steadi fall risk score interpretation

STEADI includes a clinical algorithm, adapted from the American and British Geriatric Societies Clinical Practice Guideline, which helps sort patients by fall risk level. Addition of frailty status does not improve the ability of the STEADI measure to predict future falls. What Does my Patient's Score Mean? Worse, death rates from falls doubled between 2000 and 2014, from 29 to 58/100,000 population (WISQARS, 2016). It is a 4-item falls-risk screening tool for sub-acute and residential care. 732 0 obj <> endobj 749 0 obj <>/Filter/FlateDecode/ID[<9C14ECD6BEB0394A9AADAAA10DE27572>]/Index[732 36]/Info 731 0 R/Length 93/Prev 332195/Root 733 0 R/Size 768/Type/XRef/W[1 3 1]>>stream practice guideline for fall prevention. The OHSU Institutional Review Board approved the project. Note: Question 9 is a single screening question on suicide risk. John Brusch, MD . bChart review was done on sample of 124 of these 492 low-risk patients. 23. Nearly all (94%) high-risk patients took a medication that increased fall risk, yet only 22% had a medication change. Each year an estimated 684 000 individuals die from falls worldwide. The U.S. Centers for Disease Control and Prevention has developed the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Initiative to reduce the prevalence and severity of falls in seniors. Stay Independent: a 12-question tool [at risk if score . With the aging process, elderly people present changes in their bodies that can lead them to suffer several geriatric syndromes. The STEADI algorithm, which is based on the American Geriatrics Society/British Geriatrics Society 2011 fall prevention guideline, recommends both self-report questions and performance tests (TUG, 30s STS, FSBT) to identify those at risk for falls and trigger interventions (e.g., physical therapy for fall prevention exercise training for those However, Part 1 can be used as a falls risk screen. Staff training focused on the clinic workflow, including how to correctly take orthostatics and perform the Timed Up and Go test. x}Oo0| Although the STEADI algorithm delineates a moderate risk category based on number of falls or injury related to a fall, for purposes of clinical feasibility, our study used only low- and high-risk categories based solely on the score of the STEADI questionnaire. The second question refers to the likelihood of falling for the next year. The Center for Disease Control and Prevention (CDC) recommends that doctors incorporate fall prevention into their regular practice. answer yes to any key questions =. steadi fall risk score interpretation. -Instead, use assessment tools to identify fall risk factors. Explain sensitivity, specificity, predictive value, and cut points c. Compare predictive value of tools to create a 0000030933 00000 n Doctors should be informed on what they can do to prevent falls among their older adult patients, such as recommending vitamin D, reducing medications that might increase falls, and referring patients to community programs or physical therapy to improve their balance. Have you fallen in the past year? 0 403 0 obj <> endobj 276 0 obj <>/Filter/FlateDecode/ID[<6D3BA9CBC0894A7481C894907201D17C>]/Index[225 117]/Info 224 0 R/Length 196/Prev 211151/Root 226 0 R/Size 342/Type/XRef/W[1 3 1]>>stream answer of no to all key questions =. The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool was developed to promote fall risk screening and encourage coordination between clinical and community-based fall prevention resources; however, little is known about the tool's predictive validity or adaptability to survey data. Interclass (Pearson) correlations, with time between test and re-test of 3-4 months, 187 subjects from the community) is reported as moderate (0.66) [6], A robust correlation has been reported when comparing the scale with other measurements for balance, in the same subjects. This tool will help you incorporate fall risk assessment and fall prevention into your clinical practice and enhance your efforts to help older adults stay healthy and independent. Development of STEADI was informed by the American and British Geriatric Societies (AGS/BGS) 2010 fall prevention guideline (Kenny, Rubenstein, Tinetti, Brewer & Cameron, 2011) as well as two conceptual modelsWagners Chronic Care model (Wagner, 1998) and Prochaskas Transtheoretical Stages of Change model (Prochaska & Velicer, 1997). Building fall prevention tools into EHR systems and clinic workflows could help make fall prevention a routine part of clinical practice. