One word, two meanings: Public health researchers push for clarity in talking about “population health” and ACOs

One word, two meanings: Public health researchers push for clarity in talking about “population health” and ACOs

 Are responsible care organizations really rising population health? consistent with 2 public health and policy researchers within the March twenty issue of the Journal of the yank Medical Association

Are responsible care organizations really rising population health? consistent with 2 public health and policy researchers within the March twenty issue of the Journal of the yank Medical Association, that depends on whose definition of “population health” you utilize.

The well-known goals for ACOs ar to regulate health care prices, improve quality in health care and improve population health, Dr. Lawrence Casalino and Dr. Stephen Arnold Douglas Noble from the Department of Public Health at Weill Cornell Medical faculty write within the article.

In the context of the Patient Protection & cheap Care Act and also the Centers for Medicare & health care Services’ rule for ACOs, population health refers to a health care organization’s pool of Medicare beneficiaries. And ACOs appear to possess taken their population health responsibilities that means, too, as preventive care to any or all patient and care management for patients with chronic diseases.

This is a significant discovery from the model of the past, said Noble, a visiting scientist from the united kingdom below the Commonwealth Fund’s Harkness Fellowship program. “ACOs do a really radical factor that is moving aloof from doctors solely considering what they'll do for patients once they’re before of them,” he told ME in a very phone interview. “That’s a huge factor for Americans, and I’m very affected with it.”

But the authors propose that the term population health is oft employed in a context additional closely associated with public health, and that’s a context within which ACOs aren’t furthermore poised to succeed.

“Population health is brooding about any range of individuals living in a very geographic region – it may be a county or a state – and every one of the services obtainable to them, and a part of that might be prime quality health care while not a doubt,” Noble aforementioned. however it additionally implies factors outside of the medical realm, like social services, the general public health system and socioeconomic factors. Those ar areas wherever most ACOs lack the incentives and capabilities to act effectively.

The authors argue that talking concerning ACOs therein context results in a “lack of clarity concerning what ACOs do ar concerning population health and will divert attention aloof from social and public health services and from socioeconomic factors vital to health,” they wrote. “It’s not simply a linguistics issue of very little importance if ACOs ar represented, or self-described, as operating to boost population health once what they're very doing is rising treatment for his or her own patients.”

A model that integrated that broader definition of population health would be additional of associate responsible care health community, wherever ACOs would work with different organizations to boost the general health of a precise geographic population.

Whether that’s one thing ACOs might or ought to eventually be able to do may be a whole different issue. however the sole means we’re attending to be able to have that discussion, the authors say, is that if we have a tendency to build a transparent distinction between population health in and out of the context of ACOs once formulating health care and work policy.

On that note, maybe the authors would be fans of the U.S. Agency for health care analysis and Quality’s idea of “practice-based population health.”




Source: medcitynews,com
Four healthcare trends to watch in 2014

Four healthcare trends to watch in 2014

 


2014 can still be a year of transformation because the implementation of the reasonable Care Act and therefore the changes it represents ripple through the aid trade. From conversations with aid suppliers across the country, Vree Health has known four key problems suppliers face within the returning year–and on the far side.

1. aid compensation is due for a boot

Healthcare systems, hospitals and suppliers area unit caught between 2 wide divergent business models: fee-for-service versus pay-for-performance. whereas captivated with the previous, they have to reconstitute their businesses to boost quality and manage prices across the whole care time to arrange for the latter. It’s associate concerning face that Dr. David Nash, institution Dean of the President Jefferson college of Population Health, likened to turning associate carrier around within the shipway, once he spoke at MedCity CONVERGE last year.

Consider the challenge:

Fee-for-service rewards billable infrastructure and man hours, whereas pay-for-performance rewards efficient potency.
Fee-for-service rewards in-house capabilities. Pay-for-performance rewards community cooperation.
Fee-for-service rewards failure. Pay-for-performance rewards results.
Straddling each models is reminiscent of Van Damme’s epic split during a recent Volvo Truck commercial–in alternative words, just about not possible while not steady hands at the wheel.

