Attachment A HATCh Intro VA CLCs.pdf

RESIDENT- CENTERED CARE

AN INTRODUCTION TO VA COMMUNITY LIVING CENTERS

TABLE OF CONTENTS

Introduction

Community Living Center Mission

Resident-Centered Care

Cultural Transformation

HATCh Model

Work Practices

Care Practices

Environment of Care

Leadership

Guiding Principles and Regulations

Community

VA Core Values

SUPPLEMENTAL APPENDICES

A. Questions to Ask Ourselves

B. Pre and Post Knowledge Check

INTRODUCTION

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The purpose of this manual is to provide standardized education on the VA Community Living Center (CLC) model of resident-centered care, bridge the gap between theory and practice, set expectations for CLC values and organizational culture, and to serve as a resource for VA staff.

The model has as its foundation the overlapping and complementary principals of three different programs:

CLCs Ongoing Center for Enhancing Resources & Training (CONCERT), the Institute for Healthcare improvement’s Age-Friendly Health System (AFHS), and the Patient Priorities of Care (PPC).

CONCERT: whole person, whole team practices are guided by person centered care principles created by Institute for Healthcare Improvement. (http://www.ihi.org/Topics/PFCC/Pages/default.aspx ) These principles prioritize to include “ALL” staff, their thoughts, ideas and knowledge, based on their relationship with the resident. Staff bring this valuable information to frontline huddles where they participate in developing individualized treatment plans/ interventions for each resident.

AFHS: uses the 4M’s (“What Matters, Medications, Mentation, Mobility”) to know and align care with each older adult’s specific health outcome goals and care preferences.

PPC: an approach to healthcare that empowers and equips Veterans to take charge of their health and well-being and supports them in actively participating in the care planning process. PPC is part of a Whole Health approach customized for older adults

Combined, these programs work together to enhance the experiences of Veterans and families served in the

VA CLC.

MISSION STATEMENT

The mission of VA CLCs is to restore the Veteran to the highest practicable level of well-being, maximum function and independence, prevent decline in health, and provide comfort at the end of life. VA CLCs identifies and treat Veterans’ human responses to health and illness in a compassionate manner. This mission is accomplished by the combined practices of CONCERT, AFHS, and PPC. Together they use a Whole Health, Whole Person, Whole Team approach which includes Veteran preference, incorporates person-centered goals and prioritizes the use of frontline staff.

RESIDENT- CENTERED CARE

VA CLCs is committed to providing resident-centered care. Resident-centered care identifies an approach to providing health care where the treatment plan is driven by the needs, preferences, “what matters most” and the life-long habits of the resident. Care is individualized to each resident, and the resident is an active participant in their own care when possible. Attention is paid to ensure that care meets the age-appropriate, cultural, and religious needs and preferences of each Veteran in alignment with “what matters most.”.”

The routines, work processes, procedures and schedules in the CLC should revolve around the needs and preferences of the resident. It is recommended that these preferences be obtained on admission by using the CONCERT practice and tools. An example would be the “ALL About Me Tool.” In this tool, the history of the resident (who were they before they came to live with us?), their stated preferences http://www.ihi.org/Topics/PFCC/Pages/default.aspx

INTRODUCTION

2 | P a g e and needs are the foundation for making shared, informed decisions involving the resident, family or friends and CLC staff. CLC staff problem-solve in huddles or a deep dive with the resident and other facility staff and departments to ensure the resident’s needs and goals of care are met in alignment with what matters most to the resident using the Whole Person, Whole Team Approach to care

CULTURE TRANSFORMATION

Culture transformation is the term used to describe the VA CLC’s journey from a medical model of care to a resident-centered model of care. Beginning in 2005, the CLC’s have strategically taken steps to transform the culture and practices of the CLC to become resident-centered, instead of diagnosis-driven. That cultural transformation continued with CONCERT, Whole Health, AFHS, and PPC and shifted the care focus from what is the matter with you… to what matters to you.

In the medical model, the driver of care is the diagnosis, and staff make decisions for the resident. The facility environment, policies, and rules are designed for the efficiency and ease of the CLC staff. The delivery of care is often inflexible and does not consider the resident’s individual needs and preferences. Residents often feel lonely, bored, and unhappy because the medical model produces an environment of care that does not look or feel like the way people live their lives in their homes.

