It's a pleasure to be with you all today. And I'm going to talk to you about the teamwork in treating eosinophilic esophagitis. I think with the caveat that I have the kind of great pleasure of working in a multidisciplinary clinic as well as having my own just general GI clinic where I'm working not in a multidisciplinary space. So I'm going to give kind of both perspectives with the hopeful goal of giving you some ideas of how to work in a kind of a multidisciplinary way, even if you may not be part of a multidisciplinary team. So I have no relevant disclosures. So again, the objectives are to build a case for multidisciplinary care in eosinophilic esophagitis, to describe the roles of the varying team members, to provide you an example of a model of multidisciplinary care from my own institution, and again, really to build on building alternative multidisciplinary teams that may be more approachable. Okay, so why advocate for multidisciplinary care? And kind of as a gastroenterology provider, you know, is this an individual sport or a team? Like, do we need a team to take care of folks? So EOI is a chronic disease that really will require lifelong treatment. And so as a result, you know, with all things that we take care of, of course, but really when we take care of people with chronic diseases in which there's varying treatment options, the importance of education and making sure that we're working with patients and families to get them appropriate treatment, really multidisciplinary care can help with that at multiple points. And hopefully I'll show some examples of that along the way. EOI really, though, is also an allergenic TH2-mediated disease. And so it begs the potential that we might need some help from our allergy colleagues. And many of the patients that we take care of with eosinophilic esophagitis in the GI space have comorbid allergic diseases. And so being able to work with and communicate with the care providers that are helping to manage those other allergic diseases, whether it be an allergist, a pulmonologist for asthma, or their primary care providers can really help both our kind of goals in GI, but also patient satisfaction. And the other part in terms of feeding therapists and the importance of working with dieticians is that patients really develop adaptive, but also really maladaptive strategies around eating and swallowing. And so kind of in the limited space of GI, we may not pick up on all of those and we may not be able to really assist with all of those. So being able to partner with our dieticians and our feeding therapists to help patients with maladaptive strategies around eating and swallowing. And then the other is that it's been shown now in several studies that patients with eosinophilic esophagitis have increased incidence or comorbidity of both anxiety and depression, and that this is common in patients with EOE, and these can both be impacted by the disease itself and the symptoms that patients have, as well as the treatments that we may impose on them specifically around food elimination diets. So having, again, multidisciplinary team members that can assist us in the management of these mood disorders can be very helpful. Okay, so who are the team members? So again, so speaking, this is a GI meeting, so gastroenterology providers are the key and were needed for diagnosis of eosinophilic esophagitis. You just heard about the importance of biopsies, what we need endoscopy to get those biopsies. And so obviously the gastroenterology provider is really important, and then they're coming often with symptoms of heartburn, esophageal dysfunction, and all of the rest of that. So they're presenting with GI symptoms and are being evaluated in our clinics. And so we are often the primary driver. But again, these patients can also be found in allergy clinics. So when they present with food sensitivities, food allergies, oral allergy syndrome, asthma, allergic rhinitis, atopic dermatitis, our allergy colleagues are actually getting, I think, much better screening for swallowing dysfunction because of the common finding that patients with other comorbid allergic diseases are potentially going to have eosinophilic esophagitis. But allergists are really important once the EOE diagnosis has been made, not so much in determining the food elimination diets. And so historically, allergists were often used at kind of the beginning of our understanding of eosinophilic esophagitis to help us identify what foods might be potential triggers for eosinophilic esophagitis. So there was a lot of work done, particularly in the pediatric space, around whether kind of the available allergy tests for IgE-mediated allergies could help us predict what foods are helpful in treatment of eosinophilic esophagitis. And that didn't really pan out. And so the skin prick testing that allergists do, the lab tests that are often sent either by allergists or primary care doctors, are not particularly helpful in determining the management of eosinophilic esophagitis. However, allergists are still key and critical drivers of making sure that the whole patient kind of allergic milieu is being treated. And so when patients are suffering from significant symptoms, they're able to assess for allergic rhinitis, asthma, atopic dermatitis. They're also particularly important in thinking about food reintroduction if patients are in food elimination diets, and I'm happy to answer questions later about that. And then as new medications become available for eosinophilic esophagitis, these new medications like dupilumab, that is at present the only biologic medicine that's approved for eosinophilic esophagitis, these medicines are FDA approved for other allergic comorbidities like eczema and asthma, and the allergists can really help team with us in determining whether these are the appropriate drugs for our