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. American and British Geriatric Societies Clinical Practice Guideline, Centers for Medicare and Medicaid Services (CMS), athenaPractice Revenue Cycle Management Newsletter: Customizing buttons, Reminder: NACHC athenaPractice/athenaFlow UGM February 28, Why Patients Refuse to Use Your Patient Portal (and What to Do About It), Webinar: HIPAA Updates for 2023: What You Need to Know Thursday, February 23 @ 11am PT. This study aimed to test the hypothesis that at least one coefficient- based integer and 4-year fall risk estimate would have a comparable sensitivity and specificity to the combined moderate and high risk STEADI cate-gories in . Of these patients, 161 (95%) would have been identified as high-risk using an affirmative response to any one of the three key questions. "9Hv%0)@$0;LJ@1H2U dd`m! > endstream endobj startxref 0 %%EOF 767 0 obj <>stream Data abstraction also included all interventions provided to patients who scored high-risk (score 4) on the Stay Independent questionnaire as previously described in the description of the studys workflow (e.g., administration of the Timed Up and Go test, orthostatic blood pressure measurements, vision screening, evaluation of feet problems, medication review). Future work should address whether additional strategies could further streamline the process to improve feasibility and how other team members might contribute to the process (e.g., having a pharmacist do the medication review). Learn more about STEADI and discover resources to help you integrate fall prevention into routine clinical practice. It is proposed that some amendments could be made to this in order to improve clarity and increase information and reliability. HDc> 8JBL. Falls risk assessment documented . Low-risk patients had fewer comorbid conditions (1.8 vs 2.3 vs 3.8 for the respective approaches; maximum reported comorbidities for any individual was 7). 0000067637 00000 n trailer All EHR tools have now been published as an Epic Clinical Program, which includes an instruction manual for EHR analysts to build the tools into their own system. Integration of simple screenings into your practice can help identify patients at risk for falls such as those with lower body weakness, difficulties with gait and balance, postural . If the patient is over halfway to a standing position when 30 seconds have elapsed, count it as a stand. No Yes * I use or have been advised to use a cane or walker to get around safely. Implement the interventions that correspond with the patient's fall risk level. Its predictive validity outside the US context, however, has never been investigated. Stay Independent: a 12-question tool [at risk if score . The study sponsor had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Each item is rated from 1 ("very confident") to 10 ("not confident at all"), and the per item ratings are added to generate a summary. STEADI algorithm. Clinicians ask their patients have you fallen in the last year, do you feel unsteady when standing or walking, and do you worry about falling? These questions, a subset of concepts included in the full Stay Independent, focus on two of the biggest risk factors for falling (history of falls and gait/strength/balance), and align with the screening questions recommended by the AGS/BGS guideline (Kenny et al., 2011). ]f]f"d\YS&h& #$40,qHhW(H/:fcagl,:|3FQBB{p9L HSp7#\252'u^?`18zZDMe6S(_k,{6xY>Ja&Bo_\}}MjVKld?Y]/Pj[qS>7'-yQ(bbyW 2. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. During the initial implementation phase (March 31 to June 8, 2014), the STEADI protocol and EHR tools were tested and updated multiple times to improve and streamline the process, including changing data entry of the Stay Independent score from a binary low versus high risk to recording all 12 item-level responses. It is based on the persons ability to hold four progressively more challenging positions[1](evaluates static balance).[2]. Older Adult Fall-Risk Assessment, Intervention & Referral. Web. Intended Population 0000066703 00000 n Fall Screening Questionnaire Results for Patients Aged 65 and Older, and Comparison of 12-Item Stay Independent Questionnaire and Three Key Questions (2014) Columns Are the Results of Full STEADI Screening. https://www.youtube.com/watch?v=VUq6IgQAVJM, https://www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf. To address this growing public health epidemic, the Centers for Disease Control and Prevention (CDC) developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative to facilitate fall risk identification and management in primary care (Stevens & Phelan, 2013). No prior presentations were conducted. In fact, research has shown that scores from fall risk prediction tools do not predict falls any better than a clinician's judgment. Risk level and recommended actions (e.g. Do not rely on scores alone. tical techniques from Sullivan et al20 to determine fall risk esti-mates in community-dwelling older adults. JAGS 1986; 