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THE 3 CS OF SKIN AND
WOUND CARE
Building a Successful Skin andW ound Care Program by…
Focusing on the Clinician Component of Best Practices of
Skin and Wound Care
Present ed by Tara Robert s PT and Cari Normand PT, CW S
WHY THE 3 CS OF SKIN AND WOUND CARE
ARE IMPORTANT…
In LTC and Skin and Wound Care Science there is a Lack of Focus on the
Clinician Component of Best Practices of Skin and Wound Care
W hile t he expert s cont inue t o pour t hemselves int o research and gain ground
on est ablishing sounder “best pract ices,” I propose t hat healt hcare providers
focus on t he clinician t o improve upon w ound care and w ound healing t hat
has less emphasis on "best pract ice" and more emphasis on apt it ude, at t it ude
and applicat ion. For even t he best programs focused solely on “best
pract ice” can complet ely miss t he boat on t he one common denominat or-
the clinician who is to carry out the “best practice”
BUILDING A SUCCESSFUL
SKIN AND WOUND CARE PROGRAM…
Successful skin and w ound care programs can be achieved in three steps
called the 3 Cs of Skin and Wound Care:
• We must demand and achieve clinician COMPETENCE;
• By achieving clinician competence you gain clinician CONFIDENCE;
• And finally by utilizing CONTINUOUS QA practices you w ill achieve a
successful, impactful, marketable skin and w ound care program
w hile ensuring your clinicians have continued competence and thus
confidence.

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TODAY’S OBJECTIVES…
• The participant w ill learn strategies to ensure a clinician focused skin and
w ound care program.
• The participant w ill learn strategies for the LTC Provider to apply the 3 Cs
to their organization as it relates to skin and w ound care program
efficiencies and success.
TODAY’S OBJECTIVES…
• The participant will be able to dev elop a strategic plan for a
successful skin and wound care program.
• The participant will hav e an understandingofthe importance
of skin and wound care management and its role in the future
of LTC.
QUALITY MEASURES
Funct ional QualityMeasures:
March 28, 2014: CMS Website
• One file has been added t o t he Downloads section of this page: Technical Expert
Panel on the Development of Cross-Setting Functional Status Quality Measures
• The Cent ers for Medicare & Medicaid Services contracted withRTI International to
develop funct ional status quality measures for inpatient rehabilitation facilities (IRFs),
long-t erm care hospitals (LTCHs) and skilled nursing facilities (SNFs). As part of the quality
measure development work, RTI convened a technical expert panel (TEP) in
Sept ember 2013.
• This report summarizes the feedback and recommendat ions provided by t he TEP
regarding t he proposed funct ional status measures.
http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-I nstr uments/N ursingHomeQualityI nits/NH QIQualityMeasures. html

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QUALITY MEASURES
• MDS 3.0 Measure (#0678): Percent of Residents With Pressure Ulcers That
Are New or W orsened (Short Stay) -100 or less days
• This measure captures the percentage of short-stay residents w ith
new or w orsening Stage II-IV pressure ulcers.
• MDS 3.0 Measure (#0679): Percent of High-Risk Residents W ith Pressure
Ulcers (Long Stay) -101 plus days
• This measure captures the percentage of long- stay, high-risk
residents w ith Stage II-IV pressure ulcers.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/MDS30QM-Manual.pdf
SHORT AND LONG STAY DEFINED:
The quality measure short stay and long stay definitions are:
• The short stay quality measures include all residents in an episode whose cumulative
days in t he facility is less than or equal t o 100 days at the end of the target period.. An
episode is a period of t ime spanning one or more stays, beginning with an admission
and ending w ith either a discharge or t he end of the target period (whichever comes
first ). At arget period is the span of time that defines the QM reporting period (e.g. a
calendar quart er).
• The long st ay quality measures include all residents in an episode whose cumulative
days in t he facility is great er than or equal to 101 days at the end of the target period.
An episode is a period of t ime spanning one or more stays, beginning with an
admission and ending with either a discharge or t he end of the target period
(w hichever comes first). At arget period is the span of time that defines the QM
report ing period (e.g. a calendar quart er).
http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-I nstr uments/N ursingHomeQualityI nits/NH QIQualityMeasures. html
LTC…A FUTURE VIEW:
QUALITY MEASURES
“Hospitals worried about readmissions should focus on nearby nursing homes'
pressure ulcer stats, study suggests” by Tim Mullaney
http://www.mcknights.com/hospitals-worried-about-readmissions-should-focus-on-nearby-nursing-homes-pressure-ulcer-stats-study-
suggests/article/342220/
“Out of various quality measures, pressure ulcer prevalence in particular
predicts w hether a nursing home w ill readmit residents to the hospital,
according to new ly published findings in HSR: Healt h Services Research.”
“Skilled nursing facilities w ith a high percentage of high-risk, long-stay
residents w ith pressure sores w ere more likely to readmit people to the
hospital, the researchers found. The percentage of long-stay residents
w ith an increased need for help also correlated w ith a facility's
readmission rate, they determined.”

