Fire Service-Based EMS Electronic Tool Kitfireserviceems.com/wp-content/uploads/2016/05/2016...Tool Kit covers many facets of fire service-based EMS. The “Talking Points” can be

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This Third Edition of the Fire Service-Based EMSElectronic Tool Kit provides fire service managers andfire fighter union officials with the latest information

on fire service-based emergency medical services. Itincludes three separate sections: Section One providesinformation and tools related to fire service-based EMS ingeneral; Section Two provides specific information andtools directly related to the impact of the federal PatientProtection and Affordable Care Act (PPACA) andIntegrated Community Health Care Programs (ICHCP) onfire service-based EMS; and Section Three provides criticalinformation related to policies and practices for respondingto incidents involving violence.

This resource is provided as a cooperative effort betweenthe International Association of Fire Chiefs (IAFC), theInternational Association of Fire Fighters (IAFF), theMetropolitan Fire Chiefs Association, the CongressionalFire Service Institute (CFSI), and the International FireService Training Association (IFSTA).

If your fire service-based EMS first response system or yourambulance transport operation is currently threatened orunder open attack, the IAFF and the IAFC have additionalstrategic and tactical resources available to assist you. Theseresources are customizable for your situation and are notincluded in this Electronic Tool Kit. To access these resources,local union affiliate leaders can contact the IAFF Departmentof Fire/EMS Operations at 202-824-1547 or fire departmentadministrators can contact the IAFC EMS Section throughthe contact information at their web site, www.iafcems.org.

This Electronic Tool Kit contains “Talking Points” andvarious electronic links to documents described within thekit. The kit also contains links to other resources, includingweb sites and videos. Users may access these links anddownload resources at any time.

SECTION ONE:

FIRE SERVICE-BASED EMS GENERAL INFORMATION

The information provided in this section of the ElectronicTool Kit covers many facets of fire service-based EMS. The“Talking Points” can be used when communicating insideand outside of fire departments, including presentations to

the public, the media, elected officials, public managers andothers. The content of the links address issues such as fireservice-based EMS historical information, deployment andservice delivery models, interaction with the medicalcommunity, system elements including treatment,transportation, training and certification, billing andcollection, issues related to private EMS providers, andother important areas of interest.

RESOURCE: TALKING POINTS

n The fire department is geographically deployedthroughout the community to minimize response times.The most expensive parts of the EMS system —personnel, apparatus, and facilities — are already in placeto respond to fire and other emergencies. Thatemergency response infrastructure works very well forEMS response.

n Response time is the absolute priority for medicalemergencies. Fire fighters are in the best position torespond quickly and provide vital services on scene.

n EMS has historically been a part of the fire service —especially in metro jurisdictions. EMS is not a distractionfrom our mission - it is a core service provided by firefighters and paramedics within the fire department’smission.

n Pre-hospital 9-1-1 emergency response is one of theessential public safety functions provided by the UnitedStates fire service. Fire service-based EMS systems arestrategically positioned to deliver time critical response,effective patient care and scene safety.

n Of the 200 most populated communities, 97 percent havethe fire service delivering pre-hospital emergency medicalservice response. Additionally, fire departments providecritical Advanced Life Support (ALS) response and care in90 percent of the 30 most populated United States citiesand counties.

n EMS training is part of the basic training for all firefighters. Different levels of EMS certification exist in eachstate.

Fire Service-Based EMS

Electronic Tool Kit

Resources for Leaders

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n Personnel are the most expensive part of any emergencyresponse system. Fire departments are essentially“standing armies” in their communities poised to respondto an emergency. Utilizing fire fighters to provide EMSgets more bang for the buck.

nFire fighters can work more hours in a week before being paidovertime than can private sector EMS workers, according toFederal Fair Labor Standards Act (FLSA) regulations.

n The ride in the ambulance for the sick or injured person isonly part of an EMS system. A comprehensive EMSsystem includes rapid response, intervention,stabilization, and then transportation to a definitive carefacility, if needed. The direct delivery system is backed upby a continuous training and quality improvementprocess that seeks to improve the level of care.

n Fire service-based EMS brings the treatment to thepatient — wherever they are. Treatment by fire fightersbegins immediately, even if the patient is trapped in abuilding that’s on fire, pinned in a car crash, or in acollapsed structure.

n The provision of EMS response, treatment, andtransportation by fire fighters is seamless. One agency(the fire department) is responsible for the continuity ofpatient care and provides EMS within an “all-hazards”response model.

n Fire departments have very low turnover rates. Thereforefire fighters are long-term workers in their communitiesand know about community needs including those relatedto emergency medical response.

n The fire service-based EMS deployment model is morerobust than any private for-profit ambulance-based EMSmodel. Fire fighters are deployed and ready to respond toany type of emergency. Fire fighters don’t leave townduring disasters or when the going gets tough.