Immediate pressures for modification in 2014 can return from:

The Centers for Medicare & Medicaid Services (CMS) conceive to expand the amount of services that area unit reimbursed through bundled payments
Another CMS proposal to scale back the grading codes for the complexness of visits from this 5 to 2, thereby incentivizing suppliers to forestall complications
And be careful for the sleeping large of the states, United Nations agency can before long cowl, directly or indirectly, nearly third of all Americans. PriceWaterhouseCoopers estimates that twenty six states can have managed care programs to assist contain Medicaid prices in 2014. Innovators just like the Geisinger Health System understand that if states place their muscle behind fee-for-value, it'd be transformational.

The Takeaway:

Smart suppliers can specialise in aid consumers’ needs—patients and payers alike—to build new models of care that deliver most price.


2. aid technology can facilitate drive connected care

All of those changes in payment structure advance a extremely integrated aid system. Spurred by the HITECH Act, the adoption of electronic health records (EHR) in acute care hospitals quite tripled between 2009 and 2013. Now, aid organizations (HCOs) should hinge upon these systems to interrupt out of their four walls and integrate with the whole community to:

Connect with suppliers
Connect with patients
Connect with populations
Health system and money dealer partnerships, like the HealthShare Exchange of Southeastern Pennsylvania, represent one step toward connected care. it'll enable insurers and aid suppliers to share discharge history and medicine info with patients’ physicians to boost care transitions.

Meanwhile, meeting the necessities of pregnant Use (MU) Stages 2 and 3 remains a pressing reality for several HCOs. Proactive organizations can aim to create a technology platform that not solely meets the letter necessities, however additionally enhances the patient expertise. the look and practicality of patient portals is crucial. To achieve success, they have to actually have interaction and empower patients to move participants in their own care.

Finally, as we have a tendency to steer toward population health management, the worth of aid information will increase exponentially. HCOs should focus on HIT systems that modify them to combination and analyze information from disparate sources to spot best practices for up care quality and population health.

The Takeaway:

Maximize the worth of knowledge with open-ended technologies that integrate with the whole spectrum of patient-provider bit points–mobile health apps, telehealth and medical devices–to produce a consumer-friendly health and wellbeing scheme.



3. Growth of responsible Care Accelerates

ACOs, or responsible care organizations, area unit one amongst the underpinnings of health reform. ACOs currently serve quite five.3 million Medicare beneficiaries, and lots of alternative patients area unit served by non-ACO organizations deploying similar methods.

We expect the expansion of those systems to continue in 2014 as health reform drives toward integration. Innovative aid IT solutions and effective use of health information across partnering organizations—and even caregivers and patients—will be crucial to responsible care’s success in reducing the operational and monetary inefficiencies that plague our current system.

Especially vital are going to be new models of care that modify aid suppliers and patients to attach and collaborate on preventative (rather than reactive) aid problems, like blubber and polygenic disease. New digital health tools—whether social, mobile or cloud-based—may play a big role in patient engagement and adherence. group action patient goals and private health tools into treatment regimens is important to the evolution of a very patient-centric aid system.

The Takeaway:

ACOs should notice new and effective ways in which to interact, educate and encourage their patient populations to get entangled in preventative care.



4. Individual relationships with patients area unit more and more vital

In 2014, a lot of establishments can understand that patient-provider communication and relationships area unit crucial to economic success. consistent with a study within the Journal of family medicine, physicians United Nations agency score highest on measures of patient-centered communication incur lower prices in diagnostic testing, while not compromising health outcomes.

Innovative technologies give opportunities to create and expand the patient-provider relationship through personalised experiences with the potential to drive modification in patient behavior. it's at the purpose wherever patients area unit creating daily health choices that info, motivation and regular behavioural skills recommendation will produce a true distinction within the health selections they create. The manner patient relationships area unit managed throughout the care time could even influence patients’ ability to require management of their own health–a responsibility that too several patients these days feel unempowered to tackle.

Source: medcitynews,com
What should providers look for when choosing patient engagement technology?

What should providers look for when choosing patient engagement technology?

Thanks to the proliferation of mobile technology, customers have exponentially additional health data at their fingertips these days than they need ever had. Consumer-grade medical devices ar being outfitted with progressively subtle sensors, that collect volumes of information regarding diet, sleep, heart rate, temperature, glucose, and different personal health metrics.

Thanks to the proliferation of mobile technology, customers have exponentially additional health data at their fingertips these days than they need ever had. Consumer-grade medical devices ar being outfitted with progressively subtle sensors, that collect volumes of information regarding diet, sleep, heart rate, temperature, glucose, and different personal health metrics.