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STATS…
WHAT ARE THEY AND HOW DO I DETERMINE THEM?
• M DS dat a creat es t he CM S Qualit y M easures for Indust ry Report ing and
Benchmarking
• Accuracy of MDS data is paramount.
• QMs are part of the 5 Star Reporting and each of our performance in this area is found on
Nursing Home Compare website.
• QIs are triggered by specific responses to MDS elements and identify residents who either
have or are at risk for specific functional problems needing further evaluation. QIs are
aggregated across residents to generate facility level QIs, which is the proportion of residents
in the facility with the condition. In a like manner, QIs can be aggregated across facilities to
generate the state level QIs presented in these reports. QIs are not definitive measures of
quality of care, but are "pointers" that indicate potential problem areas that need further
review and investigation. These data, at a nursing home level, are used by State survey
agencies to target survey and quality monitoring activities.
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MDSPubQIandResRep/qireports.html
STATS…
WHAT ARE THEY AND HOW DO I DETERMINE THEM?
Acquired Pressure Ulcer (PrU) Rates
• In House Acquired Methodology : Number of Residents with newly Acquired
PrUs/Current Census x 100
• Left open to interpretation, Time Frames can be manipulated, Small vs. Large
Census Variations, ultimately not a CMS Reportable Measurement versus…
• Pressure Ulcer Incidence Density Reporting (NPUAP):
• Incidence density is the best quality measure of pressure ulcer prevention programs,
according to the National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcer
incidence density is a computation based on the number of in-patients who
develop a new pressure ulcer(s) divided by 1000 patient days. Using the larger
denominator of patient days allows fair comparisons between institutions of all
sizes.
• Maybe the fair solution? Yet to be determined or recognized by CMS.
http://www.npuap.org/?s=incidence+density
THE 3 CS OF
SKIN AND WOUND CARE
“We don’t know as much as we think we know”
-a quot e by David Thomas, M.D., FACP, AGSF, GSAF, CMD at the International Nursing
Home Research Conference
Nursing homes should adopt evidence-based approaches t o pressure ulcer prevention
and t reat ment, but significantly more research is needed t o support this goal, a professor
of geriat ric medicine said inNovember.
“W hat we have been facing inthe care of pressure ulcers in nursing home is dogma.W e
desperat ely need people in nursing homes to do clinical research,” said David Thomas,
M .D., of the Saint LouisUniversity School of Medicine,where the Internat ional Nursing
Home Research Conference was held Nov. 22nd and 23rd.
There are only 51 research papers on pressure ulcers inworld literat ure, Thomas said in an
art icle by Elizabet h Newman of McKnight’s…
http://www.mcknights.com/thomas-additional-pressure-ulcer-research-trials-a-must/article/328490/ and
http://www.mcknights.com/pressure-ulcer-treatments-should-be-re-evaluated-expert-says/article/322469/