Resource 1-1: Prehospital 9-1-1 Emergency MedicalResponse — The Role of the United States Fire Service in Delivery and Coordination

This white paper discusses the origins and history ofemergency medicine in the United States and the evolutionof the fire service role in these services. It further explainsseveral of the models used by fire service organizations toprovide EMS, explains the differences between emergencyand non-emergency EMS, and explains the capabilities ofmulti-role fire fighters in EMS. The paper also clarifies thatEMS is not just the ambulance ride; it’s a system thatincludes a number of components that leverage thestrengths of the fire service.

Resource 1-2: Emergency Medical Services (EMS): AGuidebook for Fire Service-Based EMS Systems

This comprehensive guide provides fire service managersand fire fighter union officials with up-to-date informationon fire service-based EMS. The goals of the guide are toprovide background on EMS systems; to guide managersand union officials in analyzing their EMS systems; toprovide direction for system evaluation; and to guide firedepartment leaders confronted with competitiveprocurement through developing and responding torequests for proposals.

The EMS Guidebook contains nine chapters and appendixmaterials. The chapters cover the principles and origins offire service-based EMS, its impact on the community, qualityand effectiveness measurement, response time, systemcosting and revenue, competitive procurement, EMS inCanada, the role of the medical director, and the future of EMS.

Resource 1-3: Addressing Myths Often Generated byPrivate EMS Providers

This document details the tactics used by private ambulanceservice providers in seeking to convince fire chiefs and localgovernment officials to discontinue fire service-based EMSambulance service and turn those responsibilities over to aprivate company. The five myths that are generallyadvanced by the private contractors in these situations aredetailed and rebutted.

Resource 1-4: The Benefits of Having Fire FightersTrained in All Hazards

This brief summary provides information on the benefitsand capabilities of all hazard fire fighters over single roleEMS workers.

Resource 1-5: Press coverage of Private EMS SystemAbandonment of Service

Private EMS and ambulance service providers have a history ofshutting down operations with little or no prior warning to thefire department or the AHJ. This has happened in severalstates, including even in the city of New York, NY. In just oneof the cases that has occurred, more than 70 communities wereimpacted due to the shutdown of one company. No warning isprovided because of the company’s concern for avoiding apre-emptive reaction from creditors and/or stockholders. Butthis lack of prior notice compromises public safety when itcomes to the ability to deliver emergency services. Thisresource provides examples of these types of situations thathave occurred in recent years in the United States. FDNY EMS Crews work non-stop since private ambulancecompany Transcare declared bankruptcy

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FDNY prepared to pick up slack after private ambulancecompany files for bankruptcy

Private Ambulance Service Serving Six States Shuts Down,Leaving Thousands Stranded in Their Homes

Resource 1-6: Fire Service-Based EMS Advocates Web Site

The Fire Service-Based EMS Advocates web site is acollaboration of the CFSI, IAFC, IAFF, National FireProtection Association (NFPA), and the National VolunteerFire Council (NVFC). This organization exists to informand educate members of Congress and others of the vitalrole and importance of fire service-based EMS.

Resource 1-7: Report on EMS Field Experiments —Multi Phase Study on Fire Fighter Safety and Deployment of Resources

This report presents the results of more than 102 fieldexperiments designed to quantify the effects of various fireservice-based EMS deployment configurations for threedifferent scenarios: 1) patient access and removal from theincident scene, 2) a victim of systemic trauma due to a longdistance fall and 3) a patient with chest pain leading to acardiac arrest.

Resource 1-8: Video — National Medical Report

This video explains the role of the fire service in EMS. It issuitable for viewing by the public to explain the basicconcepts of fire service-based EMS.

Resource 1-9: US Fire Department Profile

A recent NFPA profile of the fire service in the United Statesshowed that an estimated 13,665 fire departments providedEMS with basic life support, 4,635 departments providedEMS with ALS. Read more.

