CME-MOC

Time Stamps

Show Notes

Subacute Rehabilitation in Skilled Nursing Facilities 

  • Terminology  
    • SAR (subacute rehab) and SNF (skilled nursing facility) refer to the same disposition option and are often used interchangeably.
    • To break it down to semantics: Subacute rehab refers to the array of services that take place WITHIN a physical building called a skilled nursing facility
  • Type of care provided
    • Specific skilled needs (such as PT or OT) that would be difficult or too complex to obtain at home
    • Notably, oversight is different than at the hospital, with one nurse assigned to many patients, and often sparser clinician (NP/PA/MD) supervision. 
  • Coverage
    • Covered by Medicare and therefore, easier to get a bed approved for patients who qualify based on nursing or therapy needs

Long-Term Care Facility or Nursing Home

  • Type of care provided
    • Nursing home patients require closer supervision with their daily activities (eg bathing, dressing, feeding, toileting) that they are not able to feasibly receive at home
    • Medication management and intermittent vital signs are performed by nurses, but these patients do not require intensive skilled care such as rehab services, IV antibiotics etc like they may in subacute rehab
  • Payment 
    • Covered by:
      • Out-of-pocket payment by the patient/family (usually referred to as a “spend down”)
      • A special form of insurance called a long-term care plan (paid into much like life insurance, but for the purpose of long-term care)
      • Medicaid if the patient qualifies (state specific requirements)
    • Not covered by: 
      • “Traditional” private insurance plans
      • Medicare 

Assisted Living Facility

  • Type of Care Provided
    • These facilities are highly variable in what services and level of support they provide residents and can have multiple different levels of care based on an individual patient’s needs
    • Aides are typically on-site 24-hours a day with one nurse who oversees their care of patients rather than a traditional nursing role
    • There are three levels of care provided at an assisted living facility
      1. Independent living or “senior” housing: most independent with residents living in their own apartment and partaking in meals and/or activities as they desire
      2. True “assisted living”: a la carte services available to assist with activities of daily living (ADLs) & independent activities of daily living (IADLs)  based on resident’s individual needs
      3. Memory care: higher level of supervision and oversight by nursing staff and aides for residents with moderate-severe dementia; often includes medication management and units often locked to prevent risks of wandering
  • Payment
    • Can be very expensive depending on the support needed. 
    • Vast majority are paid out of pocket, though some states have a certain number of apartments per facility that are reserved to support lower income patients

Acute Rehab

  • Type of Care Provided
    • To qualify, patients must be able to participate in 3 hours of combined skilled therapy (e.g. PT, OT, speech & language therapy) per day which is a big distinction compared to a SAR (<3 hours therapy/day)
    • Typically shorter stays (eg acute stroke) with plan to transition to SAR or home once more intensive therapy goals are met
  • Payment
    • Medicare or private insurance

LTACH (Longterm Acute Care Hospital)

  • Type of Care Provided
    • The most acute level of care besides an inpatient hospital stay
    • Requirements for admission are facility/insurance dependent, but usually require complex management and intensive clinician oversight (eg. tracheostomy care, vent management, severe wound infections requiring complex management)
    • Typically a MD is in-house or on-call 24/7 and there is a lower nursing:patient ratio than in other types of after-hospital facilities described above
  • Payment

Home with services

  • Type of Care Provided
    • Must be able to maintain some level of independence, unless more intensive care is needed that family or home health aides are able to provide
    • Skilled services can be performed by: visiting nurses, physical or occupational therapists, or speech and language pathologists (SLP). An attending physician would certify the need through completing a Medicare Face to Face on discharge
    • A Face to Face is a form required by Medicare that certifies that the patient is “homebound” (has reasonable hardship getting out of the home for office visits for services), has a diagnosis that requires skilled services, and which services are required
    • It is also helpful to include who the consulting skilled provider should call with issues as well as symptoms or parameters for when to call   
  • Payment
    • Skilled services are paid for by Medicare or private insurance
    • Home health aide support for ADLs/IADLs typically paid for out of pocket or through Medicaid 

Transcript

Sometimes I don’t even know the point of multidisciplinary rounds- it’s such a time suck. It interrupts my morning. PT just tells us where they go and SW just needs to make it happen. Why do they keep bothering me about where this person is going?

