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Intermittent Fasting COMPLETELY Reverses Type 2 DiabetesDiabetes management benefits -
This approach entails the collaborative efforts of care managers and FQHC providers, who synergistically work together to craft interventions that precisely tackle the distinctive hurdles confronted by each patient. Considering individual needs, circumstances, and medical histories, this cohesive team can forge customized treatment plans that maximize outcomes and enhance overall health and well-being.
Some of the treatment plans incorporated in integrative care include:. Patient education holds immense significance in diabetes care, and the inclusion of care managers amplifies educational efforts.
Care managers can provide personalized educational materials, conduct one-on-one counseling sessions, and facilitate group education programs. Diabetes Self-Management Education encompasses various aspects of diabetes management, such as:. Comprehensive patient education empowers patients to make well-informed choices and take control of their health by providing them with the knowledge and skills they need to manage their diabetes effectively.
This education is crucial for enhancing self-care behaviors, fostering adherence to treatment plans, and preventing diabetes-related complications. Effective communication is essential to successfully managing diabetes, and a team approach facilitates this crucial element.
With care managers acting as liaisons between patients and FQHC providers, there is a more seamless flow of information. This enhanced communication enables healthcare providers to make informed decisions and adjustments to the treatment plan, addressing any emerging issues promptly.
Additionally, care managers can reinforce healthcare provider recommendations, clarify instructions, and address any misconceptions or barriers patients may have, ultimately improving patient outcomes.
By focusing on preventive measures, including regular screenings and patient education, the team approach aims to identify and address potential issues early on, preventing complications that could lead to costly interventions.
For example, proactive monitoring of blood glucose levels, blood pressure, and cholesterol can help identify risks and enable timely intervention, potentially averting the need for hospitalizations or expensive treatments. Furthermore, the team approach promotes efficient resource utilization by coordinating care and streamlining communication among healthcare professionals involved in diabetes management.
So, a team approach to diabetes care that integrates care managers and FQHC providers offers many benefits to patients with diabetes. The Benefits of a Team Approach to Diabetes Care. Care managers, often nurses and trained professionals such as physicians, specialists, and therapists, work collaboratively with healthcare providers to ensure that patients have access to the necessary resources and interventions, including the following: Appointment scheduling Lifestyle modifications, e.
Increased Access to Care By integrating care managers and FQHC providers, the team approach ensures that patients with diabetes can access a wide range of essential services, including diagnostic testing, personalized dietary guidance, emotional and psychological support, and referrals to specialized services.
Better Coordination of Care At the heart of the team approach lies the emphasis on better care coordination. Among the medical professionals involved in integrative care include: Endocrinologist An endocrinologist is a medical specialist who focuses on the endocrine system, which includes the pancreas responsible for insulin production.
Podiatrist Foot complications such as venous ulcers are common among individuals with diabetes, making podiatrists essential members of the diabetes care team.
More Effective Treatment A team-based approach to diabetes care transcends the boundaries of conventional treatment methods, presenting a comprehensive and personalized paradigm. Some of the treatment plans incorporated in integrative care include: Nutrition Therapy : Nutritionists recommend healthy, personalized meal plans that not only assist in blood sugar regulation but also promote the development of sustainable eating habits.
Diabetes Self-Management Education encompasses various aspects of diabetes management, such as: Blood glucose monitoring Healthy eating habits Regular medical checkups Physical activity recommendations Medication and prescription management Mental health and stress management Comprehensive patient education empowers patients to make well-informed choices and take control of their health by providing them with the knowledge and skills they need to manage their diabetes effectively.
Improved Communication Effective communication is essential to successfully managing diabetes, and a team approach facilitates this crucial element. Cost Savings By focusing on preventive measures, including regular screenings and patient education, the team approach aims to identify and address potential issues early on, preventing complications that could lead to costly interventions.
Enhancing Diabetes Care through a Preventive Team Approach So, a team approach to diabetes care that integrates care managers and FQHC providers offers many benefits to patients with diabetes. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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August 2, For people who have diabetes—or almost any other disease, for that matter—the benefits of exercise can't be overstated. Following are some highlights of those results: Exercise lowered HbA1c values by 0.
