Respiratory Benefits Program

Transcription

1 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014

2 Alberta Aids t Daily Living BPAP Therapy Benefits Service Delivery Mdel (SDM) July 1, 2014 Apprval and Authrizatin f BPAP Therapy by the Respiratry Benefits Prgram (RBP) New requests fr BPAP will be reviewed by the RBP as they are received. Apprpriate measures will be taken t ensure Client's needs are addressed as sn as pssible. Per Plicy R-01: It remains the respnsibility f the Client s physician t initiate, terminate r change therapy and t versee the effectiveness f the therapy. Initiatin f BPAP Therapy Initiatin includes supply f equipment, educatin and fllw-up visits required during the first three mnths f therapy. The *Service Prvider * will be cmpensated at the initiatin rate fr the first three mnths f service, which includes the cst f mask. There will be an initiatin f equipment cst fr three mnths as well. Once the three mnth initiatin is cmplete the Client ges n t nging service and equipment. Clients will be required t select their BPAP prvider : Infrmatin will be prvided by referrer based n Client s needs and current client relatinship with suppliers. The Service Prvider list is available n AADL website. Clients apprved t start xygen and BPAP at the same time will be required t select a prvider ffering bth benefits. Clients already receiving ne f these benefits will nt be required t change prviders if they are subsequently apprved fr bth. If the Client is apprved fr tw BPAP machines, the Service Prvider will be cmpensated fr the first unit under Initiatin equipment and the secnd under Onging Equipment per diem. Upn determinatin that a Client is eligible fr BPAP therapy, the Service Prvider will initiate BPAP therapy in a timely manner as fllws: The expected service delivery time is based n the time and date that the service prvider receives apprval fr set up by RBP. RBP will request a cnfirmatin frm the Service Prvider t ensure the request was received and initiatin set-up is scheduled. Whenever pssible, the Service Prvider will have sme autnmy regarding set up in evening r in the mrning f the next business day. * In this dcument, the term Service Prvider is used interchangeably with Specialty Prvider Gvernment f Alberta Page 1 f 9

3 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 Urgent initiatin will be prvided within 24 hurs f client apprval in the fllwing circumstances : Client requires BPAP fr hspital discharge r t prevent hspital (re)admissin - details will be prvided by referrer in Ratinale sectin f the frm. Referrers are instructed t submit BPAP requests t RBP as sn as the discharge plan is in place. Client is starting n BPAP and xygen at the same time. Client requires BPAP fr ventilatin >16 hurs per day. All ther exceptinal circumstances will be reviewed and apprved by the RBP. Referral frms will include space fr physician t dcument ratinale fr urgent referral. Rutine initiatin requires Service Prviders: Cntact the Client within ne business day f apprval by RBP staff. Begin initiatin services within three business days f apprval, unless a delay is requested by the Client. BPAP initiatin includes the activities required t deply the BPAP equipment t the and fr the Client achieve cmpliance with the therapy. These activities may take place ver the curse f several days r weeks, depending n the Client s needs and circumstances. Specifics f the initiatin expectatins will be included in the Educatin Package requirements. Service Prvider expectatins are fund in the AADL plicy and prcedure manual. It is anticipated that mst BPAP therapy initiatin activities will be prvided by a Registered Respiratry Therapist (RRT) with clear understanding f Client needs, cnditin and equipment used. Plysmngraphic Technlgists (PSGT), Registered Nurses (RN) r ther health care prfessinals with prf f cmpetency may als prvide these services. It will be the respnsibility f the Service Prvider t restrict themselves t thse activities that they are cmpetent t perfrm and t thse apprpriate t the Service Prvider s area f practice and the prcedure being perfrmed. It will be the respnsibility f the Service prvider t cnfirm cmpetency. Hwever, their wrk must be supervised and cnfirmed by an RRT. It is expected that initiatin services will ccur in the Service Prvider s ffice/clinic setting r thrugh phne cntact, as mst apprpriate. Services may als be prvided in the Client s hme in situatins where the Client is unable t travel t the Service Prvider s ffice and a phne cnsult is nt apprpriate. An infrmatin card (develped by AHS) must be attached t the side f the Client s BPAP machine with a cntact number and the mst recent BPAP setting dcumented. This will be readily available in the event the client is admitted t hspital. On the first BPAP initiatin appintment, which must be a face t face meeting, the fllwing activities must be cmpleted: Distributin f apprpriate BPAP therapy equipment t the Client. Educatin f the Client n the peratin, maintenance, care f the BPAP equipment, any safety requirements, and infectin preventin and cntrl practices. Explanatin f the rental prgram including Client and Service Prvider expectatins. Assessment f Client's understanding f cnditin fllwed by client specific educatin 2014 Gvernment f Alberta Page 2 f 9

