Three in 10 case managers say workload is unmanageable

November 2010 Vol. 7, No. 11 Job responsibilities survey Three in 10 case managers say workload is unmanageable After reading this article, you will be able to: Analyze the results of the CMM Job Responsibilities Survey Compare your job responsibilities to your case management peers CMM asked hospital case management professionals what tasks their facilities expect them to perform and how those responsibilities affect their productivity in the CMM Job Responsibilities Survey. Nearly 500 case managers, discharge planners, social workers, clinical documentation improvement (CDI) specialists, and appeals specialists responded to the survey. Responses broke down as follows: RN/nurse case manager (30%) Director of case management (26%) IN THIS ISSUE p. 4 Extended observation cases Read providers explanations and solutions for the increase in extended observation cases. p. 6 Project BOOST Find out how one facility improved discharge processes using a toolkit created by the Society of Hospital Medicine. p. 8 Discharge plan Take a look at Morton Plant s discharge plan tool, which keeps patients informed about their condition and details their hospital stay. From the Director s Desk June Stark, RN, BSN, MEd, shares her top 10 case management best practices. Complex case Case management s persistence pays off with a difficult psychiatric patient. Manager/supervisor of case management (20%) Utilization review (UR) specialist (8%) Social worker (4%) CDI specialist (3%) ED case manager (3%) Discharge planner (3%) Appeals specialist (2%) All of the survey respondents work in the acute care setting, but the size of their facilities varies greatly. 25 or fewer beds 5% 26 49 beds 5% 50 99 beds 9% 100 199 beds 25% 200 299 beds 19% 300 399 beds 15% 400 499 beds 7% 500 or more beds 15% Workload Sixty-four percent of respondents said they have a lot to do, but feel it is manageable. On the other hand, 30% feel they are overworked and cannot manage their workload (see Figure 1 on p. 2). Respondents who have a lot to do but feel the workload is manageable made the following comments: Our department is an integrated UR case management department whose core goal revolves around UR with some unstructured case management. We are expanding our UR nurses into UCM [UR/case management] nurses who will do formalized case management along with their UR responsibilities. I usually stay two hours after quitting time for my job hours. It has become the norm for me. > continued on p. 2

Page 2 Case Management Monthly November 2010 Job survey < continued from p. 1 [We] recently combined social services and case management. We are cross-training to do both jobs due to budget cuts. In contrast, the following are comments from those who feel their workload is unmanageable: I am the RN case manager of the hospital I work at. I do UR, discharge planning, InterQual criteria tracking, and I help with core measures. I help with social issues as well (i.e., medical assistance, gas vouchers, [adult protective services] referrals, children service referrals, etc.). I cover the entire hospital. Our director is short-staffing case management to move part of her budget into developing palliative Editorial Advisory Board Case Management Monthly Group Publisher: Lauren McLeod Executive Editor: Ilene MacDonald, CPC Associate Editor: Ben Amirault, CPC-A care, which has increased our case management-topatient ratio to more than 20:1. I am required to rotate through weekends and to work holidays. Continually adding tasks and expectations has resulted in quite a struggle to maintain the level of care that we are used to giving. A lot of case managers are looking for different positions. Several respondents cited increased government scrutiny as the reason for their heavy workload. There is increasing job responsibilities for case managers as quality and costs are linked in the healthcare environment, one respondent said. Figure 1 How would you describe your workload? 