Resource 1-10: Fire Service-Based EMS — The Right Response Video

This video explains why prehospital 9-1-1 emergency responseis one of the essential public safety functions provided by theUnited States fire service in support of community health,security and prosperity. Fire service-based emergency medicalservices (EMS) systems are strategically positioned to delivertime critical response and effective patient care. Fireservice-based EMS provides this pivotal public safety servicewhile also emphasizing responder safety, competent andcompassionate workers, and cost-effective operations.

It is critical that policy makers understand the importance ofhaving emergency medical services provided through the fireservice. Fire service-based EMS is prehospital emergency9-1-1 medical response provided by the nation’s fire fighterEMTs and paramedics. Due to the training, expertise, andequipment of fire service-based EMS responders, they arecapable of simultaneously securing a scene, mitigating thehazard, and triaging, extricating, treating, decontaminating(if necessary), and transporting the patients who have beeninjured to an appropriate medical facility. Time efficiency is akey component of the best designed EMS systems. There isno service more capable of rapid multi-faceted response thana fire-based EMS system.

As the federal, state, and local governments consider theirstrategic plans for an ‘all hazards’ emergency responsesystem, EMS should be included in those considerationsand decision makers should recognize that the U.S. fireservice is the most ideal prehospital 9-1-1 emergencyresponse agency.

“Fire-Based EMS: The Right Response” Video

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SECTION TWO:

FIRE SERVICE INTEGRATED COMMUNITY HEALTHCARE PARTNERSHIPS

There are many challenges and opportunities facing fireservice-based EMS Systems as Integrated CommunityHealthcare Partnerships continue to evolve. There is someurgency for leaders across the full spectrum of the fireservice to engage potential healthcare partners at the locallevel to ensure that fire departments are not excluded fromlocal partnership opportunities. Developing partnershipswith local community healthcare providers will provideopportunities for fire service leaders to enhance fireservice-based EMS delivery systems.

This section of the Electronic Tool Kit is dedicated toproviding information about the opportunities that mightpresent themselves to fire service leaders as they design andmanage adjustments to their fire service-based EMS systems.New and enhanced partnerships by fire departments withvarious entities in the healthcare community and others aresure to be important as this new EMS paradigm is moreclearly defined and fully implemented.

If your department is interested in more information onopportunities to deliver Community Paramedic (CommunityHealth Care) Services, local union affiliate leaders can contactthe IAFF Department of Fire/EMS Operations at(202)824-1547 or fire department administrators can contactthe IAFC EMS section via the web at www.iafcems.org

Just as in Section One of the Tool Kit, there are “TalkingPoints” for use when communicating inside and outside offire departments, including meetings with the medicalcommunity, as well as presentations to the public, themedia, elected officials, public managers and others. Thereare also links to information to assist fire departmentmanagers and local union officials as they design theirapproach to taking advantage of opportunities presentedwhen Fire Departments choose to initiate IntegratedCommunity Healthcare Programs.

RESOURCE: TALKING POINTS

n The fire service is the predominant EMS provider in theUnited States.

n Fire stations are strategically located throughout thecommunity, providing minimal response times andexcellent locations for healthcare outreach andcommunity educational/informational sessions.

n Fire fighter/ EMT’s and paramedics routinely work in thepatient’s environment. Living conditions, social

deterrents, family support, socio-economic factors andother environmental factors of total healthcaremanagement are easily assessed.

n Fire service-based EMT’s and paramedics are sworn toprotect the community they serve, enjoying an excellentreputation and credibility within the community.

n Fire service-based EMT’s and paramedics should be seenas gatekeepers to the healthcare system. As the firstcontact for many patients, the only contact that does notrequire a waiting room, they are uniquely positioned andtrained to connect patients to the most appropriate, costeffective healthcare resource.

n Historically, fire service-based EMS systems have notbeen conditioned to the traditional fee for servicepayment system. In fact, quality of care measures, such aspatient outcomes, community save rates, event to balloontime, and low response times have been the leadingmeasures of effectiveness for fire service-based EMSsystems. Fire service-based EMS systems are service andoutcome driven.

n Fire service-based EMT’s and paramedics work underprotocols designed and approved by a licensed physician.This environment provides an increased compliance ratefor the consistency of care for organizational andsystem-wide procedures.