At identical time, care suppliers ar implementing IT platforms to gather that data and use it to deliver higher quality care to patients additional with efficiency.

With all this innovation, we must always be living in a very golden age for care. The inflated flow of knowledge ought to be transfer physicians and their patients nearer along. But, sadly, this can be not materializing the approach it ought to. Physicians and customers alike say they feel inundated by a flood of information and lack the tools to separate the clinically relevant from the superfluous.

This is not the state of affairs anyone had in mind once higher knowledge technologies began creating their approach into the care system.

Data: A blessing or a curse?

Data technologies ought to be paving the thanks to higher care. Patients ought to feel authorized  by the data they hold in their hands, whereas care suppliers ought to clearly see the affiliation between additional accessible knowledge and higher patient outcomes. however too several physicians and patients say they’re swamped by all the data.

It appears that the information that ought to be sanctioning higher care will, in fact, have the alternative result. while not unjust insights, knowledge will get within the approach.

Such is that the case in step with Dr. Andrew Trister, Associate in Nursing specialist at the noncommercial medical analysis organization Sage Bionetworks. In a writing originally revealed in university Technology Review, Trister states “I’m Associate in Nursing specialist, and that i have these patients United Nations agency ar early ‘quantified self’ forms of individuals. they are available in with these terribly massive surpass spreadsheets, with all this data — I even have no plan what to try and do thereupon.”

When patients feel burdened with data, they disregard it. several ar turning off the flow of knowledge by ditching their health trackers. once suppliers feel swamped with knowledge that isn’t unjust, they'll delay implementation of latest technologies that may facilitate conversations between physicians and patients.

Outcomes like these ar a step within the wrong direction.

The pressure on suppliers

Patients invariably have the choice to get rid of their health trackers or disregard communications from their physicians. care suppliers, however, ar fraught to use new technologies to make nearer ties with their patients. Achieving quality outcomes suggests that physicians got to learn an excellent deal regarding their patients, and the way to stay their care plans heading in the right direction.

The problem of suppliers drowning in knowledge can’t be resolved by merely closing down the flow of knowledge. Instead, they have to spot the correct technology which will solicit data that directly influences higher patient outcomes and additional economical care team delivery.

So, what ought to care suppliers be probing for in patient engagement technology?

Technology solutions ought to sift through the immense quantity of patient knowledge and establish the exceptions that physicians wish to review. By specializing in the correct patient at the correct time, physicians will improve outcomes and show their patients that they care. the correct technology will turn out vital reductions in adverse events, hospital readmissions, and total prices of care. however this doesn’t need to come back at the expense of patients’ expertise. Through sympathetic and personalised content, suppliers aren't solely participating with patients however earning their trust.

Focus on the basics

Back within the day, physicians would create house calls, learning regarding their patients’ health through face-to-face conversations. Most physicians don’t do house calls any longer. however {the data|the knowledge|the data} once gleaned from face-to-face visits is that the same information physicians ought to demand from patient-engagement technology. although the package concerned could also be subtle, the elemental principle is as straightforward as ever. The vital information—the unjust insights—will come back directly from the patient.

As health systems decide whether or not or the way to implement patient engagement tools, they must bear in mind the house decision. rather than victimisation technology that merely opens the floodgates of information, physicians ought to be probing for digital tools that alter Associate in Nursing in progress, genuine, two-way speech with the people they treat.

Approaching today’s authorized  patient

When patients feel swamped by data gushing into their inboxes from their care suppliers, it may well be as a result of it doesn’t appear relevant. however what if the patient is aware of the data has relevancy, as a result of it follows Associate in Nursing actual arrival from their physician? rather than causing messages that the recipient may look upon spam, what if health systems sent solely the data that buyers request throughout regular check-ins?

Patients ar way more possible to browse materials and follow recommendations that they need asked. Technology has authorized  people once it involves searching, banking, and socializing; they’ve fully grown wont to being within the driver’s seat, and that they wish that very same feeling once it involves their care.

Patients wish to learn. they require the correct answers at the correct time, and that they wish them on their personal computers and mobile devices. Patient engagement should feature that private bit and individual attention that the house decision once offered.