2% 3% Jackie Birmingham, RN, BSN, MS Vice President Curaspan, Inc. Newton, MA Stefani Daniels, RN, MSNA, CMAC, ACM Managing Partner Phoenix Medical Management, Inc. Pompano Beach, FL Wendy De Vreugd, RN, BSN, PHN, FNP West Region Senior Director of Case Management Services Kindred Healthcare Westminster, CA Deborah K. Hale, CCS President Administrative Consultant Service, LLC Shawnee, OK Robert Marder, MD Practice Director of Quality and Patient Safety The Greeley Company Marblehead, MA Peter C. Moran, RN, C, BSN, MS, CCM Nurse Case Manager Massachusetts General Hospital Boston, MA Loretta Olsen, MSN, RN Director of Case Management Memorial Hermann Health Systems Houston, TX June Stark, RN, BSN, MEd Director of Case Management, Social Work, and Support Services Tufts Medical Center Boston, MA Karen Zander, RN, MS, CMAC, FAAN Principal and Co-owner The Center for Case Management, Inc. Natick, MA Case Management Monthly (ISSN: 1547-4739 [print]; 1937-7495 [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $349/year. Case Management Monthly, P.O. Box 1168, Marblehead, MA 01945. Copyright 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail customerservice@hcpro.com. Visit our website at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CMM. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. CMM is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. 65% Source: HCPro, Inc. 30% I have too much to do, and it is unmanageable I have a lot to do, but it is manageable Perfect I have free time but not enough to take on more responsibilities

November 2010 Case Management Monthly Page 3 Figure 2 Are case managers/care coordinators expected to preform UR functions at your facility? 25 or fewer beds: 88% 26 49 beds: 96% 50 99 beds: 98% 100 199 beds: 88% 200 299 beds: 86% 300 399 beds: 75% 400 499 beds: 83% 500 or more beds: 89% Figure 3 Does your facility use a dedicated discharge planner to develop and coordinate patient discharges? 25 or fewer beds: 48% 26 49 beds: 46% 50 99 beds: 27% 100 199 beds: 25% 200 299 beds: 27% 300 399 beds: 31% 400 499 beds: 40% 500 or more beds: 40% 0% 20% 40% 60% 80% 100% Source: HCPro, Inc. 0% 10% 20% 30% 40% 50% Source: HCPro, Inc. UR and case management The majority of respondents (87%) said their case managers/case coordinators are expected to perform UR. An interesting trend emerges when analyzing the size of facilities that expect case managers/care coordinators to perform UR (see Figure 2 above). As the number of beds increases from the smallest facilities (fewer than 25 beds) to hospitals with 50 99 beds, it becomes more likely that case managers will perform UR. However, it becomes less common for case managers to do UR as the number of beds increases from 100 to 399. The pattern reverses again from 400 to 500 or more. The data suggest that hospitals with 50 99 beds are most likely to have case managers that perform UR, and facilities with 300 399 are least likely. Nearly half of the respondents (48%) said case managers are responsible for auditing medical records for medical necessity, whereas 11% of respondents said the UR specialist performs this function. Several other respondents said a combination of positions tackle the task (e.g., UR specialists and coders, coders and case managers). Case managers are also those most likely to speak with physicians about medical necessity discrepancies (58%). Dedicated positions Only one in three respondents said their hospitals have a dedicated discharge planner. Hospitals with 100 199 beds are least likely to have a discharge planner (see Figure 3 above). The likelihood of a discharge planner increases as facilities get smaller or larger. There is a near-even split between hospitals that do and don t employ a dedicated appeals specialist: 54% of hospitals have one to handle denials. n Don t miss your next issue! If it s been more than six months since you purchased or renewed your subscription to CMM, be sure to check your envelope for your renewal notice or call customer service at 800/650-6787. Renew your subscription early to lock in the current price.