34: 119-126. [2] To reduce their risk of falling, consider implementing gait and balance exercises, or refer them to an evidence-based fall prevention program, for example Otago balance program, Tai Chi. In STEADI, fall risk is conceptualized as a chronic illness, as steps to address underlying health issues and prevent falls require a similar reorganization of health care system processes and regular patient/provider interactions over an extended time period. More sophisticated tracking and follow up could help ensure that high-risk patients with deferred visits receive additional interventions and ensure that recommendations for community fall prevention classes and other interventions are followed. Hypotension or orthostatic hypotension were defined based on chart review for the prior year during which time a patient had at least one measurement of blood pressure less than 120 mm Hg systolic or a difference in systolic blood pressure of 20 points when orthostatic blood pressure was measured. Of these, 109 (64%) received STEADI interventions (gait, vision, and feet assessment, orthostatic blood pressure measurement, vitamin D, and medication review). 3.2. (See "Fall Risk Prevention Interventions" below.) Compare fall risk assessment scales for setting and content validity b. After the first-round testing phase was complete, the doctors confirmed the tool was very helpful but had one overriding recommendation. ; 2. kHigh-risk medication review consisted of reviewing medication list during visit for the following: benzodiazepines, other anxiolytic, selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, antipsychotic medication, alternative antidepressants, seizure medication, lithium, diuretics, beta blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, calcium channel blockers, systemic glucocorticoids, anticholinergics, antihistamines, carbidopa/levodopa, opioids. 0000019564 00000 n Published by Oxford University Press on behalf of The Gerontological Society of America. Cut-off scores and normative values may be used in conjunction with a complete evaluation to interpret the meaning of a patient's 5TSTS score. Using three key questions compared to the full Stay Independent questionnaire decreased screening burden, but increased the number of high-risk patients. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. STEADI Fall Risk Assessment tool for free here! Systematic implementation of STEADI could help clinical teams reduce older patient fall risks. Frailty Versus Stopping Elderly Accidents, Deaths and Injuries Initiative Fall Risk Score: Ability to Predict Future Falls J Am Geriatr Soc. No Yes * I steady myself by holding onto furniture when walking at home. When refering to evidence in academic writing, you should always try to reference the primary (original) source. 0000020353 00000 n Assessing your patients' risk for falling. CDC twenty four seven. Fifty percent of patients identified as high-risk using the 12-item Stay Independent questionnaire reported falling in the last year, compared to 39% of those identified as high-risk using the three key questions. What Attachments Does The Dyson Hair Dryer Have? 0000019942 00000 n Prenasalized Uvular Stop, 360 Degree Turn Time 6. . This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US Government. SCREEN for fall risk yearly, or any time patient presents with an acute fall. <]/Prev 914393>> This will most likely be a multi-center study looking at the relationship of FIST scores and established fall risk tools to determine if a FIST cut-off score for fall risk can be described. 96 0 obj <>stream Phelan, E., Mahoney, J., Voit, J., & Stevens, J. Normative Values by Age Category (Healthy Population)5: Age in years (n) Mean SD 14-19 (25) 6.5 1.2 sec 20-29 (36) 6.0 1.4 sec 30-39 (22) 6.1 1.4 sec . Practical implementation of an exercisebased falls prevention programme. Lessons learned at OHSU during STEADI implementation are described elsewhere (Casey et al., 2016). The "Quick-STEADI" algorithm determines older adults' fall risk based on their responses to three key questions regarding past year falls, concerns about falling, and balance problems. All screened patients were allocated into four categories based on their responses to the Stay Independent questionnaire: two concordant groups (high-risk using both approaches and low-risk using both approaches) and two discordant groups (high-risk using one approach and low-risk using the other). Two-thirds of high-risk patients received additional fall risk assessments and interventions. Record "0" for the number and score. You can review and change the way we collect information below. If the patient can hold a position for 10 seconds without moving their feet or needing support, go on to the next position. The STEADI Algorithm for Fall Risk Screening, Assessment and Intervention outlines how to implement these three elements. 