patients. Dietitians are essential, and we'll talk more about that as well. Feeding and swallowing specialists are also, again, because of those maladaptive behaviors that are seen really both in the pediatric and the adult population. And again, because this is a condition that is chronic, the importance of a nurse educator can also be, is really key and can be very helpful to the team. Additional team members that we definitely align with but aren't necessarily part of our weekly program where we see everybody together, but our psychologists, endocrinologists, some of the side effects of the medications that we might see, transition coordinators, again, this is a lifelong condition, and so being able to transition adolescents into adult care, and then researchers, depending on the priorities of the group. But multidisciplinary clinics come in different shapes and sizes, and so again, we'll go over some examples of what one could look like, but remember that multidisciplinary clinic could even be a dietician and a gastroenterologist that are aligned in the care of a patient with eosinophilic esophagitis. And multidisciplinary care can also provide kind of a one-time evaluation, so a consultation to provide input, education, and then get them back to their primary GI provider. Or they can transition and really provide longitudinal care for patients. Okay, so this is a case of an 18-year-old high school senior with three-year history of progressive solid food dysphagia. His past medical history is notable for asthma. He's lost about five pounds in the past year. He is on the lacrosse team, but weight loss really was not intentional, so he's very physically active, but he was not intentionally trying to lose weight. Okay, so on endoscopy, we're found to have white exudates, linear furrows, esophageal rings, and long segment narrowing. Because of the long segment narrowing, he did receive an esophageal dilation and was dilated effectively up to 16 millimeters, and he was diagnosed with EOE and biopsies, and as you just kind of went over what that can look like. So we're now in the clinic after the diagnosis of EOE has been made, and we're discussing with the patient and his parents regarding EOE treatments. And I really want to highlight the importance of shared decision making, but you're deciding between at the end of that conversation, between a food elimination diet or Dupixen. So how can multidisciplinary care help in this situation? So we have a student athlete with weight loss. He's really interested in a food elimination diet as a possible treatment option. He doesn't love the idea of having to take a medication every day, twice a day, doesn't quite trust himself to really do that, and thinks that actually following a diet may be easier for him, and he does not love the idea of an injection, but would be willing to consider it. So how can multidisciplinary help? So the dietician here is key, because again, we want to encourage patients and families to do the treatment that is going to work best for them. At this point, there's really not been head-to-head trials that have looked to compare diet to PPI, to swallow topical corticosteroids, or Dupixen, and so really all of the options are on the table in terms of what patients will do, and none of them will work if they don't do them. So it's really, again, the importance of shared decision making. A one food elimination diet or maybe even a four food elimination diet might be feasible in this teenager student athlete, but we really need to have the dietician do a diet recall, understand what might be contributing to some of the weight loss in their assessment, and with the GI, it's really because of decreased oral intake, and we need to support in terms of helping him to regain the weight that he's lost and make the diet successful. So a dietician is absolutely key, and there's lots of evidence that says that having a dietician rather than the GI provider alone improves the success of food elimination diets. He has a history of asthma, but you find out that he actually hasn't seen his primary care provider or other provider for asthma now in over a year. He's been using his inhalers for lacrosse pregame and occasionally has to come off the sidelines to use his albuterol as well, and he takes a controller medication during winter months, but he really hasn't checked in with anyone now in over a year. One of the options that we're thinking about is dupexin, which may or may not be an appropriate first-line treatment for eosinophilic esophagitis, but having the allergist be able to weigh in in real time about what are the potential benefits of dupexin, for example, or other treatments on his asthma, and is there actually a reason to maybe start with a biologic as first line depending on how well his asthma is controlled or not controlled. Again, the allergist right now is very key. The other thing would be if he had potential some reactions to certain foods and questions around that, they might be able to help in identifying any food sensitivities. You learn he's not eating before games or practices because of worry about transient food impaction. Again, this is what has led to the weight loss over time, but this is really maladaptive for a student athlete. He needs nutrition. He needs food. The dietician is going to help with that, but the feeding therapist is really going to help provide reassurance and guidance around how to properly help with those maladaptive feeding behaviors and to work and strategize with him, his family, and the dietician about appropriate foods to get him the nutrition that he needs as we start to improve his esophageal inflammation and narrowing. Okay, so the benefits of multidisciplinary care. The benefits to families and patients really is clear. So you get visits with a multiple specialist combined into one visit sometimes, but