Page 4 Case Management Monthly November 2010 Should CMS eliminate observation services? After reading this article, you will be able to: Explain how some hospitals misuse observation services Describe how misuse of observation services affects Medicare beneficiaries CMS has seen an increase in the number of extended observation stays and wants to know why. That was the reason it gave for holding an August 24 listening session regarding the matter. The reason providers misuse observation services may not have been as interesting as the solution proposed by some callers namely, that CMS should abolish observation services. I would love to see observation status eliminated. It has been the bane of my existence for the past four years since we got audited by the RAC [recovery audit contractor], says Rhonda Karas, BSN, telemedicine coordinator at Trinity Hospital in Weaverville, CA. Proper use of observation services is a struggle for providers, mainly because CMS has changed the rules several times over the past decade, says Michael Ross, MD, FACEP, medical director of observation medicine at Emory University in Atlanta and chair of the CMS APC Panel s observation subcommittee. The most recent change came in 2008 when CMS decided to pay a composite payment for observation services, which combined emergency or clinic visits into observation visit payment. Observation services that extend beyond 48 hours hurt the Medicare beneficiary most. Beneficiaries pay high copays for observation services and typically do not understand the difference from inpatient care until they receive a bill. CMS also does not count observation hours toward its requirement that a patient must be in inpatient care for three days before qualifying for Medicare payment for a SNF stay. That means extended observation patients have to pay out of pocket for SNF care. The questionable use of observation According to Chapter 4 of the Medicare Claims Processing Manual, CMS defines observation services as: [S]pecific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Comments made during CMS August 24 session indicated that many facilities do not use observation services in this manner. There are essentially two settings where observation patients are managed in America, Ross says. One setting is where the hospital admits a patient to a bed anywhere in the hospital but manages him or her as an outpatient. The other setting is a dedicated unit where emergency physicians often manage patients using strict protocols. Pressure from government auditors (e.g., RAC) who audit short inpatient stays has forced many facilities to treat observation patients in a setting more like the former example. According to several callers as well as a joint statement from the American Hospital Association, the Association of American Medical Colleges, and the Federation of American Hospitals, physicians often use observation for patients who are too sick to go home but do not meet Medicare s admission criteria. Although physicians feel the patients require hospital care, the hospital s utilization review committee expects Medicare will deny payment for an inpatient stay, so physicians assign patients observation status. That way physicians can keep the patients in the hospital without worrying about denials. Several callers expressed frustration with the fact that inpatient admissions hinge on admission software products such as InterQual and Milliman. A medical director of care management in Florida said admission criteria products use arbitrary definitions that are often vague

November 2010 Case Management Monthly Page 5 and difficult to understand. He also stated that the difference between inpatient and outpatient can sometimes be two or three points in their sodium level. Ross agrees that admission criteria can sometimes go against sound medical judgment. For example, InterQual does not recommend that elderly patients experiencing intractable pain be admitted. It makes no clinical sense that an elderly patient with injuries and intractable pain cannot be admitted as an inpatient, Ross says. A lot of time it is that kind of logic is what causes hospitals to misuse observation. The benefits of observation and looking forward Although many providers and beneficiaries would like to see CMS do away with observation services, Ross says that would be a bad idea. Studies published in the Annals of Emergency Medicine and the Archive of Internal Medicine show that dedicated observation units that follow a protocol provide better outcomes for their patients in the following ways: Shorter LOS Higher discharge rate Lower costs Decreased ED overcrowding Improved diagnostic performance Better patient satisfaction Better clinical outcomes (e.g., decrease in missed myocardial infarction or stroke) Better compliance with diagnostic testing That [dedicated] setting has shown again and again to outperform the inpatient setting, Ross says. There are a lot of legitimate reasons for observation services, especially in the elderly population where physicians often don t know whether a patient s symptoms will exacerbate, says Barbara Tomar, federal affairs director at the American College of Emergency Physicians in Washington, DC. Physicians need to monitor these patients over a period of time without having them take up a bed in the ED. Clinical studies show that the average LOS in a dedicated unit is 15 hours, Tomar says. Elimination of observation services could also lead to more inappropriate admissions, as