All forms of exercise—aerobic, resistance, or doing both combined training —were equally good at lowering HbA1c values in people with diabetes. Resistance training and aerobic exercise both helped to lower insulin resistance in previously sedentary older adults with abdominal obesity at risk for diabetes.
Combining the two types of exercise proved more beneficial than doing either one alone. People with diabetes who walked at least two hours a week were less likely to die of heart disease than their sedentary counter- parts, and those who exercised three to four hours a week cut their risk even more.
These benefits persisted even after researchers adjusted for confounding factors, including BMI, smoking, and other heart disease risk factors.
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Diabetes management benefits W-2 is now Endurance training for soccer players. Diabetes management benefits benfits it, log managemet your Employee Self-Service Diabetrs GMS Connect. As an employer, type 2 diabetes impacts Dabetes than just employees who are either at risk or live with the chronic condition. According to the Society for Human Resource Management, type 2 diabetes costs U. Add in the impact that additional claims have on group health insurance premiums and the effects of diabetes can ramp up your group health costs.Diabetes management benefits -
The health care team and others support the adoption and maintenance of daily self-management tasks 8 , 40 , as many people with diabetes find sustaining these behaviors difficult. They need to identify education and other needs expeditiously in order to address the nuances of self-management and highlight the value of ongoing education.
Table 6 provides details of DSMES at this critical time. Annual assessment of knowledge, skills, and behaviors is necessary for those who achieve diabetes treatment targets and personal goals as well as for those who do not. Primary care visits for people with diabetes typically occur every 3—6 months These visits are opportunities to assess all areas of self-management, including laboratory results, and a review of behavioral changes and coping strategies, problem-solving skills, strengths and challenges of living with diabetes, use of technology, questions about medication therapy and lifestyle changes, and other environmental factors that might impact self-management It is challenging for primary care providers to address all assessments during a visit, which points to the need to utilize established DSMES resources and champion new ones to meet these needs, ensuring personal goals are met.
See Table 5 for indications for referral. Possible barriers to achieving treatment goals, such as financial and psychosocial issues, life stresses, diabetes-related distress, fears, side effects of medications, misinformation, cultural barriers, or misperceptions, should be assessed and addressed.
People with diabetes are sometimes unwilling or embarrassed to discuss these problems unless specifically asked 62 , Frequent DSMES visits may be needed when the individual is starting a new diabetes medication such as insulin 64 , is experiencing unexplained hypoglycemia or hyperglycemia, has worsening clinical indicators, or has unmet goals.
Importantly, diabetes care and education specialists are charged with communicating the revised plan to the referring provider and assisting the person with diabetes in implementing the new treatment plan.
The identification of diabetes-related complications or other individual factors that may influence self-management should be considered a critical indicator of the need for DSMES that requires immediate attention and adequate resources.
The diagnosis of other health conditions often makes management more complex and adds additional tasks onto daily management. DSMES addresses the integration of multiple medical conditions into overall care with a focus on maintaining or appropriately adjusting medication, meal plans, and physical activity levels to maximize outcomes and quality of life.
In addition to the need to adjust or learn new self-management skills, effective coping, defined as a positive attitude toward diabetes and self-management, positive relationships with others, and enhanced quality of life are addressed in DSMES services 16 , The progression of diabetes can increase the emotional and treatment burden of diabetes and distress 65 , It has a greater impact on behavioral and metabolic outcomes than does depression Diabetes-related distress is responsive to intervention, including DSMES-focused interventions 68 and family support However, additional mental health resources are generally required to address severe diabetes-related distress, clinical depression, and anxiety It is important to recognize the psychological issues related to diabetes and prescribe treatment as appropriate.
Throughout the life span many factors such as aging, living situation, schedule changes, or health insurance coverage may require a re-evaluation of diabetes treatment and self-management needs see Tables 5 and 6. They may also include life milestones: marriage, divorce, becoming a parent, moving, death of a loved one, starting or completing college, loss of employment, starting a new job, retirement, and other life circumstances.
