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Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. One of the advantages to having so many of your diabetic patients being adults is that many of them already know how they learn best. This is an example of a visual aid which has an example of a sliding scale (Huizinga et al., 2008).
Watch for verbal and non-verbal clues? Visual learners:? - phrases like “ I see what you’re saying”? - May look up and away when listening or considering something new. Watch for verbal and non-verbal clues? Auditory learners:? - phrases like “ Doesn’t sound right to me, or I hear what you’re saying”? - May look off to the side when listening or considering something new. Watch for verbal and non-verbal clues? Kinesthetic learners? - Phrases like “Just doesn’t feel right”? - Used hand gestures when speaking? - May look down when listening or considering something new. This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. Please note that we are unable to respond back directly to your questions or provide medical advice. Thankfully, companies aren't just making straight-up gadgets anymore for helping us manage our diabetes. Last week, I was able to sit in on a training webinar for CDEs on recognizing and treating depression.
In this module, we will review the work of Community Care at the program and network levels to transition to a model that not only manages specific diseases but also manages individuals with multiple conditions, including mental health. Nearly 70 percent of North Carolina’s Medicaid budget is consumed by high-cost and high-risk disabled and elderly clients with serious and co-morbid (multiple) medical conditions. Through its regional community-based health care infrastructure, Community Care has the framework to implement a comprehensive chronic care program that addresses many of the important elements identified by the MacColl Institute and Ed Wagner’s research on the chronic care model.  According to Dr. Community Care recognized the importance of strong community leadership in the development of a chronic care model.  The local network leadership was challenged to convene new stakeholders and gain input and feedback into their expanded mission and strategies.
States that are able to implement a comprehensive and robust chronic care program will be in a good position to implement the new health reform provisions directed at improving the delivery and coordination of services for persons who are enrolled in both Medicaid and Medicare (dual-eligibles) and who are likely to have multiple chronic conditions. Reimbursement and financial incentives are not aligned to promote the management of individuals with chronic conditions. Team-based care, often because of reimbursement issues, does not occur as often as it should when managing individuals with chronic disease.
By implementing a sophisticated model of care management – and by using effective evidence-based tools and systems – Community Care has demonstrated that it can improve health outcomes and access while containing Medicaid costs.
Reorganize the delivery of care to those with chronic needs in ways that enhance appropriate access.
Reduce variation in care, the rate of institutionalization and the unnecessary inefficiencies and expenses in the current system.
Designed to build upon Community Care’s established foundation, the chronic care initiative emphasized an enhanced care management processes with strong ties to the medical homes and built new connections with community-based long-term care providers and hospitals.
Recognizing that the best system for enabling long-term sustainability and system reform must occur at the community level, North Carolina’s Community Care networks provide an ideal mechanism for the state to ensure access to quality services at the most reasonable cost for its citizens.
Targeted for this initiative are individuals who are eligible for Medicaid and who are in the aged, blind and disabled (ABD) or CAP-DA (Community Assistance Program for Disabled Adults) eligibility categories.
The chronic care program is designed to be “patient-centric,” addressing the physical, social, and behavioral health needs of the target population. Initially, the networks extended existing population, disease and care management initiatives, and community partnerships already in place to patients with chronic conditions. Community Care networks aligned the efforts of comprehensive care management processes that help them manage individuals with chronic and often co-morbid conditions. The flow chart below illustrates the process through which Community Care implemented the chronic care program. Working with community providers who have traditionally cared for North Carolina’s low-income residents. Building private and public partnerships where community providers can work together to cooperatively plan for meeting patient needs and where existing resources can be used most efficiently. Placing responsibility for performance and improvement in the hands of those who actually deliver the care.
Building a patient-centric model with the tools and processes that can be replicated in other networks and practices. Targeting disease and care management initiatives to a subset of the target population where the interventions will have the most impact. Ensuring that the “medical home” is supported in such a manner that enables the primary care providers to improve how they manage chronic illnesses.
Integrating local long-term care and hospital providers and support in the community-based chronic care model.
Community Care’s long-term vision for the chronic care program is to create an effective, patient-focused chronic care system for Medicaid and Medicare patients statewide.
In North Carolina, the Aged, Blind and Disabled (ABD) population accounts for nearly 70 percent of the service dollars but fewer than 30 percent of the recipients. Forty-five percent have visited the emergency department at least once in the past year. Establish links among community providers, including those in behavioral health and long-term care settings. Support the medical home effort with patient information, case management and quality-improvement efforts. Develop an informatics center to provide timely and meaningful data to the networks and practices. Provide scheduled updates to networks on best practices for the most common diseases. Provide additional and specialized consultative help to networks and practices, as indicated. Build a team of case managers who can take a holistic approach with complex patients. Identify and enroll additional practices that can serve Community Care’s target populations. Designate an informatics “champion” within each network to serve as a single point of contact.