Shreya: Sad to admit but there was a time early on when I thought “oh waiting for placement, not medically active” moving on – not my problem – the more I did patient care, the more I realized I had large knowledge gaps about where I was sending my patients to.

Ryan: You are not alone. I used to have no idea what my role was in discharge planning, or even that I had a role at all. But when I became a geriatrician, that all changed. I’ll give you an example… Recently I cared for a patient who had dementia and was admitted because of safety concerns at home. He couldn’t take care of himself at home, he didn’t have the needs to qualify him for rehab.  And the CM & family members were looking to me for the recommendation on where he should go next.

Gaby: Yeah, would this patient go to a nursing home? An assisted living facility? Home with services like visiting nurse, HHA, or adult day health? 

Ryan: Right, there are so many options. And if I didn’t know from my training what these places could offer, how could I advocate what would be the best for him?

Shreya: And that’s exactly what we hope to do today: break down our many different dispo options for patients: There’s subacute rehabs, skilled nursing facilities, nursing homes, assisted living, LTACHs or acute rehab and theres more so, first we start with 1) what are differences in resources that each of these places offer for our patients

Gaby: Number 2) We’ll clarify which patients are even eligible for which dispo options

Ryan: Number 3) how insurance impacts decisions about where patients go 

Shreya: And lastly, number 4) How much is actually covered. Be in the know about the bill that your patient may or may not have to face going to these places.

Ryan: The point is not to remember all the details we’ll discuss….especially the finances. We recognize they are very complex, even for someone like me who lives and breathes this stuff on a daily basis. Things are always changing and some of it (as we’ll highlight) is state specific. 

Shreya: But our hope is you will feel more empowered when working with an interprofessional team on disposition decisions and more informed when guiding your patients and their families through these decisions.

And that brings us  to Episode 3 of our Interprofessional Series focusing on discharge options. I’m Dr. Shreya Trivedi, a general internist at NYU. And I’m joined again by:

Ryan: I’m Dr. Ryan Chippendale, a geriatrician at Boston University.

Gaby: And I’m Dr. Gaby Mayer, an intern at NYU.

Shreya: In this series, we hope to highlight the perspectives of people that we don’t usually get to hear and go to places we don’t go, particularly when most of us spend time in clinics and in hospitals.

Ryan: Speaking of going places we don’t usually get to go, let’s play a little game I call “Oh, the Places You’ll go”

Gaby:  A little Dr. Seuss throwback! More like “Oh, the places you’re patients will go!!”

Shreya: It’s like Congratulations! Today is your Discharge Day!

You have enough oxygen in your lungs

You have passed your trial of void

You worked with physical therapy

Oh the places you’ll go!

After we await prior authorization woes!

SUBACUTE REHAB (SAR OR SNF)

Ryan: Shall we first venture into the most common discharge destination? The SAR which is also known as Subacute rehab.

Gaby: Something I found very confusing, even after researching this, is the difference between a SNF and a SAR. Can someone please enlighten me here?

Ryan: Well you have a right to be confused….because basically they are the exact same thing! 

Gaby: Really then why not just pick one word?

Ryan: Wouldn’t that be nice? The terms are often used interchangeably….But if you want to really break down to the nitty-gritty nuances: a SNF refers to a Skilled Nursing Facility which is the building or facility where SAR, or subacute rehab, takes place. 

Gaby: Okay so we are taking facility vs. services.

Shreya: As a hospitalist, I’ve sent a lot of patients to a SNF where that SAR happens, but I’ve never actually stepped foot into a skilled nursing facility. 

Ryan: Can I fill you all in on one of my geriatrics dirty little secrets – a SNF is actually a nursing home. 

Gaby: See this is why you have to have friends that are geriatricians!

Ryan: Yup. We give it the sexier name of a skilled nursing facility because the people who are eligible for subacute rehab have some skilled needs and get more services but the actual facility is the same as a nursing home.

Gaby: And by “services”at the SNF  you’re talking about some skilled need — like physical therapy, occupational therapy, medications through PICCs/midlines – that the patient can’t easily get at home. 

Ryan: And the other thing to think about when considering a SAR, is that the patients have to be rehab-able, so it’s not going to be your bedbound or advanced dementia patient… it has to be somebody that physical therapy can actually improve their functionality. 