not always. That actually results in cheaper costs to the visit for the patient in terms of out of pocket costs, but that really depends on the health care system. But most importantly, it's the same day communication among all the specialists and really allowing for comprehensive care. You come out of the day with a unified treatment approach, avoiding varying instructions that can come from allergists around food elimination diets or gastroenterology providers around use of medications, and that can result in confusion and really delay of care for these families. And so having multidisciplinary care in one clinic really can improve on this. On the follow-up side, it can be really helpful for having a single point of access for communication regarding care after clinic and allowing for improved follow-up. Several families, often our patients are very confused as to like, who do I contact? Do I contact the allergist? Do I contact the gastroenterologist? Particularly if they're on a food elimination diet, et cetera, with regards to the management of their treatment. And so having that all be at a single point of access for communication can be very helpful. And then again, depending on the goals program, multidisciplinary care, I think, does really improve access for participation and research for patients if they're interested. What about to the multidisciplinary team or the providers themselves? So I think for me, one of the number one things as a gastroenterologist that I get from working in a multidisciplinary on the day of, is I really get more input on the medical or behavioral issues that are impacting management of EOE and really impacting their symptoms. I like to think that I do a good job about asking with regards to swallowing dysfunction, using impact questions, but really having those different team members who are trained in asking about feeding dysfunction, anxieties regarding food, really getting into the details of their diet and what they might be already doing at home to make themselves feel better is really helpful in coming up with a medical and therapeutic plan for these patients. There's closed loop communication regarding plan on the day of visit. So not epic messages afterwards from the EMR or phone calls, but really just a lot of in-depth phone calls to other people. We are able to talk face-to-face and do it right there. And then it really allows you to practice at the top of your scope, but also stay in your lane and rely on the expertise of your colleagues. And I think that this can be really helpful, especially with the demands of having to see more and more patients in a specific amount of time. From a job satisfaction standpoint, we really get to learn from our other team members, just helps us have a positive feeling about the day, increase communication and collaboration regarding treatment plan, and again, that kind of increased professional satisfaction that can come from working with others. Again, so the multidisciplinary team members roles in EOE. So GI providers. We are really essential at confirming the diagnosis. I'm not going to get into it during this talk, but it's really important to be thoughtful about what is EOE. And not every esophageal eosinophilia is eosinophilic esophagitis. So we heard about kind of what reflux can look like on biopsies, but certainly infections and reflux, achalasia. There are other things that can present with similar symptoms and not be standard eosinophilic esophagitis. So it's important to kind of be thoughtful about that and really think about, is this eosinophilic esophagitis? Gastroenterology providers are essential for endoscopic evaluation in the diagnosis and in the management. We're important in interpreting both procedure and histologic results. Patients with eosinophilic esophagitis can have lots of other GI symptoms, functional abdominal pain, functional heartburn, all of that. So we're important in addressing other GI symptoms. And we are obviously essential in aiding in the development of the treatment plan. But what do all the other people help us with? So again, allergists are still very important at confirming that diagnosis. They can be very helpful at diet selection or other treatment plan, but again, not necessarily using skin prick testing or serum IgE testing. And they are essential at managing the other allergic diseases. And so this is just kind of a plot showing the development of other allergic diseases. So this is really based on pediatric data where you can see infants up to five years of age in terms of the development of when these other atopic diseases could present. But atopic dermatitis, IgE-mediated food allergies, asthma, allergic rhinitis, and then eosinophilic esophagitis being the allergic march. The dietician. So we've talked a lot about this, but they are really important in evaluating the nutritional status. They're really important in identifying what foods are even in the diet. And this takes time that any gastroenterology providers just do not have in their standard clinical schedule. They are essential for diet development and helping families with food substitutions and making sure that the diet is going to provide them with the micro and macronutrients that they're going to need. And then they can be very important and critical to diet adherence. Just like with celiac disease or other things like that, it really requires a lot of question and answer with the families in talking about diet adherence, not just asking them if they're doing it or not. And so again, bringing them in to be able to use their time and expertise in helping us figure that out. The feeding specialist. So they can identify and manage feeding dysfunction. And this can be very important because the wait times for getting into see a feeding specialist, depending on where you are in the country or the world, can