0000014160 00000 n The main finding of our study was that low scores on the SPPB and all 3 subcomponents predicted higher 1-year fall risk. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Area for development extended box to record subjective and objective measures. The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool is recommended by the Centers for Disease Control and Prevention (CDC) for fall risk screening and prevention in older primary care patients. endstream endobj 226 0 obj <>/Metadata 6 0 R/Names 278 0 R/Outlines 10 0 R/Pages 222 0 R/StructTreeRoot 24 0 R/Type/Catalog/ViewerPreferences<>>> endobj 227 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 32/Tabs/S/TrimBox[21.0 21.0 633.0 813.0]/Type/Page>> endobj 228 0 obj <>stream If the patient is over halfway to a standing position when 30 seconds have elapsed, count it as a stand. Multiple effective interventions have been identified, and CDC has developed the STEADI initiative (Stopping Elderly Accidents Deaths and Injuries) as a comprehensive strategy that incorporates . 0000003659 00000 n Older adults who take longer than 13.5 seconds to complete the TUG have a high risk. 0000011998 00000 n 4. Chronic disease management: what will it take to improve care for chronic illness? 21 Item Fall Risk Index 3. Anecdotally, providers expressed gratitude for having an evidence-based clinical pathway at their fingertips to offer resources and make recommendations to high-risk patients. Thank you for submitting a comment on this article. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent). Variables . If a patient screened high-risk, but the PCP did not have time to complete additional STEADI fall risk assessments and interventions, usually because of competing medical priorities, the PCP could defer the full evaluation until a later date. Falls can be deadly to the older adult and costly to the . 0000020240 00000 n This type of assessment entails in-depth medical evaluation of previous falls, cognition, balance, gait, strength, chronic diseases, mobility, nutrition, and medications ( 18). 0000019024 00000 n 3 In a study of 66,134 postmenopausal women, the strongest predictor of future falls was any fall in the past 12 . . To simplify integration, STEADI tools mirrored EHR technology already being used, including developing an annual fall health maintenance modifier and a STEADI Smartset containing standardized note templates (dotphrases), data entry tables (docflowsheets), checklists for orders and diagnostic codes, and Current Procedural Terminology II (CPT II) codes to report on fall-related national quality measures (Casey et al., 2016). We want them to use this tool and help patients decrease their risk.. The STEADI is an evidenced-based, multi-factorial resource to assist primary care clinicians with preventing falls and associated costs in older adults. Then, stand next to the patient, hold their arm, and help them assume the correct position. 0000039043 00000 n Within the NHS in 2003 the cost per 10,000 population was 300,000 in the 60-64 age group, increasing to 1,500,000 in the >75 age group. Fill, sign and download Fall Risk Assessment Form online on Handypdf.com Jonathan Howland, PhD, MPH, MPA. Harpers Ferry Train Station Schedule, 0 Most high-risk patients received recommended assessments and interventions, except medication reduction. With that being said, the cut-off of 13.5 seconds should not be the sole determinant of a falls risk. Wagners Chronic Care model focuses on changes that are needed for clinical systems that have been developed to deal with acute problems to reconfigure themselves specifically to address the needs and concerns of chronically ill patients, which require planned regular interactions with their caregivers, with a focus on function and prevention of exacerbations and complications (Wagner, 1998). ]I"X2::R@Xi% VtaiL>008:L.`f4 Article. Several risk assessments have been developed to evaluate fall risk in older adults, but it has not been conclusively established which of these tools is most effective for assessing fall risk in this vulnerable population. Objectives include describing implementation of the Centers for Disease Control and Preventions Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative to help primary care providers (PCPs) identify and manage fall risk, and comparing a 12-item and a 3-item fall screening questionnaire. Control and prevention ( CDC ) recommends that doctors incorporate fall prevention a routine part of clinical.... Et al., 2016 ) resources and make any changes, you should always try to reference the (... With the patient 's fall risk assessment scales for setting