Providers produce other barriers to surmount

Healthcare suppliers got to take into account however patient interactment tools will engage patients in a very purposeful approach. however there ar different vital concerns once it involves implementing an automatic system for patient engagement.

Since any new system can have an effect on clinical work flow, it's crucial that new tools either stand alone or integrate with EHR as seamlessly as potential. Care groups want tools that improve coordination and communication and don't need time beyond regulation and energy. For this reason, health suppliers ought to hunt down tools that ar adjustable to variable readiness, staffing, and supplier alignment.

Providers will face yet one more barrier if their patient engagement tools square {measure} biased toward knowledge that solely measure outcomes among bad patients with chronic conditions or different specific segments of the population. a true system of patient engagement—one which will scale back readmissions, cut costs, and boost patient satisfaction—will treat all patients equally.

Providers ought to be meticulous regarding patient engagement tools

There ar various systems for patient engagement accessible these days, and suppliers have many selections. they must solely opt for a system that will:

Enable sympathetic and personalised dialogues between physicians and patients;
Provide convenient, timely, and relevant data to consumers;
Stand-alone or integrate simply with EHR; and
Treat each patient equally
A system that falls short on any of those capabilities can possible disappoint of purposeful engagement with patients. A system that doesn't do these items can leave patients and suppliers adrift within the same deluge of information that's frustrating them these days.


Source: medcitynews,com
Stressful experiences 'can age the brain by four years'

Stressful experiences 'can age the brain by four years'



Stressful events in life, such as the death of a child, divorce or being fired, can age the brain by at least four years, US researchers suggests.
They looked at performance in memory and thinking tests of 1,300 people in their 50s to gauge brain health.
The study did not look at the risk of dementia and experts said there could be many different factors at play.
The findings were presented at the Alzheimer's Association International Conference in London.
Although the research could not establish any direct link between stress and an increased risk of dementia, stressful experiences are known to have an impact on brain function, which could then lead to dementia in the longer term.
Poorer memory
The theory is that stress increases inflammation, which could increase the chances of developing dementia - and this is currently being tested by University of Southampton researchers.
This study, from the University of Wisconsin School of Medicine, found that African Americans were more at risk of stress in life than other ethnic groups. This is because they scored poorer results in the memory tests than other groups and also tended to live in poorer neighbourhoods.
Stressful experiences across all groups included educational difficulties, financial insecurity, serious health problems and psychological trauma.
Other studies presented at the conference point to growing evidence that stress in early life and where people live can be factors in an individual's risk of developing dementia.
Dr Doug Brown, director of research and development for Alzheimer's Society, said studying the role of stress was complex.
"It is hard to separate from other conditions such as anxiety and depression, which are also thought to contribute towards dementia risk.
"However, the findings do indicate that more should be done to support people from disadvantaged communities who are more likely to experience stressful life events."
There are currently around 850,000 people in the UK with dementia.
It mainly affects people over the age of 65 and, while the likelihood of developing dementia rises sharply with age, about 42,000 of those suffering from the condition are younger than that.
Dr Carol Routledge, director of research at Alzheimer's Research UK, said there could be a number of different factors involved in the link between stress and memory decline.
But she said the brain was an "incredibly intricate organ" to research.
"There is a growing realisation that events and experiences throughout life can impact the brain decades later and researchers must take a whole lifespan approach to understanding brain health in later life."

Tips for reducing the risk of dementia

  1. Keep physically active for at least 30 minutes, five times a week.
  2. Don't smoke, or give up if you do.
  3. Eat a healthy balanced diet including oily fish, fruit, vegetables and low levels of red meat and sugar.
  4. Keep your alcohol intake to a maximum of 14 units per week for men and women.
  5. Manage other health conditions such as high blood pressure, high cholesterol and type 2 diabetes.
  6. Keep to a healthy weight to reduce your risk of type 2 diabetes, stroke and heart disease.
  7. Give your brain a daily workout by doing puzzles, word searches or crosswords or learning something new.
  8. Keeping socially engaged and have a good social network.




Source: Alzheimer's Society

Source : BBC,com
Three Large Health Systems Join North Carolina’s HIE

Three Large Health Systems Join North Carolina’s HIE

Three of the most important health systems in North geographical region, Duke Health, Novant Health and Carolinas care System, have signed agreements to attach to American state HealthConnex, North Carolina’s state-designated health data exchange (HIE).

