<<

Prosthetics: Getting the Most Out of What You Pay For Maximizing Functional Potential

PRESENTED Jennifer McCarthy, CP Agenda

• Understand some of the methods prosthetists use to objectively quantify functional potential of an injured worker

• Identify the differences between various prostheses

• Understand the importance of the socket design and fit in decreasing the rate of rejection for a .

• Recognize the impact of physical and on the overall success of the patient with the prosthesis

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME + COMPLEX CARE | | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Prosthetics Basics

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Limb Loss Statistics

• There are nearly 2 million people living with limb loss in the 1% • Approximately 185,000 amputations occur in the United States each year • In 2009, hospital costs associated with totaled more than $8.3 billion • Between 1996 and 2008, the rate of leg and foot amputations among Vascular Trauma Disease adults with diabetes declined by 45% 65% 54%

References: 1. Ziegler‐Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Archives of Physical and Rehabilitation2008;89(3):422‐9. 2. Owings M, Kozak LJ, National Center for Health S. Ambulatory and Inpatient Procedures in the United States, 1996. Hyattsville, Md.: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 1998. 3. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2009. 4. Fisher ES, Goodman DC, Chandra A. Disparities in Health and among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Robert Wood Johnson Foundation2008. 5. Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. Mortality Rates and Diabetic Foot Ulcers. Journal of the American Podiatric Medical Association2008 November 1, 2008;98(6):489‐93. 6. Pandian G, Hamid F, Hammond M. Rehabilitation of the Patient with Peripheral and Diabetic Foot Problems. In: DeLisa JA, Gans BM, editors. Philadelphia: Lippincott‐Raven; 1998.

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Distribution of Amputations

185,000 amputations per year Annual Amputations – Lower limb = 113,000 – Finger = 61,000 – Other Upper Limb = 11,000 Finger 33% Major limb amputations: 1 to 5 Upper to Lower

Lower Limb 61%

Other Upper Limb 6%

Lower Limb Other Upper Limb Finger

Reference: http://www.statisticbrain.com/amputee-statistics/

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Who Pays?

Other 2014 Uninsured 4% 7% • Total Amputations: 209,000 • Total Cost: $28.2 Billion • Does not include: Private 18% – Lost wages – Home modifications – Economic cost of death to Medicare society 58% – Unreimbursed costs

Medicaid 13%

Medicare Medicaid Private Uninsured Other

Reference: https://www.m3meetevents.com/ncvh/Documents/Material/NCVH16/2217_DB_1030_Mary_Yost_16by9_BB.pdf

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Work Related Amputations

• The CDC estimates that 3.4 million work- related injuries and illnesses were treated at U.S. hospital emergency departments in 2003

• Estimated 5,100 annual work related amputations reported - The Bureau of Labor Statistics (BLS)

• Study found the number of amputations following jobsite accidents in Michigan was nearly two-and-a-half times higher than the official estimate from the U.S. Bureau of Labor Statistics.

References: 1. http://www.foxnews.com/story/2006/04/28/cdc-over-3-million-work-related-injuries-and-illnesses-in-us.html 2. https://www.northcarolinaworkerscompensationlawyersblog.com/2016/03/work-related-amputation-results-osha-fine.html 3. http://msutoday.msu.edu/news/2013/federal-figures-miss-most-work-related-amputations/

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Operation Iraqi Freedom, Operation Enduring Freedom and Operation New Dawn

• Total number of amputation to date: approx. 1,650 • Peak number of amputations: June 2011 – July 2011: 78 • 2016: no amputations reported • Less troops, decreased intensity, change in nature of combat and ferocity of attacks

Reference: http://taskandpurpose.com/2016-milestone-amputations-military-iraq-afghanistan/

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Amputation Outcomes

• Amputations are life-changing events. • Claimants require a range of healthcare professionals, resources, and support from family and friends to help navigate the path to physical and emotional recovery. • Advances in medical procedures • Physical therapy helps patients return to their standard of life more quickly • Prosthetic limbs have become more comfortable and functional = FUNCTIONAL POSITIVE OUTCOMES!

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Initial Evaluation

How does the prosthetist decide which device is appropriate?

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Initial Evaluation

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Health History

• Complications from injury • Medications • Medical diagnoses • Previous therapy

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Review of Environment

• Home environment • Community environment • Support mechanisms

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Residual Limb Evaluation

Length Tissue Shape Other Length

Tissue Health

Pain and sensitivity

Short Bony Conical Volume stability

Scars and boney prominences Medium Muscular Cylindrical ROM Long Fleshy Bulbous Environment

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Prosthetist’s Evaluation

• Measurements • Current issues/complaints • Past prosthetic devices • Activities prior to amputation • Activities post amputation • Job Description • Describe process • Set expectations

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Outcome Measures

What objective tests exist that can help determine functional potential?