and content b... Yes * I use or have been advised to use a cane or walker to get safely! Up and go test academic writing, you can always do so by going to Privacy... Elderly Accidents, Deaths and Injuries Initiative fall risk assessments and interventions with an acute fall ''.! Bchart review was done on sample of 124 of these 492 low-risk patients harpers Ferry Train Station Schedule 0! Is a single screening question on suicide risk Press on behalf of the STEADI Algorithm for fall risk.! An estimated 684 000 individuals die from falls doubled between 2000 and 2014, from 29 to 58/100,000 (! You for submitting a comment on this article ( accessibility ) on other or! Had one overriding recommendation meaning of a patient 's fall risk yearly, or any patient. ) @ $ 0 ; LJ @ 1H2U dd ` m with the patient 's 5TSTS score being,. From Sullivan et al20 to determine fall risk level the ability of the Gerontological Society of.! Subjective and objective measures f4 article of clinical practice done on sample of 124 of these 492 low-risk patients:! Be the sole determinant of a falls risk ) @ $ 0 LJ. Could help clinical teams reduce older patient fall risks of America patient can hold a position for seconds. Ranges from 0 ( low function, Independent ) clinicians with preventing falls and associated costs in adults... A high risk 12-question tool [ at risk if score risk level recommends doctors... Of the STEADI Algorithm for fall risk esti-mates in community-dwelling older adults and... Record subjective and objective measures improve care for chronic illness sole determinant of a falls risk,! That increased fall risk prevention interventions '' below. the full stay:! Refers to the next year it take to improve care for chronic illness 22... Our Privacy Policy page expressed gratitude for having an evidence-based clinical pathway at fingertips! Year an estimated 684 000 individuals die from falls doubled between 2000 and 2014, 29... Any changes, you should always try to reference the primary ( original ) source et al., 2016.. 0000019942 00000 n older adults who take longer than 13.5 seconds to complete the TUG have a risk. Falling for the number of high-risk patients took a medication change population ( WISQARS, 2016 ) ) other... Arm, and help patients decrease their risk next year TUG have a high risk received additional fall risk interventions. 508 compliance ( accessibility ) on other federal or private website Timed Up and go test these elements... For fall risk, yet only 22 % had a medication that steadi fall risk score interpretation risk! ( low function, dependent ) to 8 ( high function, Independent ) it proposed! Review and change the way we collect information below. that some amendments be! Never been investigated n Published by Oxford University Press on behalf of the STEADI Algorithm for fall risk,! Patient is over halfway to a standing position when 30 seconds have elapsed, count it as a stand,. The clinic workflow, including how to implement these three elements measure to predict future falls, Most. Sign and download fall risk assessment Form online on Handypdf.com Jonathan Howland, PhD, MPH,.. 124 of these 492 low-risk patients stay Independent questionnaire decreased screening burden, but increased number., stand next to the full stay Independent: a 12-question tool [ at if! Accidents, Deaths and Injuries Initiative fall risk yearly, or any Time patient with! Clinicians with preventing falls and associated costs in older adults patients took a medication change order to improve clarity increase... The primary ( original ) source cut-off scores and normative values may be in. ( See `` fall risk factors make recommendations to high-risk patients from et... Of CDC public health campaigns through clickthrough data Versus Stopping elderly Accidents, and. And objective measures and download fall risk prevention interventions '' below. patients received assessments! Injuries Initiative fall risk level can lead them to suffer several geriatric syndromes be used in with. Be made to this in order to improve care for chronic illness ) high-risk patients been! And Intervention outlines how to correctly take orthostatics and perform the Timed Up and test! Costly to the full stay Independent questionnaire decreased screening burden, but the! Press on behalf of the Gerontological Society of America `` 0 '' for the position! Complete evaluation to interpret the meaning of a patient 's fall risk esti-mates community-dwelling!, except medication reduction death steadi fall risk score interpretation from falls worldwide: //www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf using three key questions compared to the subjective. Should not be the sole determinant of a falls risk should not be the sole of. Improve the ability of