Shreya: Once these subacute rehab patients get to the SNFs aka nursing homes, what can they expect in terms of the number of nurses or clinicians – is it the same as hospitals?

Susan: Nursing homes, um, have to have on staff a certain number of registered nurses. The staffing ratio in the day is, is higher than in the nighttime and they generally then fill in everything else with either CNA, you know, certified nursing assistants or medical assistants.

Gaby: That’s Susan Hedlund, a social worker from OHSU. So to put some numbers to this: typically daytime staffing in these facilities can be 1 nurse to every 20-25 pts, and at nighttime 1 nurse is often covering an entire floor (maybe 40+ patients with only the help of a few aides).

Shreya: That’s very different from the hospital. Most of our medicine floors have 5:1 nursing:patient ratio and even they are running around with their plates very full. 

Gaby: So here’s is another knowledge gap, most SNFs are staffed by LPNs and I realized I didn’t know what an LPN even was and how that’s distinct from other nurses, like RNs.

Ryan: And again you are not alone. I actually had to look up what the acronym LPN stood for. LPNs are licensed practical nurses who only have 2 years of nursing education vs. a RN that you work with in the hospital, registered nurse, who has 4 years and a bachelors in nursing. 

Shreya: And Ryan, what’s the staffing like for the clinicians at most skilled nursing facilities?

Ryan: Yeah that clinician oversight piece shocked me when I started in geriatrics. So get this: New admissions are often “admitted” by phone by someone like me, who doesn’t know the patient or even work in the nursing home. And in my state of MA, where I work, the strict regulations are that any clinician (so this can be NP/MD/PA) is not required to see a patient up until 48 hours after admission.  

Gaby: And imagine what happens all those Friday discharges to SAR!

Ryan: And it’s almost impossible for you as the discharging clinician to know the level of oversight the patient will have once they get to the facility — there’s so much variability with the different practices out there. 

But one thing to keep in mind is that after that initial admission evaluation that happens within the 48 hours, the clinician is only required to see a patient every 30 days! Now most practices see subacute patients much more frequently, likely weekly or even more if they’re sick, but these are the bare minimum regulations, which are state specific.

Shreya: I’m so humbled by how much I didn’t know about subacute rehabs. And yeah, this is definitely going to give me pause before those Friday afternoon discharges especially for those more complex patients. I think it’s definitely so easy for us on the inpatient side to be like “Oh yes, SNF’s … they have capability to do x, y, z,”  but I can imagine it can be difficult with the level of supervision from both the clinician and nursing side of things?

Gaby: I will store that in my back pocket. The other thing I’ve always wondered is: who pays for subacute rehab services?

Shreya: In terms of insurance, it’s really going to patients who have medicare that will give their SAR stays covered. I never really understand why my SW and CM on multidisciplinary rounds would remark “Oh that patient has medicare, it should be an easy placement” until now.

Todd: Patients would go and they can stay on their Medicare benefits. It’s up to a hundred days, um, for your rehab needs. Um, the first 20 are covered a hundred percent with no copays by Medicare. And then the next 80 have copays. Uh, one of the things you look at in that situation is, is what their secondary insurance is.

Shreya: That’s Todd Selmer, a case manager from University of Utah. And by secondary insurance, Todd is talking about if the patient also has Medicaid or some other private insurance that may pick up the 20% co-pay for the skilled nursing facility. 

Todd: If they have a secondary insurance that the copay is covered for the.. 80 days. Um, copays – typically, last time I looked, I think there were about $150-$170 a day, which is kind of out of reach for most people.

Ryan: In case you aren’t doing the math in your head, that would be an out of pocket cost of $5,000 for one month. I don’t know about your guys’ patient population, but that’s definitely out of reach for my 99% of my patients. I couldn’t even afford that!

Gaby: That is definitely more than my monthly rent and food combined.

Shreya: And the crazy thing about those dollars per day is that we don’t know how long patients are going to stay there for in subacute rehab beds, they can be there for weeks but for some complicated patients they can stay in rehab for months. 

Ryan: And in that vein, many of our patients voice frustration because we tell them they are going somewhere to get “stronger” but in fact once they get there, they only work with therapy a few times a week for a few hours at most. 

Shreya: More on that in a future interprofessional episode on PT!