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THE 3 CS OF
SKIN AND WOUND CARE
Further, McKnight’s Tim Mullaney ironically brings “clarity” concerning
w ound care “confusion” in his titled article, “Wound care research is
poor, show s little progress tow ard advanced treatments, analysis finds.”
Research on w ound care therapy tends to be poor and reveals few
insights for new treatment options, according to Johns Hopkins
researchers.
http://www.mcknights.com/wound-care-research-is-poor-and-has-few-answers-review/article/333861/
THE 3 CS OF
SKIN AND WOUND CARE
• LTC providers need to start somew here regardless of w hat ex perts and
research do or don’t know .
• Our starting point needs to be w ith w hat w e “do know ” as it relates to
the clinicians w ho are providing the skin and w ound care - regardless of
research, product, w ound type, assessment or resident population mix .
• There is much variation in understanding w hat are the "best practice"
standards for w ound care and w ound healing.
• Wound Care programs are complicated by many factors and is a
constantly evolving and many times confusing science.
THE 3 CS OF
SKIN AND WOUND CARE
• Controlling variables in skin and w ound care programs is difficult but key
so healthcare providers can attempt to identify the root cause.
• There is even a greater variation in clinician aptitude, attitude and
application as it relates to w ound care and w ound healing.
• These are variations w e can control or at least standardize and
influence to achieve successful LTC Skin and W ound care programs.
For these reasons, Healthcareproviders should focus on the
clinician to improve upon wound care and wound healing.

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THE 3 CS OF
SKIN AND WOUND CARE
• W e should t ake an approach t hat has less emphasis(not abandoning) on
"best pract ice" and more emphasis on clinician apt it ude, at t it ude and
applicat ion.
• For even t he best programs focused solely on “best pract ice” can
complet ely miss t he boat on t he one common denominat or of a successful
program- the clinician w ho is t o carry out t he “best pract ice”.
This is done in three steps called…
The 3 C's of Skin and Wound Care!
THE 3 CS OF
SKIN AND WOUND CARE
• We must demand and achieve clinician COMPETENCE;
• By achieving clinician competence you gain clinician CONFIDENCE;
And finally
• By utilizing CONTINUOUS QA practices you w ill achieve a successful,
impactful, marketable skin and w ound care program w hile ensuring your
clinicians have continued competence and thus confidence.
THE 3 CS OF
SKIN AND WOUND CARE
By implementing the 3 C’s of Skin and Wound Care, providers can
improve their overall success in w ound prevention and healing by first
addressing their clinicians-the constant-and improve your facility’s ability
to adjust and react to- the variables- of a skin and w ound care system.

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THE 3 CS OF
SKIN AND WOUND CARE
Before w e ex plore the 3 Cs, it is important to recognize the primary roles of
the CNA, Nurse and Therapist in a successful skin and w ound care
program.
• All clinicians can fall into one or more categories labeled Preventer,
Predictor and Promoter but each has a primary role in skin and w ound
care and ultimately w ound healing.
THE 3 CS OF
SKIN AND WOUND CARE
The CNA is primarily a Preventer-The Most Important Player.
• CNAs should be focused on carrying out the established plan of care
that addresses risk. A CNA’s role does not end there. CNAs are key to
early detection of declines and potential skin issues. The Nurse/Therapist
to CNA relationship is pow erful and important. Empow ering the
Preventer to act on behalf of the resident to challenge and shape the
plan of care is paramount to a successful program.
THE 3 CS OF
SKIN AND WOUND CARE
The Nurse is primarily the Predictor-
• Nurses are focused on identifying those at risk and predicting potential
for w ound development as w ell as predicting overall healing potential
based on assessment and health information. Nurses establish the
primary plan of care for the CNAs to carry out based on these
predictions. Prediction is repeated through routine re-assessment by the
Nurse and must include CNA feedback to ensure timely and adequate
adjustment to the plan of care.

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THE 3 CS OF
SKIN AND WOUND CARE
The Therapist is primarily the Promoter-
• Therapists are focused on promoting w ell-being, maintaining highest
level of mobility and teaching the importance of good skin care,
disease management and compliance to established plans of care.
Therapists also provide w ound healing promotion through w ound
healing modalities, active w ound care including various types of
debridement as w ell as identifying and teaching the most appropriate
turning, repositioning and transfer protocols. Like Prediction, Promotion
strategies are also routinely re-assessed by the Therapist and also must
include CNA feedback to ensure timely and adequate adjustment to
the plan of care.
THE 3 CS OF
SKIN AND WOUND CARE
Now that we understand the roles of
our LTC clinicians in a successful Skin
and Wound Care Programs, lets
explore
The 3 Cs…
THE 3 CS OF SKIN AND WOUND CARE:
COMPETENCE
Competence:
There are many w ays to ensure competence.
The Preventer, Predictor and the Promoter all must achieve
competence.