In a resident-centered model of care, the driver of care is the resident’s human response to health and illness. The resident participates in decisions about their care and routines. The facility environment, policies, and practices are designed to support the needs of the resident and are flexible to meet resident’s individual preferences. Residents have meaningful ways to spend their time and are part of a supportive community. Life in the CLC should be like the way people would live in their own homes.

Trust between the resident and their VA caregivers is the foundation of care, not the medical or psychiatric diagnosis.

WORK PRACTICES

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HOLISTIC APPROACH TO TRANSFORMATIONAL CHANGE

VA CLCs use the Holistic Approach to Transformational Change (HATCh) model (originally developed by the Quality Partners of Rhode Island now known as Health Centric Advisors https://healthcentricadvisors.org) as the framework for resident-centered care. The HATCh model is an approach to nursing home care that supports quality of life and quality of care that uses the Whole Person Whole Team and Whole Health approach. Whole Health puts “what matters” at the center of their care. The plan of care will be driven by resident’s preferences and habits. Each CLC’s approach to care and leadership should be guided by the HATCh model.

The HATCh model has six domains, and the resident is at the center of the model. CLCs put special emphasis on the work practices, care practices, and environment of care. These four categories have the largest impact on residents and staff.

The HATCh model above is trade-marked by the Quality Partners of Rhode Island now Health Centric Advisors. This model has been modified from its original.

Changes in care practices include creatively enhancing dining practices, liberalizing diets, allowing resident choice in bathing, grooming, sleep and wake schedules and offering activities for meaningful use of time. Care is provided so that the resident is respected, treated with dignity and is invited to be an active participant in their own care. All VA employees assigned to the CLC are considered care providers. Staff should be competent to provide specialized services.

Changes in work practices include alterations in shifts and work schedules for all disciplines and the empowerment of direct care staff. VA CLCs should provide a supportive, interdisciplinary work

4 | P a g e environment which engages employees in all aspects of decision-making and information sharing.

Daily huddles that include the frontline staff / direct care staff are strongly recommended as a foundational practice. Direct Care Staff are consistently assigned to care for the same residents.

All staff should be given opportunities to act as leaders. Decisions should be made as an interdisciplinary team.

Changing the environment of care includes creating designated spaces for a living room, kitchen and bedroom to reflect a home atmosphere and a greater attention to privacy and comfort. Nursing stations have been replaced with communal spaces for residents and staff to interact with one another.

CLCs have created neighborhoods or households that encourage residents, family, and staff to name, decorate, and own their place of residence and work. Residents have access to outdoor spaces, children and animals.

CHANGES IN LEADERSHIP PRACTICES INCLUDE

HOW WE SERVE THE VETERAN

❤ We serve with kindness, compassion, and respect for the dignity of the Veteran.

❤ We provide short-stay and long-stay nursing home services to Veterans who are medically and psychiatrically stable.

❤ When a resident is admitted to the CLC, we know who the resident is / was before they came to live with us, the reason why they are here, how long they will stay, and where they will go after if they will be discharged. We learn “what matters most to them” and bring that focus to set shared goals in care planning. We are always striving for the Whole – Person approach to care.

❤ We respect that “The resident does not live in our CLC; we work in the Veteran’s home.”

❤ We consistently look for ways to improve quality of life and quality of care. Quality improvement is everyone’s responsibility, and everyone is invited to contribute ideas. We use the Whole - Team approach.

❤ We respect the resident’s preferences, needs, and desires, and reserve our judgment.

❤ We change or modify outdated or unneeded practices and policies based on the most recent evidence to ensure the highest quality of care.

❤ We strive toS assign staff to the same resident daily in order to build and maintain relationships of trust and understanding between the resident and CLC staff member. We reinforce the value of these relationships during frontline huddles and deep dives, calling on caregiving staff to share what they know about the residents for whom they care.

❤ Each person assigned to the CLC is a member of the Interdisciplinary team and has responsibility for all aspects of the resident’s care. All team members, including frontline/ direct care staff should participate in IDT huddles and deep dives.

❤ We design processes and routines around the resident’s needs, preferences and life-long habits, not the convenience of staff or the facility. We should complete an All About Me on admission and update as needed.

