mandate on institutions to provide sufficient professional language assistance to staff and patients,” said Tze Chiam, Ph.D., Value Institute associate director for Research Informatics. “This team is not only developing a Christiana Care-specific staffing model, but results from this study can potentially help inform the broader industry on the development of guidelines.”

The CLIK project comes as Christiana Care faces an exploding need for language services – within the past four years alone, interpreter requests have skyrocketed from 24 to 1,800-plus monthly. Christiana Care handles these requests through its staff of 16 interpreters, augmented by the CyraCom phone system, which provides access to medical interpreters in 200-plus languages, and a pilot video remote interpreting system.

“Providing effective and efficient language services for our limited English proficient (LEP) and deaf patients is much more complex than it seems,” said Jacqueline Ortiz, M.Phil., director, Cultural Competence and Language Services. “There are multiple variables that intersect with every interpreter request – patient literacy levels, cultural issues, the type of encounter, and the encounter logistics all impact which method of medical interpretation is suitable.”

The CLIK team is quantifying demand by developing ways to better approximate and predict demand patterns. Other components of the project include a time-and-motion study of interpreters’ daily activities, computer simulation, LEP patient population projections, and a potential quality outcome study, all of which will be used to inform the staffing model and cost analysis. The project is scheduled to conclude in April.

Project Champions: Jacqueline Ortiz, M.Phil., Director, Cultural Competency and Language Services; Tze Chiam, Ph.D., Associate Director, Research Informatics, Value Institute; Eric Jackson, M.D., MBA, Associate Director, Value Institute. Key contributors: Elizabeth Brown, MD; Richard Caplan, PhD; Adebayo Gbadebo, MBA; Sarahfaye Heckler; Frank Mayer, MBA; Danielle Mosby, MPH; Claudia Reyes-Hull; Alexandra Nightingale.

William Weintraub, M.D., MACC, FAHA, FESC recently had a landmark 500th peer-reviewed manuscript accepted for publication.

In a career that has spanned more than three decades, one Christiana Care Health System leader has reached a research milestone: internationally recognized clinician-scientist William S. Weintraub, M.D., MACC, FAHA, FESC, the John H. Ammon Chair of Cardiology and founding director of the Value Institute’s Center for Outcomes Research, recently had a landmark 500th peer-reviewed manuscript accepted for publication.

“The key thing to developing a long-term career is to find satisfaction in it every day and satisfaction in helping others, whether patients, clinical trainees, research mentees, or colleagues,” Weintraub said. “It is also important not to let the setbacks that everybody has in the normal course of a career and the daunting challenges everybody faces stop you.”

Weintraub’s own career began in 1975, after receiving his medical degree from Johns Hopkins University School of Medicine, but his publishing career began even earlier: His first publication came while he was in college, a 1971 paper on the properties of superconducting magnets at very low temperatures published in Physics Letters.

His 500th article, an editorial on performing transcatheter aortic valve replacement in patients older than 90, “TAVR in Nonagenarians: Pushing the Boundaries,” will appear in the Journal of the American College of Cardiology.

Of the 498 publications between, many of which Weintraub was a lead or senior author, the ones that stand out were those in which he led or helped lead major multicenter clinical trials – EAST, LRT, TACTIC-TIMI 18, COURAGE, and ASCERT – principal findings from which were published in The New England Journal of Medicine.

Weintraub, who has contributed significantly to bringing research and grants to Christiana Care’s Center for Outcomes Research, said he is grateful to the support that he received from seasoned researchers throughout his career and he counts his mentorship of others as a way to pay it forward.

Sharon Anderson, MS, BSN, RN, FACHE, chief population health officer and senior vice president, Quality, Patient Safety & Population Health Management; guest speaker Thomas H. Lee, M.D., M.Sc., chief medical officer of Press Ganey; and Janice E. Nevin, M.D., MPH, president and chief executive officer of Christiana Care Health System.

The Focus on Excellence Awards on Jan. 20 featured a record-setting 155 entries and the themes for the annual celebration included gratitude, empathy, and courage.