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COMPETENCE: CNA
CNA (Preventer) Competence: As previously stated the CNA is truly the
most important clinician for prevention.
The Preventer provides the “by the minute” routine care that ultimately
determines the success of a skin and w ound care program. Without the
CNA’s buy in and application of prevention strategies, no program can
succeed.
COMPETENCE: CNA
Competency for CNAs consists of several pertinent areas including but
not limited to:
1. Understanding their key role in prevention
2. Understanding how the skin w orks
3. Importance of and performance of turning and repositioning
4. Hydration and nutrition importance
5. Identifying declines in conditions and new skin issues and reporting
timely and appropriately
COMPETENCE: CNA
Strategies to gain competency and empower your CNAs may include
but not limited to:
1. Compliance to providing a solid and consistent orientation on skin and
w ound care developed by the Interdisciplinary Team.
2. CNA class on skin and w ound care tailored to their skill level. Include
competitions and prizes to make it fun.
3. Wound care vendors providing training on prevention products.

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COMPETENCE: CNA
Strategies…
4. Turning, repositioning and transfer training w ith return demonstration
5. Restorative nursing training focusing on how to carryout mobility,
Range of Motion, pain management, and device/splint management
w ith skin checks
6. Identifying a strong lead competent CNA to be an influence and
peer reference.
COMPETENCE: NURSE
Nurse (Predictor) Competence: LTC nurses vary in skin and w ound care
ex pertise. LTC providers often times do not have the benefit of facility
level or Regional Wound Care Ex perts or Specialists to directly support
their facility nurses. It is certainly beneficial to have such support but it is
not impossible to gain nursing competence w ithout it. Adequate and
thorough prediction does not require specialization just competence in
risk and know ing your available resources.
COMPETENCE: NURSE
Competency for Nurses consists of several pertinent areas including but
not limited to:
1. Understanding their role in prediction of risk for developing skin issues;
2. Understanding how the skin w orks;
3. Importance of monitoring and enforcing turning and repositioning;
4. Appropriately seeking Registered Dietician intervention for max imum
hydration and nutrition plans.

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COMPETENCE: NURSE
Strategies…
5. Acting upon declines in conditions and new skin issues quickly
through thorough assessment and seeking necessary referrals;
6. Skills check off for non-sterile dressing changes and NPWT dressing
changes;
7. Ensuring optimal Preventer and Predictor communication and
empow ering the Preventer.
COMPETENCE: NURSE
Strategies to gain competency and empower your nurses may include
but not limited to:
1. Compliance to providing a solid and consistent orientation on skin and
w ound care developed by the Interdisciplinary Team;
2. Thorough in-servicing on product formulary, assessment and
documentation standards;
3. Wound care vendors providing training on prevention products.
COMPETENCE: NURSE
Strategies…
4. Turning, repositioning and transfer training w ith return demonstration;
5. Restorative nursing plan development w ith assistance of therapy
focusing on mobility, Range of Motion, pain management, and
device/splint management w ith skin checks;
6. Identify a strong lead competent Nurse to be an influence and peer
reference-doesn’t have to be certified, ex pert or specialist…Just
Competent.

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COMPETENCE: THERAPIST
Therapist (Promoter) Competence: LTC Therapists ex pertise in skin and
w ound care also varies provider to provider. Investing in Therapy w ound
care ex perts could pay off as there is great potential to reduce
unnecessary outsourcing of w ound care services and the potential to
ex ponentially improve prevention and healing times. Highly skilled
Therapists in the area of skin and w ound care can be your internal
resource for consistently achieving and maintaining competence for the
Preventer and the Predictor. This can only be done by achieving
Promoter competence first.
COMPETENCE: THERAPIST
Competency for Therapists consists of several pertinent areas including
but not limited to:
1. Understanding their role in prediction of risk for developing skin issues
and how skilled therapy can impact risk;
2. Understanding how the skin w orks;
3. Importance of monitoring and enforcing turning and repositioning and
how to teach other clinicians and the resident the importance of and
safety during and use of positioning devices.
COMPETENCE: THERAPIST
Strategies…
5. Acting upon declines in conditions and new skin issues quickly
through responding timely to referrals from nursing and physicians;
6. Skills check off for non-sterile dressing changes, NPWT dressing
changes, Compression Therapy, Unna’s Boots, etc.;
7. Additional skills check offs for all types of debridement techniques
and w ound healing modalities;
8. Ensuring optimal Preventer and Promoter communication and
empow ering the Preventer.