❤ We problem solve together as a team (during huddles / deep dives) to meet the resident’s needs. All team members have an opportunity to share opinions and ideas. The staff member that knows the resident best should lead (Nursing Assistance / LPNs).

❤ We merge traditional service roles and responsibilities if needed. Caring for our residents is everyone’s job.

❤ We address resident concerns immediately and ensure the resident will be served that day. We place residents with acute concerns / needs on the Watch List Huddle Board so these concerns can be addressed

5 | P a g e by the Whole -Team.

❤ We develop the plan of care based on who the resident is as a person, “what matters most” to the resident/MAP, the reason why the resident was admitted into the CLC, the length of anticipated stay, and the resident’s discharge destination. The resident and family or friends as appropriate participate in the development of the plan of care, always moving toward the goal of Whole-Person, Whole -Team approach to care

❤ We rely on frontline performance improvement processes and quality information to be exchanged between frontline staff and leadership through frequent consultation.

I UNDERSTAND THE WORK PRACTICES IN THE CLC.

Signature Date

CARE PRACTICES

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HOW WE CARE FOR THE VETERAN

❤ We provide care in a trustworthy, respectful, and compassionate manner.

❤ We provide skilled nursing care, rehabilitation, restorative care, mental health recovery care, dementia care, hospice and palliative care, continuing care, respite care, and geriatric evaluation and management services.

❤ We treat each resident with dignity and respect their privacy. We knock on doors and ask permission before entering a resident’s bedroom. We pull curtains and close doors before providing care.

❤ We individualize the plan of care to reflect the resident’s preferences and “what matters most”. We prioritize whole team knowledge of resident preferences and routines, such as completing an All About Me tool on admission with systems to ensure staff share and regularly update this information in frontline huddles and as well as other communication pathways.

❤ We maintain policies and competencies to ensure quality care for our residents. Examples of competencies are Dignity and Privacy, Medication Administration, Infection Control, Elimination of Physical Restraints, PICC Line Care, PEG Tube Care, and Pressure Ulcer Prevention and Care.

❤ We use “Bathing Without a Battle” techniques to enhance the bathing experience for residents.

❤ We are a restraint free environment.

❤ We strive to liberalize diets, give residents food choices that reflect their preferences, and use creative approaches to improve the dining experience. Snacks are available to residents at no additional cost 24 hours per day.

❤ We ensure meaningful use of time for residents with activities available 24 hours a day including special events and celebrations. All staff, not limited to Recreational Therapists, lead activities and engage residents to interact with others.

❤ We respect residents’ sleeping and waking cycles. we ensure our residents are getting adequate, high quality, uninterrupted sleep by collecting small data (e.g., sleep diaries, sun trackers) and using other VA QAPI improvement practices such as team deep dives

❤ We ensure residents are dressed and groomed properly each day.

❤ We ensure good oral hygiene for each resident.

❤ We provide access to animals, the outdoors, and the community.

❤ We provide intergenerational care and pay special attention to a resident’s age, generation and cultural needs.

❤ We know each resident by their name and interests, not by their diagnosis.

I UNDERSTAND THE CARE PRACTICES IN THE CLC.

ENVIRONMENT OF CARE

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WHERE WE SERVE THE VETER AN

❤ We maintain a clean and safe environment.

❤ The physical space is designed to give staff and residents cues on how to use and live in the CLC.

There are designated spaces for kitchen, dining room, living room, and bedrooms.

❤ We strive to provide private bedrooms and bathrooms whenever possible.

❤ We strive to create a true home environment that does not look or feel like a hospital or acute care setting. These personal home-like preferences should be included on the All About Me tool

❤ We use warm color palettes, appropriate lighting, soothing pictures, and decorations to create a comfortable home environment.

❤ We encourage residents to decorate their bedrooms and bring personal items from home.

❤ We do not use florescent lighting, shiny floors, or furnishings that have an institutional appearance to create a healing environment.

❤ We strive to remove traditional nurse stations.

❤ We do not use overhead paging and the environment is free from unnecessary noise.

❤ We create space that allows for privacy and quiet relaxation.

❤ We use the new approved CLC Design Guide to develop plans for construction or major renovations.

❤ We provide space for family, friends and the community to visit the resident and do not have restrictions on visiting hours.