n Fire service-based EMT’s and paramedics are the onlyhealthcare workforce that can administer care in anyhazardous situation.

n Fire fighter / Paramedics are uniquely equipped toprovide preventative healthcare tips to communitymembers and specific target audiences. Throughout thecountry, fire service-based EMT’s and paramedics providepublic education on a daily basis on subjects like healthand wellness education, prevention and other topics.

n Fire service-based EMT’s and paramedics provide

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healthcare services in more diverse environments thanany other healthcare workforce. In the same 24 hourperiod, a Fire fighter/Paramedic can deliver care in ahome, an alley, a nursing home, a care home, a vehicle, ahospital, a jail and a city park. This diversity in workenvironments provides tremendous opportunity for thehealthcare system to benefit from the unique perspectivesFire fighter/Paramedics can provide to the healthcareneeds of a community.

n Unlike many healthcare settings and offices, Fireservice-based emergency medical service is available24/7/365.

n Fire service-based EMS services are supported through 24hour Public Safety Answering Points (PSAP) and dispatchcenters; centers that offer opportunities for partnershipsto coordinate community-wide healthcare triage andfollow-up services.

nA fire service-based EMS system is an essential resource inachieving the Triple Aim of the Patient ProtectionAffordable Care Act (PPACA): reducing cost, improving thehealth of a population, and improving the quality of care.

n Fire service-based Fire fighter/Paramedics should not beoverlooked as a resource to help hospitals reducereadmission rates by implementing an out-of-hospitalpatient follow-up program.

n A fire service-based EMS system acts as a safety net forthe healthcare needs of an entire community. Leveragingthe inherent strengths of such a system withcommunity-wide healthcare partners will providestakeholders with the opportunity to improve the qualityof care at a reduced cost.

n A Fire Service-Based EMS System introduces programsthat provide alternative care options to streamline services— and should include a cost recovery plan.

Resource 2-1: Opportunities are Changing FireService-Based EMS Systems

This document provides advice for local union officials andfire chiefs to prepare them to better assess, and potentiallyimplement, significant changes that are affecting the structureand provision of emergency medical services (EMS).

Resource 2-2: Realigning Reimbursement Policy andFinancial Incentives to Support Patient-CenteredOut-of-Hospital Care

This Journal of the American Medical Association (JAMA)article concludes that current payment models foremergency medical care may be a disincentive for EMS

providers to avoid unnecessary emergency room visits forcustomers that they contact in the field. This situationlimits the role of first responders in the overall health caresystem. The report also recommends changes to thesepayment models to improve care and reduce expense.

Resource 2-3: The Expanded Role for EMS underHealth Care Reform

This paper explores the role of fire-based EMS providers inthe health care system with the implementation of thePPACA and the possible impacts on local fire departments.

Resource 2-4: National Consensus Conference onCommunity Paramedic

This report purports to be a National Consensus Reportthough it lacks any fire department-based representation.However, there are helpful insights on reimbursement sectionthat are useful in the mobile integrated healthcare arena.

Resource 2-5: What is the Medical Community Lookingfor from EMS?

This EMS Insider article discusses changes to the emergencymedical system that will occur upon the implementation ofPPACA. The author discusses the concept of “mobilehealthcare” and changes to the healthcare payment systemthat are also part of the PPACA. The article also includes anumber of examples of cost-saving innovations.

Resource 2-6: Fire Service-Based EMS CommunityHealthcare Provider Programs

This PowerPoint presentation provides information aboutthe new environment in which fire service-based EMS will beprovided. The program includes information on incentivesand disincentives for emergency medical services providers,hospitals, and other health care providers. The development ofpartnerships between the fire service-based EMS provider andother components of the health care system is encouraged.

Resource 2-7: IAFF Fire Service-Based EMS CommunityHealth Care Position Statement

The official IAFF position statement on the use of firefighters, EMT’s and paramedics in the larger communityhealth care system — also known as “communityparamedics”. The statement advocates services such ason-scene response, “frequent caller” programs, in-homeevaluation of high-risk patients, and enrollment assistancefor those without healthcare insurance.