What’s a lot of, Wilmington-based Coastal Connect, a regional bucket along in southeastern North geographical region, additionally has united to attach to American state HealthConnex, which is able to add 5 hospitals and over a hundred information contributors, acute and mobile, to the growing broad bucket along.

Duke Health, primarily based in Durham, operates 3 hospitals. Novant Health, primarily based in city, operates fourteen medical centers and many patient facilities and medical man clinics and serves patients in Virginia, North and
 

South geographical region and Georgia. Charlotte-based geographical regions care System serves patients in North and South Carolina and operates eight hospitals.

The 3 giant health systems and Coastal Connect be a part of foundational participant, UNC Health Care, and twenty six hospitals that ar taking part within the broad bucket along. in line with a American state HealthConnex announcement, additionally to hospital and health system integrations, the bucket along is also within the method of connecting with many medical man practices, health departments, federally qualified health centers, rural health clinics and alternative mobile facilities that use cloud-based and on-premise electronic health/medical record (EHR/EMR) solutions.

“In the past year, the full variety of distinctive patients in American state HealthConnex grew by nearly thirty p.c totaling value to three.7 million,” organization officers same within the announcement.

Created by the North geographical region General Assembly, {nc|North geographical region|Old North State|Tar Heel State|NC|American state} HealthConnex is that the state-operate health data exchange and is managed by the North Carolina Health data Exchange Authority (NC HIEA) housed at intervals the N.C. Department of knowledge Technology.





Source: healthcare-informatics,com
Health Information Exchange adds state's largest health care systems

Health Information Exchange adds state's largest health care systems

 

Three of North Carolina’s largest health care systems – Duke Health, Novant Health and Carolinas care System – have signed agreements to attach to Old North State HealthConnex, North Carolina’s state-designated Health data Exchange (HIE).

Additionally, Coastal Connect, a regional speed in southeastern North geographical region, has formally in agreement to attach to Old North State HealthConnex. This association can add 5 hospitals and quite one hundred knowledge contributors, acute and mobile, to the wide  speed.

NC HealthConnex else 3 of North Carolina's largest health systems to its exchange.
Enlarge
NC HealthConnex else 3 of North Carolina's largest health systems to its exchange.

NC HealthConnex is meant to be an identical electronic system within which suppliers will share patient health data.

The 3 new signees be part of foundational participant UNC Health Care and twenty six hospitals that ar connected, or within the queue for association, to Old North State HealthConnex. additionally to hospital and health system integrations, Old North State HealthConnex is within the method of connecting with variety of medico practices, health departments, federally qualified health centers, rural health clinics, and different mobile facilities that use cloud-based and on-premise electronic health/medical record services.

The State of North geographical region passed legislation in 2015 mandating that health care suppliers receiving state funds for the supply of health care services to attach and submit clinical and patient demographic knowledge to the state-designated health data exchange, currently Old North State HealthConnex.

In the past year, the entire range of distinctive patients in Old North State HealthConnex grew by nearly thirty %, totaling near three.7 million, in step with the North geographical region Department of data Technology.

“Duke is happy to attach to Old North State HealthConnex, and be part of a growing community of supplier organizations with the shared goal of delivering outstanding care to the voters of North geographical region,” aforesaid Duke Health vp and Chief data Officer Dr. Jeffrey Ferranti in an exceedingly statement.







Sumber:https://www.bizjournals,com/
Aids deaths halve as more get drugs

Aids deaths halve as more get drugs

 Deaths coupled to Aids have halved in a very decade, official figures shows.  The condition, that is caused by HIV, wont to be one among the highest ten causes of death worldwide.