❤ We care for ourselves and bring our best version of ourselves into the workplace

I UNDERSTAND THE ENVIRONMENT OF CARE PRACTICES IN THE CLC.

LEADERSHIP

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LEADERSHIP PRACTICES WE FOLLOW:

❤ We believe that leadership “is the ability to influence outcomes, regardless of a person’s title or position.” Staff should be given opportunities to act as leaders and affect change.

❤ We invite all stakeholders, especially the resident, to engage in shared decision making (Whole-Person, Whole -Team approach).

❤ We listen to others and seek advice from our staff. We elicit the input from frontline staff on issues that directly impact them.

❤ We are continually learning and teaching ways to improve. We utilize CONCERT, Just-In-Time (JIT) teaching practices.

❤ We empower others and create opportunities for people to take on responsibilities and leadership roles. We encourage everyone have a chance to facilitate during huddles.

❤ We encourage a culture of innovation and change.

❤ We model selfcare and provide opportunities for staff self-care.

We nominate staff for awards and give recognition for accomplishments. We seek out and celebrate “Bright Spots

❤ We participle in and implement national quality initiatives.

❤ We are responsible for Quality, Care, and Cost.

❤ We support and provide opportunities for professional development.

❤ We believe that personal commitment, competency, conflict and creating a community of committed persons are the foundation to leading and sustaining change.

❤ We lead, guide, direct and observe care in helpful ways to assist staff improve.

❤ We do the right thing for the right reason. We confront unethical and unkind behavior.

❤ We do not tolerate any form of abuse or neglect and take immediate action if reported or observed.

I UNDERSTAND THE LEADERSHIP PRACTICES IN THE CLC.

GUIDING PRINCIPLES AND REGULATIONS

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Guiding Principles and Evidence-Based Practices We Follow:

Hatch Model : is an approach to nursing home care that supports quality of life and quality of care that uses the Whole- Person Whole -Team approach

CONCERT (CLCs Ongoing Center for Enhancing Resources & Training): whole person, whole team practices are guided by person centered care. These principles prioritize to include “ALL” staff, their thoughts, ideas and knowledge, based on their relationship with the resident. Staff bring this valuable information to frontline huddles where they participate in developing individualized treatment plans/ interventions for each resident.

Age Friendly : An initiative of The John A. Hartford Foundation and the Institute for Healthcare

Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), designed Age-Friendly Health Systems to meet this challenge head on.

The goal of the initiative is to rapidly spread the 4Ms Framework to U.S. hospitals and health care systems. Age- Friendly Health Systems aim to: Follow an essential set of evidence-based practices, cause no harm; and Align with What Matters to the older adult and their family caregivers.

PPC: (Patient Priorities of Care) an approach to healthcare that empowers and equips Veterans to take charge of their health and well-being and supports them in actively participating in the care planning process.

Whole Health: care that supports your health and well-being. Whole Health centers around what matters to you, not what is the matter with you. This means your health team will gets to know you as a person, before working with you to develop a personalized health plan based on your values, needs, and goals.

Whole Person : Refers to the physical, mental, and psychosocial well-being of each person. It includes the person’s military and work history, family history and current life, customary routines and preferences, areas of interest and ways to help the Veteran thrive.

Whole Team : Involving everyone who provides care or interacts with the Veteran, including frontline staff who provide direct care and IDT members and EMS. The foundation of whole team approach is focused on the relationships the staff have and how that shapes the resident experience. (termed Relational Coordination) Good communication, good relationships equate to higher quality care.

VA QAPI: Is defined by breaking down the components into two parts. “QA” is a process of monitoring care that has already taken place and to ensure that it meets an acceptable level of quality and proactively sets and monitors performance targets. QA looks back over what has already happened (e.g., Big Data) to figure out what needs to improve. QA looks for patterns across Veterans. “PI” proactively looks at emerging issues (e.g., Small Data) and responds rapidly through small test of change. PI focuses first on the individual veteran although it can expand its focus to look across Veterans. It looks at individual situations and reviews processes of care with an intention to prevent a decline and promote the individual’s highest practicable wellbeing. Performance improvement draws on the “Whole Team” through front-line structure and processes (e.g., Huddles, Deep Dives, collection & analysis of small data).

https://www.johnahartford.org/ https://www.aha.org/front https://www.chausa.org/ https://www.chausa.org/

GUIDING PRINCIPLES AND REGULATIONS

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High Reliabi l ity Organization (HRO): An organization that experiences fewer than anticipated accidents events of harm despite operating in highly complex, high-risk environments where even small errors can lead to tragic results. HROs establish trust amongst leaders and staff by creating a Just Culture that balances individual accountability with systems thinking. Core HRO practices are achieved through implementation of VA QAPI/CONCERT practices.