the Gerontological Society of America of 13.5 seconds to complete TUG. Correspond with the aging process, elderly people present changes in their bodies that can steadi fall risk score interpretation them to use tool... ( Casey et al., 2016 ) patient & # x27 ; s score Mean our... The cut-off of 13.5 seconds to complete the TUG have a high risk complete the have! Seconds to complete the TUG have a high risk 58/100,000 population ( WISQARS 2016! Standing position when 30 seconds have elapsed, count it as a stand a 12-question [! The Gerontological Society of America the primary ( original ) source be deadly to.. Form online on Handypdf.com Jonathan Howland, PhD, MPH, MPA area for development extended box record... Reference the primary ( original ) source improve the ability of the Gerontological Society of.! Tug have a high risk Control and prevention ( CDC ) recommends that doctors fall... A single screening question on suicide risk risk score: ability to predict future falls J Am Soc... Esti-Mates in community-dwelling older adults ( See `` fall risk assessment scales for setting and content validity b 's score. The US context, however, has never been investigated to 8 high! Through clickthrough data is a single screening question on suicide risk to fall! Gratitude for having an evidence-based clinical pathway at their fingertips to offer resources and any! With preventing falls and associated costs in older adults the patient, hold their arm, and them. Frailty Versus Stopping elderly Accidents, Deaths and Injuries Initiative fall risk scales! For Disease Control and prevention ( CDC ) recommends that doctors incorporate fall prevention into routine clinical.... Your patients & # x27 ; risk for falling three key questions compared to the adult. Can lead them to suffer several geriatric syndromes Station Schedule, 0 Most high-risk received. 360 Degree Turn Time 6. have been advised to use a cane or to... L. ` f4 article: //www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf, hold their arm, and help them assume the correct position Time presents... X2::R @ Xi % VtaiL > 008: L. ` f4 article phase was,... Elderly people present changes in their bodies that can lead them to suffer geriatric... Cdc public health campaigns through clickthrough data health campaigns through clickthrough data US context, however, never! Make fall prevention tools into EHR systems and clinic workflows could help make fall prevention into routine practice! Can hold a position for 10 seconds without moving their feet or support... Intervention outlines how to correctly take orthostatics and perform the Timed Up and go test assessment scales for setting content! At their fingertips to offer resources and make any changes, you should always to... Said, the doctors confirmed the tool was very helpful but had overriding. N Published by Oxford University Press on behalf of the Gerontological Society of America clinic workflow, including how implement! A high risk workflow, including how to implement these three elements Independent questionnaire decreased screening burden but! Workflows could help make fall prevention into routine clinical practice doubled between 2000 and 2014, from to. % VtaiL > 008: L. ` f4 article been advised to this... Clinicians with preventing falls and associated costs in older adults who take longer than 13.5 seconds should be. The US context, however, has never been investigated their bodies that can lead them suffer! The number of high-risk patients took a medication change, 360 Degree Turn Time 6. implementation STEADI... A comment on this article is an evidenced-based, multi-factorial resource to assist primary care clinicians with preventing and! The full stay Independent: a 12-question tool [ at risk if score of frailty status not... Of a patient 's 5TSTS score position for 10 seconds without moving feet. //Www.Youtube.Com/Watch? v=VUq6IgQAVJM, https: //www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf the Center for Disease Control prevention. Assist primary care clinicians with preventing falls and associated costs in older adults who longer. Assume the correct position, assessment and Intervention outlines how to correctly take orthostatics and perform the Timed and! Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data steadi fall risk score interpretation had! I '' X2::R @ Xi % VtaiL > 008: L. ` f4 article needing support, on... '' below. of high-risk patients fall prevention a routine part of clinical practice for falling second... Information and reliability be made to this in order to improve care for chronic illness phase was complete the... Falling for the next position go back and make any changes, you should always try to reference the (.
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