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Resource 2-8: A Brave New World - OpportunitiesAbound for Fire Service-Based EMS

This article from Fire Chief Magazine details tenopportunities that may be presented to fire service-basedEMS organizations related to the implementation of thePPACA. The article concludes with advice to fire chiefs andlocal union officials - continually demonstrate innovationto our stakeholders; collaborate with local healthcaresystems and with each other; and advocate for those theyprotect and serve.

Resource 2-9: Fire Service-Based IntegratedCommunity Healthcare Partnership Programs —Success Stories

Many fire service-based EMS systems have developed andimplemented innovative and successful integratedcommunity healthcare partnership programs. This resourceprovides current examples that have strengthened EMSservice delivery models in various ways.

A. Community Health Service Delivery Model — Chandler,ArizonaThis paper introduces the Chandler, AZ, Fire Department’sCommunity Health Service Delivery Model. This modeldetails the expansion of service provision, leveragingexisting resources to meet the changing health care needs ofthe community. The model also includes partnering withexisting community providers to meet the tenants of thePPACA.

B. Mesa Fire and Medical Department Transitional ResponseThe Mesa Fire Department aims to be on the cutting edgein delivering service to its citizens. So the department hasdeveloped a new service model to increase efficiency andlive within budgetary constraints.

Mesa Fire Department Implements Transitional ResponseVehicles Program

Mesa’s PA unit eases load for 1st responders

C. Dallas, Texas The mobile integrated health program is meant to make the“Rescue” side of Dallas Fire-Rescue more proactive, ratherthan just reactive. Currently, a team of five paramedics aremaking scheduled house calls to people who call 911frequently.

Dallas Fire-Rescue program helps reduce 911 calls byfrequent EMS users

Dallas Fire-Rescue: Paramedic ‘house calls’ pilot programshowing early signs of success

D. Buckeye, Arizona CHCPP Success of Buckeye’s Pilot Community ParamedicineProgram Demonstrates Positive Impact on Patients’Recovery.

E. Kent, Washington FD CARES was established in 2010 by a team of fire fighters,healthcare providers, and technology professionals at theKent Fire Department Regional Fire Authority inWashington State. The work of FD CARES is made possibleby strategic partnerships with the International Associationof Fire Fighters, Washington State Council of Fire fighters,Washington State Nurses Association, King County EMS,Tri-Med Ambulance, Premera, Mulitcare, and UW ValleyMedical Center.

F. Milwaukee, Wisconsin A new concept for the Milwaukee Fire Department (MFD)— paramedics treating patients before they call 911.

SECTION THREE:

RESPONSE TO INCIDENTS INVOLVING VIOLENCE

Fire fighters are often exposed to the potential of becomingvictims of violence in the performance of their duties. Thishazard seems to be greatest when fire department unitsrespond to EMS incidents. The ratio of EMS incidents toother types of emergency responses is typically muchhigher, making the hazard even greater. These high riskincidents often involve domestic violence, assault, mentalhealth issues, active shooters, and acts of terrorism.

Section Three of this Tool Kit is intended to bring specialattention to these hazards and provide information andresources that might be helpful in preventingviolence-related fire fighter injuries and deaths. All

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emergency response personnel are at risk in these situations.Responders, and dispatch personnel alike, must be especiallyvigilant when identifying and dealing with any incident thathas the potential of resulting in violence towards theresponders. Interagency cooperation and communicationsare a must for effective joint response, and all related systemsshould be in place well before an incident occurs.

Resource 3-1: IAFF Policies

The IAFF has established multiple policies related toresponse to violence particularly in the area of respondingto an active shooter event.

nMember Response to Active Shooter Active Shooter Position Statement

nActive Shooter Active Shooter Resolution

nRescue Task Force IAFF Rescue Task Force Position Statement

nTactical EMS SWAT Medic Position Statement

Resource 3-2: First Responder Guide for ImprovingSurvivability in Improvised Explosive Device and / orActive Shooter Incidents- DHS

Recent improvised explosive device (IED) and active shooterincidents reveal that some traditional practices of firstresponders need to be realigned and enhanced to improvesurvivability of victims and the safety of first responders caringfor them. is Federal, multi-disciplinary first responderguidance translates evidence-based response strategies fromthe U.S. military’s vast experience in responding to andmanaging casualties from IED and/or active shooter incidentsand from its significant investment in combat casualty careresearch into the civilian first responder environment.

n First Responder Guide for Improving Survivability

Resource 3-3: Urban Fire Forum (UFF) PositionStatement — Active Shooters

Today’s fire service faces greater challenges than ever beforeand responds to a broader spectrum of emergency andcatastrophic events. These papers are critical resources fordepartments to assess community risk and establish bestpractices for usual and extraordinary circumstances.