Ryan: Ooo can’t wait for that. So for me it’s important that we don’t over-sell it, because we don’t want them frustrated when they get there but at the same time highlight the importance of SAR as a bridge to get these patients home safely.

Gaby: So to summarize: a SAR takes place in a SNF (which is a physical nursing home). It’s a place for patients with specific skilled needs (like PT or OT) that they can’t easily arrange for at home. It’s worth noting that oversight is different than at the hospital, with one nurse assigned to many patients, and sparser physician supervision. On the subject of insurance, one quick take away: can be easier for Medicare patients to get coverage.

LONG TERM ACUTE CARE FACILITY/NURSING HOME

Gaby: So now that we are on the same page about subacute rehab, what actually are the differences between patients who are good candidates for a SAR bed vs a nursing home bed?

Susan: Let’s say you have a frail, elderly person who needs help with bathing, with feeding, and with walking, right? But doesn’t have anything acute medical. And so that’s, that’s a lot of our frail elderly, right? So a lot of our frail elderly who need some assistance, but um, don’t need a lot of medical intervention per se. 

Shreya: So it sounds like a nursing home patient may have some medications that need management, some intermittent BP monitoring, but it is not the level of care or therapy that the SAR patients have. And it’s more that the NH home patients require assistance with their ADLs and their family can no longer provide or afford the 24/7 care that the patient needs at home

Ryan: Right, and that’s why the nursing home level patients are often commonly referred to as long-term or custodial care residents… it’s because they live there. And in many nursing homes, these long-term care residents are mixed among subacute (SAR) patients.

Gaby: And that’s why that staffing ratio of  1 nurse: to 20ish patients is usually the same as what one would expect for the subacute rehab patients, the nurse might actually be taking care of some long term care residents and some subacute patients. At least from an acuity standpoint, that sounds like a healthy mix of patients

Ryan: Yes it does, but trust me, it doesn’t mean that those long-termers can’t become active from either a medical or behavioral standpoint which can get very busy, very fast. And I’ll tell you that’s exactly what’s happening with the COVID pandemic right now. These longterm-ers are getting very sick alongside the already sick subacute patients and the nurses are really stretched thin. 

Gaby: There are lots of policy lessons to be taken from the COVID pandemic – is there an MD oversight difference? What is the MD oversight for nursing home residents?

Ryan: In my state of MA, the strict regulations state that nursing home residents only have to be seen by an MD every 120 days. That’s every 4 months!! Again, they are often seen more regularly by many nursing home docs, especially if those acute issues come up, but I like to think of these more like complex but stable primary care patients that you would only be seeing in the office every 3-4 months.

Shreya: Thats an analogy I hadn’t thought of! I have another question for you guys, who pays for the nursing home bed? 

Gaby: Nursing home care is generally paid for either privately (out of pocket or longterm care insurance bought by the individual) or by Medicaid, NOT Medicare. Note that I didn’t say anything about regular private insurance – those don’t cover nursing home care. 

Shreya: As someone who is not a health policy wonk, the teaching point is: our patients who have Medicare get their subacute rehab stays covered and patients who have Medicaid can get nursing home level stays covered. But another thing i’ve noticed is that it takes soo long for us to find those medicaid patients a  nursing home level bed !

Ryan: Let me break this down on how and why this could be..  If I’m a nursing home administrator trying to keep my nursing home financially sound and say I have 10 beds available. Medicare is going to pay me a significant amount more for subacute patients lying in those beds, rather than Medicaid will pay me for longterm care residents. So If I’m that nursing home director, I want as many Medicare patients in my facility as possible…. So i get higher payments  

Shreya: Ah moneyyyyy!

ASSISTED LIVING FACILITY (ALF)

Gaby: Ok, so now I think I have SAR and nursing home patients straight. But what about assisted living facilities? I think they remain the biggest enigma in this whole schema of dispo options.

Ryan: Agree and that’s the big black hole and that’s because there’s a lot of variability in each assisted living facility & on what patient makes a good candidate for them. I’ll give you a general rule of thumb, patients in assisted living facilities are more functional and have some level of independence in their activities, but require more assistance than they can get at home. 

Gaby: So this is much more like living at home with a home health aide than it is a “formal” nursing home?  