4 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 abut their cnditin, the need fr and benefits f BPAP therapy and the prcess f habituatin t BPAP therapy. Depending n the assessment f educatinal need, a referral back t Physician fr further discussins regarding patient diagnsis may be required. Mask fitting. Infrmatin regarding the rle f the Service Prvider and RBP participatin in the Client s care. Review f relevant RBP plicies, timelines and testing requirements. Review f Client respnsibilities, including: Wrking twards achievement f cmpliance with therapy. Ntifying RBP and the Service Prvider if the Client intends t mve ut f prvince, changes address, n lnger uses r requires BPAP, enters a lng-term care facility, r changes physician. Replacement f lst, stlen r damaged equipment. Required assessment/testing as required by RBP and arranged by the Service Prvider and/r physician. Dcumentatin f the Client s understanding and agreement t cmply with equipment care and safety requirements and Client respnsibilities. Review f cnditins where the BPAP therapy will be discntinued r the client will be expected t cver the cst f the benefit: Misuse f equipment Failure t cmplete the required assessment/testing as required. Client refusal f therapy (requires written dcumentatin frm client whenever pssible.) Cmments and cncerns abut difficulties with client set up must be included in Client's recrd. The Service Prvider must prvide the Client with cntact infrmatin t address questins r cncerns regarding BPAP equipment and t cmmunicate expected timeframe fr service. During the initiatin perid (three mnths), the Service Prvider will prvide nging supprt and interventin as required t assist the Client t achieve cmpliance with therapy, including: Onging cntact with client t assess prgress f therapy Three mnth cmpliance dwnlad reprt (targeting American Academy f Sleep Medicine standard f 4 hurs/night, 70% time) t be dcumented and reviewed by treating physician. Therapy supprt t address cmfrt, desensitizatin and habituatin. Mask trials as deemed clinically apprpriate by Service Prvider. Effrts t achieve cmpliance with BPAP therapy may require cllabratin with ther healthcare prfessinals including Client s physician and/r specialty clinic. If the client is experiencing difficulty achieving cmpliance: The Service Prvider must infrm the physician earlier than the three-mnth initial deadline when the Client is experiencing difficulty in achieving cmpliance. The Service Prvider is 2014 Gvernment f Alberta Page 3 f 9

5 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 expected t keep detailed dcumentatin regarding remedy measures. A cllabrative apprach is required fr Clients experiencing difficulty achieving cmpliance with BPAP therapy, and where it is anticipated that the Client may nt achieve cmpliance within the three-mnth perid. Clients wh are nn-cmpliant within the three-mnth perid may be given an extensin trial perid if it is recmmended by the Physician r Service Prvider and apprved by the RBP. This will be cmpensated at the Service and Equipment rate. It is t be made clear t all stakehlders that remving the BPAP device frm the Client s hme is the FINAL step fr clients refusing therapy. If it is decided that the client is t be discntinued frm BPAP therapy: The Service Prvider is expected t ntify the physician BEFORE the Client s therapy is discntinued. It is the respnsibility f the Service Prvider t retrieve their equipment frm the Client. Cmments and cncerns regarding client challenges must be included in the Client recrd. The Service Prvider must include the discntinuatin f clients in the first 2 weeks f the mnths t RBP. The Service Prvider will infrm the physician that the Client can be restarted n therapy nce the Client agrees t be cmpliant. Onging BPAP Service Delivery The Service Prvider will be cmpensated at a Service and Equipment rate fr nging service which starts after the 90 day initiatin perid. The Service Prvider will prvide nging supprt t prmte and maintain Client cmpliance with BPAP therapy. This will be dcumented n Client s file and be available fr audit. The extent and frequency f supprt prvided t individual Clients will vary based n the circumstances and assessed needs f the Client and requirement. It is expected that Onging BPAP service Delivery activities will be prvided by a Registered Respiratry Therapist (RRT) with clear understanding f Client needs, cnditin and equipment used. Plysmngraphic Technlgists (PSGT), Registered Nurses (RN) r ther health care prfessinals with prf f cmpetency may als prvide these services. It will be the respnsibility f the Service Prvider t restrict themselves t thse activities that they are cmpetent t perfrm and t thse apprpriate t the Service Prvider s area f practice. It will be the respnsibility f the Service prvider t cnfirm cmpetency. All wrk must be supervised and cnfirmed by a RRT. It is expected that the services prvided t the Client will ccur in the Service Prvider s ffice/clinic setting r thrugh phne cntact, as mst apprpriate. At the Service Prvider s discretin, these services may be prvided in the Client s hme, r hspital setting in situatins where the Client is unable t travel t the Service Prvider s ffice fr services and a phne cnsult is nt apprpriate Gvernment f Alberta Page 4 f 9