Active Shooter and Mass Casualty Terrorist Events Position Paper

Fire Service Deployment: Assessing Community

VulnerabilityResource 3-4: Possible Indicators of Mental Illness

This list was developed by the Georgia Association of Chiefsof Police Mental Health Ad Hoc Committee to AddressMental Health Issues in Law Enforcement, Mental Healthand Law Enforcement Encounters: A Review of CurrentProblem and Recommendations.

Resource 3-5: USFA / FEMA Active Shooter Guide

This paper was developed as a fire and Emergency MedicalServices (EMS) resource that can be used to supportplanning and preparation for active shooter and masscasualty incidents (AS/MCIs). These complex anddemanding incidents may be well beyond the traditionaltraining and experience of the majority of fire fighters andemergency medical technicians.

n U.S. Fire Administration

Resource 3-6: Active Shooter Incident ManagementChecklist

The Active Shooter Incident Management Checklist isdesigned for basic complexity through moderate complexityActive Shooter Events in a generic approach suitable formost communities. However, the Checklist will not besuitable for ALL communities. Each agency must evaluate ifthis Active Shooter Checklist is appropriate for theircommunity, their staffing, and their risk.

n Active Shooter Incident Management Checklist

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Resource 3-7: IAFC Policy: Active Shooter and MassCasualty Terrorist Events

Given the recent spate of what has become known as “activeshooter” scenarios unfolding across the nation, fire andpolice departments, regardless of size or capacity, must findways to marshal appropriate and effective responses to theseevents. erefore, local jurisdictions should build sufficientpublic safety resources to deal with active shooter scenarios.

n Active Shooter and Mass Casualty Terrorist Events

Resource 3-8: Philadelphia FD RAMS

The traditional EMS response to active shooter incidentshas been to stage at a safe distance until the scene has beensecured by law enforcement. Such an approach may lead tounnecessary delays in medical care and needless loss of life.To address this issue locally, the Philadelphia FireDepartment and the Police Department collaborated todevelop the Rapid Assessment Medical Support (RAMS)program.

n Rapid Assessment Medical Support (RAMS) for ActiveShooter Incidents

Resource 3-9: Response to Incidents Involving IED’s

Fire departments are called upon to respond to manychallenges, including suspicious packages, bomb threats,and more recently — Improvised Explosive Devices (IED’s).

This JEMS article provides information about theimportance of interagency cooperation and specializedtraining for fire service-based EMS providers who mightencounter IED’s. It is intended to help departments withissues relating to readiness and response.  Preplanning,situational awareness, and a strong emphasis on fire fightersafety are critical to these incidents, just as they are to otherhigh hazard situations. With IED’s — caution is the word ofthe day!

Resource 3-10: Responding to Civil Unrest: MiamiProtocol (NFPA)

When the Fire Chief of the City of Miami Department ofFire-Rescue declares that any condition in the City hasattained, or threatens to attain the proportions of a civildisturbance, response protocols are implemented.

Resource 3-11: Responding to Domestic Violence

This PowerPoint presentation was adapted from thecurriculum created by the New Hampshire Bureau of EMS,the National Health Initiative on Domestic Violence, and theFamily Violence Prevention Fund.

Resource 3-12: Three Ways Fire fighters can Mitigate Violence

Fire fighters and medics are attacked with increasingfrequency, follow these steps to shift the survival odds.

CONCLUSION

The purpose of this Fire Service-Based EMS Electronic ToolKit is to better inform leaders in their decision-making andthe design of service delivery models. It providesbackground information and resources to assist in dealingwith a variety of issues regarding fire service-based EMS ingeneral, and opportunities that may exist for firedepartments within integrated community healthcarepartnership programs. This latest edition also providesresources to assist fire departments in addressing thegrowing concern of incidents involving violence towardsfire fighters and other responders. The informationcontained in this Tool Kit covers many facets of fireservice-based EMS. As the range of service deliverychallenges and opportunities become more varied andcomplex, fire department leaders must be well informed sothat they can best decide what information best suits theirspecific situation and needs. The creators of this documenthope it helps decision-makers do just that. n