Ryan: Correct. Typically the care is performed entirely by aides at assisted living facilities, NOT nurses like in the nursing home. There usually is 1 nurse on site who is responsible for supervising all of those aides, but he or she  does not have a traditional nursing role. They don’t pass meds or check BPs like we talked about in SARs or nursing homes. If a patient is sick, they will call the PCP or send the pt to the ED.

Shreya: Something else I learned is: not all assisted living facilities are the same – some of them (not all) have different levels of care under one roof or within one complex of buildings.

Ryan: Yes just to set this up – there’s 3 levels of care we think about with these facilities. 1. Independent living or “senior” housing, 2. The true Assisted living level of care, and 3. Memory care.  Let’s start off with  Senior Housing: 

Susan: So those are like apartments and people can come down for meals or not depending on what they need. But there are people available around the clock so that if they have an emergency or um, they need some help if they’ve fallen, you know, there are people in the building at all times, but essentially the person has to be independent in their adls, able to feed themselves and bathe and dress and all of that.

Shreya: The next level is the “true” Assisted living level care which has  “a la carte” services that are tailored to each individual residents’s needs:

Susan: Assisted living is one where you might have someone come to your room to give you medications, may help you with some bathing and just some general nonmedical assistance other than, you know, dispensing medication.

Todd: They have one nurse on at night and two aides for 60 patients. So a little bit of help, but not a lot. So most times people in assisted living settings are mostly independent.

Shreya: And then there’s memory care. This is the exception to the rule about nursing supervision. Usually this level of assisted living requires medication management and well-trained staff around dementia management, in addition to other support in activity levels.

Susan: And then the third category that exists in both nursing homes and assisted livings are memory care and memory care are usually locked units. And those are for people who have more advanced dementias. Um, and both nursing homes, assisted livings, you generally have both of those things available or have memory care available so that the idea is that people can age in place and stay in the same facility even if their care needs change.

Gaby: And I’ve been warned that there is a lot of variation from one assisted living facility to the next. 

Ryan: This is absolutely true for all the different facilities we’ve discussed but I do worry/think about variability most with Assisted livings.

Susan: I was working with a family recently that did have resources and they picked an assisted living that had lots of, in addition to food and assistance, they had lots and lots of social activities and different things that people could participate in. Other places have far less. And so I always encourage families to go and interview and see what services are included because a lot of times there’s an extra cost for the extra services that are added in.

Shreya:  As Susan alluded to, this can get pricey. The vast majority are paying out of pocket, though some states have waivers for patients who cannot pay. But is definitely on the higher price point.

Ryan: One last geri pearl is that usually our patients will not get discharged directly from the hospital straight to a new assisted living facility. The beds are hard to find and it requires a lot of paperwork & legwork mostly on the family and PCP side of things. So really they’re only going to be discharged to one of these facilities if they came from there. And if you think they need an ALF, you usually need a bridge plan until that can be arranged. 

Gaby: So to sum things up: assisted living facilities are what we’d traditionally think of as senior community living. These facilities have someone on-site 24-hours a day, but the level of care varies depending on the patient’s level of independence, and can range from full independence to, in memory care, more dependence on staff. But unlike a SAR, these patients have no skilled needs

Shreya: And given how much variability there is, think what I’m gonna take away is the next time I have a patient who gets admitted from an assisted living facility, is to ask about what resources they have available to them and if that place is still appropriate for them at discharge. 

ACUTE REHAB

Ryan: Alright the next few “places we’ll go” (bringing back that Dr. Seuss theme) will be relatively quick –we’ve gotten to the lightning round — because luckily these facilities have more narrow criteria for them! Say you have a physical therapy note that says ‘Patient would benefit from over 3 hours of therapy a day.’ When you are at those discharge planning rounds — where will you recommend that this patient goes?

Shreya: The 3 hour thing always makes me think of acute rehab. I’m trying to call up physiatry to make sure they’re aware.  Todd is going to explain which patients are good candidates for acute rehab:

Todd: Like if you’re getting around really well and then they can get you back up to your baseline pretty quick, then they go to an acute care rehab, which I think most stays are, you know, in that two week window and then back to home.

Shreya: The key to qualifying for ACUTE rehab vs. subacute is that patients have to be capable of doing > 3 hrs of therapy PER DAY. But this is all therapies combined – PT, OT, speech language pathology, etc that adds up to that 3 hour requirement

Gaby: Yes and similar to SAR, acute rehab is paid for by Medicare or private insurance.