Sharon Anderson, MS, BSN, RN, FACHE, chief population health officer and senior vice president, Quality, Patient Safety & Population Health Management, thanked the judges — a diverse group of more than 200 Christiana Care staff representing disciplines throughout the organization — who devoted substantial time and thought to the task of selecting the winners. She also gave special thanks to the 58 employees whose year-round volunteer work help to make the exhibit and awards program possible.

“Today we celebrate the end of another year of Focus on Excellence competition by announcing the winning entries,” Anderson said. “Yet every project entry, whether it wins or not, represents Christiana Care staff’s commitment to drive improved performance in all that we do in support of The Christiana Care Way. The quantity and diversity of the submissions have always been reflective of Christiana Care’s innovation and teamwork to better serve our patients, families, and community.”

Teams are encouraged to identify an opportunity for improvement, then develop and carry out a plan to achieve improvements in process or outcomes using the Plan-Do-Check-Act or Lean Six Sigma DMAIC model. Teams create a storyboard that explains the project, and all 155 of the project storyboards are displayed in an exhibit in October, in conjunction with National Healthcare Quality Week. Winning projects were displayed again in the Education Center in January. All entries, in PowerPoint, plus a comprehensive book of abstracts in PDF format, are now available for viewing by Christiana Care employees on the Center for Quality & Patient Safety/Service Lines intranet site.

Team Four: News Flash! Extra Extra: Early Detection System to Achieve Higher Standards." Front row: Caroline Snowberger, D.O., Kevin Patel, M.D., Hasan Alhasani, PharmD. Back row: Lindsey Hoosty, BSN, RN III, Linda Bernard, D.O., Meghan Madrigal, M.D., Kaitlin McLean, M.D.

The Value Institute Academy celebrated the completion of the 20th ACT course on Dec. 2 at the John H. Ammon Medical Education Center with four teams of interprofessional learners reporting on their performance-improvement projects

ACT (Achieving Competency Today) is a graduate-level interdisciplinary approach to the science of improvement through experiential learning. Over the years, more than 70 ACT project teams – which include resident physicians, pharmacists, nurses, and other health professionals – have been taught a framework for identifying and analyzing opportunities for improvement in health care settings.

“What started in 2005 as an experiment has continued to grow and has become one of the liveliest, most enriching and — in my opinion —best professional education and development programs at Christiana Care,” said Neil Jasani, M.D., MBA, FACEP, chief learning officer, vice president of Medical Affairs.

As part of the twice-a-year, 12-week curriculum, ACT team members identify a systems issue, develop an improvement project plan, test an intervention, and measure the effect.

For the ACT teams — and the 29 learners — the most recent projects had an overarching theme of improving communication in targeted medical areas and explored how to:

• Improve the medication order clarification process for internal medicine residents and the Department of Pharmacy (“Is There a Doctor in the House?”).
• Improve the consultation process between providers and consultants within a specific medical teaching team. (“Who You Gonna Call?”).
• Increase the number of documented “goals of care” discussions on two Christiana Care medical units, 5A and 6A. (“Tackle the Bear – Discuss Goals of Care”).
• Evaluate a National Early Warning System (NEWS) as a way to detect early clinical deterioration of patients and prevent the need for acute resuscitation. (“News Flash! Extra Extra: Early Detection System to Achieve Higher Standards”). This project leveraged the work on the Christiana Care Early Warning System (CEWS) project, a collaborative interdisciplinary effort guided by the Value Institute.

Stephen Hoover, MS Medical Informatics Project Manager

Susan Mascioli, MS, BSN, RN, CPHQ, NEA-BC, LSSBB, director, Nursing Quality and Safety and interim director for the Magnet program, joined Christiana Care Health System in 1986 as a staff nurse in the Emergency Department and Post-Anesthesia Care Unit. She earned her nursing diploma from the Nursing School of Wilmington in 1980, her bachelor’s degree in nursing from Widener University in 1989, and her master’s degree in health care administration from Wilmington College in 2007.