Cultural Transformation (Resident -Centered Model of Care): Cultural transformation is the term used to describe the VA CLC’s journey from a medical model of care to a resident-centered model of care. The resident participates in decisions about their care and routines. The facility environment, policies, and practices are designed to support the needs of the resident and are flexible to meet resident’s individual preference

GOVERNMENT AND REGULATION PRACTICES, WE FOLLOW:

❤ GEC Policies and Directives for the CLC

❤ Each resident’s needs are assessed using the Minimum Data Set (MDS). MDS reports are accurate and reflect the resident’s true status and preferences.

❤ We incorporate MDS generated Resident Utilization Groups (RUG) data for nurse staffing, aiming for the recommended minimum of 3.9 to 4.1 hours per patient day (HPPD).

❤ SOP for VA QAPI

❤ CLC Compare and SAIL Data

❤ We are always prepared to be surveyed by the Unannounced Survey Process, and any other government oversight body.

I UNDERSTAND THE GOVERNMENT AND REGULATIONS PRACTICES IN THE CLC.

COMMUNITY

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HOW WE INTERACT WITH THE COMMUNIT Y:

❤ We welcome the community and volunteers into the CLC.

❤ We provide opportunities for residents to participate in community events and activities.

I UNDERSTAND THE C OMMUNITY PRACTICES IN THE CLC.

VA CORE VALUES

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VA CORE VALUES WERE ESTABLISHED IN JULY 2011.

All staff in the CLC are expected to model and uphold the VA Core Values. These are the values that define who we are as VA employees and set the standard for the organizational culture we want to achieve in the CLC. “I CARE” is more than just words. It is a personal commitment to act.

VA Core Values: I CARE

Integrity

Because I care I will…Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.

Commitment

Because I care I will …Work diligently to serve Veterans and other beneficiaries.

Be driven by an earnest belief in VA’s mission. Fulfill my individual responsibilities and organizational responsibilities.

Advocacy

Because I care I will …Be truly Veteran-centric by identifying, fully considering, and appropriately advancing the interests of Veterans and other beneficiaries.

Respect

Because I care I will …Treat all those I serve and with whom I work with dignity and respect. Show respect to earn it.

Excellence

Because I care I will…Strive for the highest quality and continuous improvement. Be thoughtful and decisive in leadership, accountable for my actions, willing to admit mistakes, and rigorous in correcting them.

I UNDERSTAND THE VA CORE VALUES AND PLEDGE TO UPHOLD THESE VALUES IN THE CLC.

QUESTIONS TO ASK OURSELVES

Appendix A

The CLC treats human responses to illness in a way that nurtures the Veteran’s mind, body, and spirit. The emphasis is on quality of care and quality of life using the Whole-Person, Whole-

Team approach.

I. . | The care we provide should reflect how the Veteran would live if he or she was able to receive care in their home. Think about how you live your life at home and your daily routine as you answer these questions.

A. If I was not feeling well, would I want someone to wake me up 2-3 hours earlier to eat a breakfast that is not my usual choice?

B. Would I want to take a bath or shower in front of other people? How would I feel if I was told I could not have a shower or bath every day?

C. If I had to live in the CLC, how many different people would I want to deliver my intimate personal care? How would I feel if these people were strangers, I had just met that day?

D. Would I miss going outside after 3 or 4 days of being in one room indoors?

E. Would I want to eat cafeteria food off a tray alone in my bedroom or in a noisy dining hall for an extended period?

F. How would I feel if someone else had control over everything I ate? If I had my access to food restricted?

G. If I had to leave my home for an extended period, what would I miss? My friends and family?

My pets? My possessions? How would missing these things affect my mood and outlook on life?

H. How would I feel having to sleep apart from my significant other? What if it was a permanent living arrangement?

I. If I had to live in the CLC, could I continue the important relationships and activities in my life?

J. How would I feel if someone restricted the amount of time my loved ones could spend with me during a time of crisis or stress?