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Functional Classification Levels

• K0: The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance his or her quality of life or mobility

• K1: The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory

• K2: The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulatory

• K3: The patient has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or activity that demands prosthetic utilization beyond simple locomotion

• K4: The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Functional Classifications

• “Bilateral amputees often cannot be strictly bound by functional level classifications.”

• Bilateral amputees still must be assigned a functional level and given the appropriate componentry; however, if there is a well-documented clinical need for components that exceed a bilateral amputee’s functional level classification, the patient may receive components beyond his or her functional level.

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Outcome Measures: Lower Extremity

• Amputee Mobility Predictor – with prosthesis (AMP) • Amputee Mobility Predictor – No prosthesis (AMPNoPro) • Timed Up and Go (TUG) • 6-Minute Walk Test (10 minute) • PAVET (Hanger only) • Prosthesis Evaluation Questionnaire (PEQ) • L-Test

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Outcome Measures: Lower Extremity

The Amputee Mobility Predictor (AMP) is a quick and easily administered assessment tool to determine a lower limb amputee’s current functional status as it relates to mobility with a prosthesis, as well as establish the appropriate K- Level as described by Medicare.

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Amputee Mobility Predictor

• What is my current functional level or potential?

Functional AMP AMPnoPro Level K0 0 - 14 0 - 8 K1 15 - 26 9 - 20 K2 27 - 36 21 - 28 K3 37 - 42 29 - 36 K4 43 - 47 37 - 43

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Outcome Measures: Upper Limb

• DASH Outcome Measure – The of the Arm, and Hand (DASH) Outcome Measure is a 30- item, self-report questionnaire designed to measure physical function and symptoms in patients with any or several musculoskeletal disorders of the upper limb • What else is there ???

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Upper Limb Outcome Measures

Rejection rates are relatively high regardless of the type of prosthesis • body-powered prostheses: 26% (16-66%) • myoelectric prostheses: 23% (0-75%)

Carey SL, Lura DJ, Highsmith MJ. Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review. J Rehabil Res Dev 2015; 52(3): 247-262.

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Upper Limb Prosthesis Rejection

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Upper Limb Prosthesis Acceptance

Most important: 1. Patient involvement in prosthesis choice 2. Fitting Timeframe: “Golden Window” – within first 30 days of amputation if medically possible

Upper Limb Prosthetics: Factors that Influence Prosthesis Acceptance and Rejection; Andreas Kannenberg, MD, PhD – Executive Medical Director North America, AOPA World Conference Presentation September 2017

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Suspension and Socket Designs What impact does the socket have on prosthesis utilization, and function?

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Transtibial Suspension

Strap Sleeve Suction Suction Elevated with lock with/valve Vacuum Post-Op Preparatory All tissue Fleshy Definitive Definitive Definitive Boney Boney Fleshy Cylindrical Cylindrical Muscular Muscular All lengths All lengths Cylindrical Cylindrical Cylindrical Short Conical Short Medium All lengths Medium

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Transfemoral Suspension

Belt Suction Suction Elevated w/ valve w/ Lock Vacuum Post-Op Preparatory Definitive Preparatory Preparatory Pistoning Definitive Definitive Secondary Intimate fit Secure Most secure Suspension No volume Volume Technically All lengths change Fluctuation challenging Med, Long Short ,Med All lengths

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Osseostabilization: The HiFidelity Interface

• Skeletal control of prosthesis – High compression areas – Unrestricted flow of soft tissue • Mimics skeletal motion • Increased rotational control • Increased comfort • Increased • “I feel like the prosthesis is part of me.”

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Socket-less systems: Osseointegration

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Component Selection

What is the most appropriate device?

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. K Level Specified Components

Functional Level K2 K3 K4 Description Single speed + K2 + varied No restrictions uneven terrain cadence Activities Household chores Running Gardening Full-time work Basketball Cooking Yard work Jumping Cleaning Coaching Lifting objects Devices 4-bar C-Leg Genium X3 Flexible keel feet Genium Cheetah BiOM/emPOWER Carbon feet Samples

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Foot /Ankle Prosthetics

Conventional Passive Quasi-Passive Power

Elastomer Carbon Spring Microprocessor Powered Activation Bionic Emulation

SACH or FlexFoot Proprio EmPower SAFE Renegade or Elan

K1, K2 K3, K4 K3 K2, K3 Single speed Light, Durable Stairs, ramps Normalized ambulation Low activity only All activities Low to moderate Low to moderate

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Prosthetic

Conventional Passive Quasi-Passive PowerPower

Mechanical Mechanical Microprocessor Powered Activation Weight-activated Hydraulic Fluid Controlled