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COMPETENCE: THERAPIST
Strategies to gain competency and empower your Therapists may
include but not limited to:
1. Compliance to providing a solid and consistent orientation on skin and
w ound care developed by the Interdisciplinary Team;
2. Thorough in-servicing on product formulary, assessment and
documentation standards;
3. W ound care vendors providing training on preventionproducts;
4. Skin and W ound Care Documentation and billing standards review .
COMPETENCE: THERAPIST
Strategies…
5. Assisting in developing restorative nursing plans for mobility, Range of
Motion, pain management, and device/splint management w ith skin
checks as w ell as deem CNA and Nurses competent in restorative
nursing through skills check offs;
6. Identify a strong lead competent Physical Therapist to be an
influence and peer reference;
7. Develop and train on w heelchair, cushion and therapeutic support
surface formulary related to risk levels.
SUGGESTED AREAS FOR
COMPETENCIES
BY DISCIPLINE OR EXPERTISE
Competencies are needed for all clinicians:
*Hand-w ashing
*Turning, Positioning and Transfers
*Skin and Wound Care Orientation Policy and Procedure Content
*Therapeutic Support Surfaces

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SUGGESTED AREAS FOR
COMPETENCIES
BY DISCIPLINE OR EXPERTISE
Additionally, Nurses require competency in:
*Braden or Norton Risk Tool
Nurses and Therapists require competency in:
*Non-Sterile Dressing Changes
*Negative Pressure Wound Therapy
*Unna’s Boots and Compression Wrapping
*Mist Therapy
Therapists require competency in:
*Wound Healing Physical Agent Modalities
SUGGESTED AREAS FOR
COMPETENCIES
BY DISCIPLINE OR EXPERTISE
Therapists(refer to state practice act) and Certified Wound
Specialists(nurses or therapists) require competency in:
*Debridement
*Silver Nitrate Application
*Doppler for ABI
THE 3 CS OF SKIN AND WOUND CARE:
CONFIDENCE
Confidence:
All clinicians w ill gain confidence by repetition and consistency of the
provider (facility) to support them.

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CONFIDENCE
Strategies to ensure the Preventer, Predictor and Promoter achieve
confidence in Skin and Wound Care include, but are not limited to:
• Facilities should never assume clinicians “get it”.
• Provide repeat trainings;
• Do unannounced skills check offs ex . Non-sterile dressing change;
• Avoid making changes to formulary unless systematically rolled out;
• Demand quarterly trainings to your staff by your formulary vendors;
• Don’t forget the night shift!
CONFIDENCE
Strategies…
• Create a meaningful rew ard system for your staff w ho are compliant,
positive and achieve outcomes.
• All levels including administration needs to know the program, the
formulary and understand and promote the philosophy of skin and
w ound care for your facility so staff can be confident and never feel
undermined.
• Empow er your staff, w hich means you believe they are competent,
w hich will breed confidence.
• Seek specializations for staff members that show interest in the area of
skin and w ound care.
• Create a culture that encourages and establishes the ex pectation for
skilled therapy participation in the w ound care program.
USE OF FACETIME VIA IPHONE
FaceTime can be a very simple way to assist your clinicians ingaining confidence in all
areas of w ound care.
FaceTime is “real t ime” and leaves no evidence behind that can create a HIPPAissue.
Considerat ion by each end user for privacy during FaceTime is key as well as consent
from t he resident or RP.
Regional Expert or Compet ent Clinician can supervise advanced skills like
debridement and help direct t he clinician during their learning phases.
FaceTime can eliminat ethe need for outsourcing wound care, can reduce expense,
can ensure proper assessment and timely interventionsto achieve expedited healing
and ult imately gain clinician confidence.
A specific benefit of reducing or eliminating outsourcing is that it encourages the
facility’s ownership of the wound care program and the necessity for a comprehensive
treatment plan to established by the Interdisciplinary Team. Outsourcing typically only
deals with which dressing to use or leads to more extrememeasures that are not
necessarily needed.