Changing health care providers can also be a time at which additional support is needed. DSMES affords important benefits to people with diabetes during transitions in life and care. Providing input into the development of practical and realistic self-management and treatment plans can be an effective asset for successful navigation of changing situations.
The health care provider can make a referral to a diabetes care and education specialist to add input to the transition plan, provide education and problem solving, and support successful transitions.
The goal is to minimize disruptions in therapy during any transition, while addressing clinical, psychosocial, and behavioral needs.
Additionally, MNT helps prevent, delay, or treat other complications commonly found with diabetes such as hypertension, cardiovascular disease, renal disease, celiac disease, and gastroparesis. MNT is integral to quality diabetes care and should be incorporated into the overall care plan, medication plan, and DSMES plan on an ongoing basis 1 , 40 , 69 — 72 Table 8.
Although basic nutrition content is covered as part of DSMES, people with diabetes need both initial and ongoing MNT and DSMES; referrals to both can be made through many electronic health records as well as through hard copy or faxed referral methods see Supplementary Table 1 for specific resources.
Everyday decisions about what to eat must be driven by evidence and personal, cultural, religious, economic, and other preferences and needs 69 — The entire health care team should provide consistent messages and recommendations regarding nutrition therapy and its importance as a foundation for quality diabetes care based on national recommendations Despite the proven value and effectiveness of DSMES, a looming threat to its success is low utilization due to a variety of barriers.
In order to reduce barriers, a focus on processes that streamline referral practices must be implemented and supported system wide. Once this major barrier is addressed, the diabetes care and education specialist can be invaluable in addressing other barriers that the person may have.
Without this, it will be increasingly difficult to access DSMES services, particularly in rural and underserved communities. With focus and effort, the challenges can be addressed and benefits realized.
The Centers for Disease Control and Prevention reported that only 6. This low initial participation in DSMES was also reported in a recent AADE practice survey, with most people engaging in a diabetes program diagnosed for more than a year These low numbers are seen even in areas where cost is less of a barrier because of national health insurance.
Analysis of National Health Service data in the U. This highlights the need to identify and utilize resources that address all barriers including those related to health systems, health care providers, participants, and the environment.
In addition, efforts are being made by national organizations to correct the identified access and utilization barriers. Health system or programmatic barriers include lack of administrative leadership support, limited numbers of diabetes care and education specialists, geographic location, limited or lack of access to services, referral to DSMES services not effectively embedded in the health system service structure, limited resources for marketing, and limited or low reimbursement rates DSMES services should be designed and delivered with input from the target population and critically evaluated to ensure they are patient-centered.
Despite the value and proven benefits of these services, barriers within the benefit design of Medicare and other insurance programs limit access.
Using Medicare as an example, some of these barriers include the following: hours allowed in the first year the benefit is used and subsequent years are predefined and not based on individual needs; a referral is required and must be made by the primary provider managing diabetes; there is a requirement of diabetes diagnosis using methods other than A1C; and costly copays and deductibles apply.
A person cannot have Medicare DSMES and MNT visits either face to face or through telehealth on the same day, thus requiring separate days to receive both of these valuable services and possibly delaying questions, education, and support. Referrals may also be limited by unconscious or implicit bias, which perpetuates health care disparities and leads to therapeutic inertia.
To address these barriers, providers can meet with those currently providing DSMES services in their area to better understand the benefits, access, and referral processes and to develop collaborative partnerships.
Participant-related barriers include logistical factors such as cost, timing, transportation, and medical status 34 , 77 , 78 , For those who avail themselves of DSMES services, few complete their planned education due to such factors.
Underutilization of services may be because of a lack of understanding or knowledge of the benefits, cultural factors, a desire to keep diabetes private due to perceived stigma and shame, lack of family support, and perceptions that the standard program did not meet their needs and is not relevant for their life, and the referring providers may not emphasize the value and benefits of initial and ongoing DSMES 34 , 79 , 80 , Health systems, clinical practices, people with diabetes, and those providing DSMES services can collaborate to identify solutions to the barriers to utilization of DSMES for the population they serve.