well as create more admitted patients waiting in the ED for an inpatient bed, she says. Further, if hospitals don t have an observation or clinical decision unit for patients when physicians haven t made the decision to admit or discharge, physicians may err on the side of caution and admit them. Those admissions may not meet medical necessity criteria, thus subjecting hospitals to RAC scrutiny. Dedicated observation units give hospitals the flexibility to place borderline patients in a unit where they can be closely monitored outside of the ED. When used properly, observation services provide better outcomes for patients who would not benefit from being grouped with the normal hospital case mix, Ross says. Because patients do so well in dedicated observation units, Ross would like to see CMS make small policy changes that address the payment issues rather than do away with observation altogether. For example, CMS could include observation hours for meeting the requirement for a SNF stay. Valerie Rinkle, MPA, revenue cycle director for Asante Health System in Medford, OR, offered a simple solution on the call: Medicare could pay for observation services the way Oregon Medicaid does. If a patient stay is 24 hours, Oregon Medicaid will pay for the stay using outpatient rates. If the stay is more than 24 hours, it qualifies as an inpatient stay. Loretta Olsen, MSN, RN, director of case management at Memorial Hermann Health Systems in Houston, agrees with putting a strict 24-hour limit on observation services. Within 24 hours of the time the physician writes an order for observation services, the physician must either document the reasons why the patient must be admitted as an inpatient or discharge the patient, says Olsen. That s the way observation was originally set up, she says. Observation is when you think you need the patient in the hospital for 23 hours to decide if they truly need to be inpatient. n

Page 6 Case Management Monthly November 2010 BOOST patient satisfaction and reduce readmissions After reading this article, you will be able to: Demonstrate how Morton Plant Hospital improved discharge processes Describe Project BOOST Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is gaining popularity among providers nationwide as a method to reduce preventable hospital readmissions. Since the program began in September 2008, more than 1,400 facilities have downloaded the free toolkit from the Society of Hospital Medicine s (SHM) website, and 65 sites have enrolled in the mentorship program. (See the All about BOOST sidebar below for more information on Project BOOST.) Analyzing needs Project BOOST recognizes that every facility performs discharge planning differently and will have different needs. Therefore, Project BOOST uses a method called process mapping. Facilities create a flow chart that illustrates their discharge process. This will typically reveal weaknesses in the process. Such was the case at Morton Plant Hospital (MPH) in Clearwater, FL. Project mapping showed how MPH s discharge process lacked appropriate communication between departments, says Jordan Messler, MD, FHM, medical director of hospitalists at MPH. In some cases the miscommunication led to patient dissatisfaction and redundant use of resources. For example, MPH nurses would sometimes perform patient education but fail to tell the social worker. The social worker would then unknowingly repeat the information. The MPH team also discovered that although the staff did a good job of identifying patients who were at risk, it did not have procedures in place to address those risks, says Diana Cripe, MSW, director of case management. For example, if a patient had multiple medications, there was no policy to have a pharmacist advise the patient about which medications were dangerous to mix. We didn t have anyone that was actually putting processes in place to intervene with the patient. That was one of the big aha moments for us, Cripe says. BOOST initiatives The BOOST team at Morton Plant, which included directors, managers, and frontline staff, decided to focus on All about BOOST Project BOOST is a toolkit that hospitals can use to improve their discharge process with the goal of improving patient care, patient satisfaction, and reducing hospital readmissions, says Mark Williams, MD, FHM, professor and chief of hospital medicine at Northwestern University and Project BOOST s principal investigator. The toolkit, which walks hospitals through the entire process of implementing the BOOST program, is available on the Society of Hospital Medicine s website at no cost (www. hospitalmedicine.org/boost). However, facilities can also enroll in the Project BOOST mentorship program. Facilities enrolled in the mentorship program work with an experienced hospitalist who guides them through the implementation of the toolkit, helping identify areas that need improvement, setting goals, and getting support from staff and administrators. The mentorship program begins with a two-day training session where representatives from all the enrolled hospitals meet their mentors and receive education on care transitions and quality improvement initiatives. Afterward, each mentor stays in contact with his or her mentee facility for a year and helps develop tools and strategies that fit the facility, Williams says. Facilities enrolled in the mentorship program can also learn from each other through the program s listservand share tools they have developed and lessons learned.