She has worked in performance improvement, quality, and safety since 1990 and assumed her current role as director of Nursing Quality and Safety in 2010. She earned her Lean Six Sigma Green Belt in 2013, was named a Value Institute scholar in 2014, and earned her Lean Six Sigma Black Belt in 2015. She also serves as interim director of Christiana Care’s Magnet program, a nationwide program recognizing nursing excellence.

Before becoming a Value Institute scholar, Mascioli worked with Value Institute staff on various quality and safety improvement projects, including research regarding prevention of patient falls while working on her LSS Green Belt, and said it was positive collaborations with Value Institute staff, including research design and publication assistance, that motivated her to become a scholar. She has collaborated with members of the Value Institute to co-author six published or pending journal articles and has presented posters and podium presentations at numerous regional and national conferences.

		Lynn Bayne, Ph.D., ARNP, NNP-BC Nursing Research Facilitator Acute Medicine Service Line
		Bradley Sandella, D.O., ATC Physician; Program Director, Sports Medicine Musculoskeletal Health Service Line
		Yukiko Washio, Ph.D., BCBA-D Maternal and Infant Health Researcher Women and Children Service Line

Staff and scholars from the Value Institute shared a sampling of the innovative clinical and translational research taking place during Delaware IDeAs 2016, a joint conference of the Delaware Clinical and Translational Research Program (CTR), the Delaware IDeA Network of Biomedical Research Excellence (INBRE), and Centers of Biomedical Research Excellence (COBRE) – programs funded by the U.S. National Institutes of Health’s Institutional Development Award (IDeA) program – and Delaware Bio, held Feb. 24-25 at the University of Delaware.

“The intent was to bring together collaborators from across Delaware and partners such as South Carolina, work across any silos we might still be in, and really build new relationships between researchers,” said Omar Khan, M.D., MHS, co-director for the Community Engagement & Outreach component of the multi-site CTR-ACCEL program and service line leader for Primary Care & Community Medicine at Christiana Care.

Kathleen Brady, M.D., Ph.D., associate provost for Clinical and Translational Science and director of the South Carolina Clinical & Translational Research Institute at the Medical University of South Carolina, one of Christiana Care’s partners in the CTR-ACCEL program, delivered the conference’s keynote address, “Lost in Translation: Trials Tribulations and Successes in Translational Research.”

Representatives of the Value Institute, a core INBRE facility, presented a selection of research projects during the meeting:

• Senior Clinical Researcher and Value Institute Scholar Susan Howard-Smola, J.D., MBA, presented “Medical Home Without Walls: Patient Engagement Informing a Randomized Clinical Trial.”
• Value Institute Scholar Michael Vest, D.O., presented “Energy Balance and Outcomes of Obese, Mechanically Ventilated Patients in ICU.”
• Value Institute Scholar Sandra Weiss, M.D., FACC, presented “Effects of Radial Artery Catheterization on Dimensions and Endothelial Function.”
• Senior Clinical Investigator and Value Institute Scholar Dominique Comer, Pharm.D., M.S., presented “Building a Bigger Bridge: Linking Outpatient Data to Electronic Medical Records to Improve Longitudinal Health Care for Ischemic Heart Disease.” (Oral presentation.)
• Research Associate and Value Institute Scholar Dani Mosby, MPH, presented “Building a Bigger Bridge: Linking Outpatient Data to Electronic Medical Records to Improve Longitudinal Health Care for Ischemic Heart Disease.” (Poster presentation.)
• Senior Physician Scientist Claudine Jurkovitz, M.D., MPH, presented “Linking Data for Kidney Care.”
• Senior Clinical Investigator and Value Institute Scholar Tze Chiam, Ph.D., presented “Development of Prediction Model for Clinical Outcomes and Costs Associated with Cardiac Surgery.”
• Senior Clinical Investigators and Value Institute Scholars Muge Capan, Ph.D., and Kristen Miller, Dr.PH., presented “Sepsis Visual Risk Profiling Model.”

Susan Howard-Smola, J.D., MBA, senior clinical researcher, presented “Medical Home Without Walls: Patient Engagement Informing a Randomized Clinical Trial” at Delaware IDeAs 2016.