6 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 The Service Prvider will maintain cntact with the Client s physician and ther health care prviders as required t ensure that the Client s needs are met and that there is cntinuity f care amngst the Client s health care team. Dcumentatin f Client s cnditin, mst recent BPAP settings, assessment f their understanding and prgress will be recrded n Client s chart and cpies sent t the physician and ther health care prviders participating in the Client s care. The Service Prvider will cmplete BPAP setting changes based n a revised prescriptin frm physician. They will be respnsible fr prviding dcumentatin and ntificatin t ther health care prviders and Client ntes (benefit nte). All BPAP Clients will receive at least tw cmpliance dwnlads at 3 and 9 mnths each ne must be accmpanied by a cmpleted reassessment frm. The cmpliance dwnlads can be attained by any manner the Service Prviders chses, (ffice visit, mdem dwnlad, r Client hme visit). There must be an annual face t face Clinical assessment visit within the first year f therapy. An annual face t face clinical assessment is t take place n mre than three mnths prir t the expiry f the BPAP funding term and will include: Dcumented cnfirmatin that the Client cntinues t use BPAP therapy frm the Service Prvider and a dwnlad f the Client s cmpliance with BPAP therapy. Additinal r cntinuing educatin as needed, including: Educatin n the peratin, maintenance, and care f BPAP equipment. Clinical educatin regarding the Client s cnditin and the need fr and benefits f BPAP therapy. Referral t physician fr further educatin, as required. Fr BPAP Clients authrized as lng-term users: Service Prviders will take a cmpliance dwnlad every six mnths and retain it in the Client s recrd. If cmpliance criteria are met the Client can be autmatically apprved. The Service Prvider will ensure that clinical and cmpliance infrmatin btained frm Clients, including the annual assessment results, is shared with the Client s physician in a timely manner. An Educatin Package Certificate with the apprpriate infrmatin sharing agreement disclsure clause will be included in the initiatin package. The Service Prvider will ensure that a Registered Respiratry Therapist experienced with BPAP therapy is available t address Client cncerns. The Service Prvider will prvide 24-hur emergency service t address Client BPAP cncerns and respnd t equipment failure within ne hur f Client request. If an equipment prblem cannt be reslved ver the phne, the Client will be expected t cme t the Service Prvider's ffice with the equipment as sn as pssible, unless the Service Prvider and the Client mutually agree that attendance is nt necessary. Hme visits are nly required by exceptin and at the Service Prvider s discretin Gvernment f Alberta Page 5 f 9