November 2010 Case Management Monthly Page 7 improving interventions with all patients before zeroing in on high-risk patients. One of the first problems the team tackled was the discharge paperwork provided to patients. The team felt it was too regulatory and wasn t patient-focused. So the team developed an easy-to-follow discharge handout called the Patient Discharge Plan (see p. 8). Each inpatient has a Patient Discharge Plan form that the multidisciplinary team marks throughout his or her stay. Looking at the form, patients can easily see the problem they presented with, the care they received while in the hospital, and the specific healthcare goals they need to monitor after they leave. The form is also useful when patients attend follow-up appointments, Cripe says. Patients can present the form to their care providers so the provider can get a picture of what went on during the patient s hospital stay. The team also improved the delivery of discharge instructions through the teach-back method of patient education, which uses open-ended questions to engage the patient. For example, a nurse might ask, Mrs. Baker, what is your understanding of why you were in the hospital? This requires the patient to demonstrate understanding rather than simply listening to the nurse and then saying, Yes, I understand. The MPH team also selected a unit to pilot more intensive initiatives. The pilot unit calls patients who are discharged home or to an independent living facility within 48 hours of discharge. The nurse, social worker, or physician makes sure the patients understand their discharge instructions, take their medications properly, and keep appointments with their PCPs. The pilot unit has also begun doing interdisciplinary rounds. The rounds allow the hospitalists, case managers, and social workers to discuss the discharge plan proactively. Setting the discharge plan early allows the team to educate patients throughout their stay, rather than waiting to cram all the information in right before discharge, Cripe says. Outcomes and future The MPH team is starting to see the fruits of its labor. Since implementing BOOST initiatives, satisfaction scores on discharge planning and communication have risen 40% in just three months, Messler says. We are hopeful in the next year we will see our readmission rates improve, but we haven t implemented all of our tools yet, says Messler. The demonstrated effectiveness has motivated staff members to embrace the BOOST initiatives. Originally they were cynical, but initiatives such as the teach-back method have proven to make their jobs easier. Once they saw the patients were understanding it and they weren t being asked five times to clarify something, or they saw the satisfaction scores start to go up, they got it. They are so engaged in the process now to the point where they want to keep adding tools, Cripe says. n CMM Subscriber Services Coupon q Start my subscription to CMM immediately. My subscription will include 8 copies of CMM each month. Options No. of issues Cost Shipping Total q Electronic 12 months $349 (CMTME) N/A q Print & Electronic 12 months of each $349 (CMTMPE) $24.00 Order online at www.hcmarketplace.com. Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at 888/209-6554. *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax E-mail address (Required for electronic subscriptions) q Payment enclosed. q Please bill me. q Please bill my organization using PO # q Charge my: q AmEx q MasterCard q VISA q Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of CMM.) Mail to: HCPro, P.O. Box 1168, Marblehead, MA 01945 Tel: 800/650-6787 Fax: 800/639-8511 E-mail: customerservice@hcpro.com Web: www.hcmarketplace.com

Page 8 Case Management Monthly November 2010 Patient Discharge Plan Editor s note: We have included the first page of Morton Plant s Patient Discharge Plan below. You can view the entire form at www.casemanagementmentor.com. Source: Diana Cripe, MSW, director of case management at Morton Plant Hospital in Clearwater, FL

Top 10 hospital case manager best practices by June Stark, RN, BSN, MEd Case management is a relatively young healthcare specialty. It was introduced in the mid- 80s as a response to Medicare s prospective payment system and the associated need for shortened hospital stays. Over the years, case management has evolved as it has continually responded to ongoing changes in healthcare. As the case manager s role has matured, specific best practices have proven to be a valuable conduit to the provision of care coordination, outcome achievement, and quality of care. I have listed below what I believe to be the top 10 best practice components for a hospital case manager: 1. Patient admission assessment. Determine the discharge needs for all patients, and conduct a risk appraisal to determine a patient s ability to provide self-care and potential for readmission. Use a tool for readmitted patients that determines the reasons for readmission. 2. Care coordination rounds with nursing staff. Case managers should round with nurses at least once daily to communicate discharge and patient flow issues. These rounds establish common goals and direction for nursing and case management activities. 