Creative and innovative solutions include offering a variety of DSMES options that meet individual needs within a population such as telehealth formats, coaching programs, just-in-time services, online resources, discussion groups, and intense programs for select groups, while maximizing community resources related to supporting healthy behaviors.
Credentialed DSMES programs as well as individual diabetes care and education specialists perform a comprehensive assessment of needs for each participant, including factors contributing to social determinants of health such as food access, financial means, health literacy and numeracy, social support systems, and health beliefs and attitudes.
This allows the diabetes care and education specialist to individualize a plan that meets the needs of the person with diabetes and provide referrals to resources that address those factors that may not be directly addressed in DSMES.
It is best that all potential participants are not funneled into a set program; classes based on a person-centered curriculum designed to address social determinants of health and self-determined goal setting can meet the varied needs of each person.
Environment-related barriers include limited transportation services and inadequate offerings to meet the various cultural, language, and ethnic needs of the population.
Additionally, these types of barriers include those related to social determinants of health—the economic, environmental, political, and social conditions in which one lives The health system may be limited in changing some of these conditions but needs to help each person navigate their situation to maximize their choices that affect their health.
It is important to recognize that some individuals are less likely to attend DSMES services, including those who are older, male, nonwhite, less educated, of lower socioeconomic status, and with clinically greater disease severity 84 , Further, studies support the importance of cultural considerations in achieving successful outcomes 84 — Solutions include exploring community resources to address factors that affect health behaviors, providing seamless referral and access to such programs, and offering flexible programing that is affordable and engages persons from many backgrounds and living situations.
The key is creating community-clinic partnerships that provide the right interventions, at the right time, in the right place, and using the right workforces Several common payment models and newer emerging models that reimburse for DSMES services are described below.
For a list of diabetes education codes that can be submitted for reimbursement, see Supplementary Table 2 Billing codes to maximize return on investment ROI in diabetes care and education. CMS has reimbursed diabetes education services billed as diabetes self-management training since 40 , In order to meet the requirements, DSMES services must adhere to National Standards for Diabetes Self-Management Education and Support and meet the billing provider requirements 40 , Ten hours are available for the first year of receiving this benefit and 2 h in subsequent years.
Any provider physician, nurse practitioner, PA who is the primary provider of diabetes treatment can make a referral; there is a copay to use these services. CMS also reimburses for diabetes MNT, which expands access to needed education and support.
Three hours are available the first year of receiving this benefit and 2 h are available in subsequent years. A physician can request additional MNT hours through an MNT referral that describes why more hours are needed, such as a change in diagnosis, medical condition, or treatment plan.
There are no specific limits set for additional hours. There is no copay or need to meet a Part B deductible in order to use these services. Many other payers also provide reimbursement for diabetes MNT Reimbursement by private payers is highly variable.
Many will match CMS guidelines, and those who recognize the immediate and longer-term cost savings associated with DSMES will expand coverage, sometimes with no copay. With the transition to value-based health care, organizations may receive financial returns if they meet specified quality performance measures.
Diabetes is typically part of a set of contracted quality measures impacting the payment model. Health systems should maximize the benefits of DSMES and factor them into the potential financial structure.
There are reimbursable billing codes available for remote monitoring of blood glucose and other health parameters that are related to diabetes. The use of devices that can monitor glucose, blood pressure, weight, and sleep allow the health care team to review the data, provide intervention, and recommend treatment changes remotely.
Sample referral forms that provide the information required by CMS and other payers for referral to DSMES and MNT are available along with reimbursement resources see Supplementary Tables 1 and 2.
These or similar forms can be embedded into an electronic health record for easy referral. Health systems and clinical organizations can maximize billing potential by facilitating the reimbursement process, ensuring all applicable codes are being utilized and submitted appropriately.
This usually requires support from those who frequently work with health care codes such as staff in billing and compliance departments.
Shared medical appointments can be performed with DSMES and they are reimbursable medical visits. This Consensus Report is a resource for the entire health care team and describes the four critical times to refer to DSMES services with very specific recommendations for ensuring that all adults with diabetes receive these benefits.