be really long and having access to that. So if they can see the patient, evaluate and help determine the priority or the severity of symptoms and whether they really need to be pushed to get into feeding specialists can be very helpful, particularly in our younger patients that really develop a lot of feeding dysfunction as a result of eosinophilic esophagitis. And then particularly in our older patient, a one-time visit with them can be incredibly beneficial to evaluate and really start therapies and provide helpful strategies for patients who might be having daily dysphagia and not really actually thought about the things that they can do to move their maladaptive strategies to adaptive strategies. So lubrication of food, chewing, having water and liquids to help them swallow and all of that. A one-time visit with a feeding specialist can really improve the quality of life for patients who are suffering from intermittent solid food dysphagia. What about these other specialists? So again, in our program, we don't have endocrinologists or behavioral health that visit patients with us in the multidisciplinary team, but we have worked and aligned relationships very closely with endocrinologists and behavioral health specialists that really understand the EOE population and the medications and treatments that we use. So endocrinologists are really important, particularly in the pediatric space where patients can have growth delay either because of failure to thrive and poor nutrition that resulted because of their feeding dysfunction prior to diagnosis. And then they can also be helpful because certainly there have been reports of the swallowed topical steroids causing adrenal insufficiency or low fasting morning cortisol levels. And so having an endocrinologist that understands EOE, understands the medications that you can quickly refer patients to is really beneficial. The other is behavioral health support. So again, there is a higher rate than the general population of anxiety and depression in patients with eosinophilic GI disease. And so having behavioral health support that can address behavioral issues, really barriers to adherence, which can be very helpful, particularly in the adolescent and young adult population and providing coping skills around how do you kind of manage life with if you were on a significant food elimination diet, for example. Eating is such an important part of our social fabric that when you really interrupt that with food elimination diets, having providing coping skills for families around that can be very beneficial. Okay, so what about a multidisciplinary clinic versus like a team? So a combined clinic, which is what we do at the Children's Hospital of Colorado, patients come in and they see a gastroenterologist, an allergist, a dietician, and a feeding therapist, and then a nurse educator. And so it's one long visit. That is a huge positive, but certainly some of our patients, either the very young ones or patients with neurodevelopmental disorders or things, that one long visit is really not bearable. But the combined clinic is one long visits. It can be very efficient for patients. They're already taking a day off work and school or an afternoon or a morning, for example. It does require complex scheduling. And so we'll get into this in terms of the building of a team, but that can be a barrier to developing a combined clinic where everyone is seeing the patient on the same day. Although on the positive side, as I've said, it really helps with ease of communication. Patients may get more than they need. They may not have to see everybody, but they end up seeing everybody. And that can sometimes be a negative when we think about costs and providing efficient and effective care. This is in contrast to what I term the relay team, which is where you are the GI provider, you are the person seeing them, but then you refer out to those trusted colleagues on an as-needed basis. And so a relay team does require multiple days for visits to become effective. It is much more efficient for the provider. It fits in a standard clinical template, whereas a combined clinic often does not. But on the other hand, so that's why I put efficiency in quotes, it really ends up protracting communication. So more follow-up, more chances for things to slip through the cracks, more for you to make sure that you don't miss the follow-up or that families have to call you back for. So it can be efficient for providers from the hospital system's perspective in that it fits in a standard clinical template, but it's not always the most efficient thing for us as providers, as we well know. But it does allow for kind of targeted multi-day involvement. So you see the patient, you kind of assess what the needs are likely to be, and then you refer out. And if there are no issues with regards to dietary needs or things like that, well, then you don't have to refer out to a dietician. Which brings me to the point that not everyone needs a big team. So mild to moderate EOE that responds to first-line therapies of either a proton pump inhibitor or swallow topical corticosteroid in which their dysphagia is improving and they're well-adjusted and they're dealing with that doesn't probably need a big team. If they don't have really much in the way of atopic disease other than eosinophilic esophagitis, they too may not need to see an allergist. And again, for patients that really are unable to attend or tolerate long clinic visits, again, having big teams can sometimes be a barrier for them. So building a multidisciplinary clinic. If you're interested, you love EOE, and you really wanna provide multidisciplinary care, whether it be for EOE or celiac or IBD, what do you need to do? And you really need to identify the stakeholders. You need to have passion and this be purpose-driven because as we'll kind of talk