7 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 Equipment Requirements The Service Prvider must prvide the Client with a BPAP machine apprved fr use by Health Canada and meeting the requirements f the Client s prescriptin. Only ne BPAP machine will be prvided t each client unless RBP grants prir apprval fr a secnd machine. The Service Prvider must prvide apprpriate equipment frm the fllwing categries, within the initiatin timelines specified in this dcument: 1. Spntaneus Mde Machine a) Ventilatin mde: Spntaneus (S). b) Pressure range: IPAP 4 cmh20 t 25 cmh20, EPAP 4 cmh20 t 15 cmh20. c) Ramp r ramp-like capabilities with unlimited number f ramps per night. 2. Spntaneus, Spntaneus/Timed, Pressure Cntrl & Pressure Regulated Vlume Cntrl Mde Machine a) Ventilatin Mdes: Spntaneus (S), Spntaneus/Timed (S/T), Pressure Cntrl (PC) and Pressure Regulated Vlume Cntrl b) Pressure range: IPAP 4 cmh20 t 25 cmh20, EPAP 4 cmh20 t 15cmH20 c) Ramp r ramp-like capabilities with unlimited number f ramps per night. d) Rate 0 30 breaths per minute. 3. Spntaneus, Spntaneus/Timed Mde Machine with IPAP up t 30 cm H 2 0 e) Ventilatin Mdes: Spntaneus (S), Spntaneus/Timed (S/T) f) Pressure range: IPAP 4 cmh20 t 30 cmh20, EPAP 4 cmh20 t 20 cmh20 g) Ramp r ramp-like capabilities with unlimited number f ramps per night. h) Rate 0 30 breaths per minute. All BPAP machines must have the fllwing accessries/capabilities: Heated humidifier, a carrying case, cnnectr, tubing (6 feet frm machine t mask) replacement filters and masks. Pressure adjustment: clinical menu system nt easily accessible r bvius t patient. Cmpliance capability, therapy memry retrievable thrugh direct cmputer link (200 days minimum). Memry cntent: pressure settings, date and time f each use, including actual usage hurs at set pressure. Assciated sftware t accept data dwnlads. Electrical requirements: VAC, 12 VCD capabilities. Altitude cmpensatin capability. Cmplete with all necessary peratin manuals and instructins. The Service Prvider will ensure that all equipment is maintained and repaired per manufacturer s specificatins. Batteries will nly be prvided by RBP prir apprval Gvernment f Alberta Page 6 f 9

8 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 Previus BPAP Client Enrllment in New Service Delivery Mdel Previus clients are defined as Clients receiving BPAP therapy apprval prir t July 1, 2014 where the BPAP unit was purchased by AADL. Once a face-t-face assessment has been cmpleted by the Service Prvider, an equipment r service request fr a previus client will be reviewed n case-by-case basis. The level f enrllment will be determined by the RBP based n client needs. Previus clients may be enrlled at ne f three service levels: Service nly Equipment nly Service and Equipment Previus Clients requiring sft gds nly can btain their BPAP supplies frm any f the AADL apprved BPAP Service Prviders but will NOT be enrlled in the new service mdel. When reviewing the request t enrll a previus Client, RBP will cnsider the Client s present cverage, including warranty and length f time wning equipment and accessries (mask). Existing warranty/plicy will be fllwed. Clients r physicians cntacting AADL/RBP with service/equipment requests will be directed t the Client s current Service Prvider fr assessment. Requests fr service r assessment must be initiated by the Client, Client s physician r hmecare wrker r RRT invlved in Clients care. General n-barding f Clients must nt be initiated by the Service Prvider. Clients wh have discntinued therapy fr ne year r lnger may be restarted with prir apprval frm RBP. Enrllment level will be determined by RPB nce the referral has been made by Physician r Service Prvider and initial assessment f needs has been cmpleted. The previus Client is expected t remain with their present BPAP Service Prvider unless they specifically request a change. Once the Clients have been enrlled in the SDM, they must get their sft gds frm the Service Prvider they are enrlled with in rder fr the sft gds t be cvered by the prgram. Requests frm previus Clients t change Service Prviders will be reviewed by the RBP staff and respnded t accrding t AADL Plicies and &Prcedures. Issues dcumented n the Client s recrd (i.e. failure t pay fr replacement equipment, changing vendrs t avid payment, misuse f equipment, etc.) will be cmmunicated t the new Service Prvider. Clients Requiring Equipment Assistance: If the equipment is under warranty, Medigas is respnsible fr addressing the equipment issue. If the equipment issue cannt be reslved by Medigas, and the Client requires a replacement, Medigas will prvide a warranty replacement. The Client will nt be enrlled in the new SDM. If the equipment is nt under warranty, AADL expects BPAP Service Prviders t assist the Client t trublesht equipment issues even thugh the Client s BPAP was setup prir t the new SDM Gvernment f Alberta Page 7 f 9