LTACH

Ryan: For our next place, say you’ve been caring for a patient who needs trach care, on multiple antibiotics, needs complex wound care, and is just too “sick” for SAR. Where shall he go?

Shreya: Everytime I hear trach, especially if they are vent dependent, I think LTACH.

Ryan: The name truly captures what can be provided here. It’s short for Long Term Acute Care Hospital:

Susan: They are often utilized for people who don’t necessarily need to be in an acute care hospital any longer, but their care needs are so great that most nursing homes aren’t able to accept them because they have such, such high acute needs. It might be, um, a person who is still vent, vent dependent and not able to be weaned easily. It might be someone who, um, is, is fairly obese and needs a lot of assistance just in, in getting out of bed and ambulating, people with really difficult to heal wound care. Um, so they end up being in a subacute setting, uh, where they can get more nursing care and it’s under the supervision of, of their hospitalists in those settings. 

Shreya: As Susan just pointed out: unlike SAR, in LTACH there is always an in-house MD 24/7 and more nursing oversight.  

HOME

Ryan: And last, but certainly not least, let’s end with the best case scenario for all involved….that is home sweet home!

Gaby: We talked a lot about home care options in our first interprofessional episode on home health aides so hopefully this is not too unfamiliar to you.

Shreya: Yes and plug for that episode if you haven’t listened yet. The takeaway is if a patient is going home and needs some support, it’s going to come from skilled nursing agencies.  

Ryan: I would say the majority of my patients who get discharged require some kind of skilled nursing – whether that’s a visiting nurse to check on weights/BPs/BSs, or PT/OT to help them get them back to their functional baseline. 

Shreya: And to get support at home, they either need to have medicaid by meeting a certain income requirement. If the patient has medicare, an attending physician just has to certify that the patient is “homebound” — which basically means that they have a reasonable hardship getting out easily to appointments for, say, PT or to see a nurse in clinic.

Ryan: And that whole certification process is sometimes referred to as a “face to face”. It’s that ever-elusive form that we are always yapping about on discharge rounds. 

Shreya: Good news is it takes only a few minutes and many of your EMRs probably have a quick template you can pull up and route to your case manager or social worker.

Ryan: And something I always preach to my trainees in their discharge summaries and something we as attendings can be mindful of in our F2Fs is that it helps to be VERY specific about what you want the visiting nurse to do and when and who to call. So as an example: instead of writing “check BS” for someone who was admitted for hyperglycemia. I’ll write: please help the patient check &  log fasting blood sugars daily and call if their BS is  <70 or >350. Pretend you are writing orders for your visiting nurses just like you would be an RN on the floors. 

Shreya: Props for writing exact instructions and the exact number to contact. Often home care workers say that feel like they are in a limbo with whether they have any Qs or find a discrepancy like when they find three different beta-blockers at home — they will call the hospitalists who either they can never reach or says the patient was discharged and not my responsibility and on the other hand, the HHA will call the PCP who may say sorry i haven’t seen the patient since discharge and they would be in limbo about the next steps. 

Ryan: Alright, maybe we can Dr. Seuss summarize this episode

Shreya: This was harder said than done but I did my best with some of the big points:

But on you will go

Through the SAR which is in the SNF.

which from a nursing home may seem no diff .

but you’ll get different therapy you’ll discover.

And different insurances will cover

a frightening financial hurdle,

But on you will go

And if you are independent and have some wealth

maybe end up in assisted living facility for good health.

Today is your day!

Your transport is waiting.

So…get on your way!

Just call her Dr. Dreya!

No! Dr. Dre like Dr. Shrey!

I’m ready for motherhood!

Shreya: And with that’s a wrap for todays episode. If you found this episode helpful, please share with your colleagues or your team and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! 

If you want to add any of your own tips or share challenges, tweet us and leave a comment on our website page, on instagram or facebook page Thank you to Dr Kabao Vang from University Minnesota for the accompanying graphic, to Solon Kelleher  for audio editing, to peer reviewers Dr. Colleen Chritmas and Dr. Anna Goroncy as well as the case managers and nursing home directors for reviewing this episode and thanks to you!  

As always we love hearing feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions. 

Conflict of Interest: None reported

References


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