about, there is not much in the way of direct financial incentive to hospital systems doing these multidisciplinary clinic. There needs to be some other higher or collective or agreed upon goal that they're trying to do. So either at the hospital level, so locally, or they trying to be kind of first and best in a certain area. And so we can convince section, hospital and other providers that this is really gonna be key for moving us as a group into a new space. Maybe you want to capture more patients from a different region. So maybe the multidisciplinary clinic is actually positive because you actually wanna serve a larger geographical region. People are gonna be traveling from a long time and you really wanna help coordinate those visits. And that's certainly true for us in Colorado, where in the pediatric space, we really take care of a seven to nine state region. And then alternatively, is it just kind of a personal drive of making care for patients better? And again, that might be a little bit more of an uphill battle from a systems perspective of convincing them. But again, getting buy-in as to what might be those other motivators and drivers for the section, the hospital and the additional providers that you're gonna need to pull in to do a multidisciplinary clinic. All right, so what are the steps of building a multidisciplinary clinic? So this came from a paper on kind of the suggested steps to building a successful multidisciplinary swallowing clinic. So it was kind of in the aerodigestive and swallowing space, but the same things apply. You need to develop a business plan and it needs to have the vision of the program. What is the motivator? The second thing is that, again, as I said, you need to obtain physician and administrator buy-in. So you need to communicate with your colleagues, determine the people that are invested, and having administrative buy-in is just as key. Then you need to go to the hospital and secure hospital resources. And this can be one of the trickier areas of convincing them that you need the space, the time and the infrastructure to be able to pull off a multidisciplinary clinic. It can be very helpful to have a multidisciplinary clinic coordinator. And this is a full-time dedicated coordinator. A coordinator can be really however you define it. At different EOE programs across the country, coordinators can be nurses, they can be schedulers, and more kind of from the administrative side. They can be advanced practice providers, and they can be dieticians. So there can be really, there's a lot of different examples of who the full-time dedicated coordinator can be. Admittedly, they're not always full-time. And I think that that's the other reality of doing multidisciplinary clinics today in modern medicine. You have to coordinate the scheduling logistics, you work with provider schedulers, really develop those support services, and create that patient flow template. This recommends certainly a mock day, and I would say you probably have to have a mock week in terms of how this might be. But it can be very helpful to providing. So even if you might not be driven to do clinical research or translational research with the patients you're seeing, tracking patients and data collection is really helpful and important to convincing the hospital system that this is something that they should continue to invest in. Because oftentimes these multidisciplinary clinics aren't bringing in necessarily a lot of money on the day, but it's the downstream influence from a financial perspective that sometimes can make them look at least a bit more positive on the financial side. So tracking patients, their data collection, procedures can be helpful for that. Okay, so what's ours? Ours is the Gastrointestinal Eosinophilic Diseases Program at the Children's Hospital of Colorado. And again, this is just one example, but it's a multidisciplinary program. So what do we do? So before the visit, we obtain all the records. We do attempt to get the pathology slides from the outside hospital and have our pathologists review those. So we need buy-in from our pathologists to do that. That is orchestrated by the scheduling coordinator and the medical assistant for our team. We have a primary kind of entry gate gastroenterologist who reviews all of the records and determines that they are actually appropriate for Eosinophilic Diseases Program. They need to have eosinophilic GI disease to get into our program. That's how we work, but that's not how all of them are. Once is that that's been okayed, we go through the scheduling and insurance approvals. If it's a long distance patient, we do more work upfront to ensure that we are having procedures scheduled for them the week that they're here with us and whether they need to see any other subspecialists than what we offer in our multidisciplinary program. And then we provide a lot of education and patient instructions, particularly on the allergy side with regards to what they need to do to prepare for their visit. During the visit, so we have a team discussion before clinic. So again, this is non-face-to-face patient time that is used, but it is in discussion on the day. So from a billing perspective and anything, if you're in the United States, this all does count towards patient care. And the patient is then scheduled with all team members in a Tetris of schedule that is put together. And then we have huddles and communication between provider visits, as well as at the end of the visit to ensure that the patient instructions that we're all aligned with them. What happens after? So after the visit, patients often need follow-up procedures and testing. So the importance of result communication back to the families, and this is done both at the provider level as well as the nursing level, communication of management changes based on those results and