9 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 If the issue cannt be reslved by the Service Prvider and the Client requires a replacement, a request must be sent t RBP fr review. Clients Requiring Clinical Supprt: Clients requiring clinical supprt may be identified by their Physician, staff at the Sleep Lab r Clinic, r by an AHS r Service Prvider RRT. A Client may als request clinical supprt. If the Client cntacts RBP/AADL requesting clinical supprt, the Client will be referred t the BPAP Service Prvider, as selected by the Client, fr assessment. Clients Requiring an Secnd BPAP Unit: The request fr a secnd BPAP fr a client started n BPAP therapy prir t July 1, 2014 must be submitted by a physician r staff at Physician s ffice, based n RBP plicies Gvernment f Alberta Page 8 f 9

10 Respiratry Benefits Prgram BPAP Service Delivery Mdel July 1, 2014 Glssary BPAP Prvider - an rganizatin that prvides BPAP services wh is selected by the client and apprved by the Respiratry Benefits Prgram. Clinical Assessment - an assessment cnducted by a Registered Respiratry Therapist which will include a review f current medicatins at least but nt limited t the fllwing measurements: Oxygen saturatin; Shrtness f breath Bld Pressure; Dwnlad f BPAP Heart Rate; cmpliance Chest Auscultatin; Cllabrative Apprach - the mutual engagement between the Client and Service Prvider t define, assess and reslve prblems assciated with all aspects f the BPAP service delivery. Cmpetence - the cmbined knwledge, skills, attitudes and judgment required t prvide BPAP services t clients. Cmpliance - patient is using the BPAP equipment as prescribed by the physician and instructed by the Service Prvider. Gal is fr the Client t meet r succeed AASM standard guidelines f 4 hurs 70 % f the time within 9 mnths Infrmatin Card - a card cntaining all pertinent infrmatin re BPAP set up and cntacts. Is attached t the side f the clients BPAP machine fr quick access t client settings Initiatin - includes a supply f equipment, educatin and subsequent fllw-up visits as required during the first three mnths f therapy. Initiatin Appintment - the first face t face meeting between the client and the Service Prvider. Initiatin Equipment - the first face t face set up and intrductin t BPAP equipment and initial mask fit. Onging Equipment - equipment prvided n rental mdel after the first 90 days f use. On-barding - the prcess f enrlling clients wh were already receiving benefits befre July 1, 2014 int the Respiratry Benefits Prgram fr funding purpses. Physician - a regulated member f the Cllege and Physicians and Surgens f Alberta, in mst cases the client s Family Physician, Pulmnary Physician r equivalent. Previus Client - a client receiving BPAP therapy apprval prir t July 1 st, 2014 where the machine was purchased by AADL Referrer - an apprved prfessinal wh submits requests fr client s Respiratry Benefits. Service Prvider an rganizatin apprved by RBP t prvide BPAP services t clients. Sft gds - masks, tubes, cnnectrs and ther supplies used t cnnect patient t BPAP machine Supervisin - Registered Respiratry Therapist mnitring/inspecting the apprpriateness, prgress, effectiveness and patient cmpliance fr BPAP services delivered by Plysmngraphic Technlgists r Registered Nurses Gvernment f Alberta Page 9 f 9