Safety-knee Mauch or C-Leg Power Knee Mechanical 3R80 Lock

K1, K2 K3, K4 K3 K3 Single speed Durable Stable, all terrain Stair assist, all terrain Low activity only All activities Low to moderate Moderate

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Finger Prosthetics

• Body powered mechanical fingers: x- finger, Naked Prosthetics • Myoelectric partial hand prosthesis: i- digits quantum • Silicone cosmetic restoration • Mechanical locking fingers: Point design, titan fingers

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Upper Limb Myoelectrics

beBionic i-limb Quantum Michelangelo Entry level multi-digit Hand Upgrade from beBionic Upgrade from i-limb

• Traditional electrode control ▪ 4 methods of control– ▪ Most durable on the market • Manual positioning thumb Gesture, App, Muscle, ▪ Faster than multi-digit hands • 14 grip patterns Proximity ▪ Stronger grip than multi-digit • Individual Motors in each finger ▪ Electronically rotating thumb hands • Palm design makes the hand ▪ 36 grips patterns ▪ Most natural looking

quieter than ever ▪ Variable digit-by-digit grip ▪ Most natural functioning ▪ Soft finger pads and a wide strength ▪ Integrated wrist motion thumb profile ▪ Titanium strengthened digits available

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Pattern Recognition

• Multiple electrode sites rather than conventional two-site • Control multiple devices: , wrist, hand • Pattern at which the myo-sites are signaled become learned or recognized by the Pattern recognition software. • “” training • More natural and intuitive • Less fatigue of the residual muscles • Reduces the potential of rejection or abandonment. • Can be used in combination with TMR (Targeted muscle reinnervation)

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Therapy Considerations

Once the prosthesis is delivered how can therapists help?

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Amputation Centers of Excellence Premier Regional Rehab Hospitals

One Call is proud of our relationships with Centers of Excellence and premier regional rehab hospitals Location Facility Location Facility

▪ Emory Hospital System ▪ Rusk Rehabilitation at NYU Langone Atlanta, GA New York, NY ▪ Shepherd Center Medical Center

Boston, MA ▪ Spaulding Rehab ▪ Hospital for Special Surgery-Limb Savage New York, NY and Amputation Reconstruction Center ▪ Carolina Rehab Charlotte, NC ▪ Rehab Center of Charlotte ▪ Mount Sinai - Amputation Specialty New York, NY Program ▪ Shirley Ryan Abilities Lab / Rehab Institute Chicago, IL of Chicago (RIC) ▪ Moss Rehab Philadelphia, PA ▪ Magee Rehab Durham, NC ▪ Duke University Hospital ▪ Amputation Prevention Center-Rose Pomona, CA ▪ Casa Colina Denver, CO Medical Center Richmond, VA ▪ Sheltering Arms- iReach Recovery Center Edison, NJ ▪ Johnson Rehabilitation Institute San Antonio, TX ▪ Reeves Rehabilitation Center Encinitas, CA ▪ Scripps Acute Rehab Englewood, CO ▪ Craig Hospital San Diego, CA ▪ Sharp Hospital ▪ San Jose Rehab Houston, TX ▪ TIRR Memorial Herman San Jose, CA ▪ Santa Clara Valley Medical Center Knoxville, TN ▪ Patricia Neal Rehabilitation Center Scottsdale, AZ ▪ Johnson Rehabilitation Institute La Jolla, CA ▪ Scripps Memorial Lincoln, NE ▪ Madonna Washington, D.C. ▪ MedStar National Rehabilitation Hospital

Littleton, CO ▪ Littleton Adventist ▪ Healthsouth Tucson, AZ ▪ Univ of AZ Medical Center Trauma Unit Louisville, KY ▪ Frazier Rehab Hospital

Nashville, TN ▪ Vanderbilt Health System West Orange, NJ ▪ Kessler Institute for Rehabilitation New Orleans, LA ▪ Touro - Limb Loss Rehabilitation Program Wheaton, IL ▪ Marianjoy Rehabilitation Hospital

Bold denotes recognized Center of Excellence

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Physical Therapy

• Basic including pelvic rotation for forward progression • Advanced gait training – Stair climbing – Running mode – Steep inclines • Identify changes in functional level

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Occupational Therapy

• Familiar with technology – Take advantage of features of the device – Trouble shoot issues – Collaborate with prosthetist • Facetime with manufacturers • Training with manufacturers • Community: bank, restaurants, grocery shopping • Home environment • Work environment and specific tasks

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Summary

• Initial Evaluation • Outcome Measures • Socket Designs • Component Selection • Therapy Considerations

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved. Thank you

DENTAL | DIAGNOSTICS | EQUIPMENT + DEVICES | HOME HEALTH + COMPLEX CARE | PHYSICAL THERAPY | TRANSPORT + TRANSLATE

©2018 One Call Care Management. All Rights Reserved.