really arranging a follow-up. And that's really managed by really all members of the team. So what are some alternative strategies? So oftentimes that is a big undertaking, but what I would say to putting together a multidisciplinary team if you don't have one, and I'd be happy though to talk with people offline if they're interested in developing a multidisciplinary team, because I do think that it really is very important for these patients and really champion with it with regards to professional satisfaction and communication. But what if that's not possible to you? How can you still develop the concept of multidisciplinary care even within your own practice? And so the key here is networking and getting out there and really identifying practitioners in your system or possibly outside your system sometimes that has clinical and professional interest in caring for patients with eosinophilic esophagitis or whatever the area is that you might be of interest. And so finding that dietician, finding that allergist and finding those feeding therapists, because not all feeding therapists are trained and interested in the area of eosinophilic esophagitis and the strategies that are used for patients with eosinophilic esophagitis can be very different than those that actually have kind of oral pharyngeal dysphagia and other things of that nature and where they're chewing and swallowing, their chewing may not work as well. So again, finding feeding therapists that understand eosinophilic esophagitis is really worth the time and effort. In terms of specifically advanced practice providers, so advanced practice providers are really involved and see patients along the whole entirety of the spectrum with regards to eosinophilic esophagitis, but I wanted to give some thought particularly around how advanced practice providers can really position themselves within a multidisciplinary teams if that was an area of interest. And so one, I think advanced practice providers that are program coordinators for multidisciplinary teams, I think are often incredibly successful because they can operate at a much higher level with regards to restrictions and what they're allowed to do within a hospital system and really work at their top of scope when they are the program coordinators for multidisciplinary care. And so I think that multidisciplinary programs that have advanced practice providers as their program coordinators are often highly successful. We do not have that as part of our model, but it is something that I think really has value added. I think the other potential area is in seeing patients in follow-up. This is really an opportunity when patients are seen in multidisciplinary care for them to have more touch points with that larger multidisciplinary team, but in a much more efficient and effective and cost-effective way of having them see a single provider who then can communicate back to that larger team as needed and to be able to work again at that high level of scope of practice to help in the management of really all of those things, the allergy, the GI and all the rest of that. So I think that that is also an area for really potential benefit to multidisciplinary teams. The other is that point of entry. So I can say that there are many times patients are diagnosed with eosinophilic esophagitis, they've presented with their symptoms, they've gotten their scope, but now those providers, as we've become more and more highly sub-specialized, providers will refer to EOE experts and have, but we, to get them into the multidisciplinary team, again, is that Tetris of scheduling, can't always happen as quickly as some may want. And so having advanced practice providers who are really experts in the area of eosinophilic esophagitis is a great opportunity for that point of entry to the multidisciplinary team because they can provide kind of standard education to families around what is EOE, they can present treatment options and really begin to work with families about understanding that shared decision-making in choosing the right treatment for them. So it can be a great opportunity for getting into multidisciplinary teams. And then that advanced practice provider, if already part of the multidisciplinary team, has seen that patient and can really present them to all the other disciplinary members of the team. So in conclusion, multidisciplinary care, really, I first want to say, is not necessary for all eosinophilic esophagitis patients, and we highlighted some of those. So certainly those that do not have a strong atopic history, who have mild to moderate disease, that respond well to proton pump inhibitors or swallow topical corticosteroids, really may not need multidisciplinary care. But for the complicated EOE patient, multidisciplinary care provides a multidisciplinary lens on patient symptoms and treatment goals, improved communication among team members, that single visit that most patients and families really like, consensus treatment plan communicated to the patient, comprehensive patient education, and an opportunity to participate in research, depending on, again, the goals of the team. Building a multidisciplinary team really does require buy-in from stakeholders. And when there is not the availability of a multidisciplinary clinic team, kind of that relay team option is an alternative, and I'll say more approachable option for providing support to our families. So with that, I'll just say thank you so much, and I will be happy to answer more questions in the Q&A area. The picture on the left is our multidisciplinary team. So again, it's a very large group of people that are all dedicated to the care of children and adolescents with eosinophilic GI diseases.

multidisciplinary care

eosinophilic esophagitis

team-based approach

collaborative clinic

comprehensive care

patient outcomes

care coordination