3. Physician rounds. These rounds identify each patient s healthcare status and readiness for discharge. The case manager uses this time to coordinate what is needed by the physicians to ensure a timely discharge for all appropriate patients. 4. Whiteboards. These boards should be at the foot of every patient s bed to supplement communication during daily rounds and reinforce the directions the care team has given patients and families concerning the hospital stay and pending discharge. 5. Electronic resources. Software tools can help case managers create their own personal records for each case. This allows them to analyze trends. For example, a case manager could pull all the patients who were discharged to a particular facility. E-discharge tools also cut down on the time it takes for an accepting facility to screen and accept a transfer. 6. Clinical pathways. Healthcare institutions use evidence-based practice to create clinical pathways, which make them a valuable tool for patient care coordination and LOS maintenance. 7. Nationally recognized clinical criteria. Use clinical criteria to establish a patient s appropriate admission status and medical necessity for the provision of clinical reviews to payers and a case manager s documentation. 8. Checklists. As case managers take on more responsibilities, such as core measures, statewide mandates, and readmission prevention measures, many have created checklists to keep track of all the tasks they are expected to complete with each patient. 9. Family meetings. Arrange meetings with all members of the healthcare team and the patient s family to communicate patient status and discharge plans and obtain family consensus with the care plan. 10. Discharge software. Use discharge software to quickly send all the information needed to create a safe and seamless transfer. The case manager s role is expanding in response to the aging population and healthcare reform. Use these best practices as improvement targets. n Editor s note: Stark is director of case management, social work, and quality support services at Tufts Medical Center in Boston. A supplement to Case Management Monthly November 2010

Complex case Persistence pays off with difficult psychiatric patient Sarah arrives at a large medical center after a failed suicide attempt in which she ingested multiple drugs, drank alcohol, and left a suicide note. Sarah has a history of mental illness. She has seen a psychiatrist who diagnosed her as bipolar. Sarah had attempted suicide several times before her most recent admission. Obstacles to discharge After several days of acute care, Sarah is medically stable for discharge. Sarah s family is fearful that she will try committing suicide again if she returns home. Her physician agrees. Sarah s physician and psychiatrist decide to transfer her to a facility that has a dedicated psychiatric unit. The case managers work with Sarah, her family, and the psychiatrist to find a facility that fits Sarah s needs. Sarah tells the case managers that she does not have healthcare insurance. She applied for Medicaid and disability benefits on three separate occasions and was denied each time, despite her history of mental illness. The fact that Sarah is unfunded makes the case managers job more difficult. The number of psychiatric beds in the area is shrinking because patients are typically unfunded and facilities cannot operate without reimbursement. Questions? Comments? Ideas? Contact Associate Editor Ben Amirault, CPC-A Telephone 781/639-1872, Ext. 3934 E-mail bamirault@hcpro.com Case management intervention The case managers call more than a dozen facilities hoping to find a bed for Sarah. They find a bed in an out-of-state hospital, but the accepting hospital s psychiatrist feels that a transfer across state lines is not conducive to Sarah s well-being and denies the transition. The case managers keep looking. In the following days, they continue to call each of the facilities, sometimes calling the same hospital multiple times in one day. After three days on the phone, the case managers find a bed one hour away. Sarah, her family, and her psychiatrist all agree to the transfer. Suddenly, a closer facility calls with good news it is willing to accept Sarah. The closer facility is actually in a neighboring state, which surprises the case managers. Out-ofstate facilities are typically less likely to accept psychiatric patients because they usually do not receive reimbursement. Sarah, her family, and her psychiatrist all agree that the closer facility is a better option, and she transfers there. Lessons learned Sarah s case managers learned that persistence pays off. If they had not contacted as many facilities as often as they did, they would not have found the best available option for their patient. The case management team also learned the hard reality that help for mentally ill patients is typically eliminated from state and federal budgets, making it more difficult for case managers and social workers to provide the care that patients such as Sarah need. n CMM, P.O. Box 1168, Marblehead, MA 01945 Telephone 781/639-1872 Fax 781/639-2982