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THE 3 CS AND
FACETIME EFFECT
 Increased number of
available competent
therapists by 63%
 Decreased number of
facilities outsourcing
w ound care by 85%
THE 3 CS AND
FACETIME EFFECT
 Decreased in house
acquired rate by .52%
 Decreased QM for High
Risk from 9.2 to 7.2 or by
22%
THE 3 CS OF SKIN AND WOUND CARE:
CONTINUOUS QA
Continuous QA:
Without continuous Quality Assurance no facility can confidently know
their staff is competent or confident in skin and w ound care. Areas QA
should focus on include but are not limited to
• Review ing the skin and w ound care systems:
• Do they w ork?
• Are w e compliant to them?
• Do w e get the desired outcomes w e w ant?

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CONTINUOUS QA
• Training and Orientation:
• Is it provided and provided consistently?
• Is it appropriate and contain all necessary information?
• Are competencies performed and validated?
• Facility Wound Caseload:
• Acquired vs Admit w ith rates;
• Staffing to volume and ex tent of w ounds is appropriate;
• Product and prevention tools (Par Levels) are adequate and
available to the clinicians.
CONTINUOUS QA
• Community Recognition and Referral Sources:
• Is your facilit y know n for “good” or “bad” w ound care?
• Is w ound care your niche?
• Are your vendors reflect ing posit ively or negat ively on your facilit y?
• Do you market your t eam’s specializat ions and advanced w ound care
approaches?
• Survey Success:
• Is your skin and w ound care syst em support ing good survey out comes?
• Do your Human Resource records show current compet encies?
• Does your st aff demonst rat e confidence during t he survey process?
• Are your vendors accessible and support ive during t he survey process?
LTC…A FUTURE VIEW FOR QUALITY
MEASUREMENT
Quality Assurance and Performance Improvement
CMS QAPI VIDEO
• https://w ww.youtube.com/w atch?v=XjkNNEjO_Ec#t=542
• http://w ww.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/NHQAPI.html

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THE 3 CS OF SKIN AND WOUND CARE:
TRADE SECRETS
Invest in an Ex pert and then train the Trainer.
Start w here your staffing is strongest and most stable and w here you w ill
get immediate buy in. Then use this success to mentor other sites and
ex pand.
Try FaceTime.
Establish ex pectations for reporting time frames, standardize content
and force review cycles.
Max imize your vendor resources for education and support.
Organize your promotional materials and be consistent in your delivery
to your stakeholders.
THE 3 CS OF SKIN AND WOUND
CARE: TRADE SECRETS
Establish and prioritize need for oversight.
Meet educational needs routinely and be able to identify deficits for
“ex tra” training.
Commit to a thorough orientation program at all levels.
Anticipate barriers.
Be positive and ex pect push back.
Survey your teams and humble yourself to the results to improve the
program.
THE 3 CS OF SKIN AND WOUND CARE:
ASK YOURSELF
Does your organization “assume” you have an effective and marketable
skin and w ound care program or does your organization “know ” it? The
only w ay to know it is to do the homew ork. If you are not sure how to get
started consider researching the CMS Quality Assurance and
Performance Improvement (QAPI) program for guidance at
http://cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/NHQAPI.html.

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THE 3 CS OF SKIN AND WOUND CARE:
GET BUSY!
The science and philosophy surrounding skin and w ound care to define
best practice is constantly evolving. Meanw hile, adopting the 3 Cs
approach, LTC providers can achieve competence and confidence for
the constant of skin and w ound care-your clinicians-and by applying
continuous QA achieve success.
THE 3 CS OF SKIN AND WOUND CARE:
FINAL ADVICE
Consider a 4th C: Consistency…
Your staff w ill benefit most by your support and approach to a skin and
w ound care program being CONSISTENT!
Consider a 5th
C: Creativity…
As long as your residents’ needs are met there are no other rules! Make it
fun, be unique and connect w ith your team’s creativity.
THANK YOU!
Tara Roberts PT
318-286-3533 Cell
484-233-8069 Fax
Troberts1@Comcast.net
Troberts@Nex ion-health.com
Cari Normand PT, CWS
318-780-3747 Cell
414-375-3668 eFax
Cnormand@Nex ion-Health.com