K. What’s my favorite part of my day? Could I replicate that in a CLC?

L. How would I feel if I could no longer surf the internet, watch my favorite TV shows, or listen to the music I like?

QUESTIONS TO ASK OURSELVES

A

II. . | A person’s ability to exert control over their life and their environment is very important to maintaining their identity, connection with others, and establish home. Think about how the decisions you make every day and the control you have over your own life as you answer these questions.

A. How would I feel if I lost my mobility or ability to care for myself and had to rely on other people every day?

B. How would I feel if someone else had control over when I went to the bathroom, went to bed, or what time I could eat?

C. If I lived in a CLC, would I feel that my privacy was compromised if people constantly walked in and out of my bedroom without knocking or asking permission to enter? If I had to share a bedroom with a roommate I did not know very well?

D. How would I feel if I could not spend private, uninterrupted time with my loved ones for an extended period?

E. How would I feel if someone I did not recognize tried to undress me, touch me, or force me to do something I didn’t want to do?

F. If I had to depend on others for my care, would I feel comfortable complaining if I was unhappy or making recommendations for improvement?

G. How would I feel if my health care providers did not listen to my opinions or seemed to care about what I thought? What if I disagreed with them about my care?

H. What if most people I interacted with every day seemed too busy to spend time with me? Or rushed through the things we did together?

I. What would it feel like to have no connection to the place or people around me? When you stay in a hotel or someone else’s home for a long period of time, does that become home for you?

J. What would it feel like if someone else had control over whether I got to go home or not?

If someone else had power to determine where I lived?

K. How would I feel if someone was trying to force me to exercise, go on a diet, stop smoking or refused to let me drink, but I didn’t want to do those things?

L> If I was not able to have my family visit in person, how would that make me feel?

RESIDENT-CENTERED CARE:

PRE AND POST KNOWLEDGE CHECK

B

INSTRUCTIONS:

Please answer the questions to the best of your ability before reviewing the Resident-Centered Care:

An Introduction to the VA Community Living Centers. Record your answers in the Before Column.

After reviewing the Resident-Centered Care: An Introduction to the VA Community Living Centers, answer the questions again in the After Column. Once finished, ask your proctor for the answer key and calculate your percent of knowledge increase.

QUESTION BEFORE AFTER

1. True or False

In the CLC, the driver of care is the Veteran’s medical diagnosis.

2. Multiple Choice

How can staff provide Resident-Centered Care?

A. Give special treatment to some residents

B. Provide age and culturally appropriate activities

C. Ignore policies and rules to give the Resident what they want

D. A and B

3. Multiple Choice

Residents who are being cared for using the medical model may feel…

A. Lonely, bored, and isolated

B. Happy, safe, and well cared for

C. Able to make their own decisions

D. B and C

4. True or False

Good care can be delivered without following any cultural transformation or resident-centered care practices.

5. True or False

In the CLC, our residents live in the staff’s facility.

PRE AND POST KNOWLEDGE CHECK continued

QUESTION BEFORE AFTER

6. Multiple Choice

The framework for resident-centered care in the CLC is based on the:

A. Joint Commission standards

B. Holistic Approach to Transformational Change (HATCh) Model

C. Unannounced Survey Program

D. The CLC’s local policies and rules

7. True or False

In the CLC, traditional nursing stations should be removed, and overhead paging should be turned off.

8. Multiple Choice

Which of the following reflect CLC Care practices?

A. Bathing Without a Battle technique

B. Restraint-free environment

C. Strict diets and only health food choices

D. A and B

E. A, B and C

9. True or False

When a resident is admitted to the CLC, staff should know:

1. who the resident was before they came to the CLC?

2. the reason why the resident is at the CLC

3. how long the resident will stay

4. where the resident will go after discharge

10. Multiple Choice

The CLC polices, schedules, and processes should revolve around:

A. The way things have been done in the past

B. What works for the majority of the residents?

C. Ease and efficiency for the staff

D. Each resident’s needs and preferences

CALCULATE TOTAL CORRECT ANSWERS IN EACH COLUMN ➡

Knowledge Check!

minus divided by 10 then multiplied by 100 = % knowledge

PRE AND POST KNOWLEDGE CHECK continued

(After ) (Before)