Diabetes is a complex condition that requires the person with diabetes to make numerous daily decisions regarding their self-management. DSMES delivered by qualified personnel using best practice methods has a profound effect on the ability to effectively undertake these responsibilities and is supported by strong evidence presented in this report.
DSMES has a positive effect on clinical, psychosocial, and behavioral aspects of diabetes. DSMES provides the foundation with ongoing support to promote achievement of personal goals and influence optimal outcomes. Despite proven benefits and demonstrated value of DSMES, the number of people with diabetes who are referred to and receive DSMES is significantly low 73 — Barriers will not disappear without intentional, holistic interventions recognizing the roles of the entire health care team, individuals with diabetes, and systems in overcoming issues of therapeutic inertia The increasing prevalence of type 2 diabetes requires accountability by all stakeholders to ensure these important services are available and utilized.
health care system has changed with increased attention on primary care, technology, and quality measures DSMES services that directly connect with primary care are effective in improving clinical, psychosocial, and behavioral outcomes 92 — A variety of culturally appropriate services need to be offered in a variety of settings, utilizing technology to facilitate access to DSMES services, support self-management decisions, and decrease therapeutic inertia.
This article is being published simultaneously in Diabetes Care DOI: The authors would like to acknowledge Mindy Saraco Managing Director, Scientific and Medical Affairs from the ADA for her help with the development of the Consensus Report and related meetings and presentations, as well as the ADA Professional Practice Committee for providing valuable review and feedback.
The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Christine Beebe Quantumed Consulting, San Diego, CA , Anne L.
Burns American Pharmacists Association, Alexandria, VA , Amy Butts Wheeling Hospital at the Wellsburg Clinic, Wellsburg, PA , Susan Chiarito Mission Primary Care Clinic, Vicksburg, MS , Maria Duarte-Gardea The University of Texas at El Paso, El Paso, TX , Joy A. Dugan Touro University California, Vallejo, CA , Paulina N.
Duker Health Solutions Consultant, King of Prussia, PA , Lisa Hodgson Saratoga Hospital, Saratoga Springs, NY , Wahida Karmally Columbia University, New York, NY , Darlene Lawrence MedStar Health, Washington, DC , Anne Norman American Association of Nurse Practitioners, Austin, TX , Jim Owen American Pharmacists Association, Alexandria, VA , Diane Padden American Association of Nurse Practitioners, Austin, TX , Teresa Pearson Innovative Health Care Designs, LLC, Minneapolis, MN , Barb Schreiner Capella University, Pearland, TX , Eva M.
Vivian University of Wisconsin, Madison, WI , and Gretchen Youssef MedStar Health, Washington, DC. Duality of Interest. is on an advisory board of Eli Lilly.
is the treasurer for the American Academy of Nurse Practitioners Certification Board of Commissioners and Vice President of the American Nurse Practitioner Foundation. reports receiving an honorarium from ADA as an Education Recognition Program auditor and is a participant in a speakers bureau sponsored by Abbott Diabetes Care and Xeris.
reports being a paid consultant of Diabetes — What to Know, Arkray, and DayTwo. reports being a participant in speakers bureaus sponsored by Boehringer Ingelheim, Novo Nordisk, and Xeris. reports research grant funding from Becton Dickinson. has received honoraria from ADA. No other potential conflicts of interest relevant to this article were reported.
Author Contributions. All authors were responsible for drafting the article and revising it critically for important intellectual content. All authors approved the version to be published.
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toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. Figure 1. View large Download slide. The four critical times to provide and modify diabetes self-management education and support.
Table 1 DSMES Consensus Report recommendations. DSMES improves health outcomes, quality of life, and is cost effective, and people with diabetes deserve the right to DSMES services.
Therefore, it is recommended that:. Discuss with all persons with diabetes the benefits and value of initial and ongoing DSMES. Ensure coordination of the medical nutrition therapy plan with the overall management strategy, including the DSMES plan, medications, and physical activity on an ongoing basis.
Identify and address barriers affecting participation with DSMES services following referral. Expand awareness, access, and utilization of innovative and nontraditional DSMES services. Facilitate reimbursement processes and other means of financial support in consideration of cost savings related to the benefits of DSMES services.