Deaths coupled to Aids have halved in a very decade, official figures shows.
The condition, that is caused by HIV, wont to be one among the highest ten causes of death worldwide.
A report by the Joint UN Programme on HIV/Aids (UNAids) showed deaths had fallen from a peak of one.9 million in 2005 to one million last year.
It aforesaid the "scales have tipped", with over 1/2 individuals obtaining drug treatment for the primary time.
An HIV infection can't be cured - it will solely be contained with daily doses of antiretroviral medical care.
Unchecked, it destroys the system, inflicting Aids. At now individuals tend to die from alternative "opportunistic infections" like T.B..
Worldwide, 36.7 million live with HIV and fifty three of them are becoming the medical care that offers a near-normal expectancy.
Michel Sidibe, the chief director of UNAids, said: "We met the 2015 target of fifteen million individuals on treatment and that we ar not off course to double that range to thirty million and meet the 2020 target.
"We can still rescale to achieve everybody in want and honour our commitment of effort no-one behind."
UNAids aforesaid japanese and southern continent were "leading the way" and had cut new HIV infections by nearly a 3rd since 2010.
Life expectancy has hyperbolic by ten years over the past decade too.
The agency has set a series of goals called the 90-90-90 targets.
The aim is for ninetieth of individuals with HIV to be diagnosed, ninetieth of these to urge medical care and ninetieth of these to own their infection suppressed, by 2020.
In 2016 the figures were seventieth, seventy seven and eighty two severally.
Mr Sidibe added: "Communities and families ar thriving as Aids is being pushed back."
However, the agency warned that inadequate treatment in geographical region, the center East, Asia and japanese Europe had seen death rates increase sharply.
Oxygen Therapy Reverses Brain Damage In Drowned Toddler

Oxygen Therapy Reverses Brain Damage In Drowned Toddler

   in February 2016, 2-year-old Eden Carlson sunken  in an exceedingly family pool. She was submerged within the water for quarter-hour. Her heart didn't beat on its own for 2 hours, and Eden suffered brain injury as a results of element deprivation throughout the incident.

in February 2016, 2-year-old Eden Carlson sunken  in an exceedingly family pool. She was submerged within the water for quarter-hour. Her heart didn't beat on its own for 2 hours, and Eden suffered brain injury as a results of element deprivation throughout the incident.

First famous Case Of Brain injury Reversal
Now, simply months once the accident, doctors reportable that they were ready to with success come back the child's ability to steer and speak. mistreatment AN gas medical care, they were ready to reverse the severe brain injury, in what's believed to be the world's initial case of brain injury reversal.

The doctors gave the kid O, with pressure on top of the overall gas pressure to awaken her brain. The treatment known as hyperbaric O medical aid (HBOT) concerned increasing the quantity of O in Carlson's blood and repairing her broken tissue during a sealed and controlled chamber.

Normobaric O medical aid And Hyperbaric O medical aid
During the initial stages of the treatment, the bambino was given O treatments at "normobaric level," or water level, that is that the supposed normobaric O medical aid. it had been administered fifty five days once the drowning incident and was done doubly per day for forty five minutes per treatment. This helped the kid regain her arm and hand movements, also as her partial ability to eat and speak in brief spurts.

After 3 weeks, the bambino proceeded to being administered hyperbaric O medical aid, throughout that she was given pure O at pressures on top of that of the atmosphere inside a special chamber known as chamber.

The tike was stirred to a brand new Orleans hospital to endure hyperbaric O medical aid. in precisely ten sessions, Carlson's mother aforementioned that her kid was back to close traditional. The tike was even ready to walk and speak higher than before the incident. She was additionally determined to own marked enhancements altogether of her motor and medical specialty functions, and knowledge tests.

The tomography scan taken 162 days once the incident disclosed that Carlson still has delicate residual brain injury however the animal tissue and nervous tissue atrophy that the kid suffered was virtually totally reversed.

"Subacute normobaric O and HBOT were ready to restore drowning-induced animal tissue nerve tissue and nervous tissue loss, as documented by consecutive tomography, and synchronic medical specialty perform, as documented by video and physical examinations," the doctors World Health Organization treated Carlson reported  in Medical Gas analysis

Oxygen Treatments For Brain harm
Doctors aforesaid that the chemical element treatments, that helped with the dramatic reversal of Carlson's severe brain harm, encourage the brain cells to survive and cut back swelling.

"The surprising regrowth of tissue during this case occurred as a result of we tend to were ready to intervene early in a very growing kid, before long tissue degeneration," aforesaid Paul Harch, director of hyperbaric medication at LSU Health urban center faculty of drugs.

"Although it's not possible to conclude from this single case if the ordered application of normobaric chemical element then HBOT would be more practical than HBOT alone, within the absence of HBOT medical care, short period, repetitive normobaric chemical element medical care is also Associate in Nursing possibility till HBOT is on the market."






Source:http://www.techtimes,com/articles/211810/20170720/oxygen-therapy-reverses-brain-damage-in-drowned-toddler.htm