The Value Institute is built on a model of high-level collaboration. The Value Institute partners with academic institutions, corporations, health care professionals, and thought leaders who share our commitment to improving health care value and delivery by turning evidence into reality. We cultivate relationships with patients, clinicians, sponsors, and professional colleagues who recognize the importance of improving health care delivery and health outcomes, organizational excellence, and quality and safety.

You can partner with the Value Institute on collaborative research, including clinical trials, database studies, and demonstration projects. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. One of our team members will then contact you to discuss your research plans. Value Institute staff members are actively involved in 101 research projects in a variety of disciplines.



Awards

Ryan Arnold, M.D., MS, Jamie Rosini, Pharm.D., BCPS, Connie Shah, Pharm.D., Shawn Fellows, Pharm.D., Suraj Rajasimhan, Pharm.D., BCPS, John Jesus, M.D., Brian Levine, M.D., FACEP, FAAEM, and Deb Marco, RN, received the Focus on Excellence Optimal Health Quality Award for “ED Pharmacists Decrease Time to Antibiotics for Sepsis Patients in the ED.”

Dominique Comer, Pharm.D., M.S., Shawn Smith, MBA, Janine Jordan, M.D., Pamela Boyd, MSN, RN, CNOR, Ann-Marie Baker, MSN, RN-BC, Jennifer Goldsack, MChem, MA, MS, Sue Coffey-Zern, MD, and Rae Burton, patient advisor, received the Focus on Excellence Innovative Tools Award for “Improving HCAHPS Scores using iRound Technology.”

Campbell M, Miller K , McNicholas KW. Post event debriefs: A commitment to learning how to better care for patients and staff. The Joint Commission Journal on Quality and Patient Safety. 2016 Jan; 42(1):41-7. PMID: 26685933.

Goldsack JC, DeRitter C, Power M, Spencer A, Taylor CL, Manta CJ, Kirk R, Drees ML. Increasing the efficiency of a targeted methicillin-resistant Staphylococcus aureus screening program. American Journal of Infection Control. 2016 Jan 1; 44(1):117-9. PMID: 26769283.

Mosby D, Lopresto BI, Bacon A, Levy S. P-212 Systematic review: Fecal microbiota transplantation in the treatment of pediatric gastrointestinal diseases. Inflammatory Bowel Diseases. 2016 March. doi:10.1097.

Tanaka L, Khan OA, Jackson EV, Miller KM, Chiam TC. Choosing Wisely in Delaware: Rationale for evidence-based diagnosis and evaluation of low back pain. Delaware Medical Journal. 2016 Jan; 88(1):14-8. PMID: 26934760.

Yang CS, Marshall ES, Fanari Z, Kostal MJ, West JT, Kolm P, Weintraub WS, Doorey AJ. Discrepancies between direct catheter and echocardiography-based values in aortic stenosis. Catheterization and Cardiovascular Interventions. 2016 Feb 15; 87(3):488-97. PMID: d26033475.

R Arnold, M Capan, P Akesson, A Linder. Impact of Disease Severity Assessment on Performance of Heparin-Binding Protein for the Prediction of Septic Shock. Poster presented at: The International Symposium on Intensive Care and Emergency Medicine; 2016 March 15-18; Brussels, Belgium.

JM Glasgow, P Kolm, DJ Elliot. Impact of Hospitalist Workload on Utilization of Imaging and Consultations. Presented at: Society of Hospital Medicine Annual Conference; 2016 March 6-9; San Diego, CA.

M Cipolle, J Pirrung, E Meyer, G Tinkoff, B Ingraham Lopresto, E Robinson. Embedding a Hospitalist on the Trauma Service Reduces Mortality and Readmissions. Presented at: EAST Conference; 2016 January 12-16; San Antonio, TX.

Collaborations is a quarterly release of Value Institute news and events. Visit our website to read our 2014 annual report, watch our video and learn more about the Value Institute. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. To subscribe to Collaborations, please send an e-mail with “Subscribe to Collaborations” in the subject line.