View Large. Table 2 Key definitions. This process incorporates the needs, goals, and life experiences of the person with diabetes.
Note: Diabetes services and specialized providers and educators often provide both education and support. Yet on-going support from the primary health care team, family and friends, specialized home services, and the community are necessary to maximize implementation of needed self-management.
Education is used in the National Standards for Diabetes Self-Management Education and Support and more commonly used in practice. In the context of this article, the terms have the same meaning.
Clinical staff who qualify for this title may or may not be a CDCES or BC-ADM, yet all who hold the CDCES and BC-ADM certifications are diabetes care and education specialists. Note: The Certified Diabetes Educator CDE certification title is now CDCES. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.
Benefits rating. Table 4 Summary of DSMES benefits to discuss with people with diabetes 15 — 28 , 30 — 33 , 40 , Table 7 Sample questions to guide a person-centered assessment Table 5 Factors that indicate referral to DSMES services is needed.
Table 6 Checklist for providing and modifying DSMES at four critical times. Four critical times. Table 8 Overview of MNT: an evidence-based application of the nutrition care process provided by the RDN 1 , 40 , 69 — Characteristics of MNT reducing A1C by 0.
If they are not confident in these areas it is difficult to take advantage of the full impact of nutrition therapy. Implementation and assessment will drive confidence 2. American Diabetes Association. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes— Search ADS.
Management of hyperglycemia in type 2 diabetes, A consensus report by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD. Projection of the future diabetes burden in the United States through Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes— Evaluation of the cascade of diabetes care in the United States, Overcoming therapeutic inertia [Internet].
Accessed 3 September Centers for Disease Control and Prevention. Social determinants of health [Internet], Accessed 30 March Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis.
The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: a meta-analysis. Group based training for self-management strategies in people with type 2 diabetes mellitus. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control.
Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. All your medications will be reviewed, and it will be determined if you may warrant a change in medications.
Several solutions will be provided to help lower your blood sugar, including a change in diet and the need for exercise. At the second meeting which is usually held a week after the first one, the diabetic nurse will review your blood glucose levels over the past week.
Suggestions will be made to fine-tune your blood sugar levels. The third meeting is usually held about a month later and generally involves the diabetic nurse, diabetic educator, and diabetic manager.
At this meeting, the following issues are typically discussed: Importance of medication compliance Learning to read food labels Eating healthy Lowering the risk of diabetic complications Lowering stress at home Importance of being physically active Types of exercises that can help lower blood sugars How frequently should you monitor blood sugar levels?
How to work effectively with your healthcare provider Throughout the duration of the program, the diabetic patient will be regularly in contact with a dietitian, diabetic education, pharmacist, or a diabetic nurse.
How Do These Diabetic Management Programs Help? There is good data to show that people who participate in diabetic management programs have the following benefits: Reduce the risk of developing diabetic complications A lower level of A1C Better quality of life Marked reduction in healthcare expenses What Is The Cost Of Diabetes Management Programs?
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Call the helpline atoption 5, and talk benefis choice counselors to enroll Diaetes a SoonerSelect health beneifts Diabetes Managemet Education Diabetes management benefits Managwment DSMES services Diabetes management benefits people with diabetes learn how to Diabetes management benefits the Diabetes management benefits care of themselves. Ask Meal prepping for strength training doctor for a referral Diabefes DSMES services to help you manage your diabetes. Your first step should be asking your doctor to refer you for DSMES. DSMES services include a health care team who will teach you how to stay healthy and how to make what you learn a regular part of your life. Click here to learn more. This CDC-recognized lifestyle change program is a structured program—in person or online—developed specifically to prevent type 2 diabetes and is designed for people who have prediabetes or are at risk for type 2 diabetes, but who do not already have diabetes.
Participation in DSMES is linked Diabetes management benefits positive benetits in health Henefits and improved diabetes-related outcomes. Benefits of DSMES Diabetws include: 1. Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report. Diabetes Self-Management Education for Adults With Type 2 Diabetes Mellitus: A Systematic Review of the Effect on Glycemic Control. Skip directly to site content Skip directly to search. Español Other Languages.
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