11 Respiratry Benefits Prgram BPAP Service Delivery Mdel Educatin Package Requirements July 1, 2014 Backgrund Service Prviders * are respnsible fr prviding quality BPAP therapy benefits and services t eligible AADL clients. AADL respects that each Service Prvider has their wn standard f care that differentiates them frm ther prviders. AADL defines minimum standards fr service and cmpliance dcumentatin t ensure BPAP therapy clients have the best pprtunity fr success with their recmmended treatment. These standards are detailed in the Service Delivery Mdel (SDM) and this dcument. All Service Prviders are required t meet r exceed the minimum standards. AADL requests that Service Prviders develp their wn Educatin Packages which must include the fllwing frms befre they can deliver service under the BPAP therapy under the new service mdel. Client Educatin Package Checklist BPAP Specialty Supplier s Rles and Respnsibilities BPAP Client s Rles and Respnsibilities BPAP Client Declaratin Frm BPAP Client Declaratin Frm Requirements The Educatin Package shuld include Client and Service Prvider rles and respnsibilities, detailed infrmatin abut the rental prgram, cntact phne numbers and website addresses fr Service Prvider, AADL and the RBP. There shuld be a cmplete package available fr audit. Each Educatin Package must be available in English and any written Client infrmatin shuld be at grade 5-6 level. Service Prviders may develp cpies in ther languages at their discretin. Service Prviders that develp materials in ther languages shuld infrm RBP, they will maintain a recrd t facilitate language-apprpriate referrals. The Client (caregiver) shuld demnstrate understanding f all infrmatin and the Service Prvider shall gage understanding in each area befre Service Prvider signs ff n BPAP Educatin Package certificate. Service Prviders are expected t include the Client s main supprt r caregiver in infrmatin and instructin sessins whenever pssible. * In this dcument, the term Service Prvider is used interchangeably with Specialty Prvider Gvernment f Alberta Page 1 f 3

12 Respiratry Benefits Prgram BPAP SDM Educatin Package Requirements July 1, 2014 Prgram Infrmatin (written and verbal) The Service Prvider is expected t prvide infrmatin t the Client (caregiver) regarding the BPAP Therapy Prgram including the fllwing: Rles and respnsibilities f stakehlders in the AADL BPAP prgram, including: AADL. The cntracted respiratry Service Prvider. Other health care prfessinals invlved in the Client s care. Client respnsibilities, including: Replacing lst r damaged equipment. Ntifying RBP and Service Prvider f the fllwing changes: Intent t mve ut f the prvince. Changing name r address. N lnger using r requiring BPAP therapy. Entering a lng-term care facility. Changing physician. Service Prvider s rental prgram and Client expectatins. Equipment retrieval prcess when BPAP n lnger required. Functin and imprtance f infrmatin card n the side f the BPAP machine when attending fllw-up physician appintments r being admitted t hspital. Meaning f Educatin Package certificate and requirement fr signed dcumentatin f the Client s agreement t fulfill relevant respnsibilities and understanding f their bligatins and rights. Treatment Instructins (written and verbal) Once an assessment f the Client understanding f their cnditin and need fr BPAP therapy is cmpleted, prvide educatin abut the fllwing: Client s cnditin. (If a greater need fr infrmatin regarding the disease prcess exists, the Service Prvider is expected refer the client back t the physician fr educatin.) Purpse and benefits f BPAP therapy. Ptential cmpliance issues such as mask fit, nasal symptms, pressure issues. Truble-shting ptins. Prcess f habituatin t BPAP therapy and expectatins fr client. Client specific plan f care (t be kept n Client s file): Dcumentatin regarding assisting the Client in wrking twards cmpliance with therapy. Prvide individual Client fllw-up schedule and plan. Requirement t cmplete assessment/testing as arranged by the cntracted respiratry Service Prvider and/r physician Gvernment f Alberta Page 2 f 3

13 Respiratry Benefits Prgram BPAP SDM Educatin Package Requirements July 1, 2014 Cmpliance dwnlads at 3 and 6 mnths. Annual face t face assessment and cmpliance dwnlad. Rle and expectatins f Service Prvider regarding the treatment plan. Need fr Client participatin, cperatin and cmpliance. BPAP Unit Instructins (written and verbal) The Service Prvider is expected t prvide infrmatin t the Client (caregiver) regarding the BPAP unit including the fllwing: Instructins fr peratin, maintenance and care f the BPAP equipment. Safety requirements, including infectin preventin and cntrl practices. Cleaning instructins fr mask, machine, tubing and filters. Prducts and prcess required fr cleaning. Client shuld be able t demnstrate hw t turn the machine n and ff. Client shuld demnstrate hw t clean the machine and the accessries. Explanatin f mask fitting perid including trial perid. Explanatin f truble-shting services prvided by Service Prvider. 24 hur cntact infrmatin fr Service Prvider. Cntact infrmatin fr manufacturer including phne number and website where they may view instructinal vides. Educatin Package certificate t be develped by AADL Gvernment f Alberta Page 3 f 3