Identify a “chronic care physician champion” to lead the effort at the community level. Designate one or two key practice staff members to serve as a consistent liaison(s) with network.
Build additional capacity, such as establishing care teams, to proactively manage chronic illness and preventive care.
While not exhaustive, these strategies represent some of most important components in a successful chronic care program.
Early in 2007, the networks piloting the chronic care program received funding to support development activities and to begin identifying a replicable model. In concert with the networks’ chronic care leadership, the central office developed a strategic planning document outlining the three design phases to implement the design features needed to implement a chronic care program. Outlined below are the program components Community Care considers essential as well as the infrastructure and processes developed to support them. Enrollment and outreach – Each network created a plan in concert with its local departments of social services (DSS) to boost enrollment of ABD and dually eligible patients into Community Care (networks with strong partnerships with local DSS offices have higher enrollment rates). In addition, family members and other caregivers were included in patient care discussions, and practice staff members used communication methods such as “teach back” and motivational interviewing to enhance outcomes. Patient-Centered Medical Home (PCMH) – The essence of our chronic care program is the value and importance of a PCMH in caring for patients with chronic conditions. Disease management of chronic illness(es) such as (diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension, depression, etc.) occurs. Electronic health information records are available to optimize patient care and management.
Recent research has found that transitional support sometimes can help to prevent unnecessary readmissions and improve patients’ medication adherence. Forged links with nearly all North Carolina hospitals to obtain timely information about their hospitalized patients.
Embedded care managers in hospitals with large numbers of ABD admissions, and participated actively early in the discharge planning. Scheduled visits with patients in the hospital and then followed up with home visits within three days of discharge. Performed “medication reconciliation” on hospitalized patients that seek to make sense of all the different medications the patients may take (from the medicine cabinet, the PCP’s list, hospital discharge instructions, specialists and behavioral health providers, over-the-counter meds, etc). Built relationships in the community to share information among a variety of local agencies, including LMEs, behavioral health providers and long-term care support providers. Updated the patients’ medical homes about hospitalizations, other prescribed medications, social and environmental concerns, and other agencies providing services such as PCS, home health care and behavioral health support.
Encourage the patient and caregiver to play a central and active role in the formation and execution of the care plan. Promote self-management skills and direct communication among the patient and caregiver, the PCP and other care providers. Care managers are embedded in large tertiary hospitals and work as part of hospital discharge planning teams.
Post-discharge home visits not only support medication reconciliation efforts but also provide care managers with valuable knowledge about the patients’ home environments and support issues. Pharmacy home – The pharmacy home component of the model is designed to ensure that high-risk patients with complex medical problems and multiple medications have a “pharmacy home” that helps coordinate their pharmacotherapy regimens. The ABD population enrolled in Community Care takes an average of more than seven medications per month. A multi-disciplinary team of Community Care staff, network staff and PCPs supports the Pharmacy Home.


Identify the patient’s current medication list and relevant medical conditions by Medicaid claims and, if necessary, chart audits and direct communication with practices (network pharmacist). Provide recommendations and other information as appropriate to the PCP so prescriptions can be changed, added or stopped (network pharmacist, care manager, PCP).
In Community Care, local care managers work to support the efforts of the medical homes and PCPs. Incorporate a standardized approach to assessment, screening, care planning, care coordination and management priorities.
Ensure effective disease management practices occur in the medical homes via the adoption of evidence-based best practices for chronic conditions. Target interventions where they will have the greatest impact, and integrate population stratification methods that help identify patients who will benefit most. Please refer to Module 11 for more detailed information on care management strategies, including population stratification, comprehensive health assessments and care plans. Integrating mental health services into a primary care setting offers a viable and efficient way to ensure that patients have access to needed behavioral health services.
Several Community Care networks collaborated on a series of pilot programs to create an initial model of mental health integration. Increase the comfort level of PCPs in identifying and treating patients with depression who present in their office. Improve communications between PCPs and behavioral health care providers at the local levels. Ensure, through improved coordination, that patients are able to access care at a point in the system where their health and behavioral health needs can be optimally met. PCPs do not have the same relationships with behavioral health providers as they do with other specialty providers, such as cardiologists or endocrinologists.
Building relationships between physical and behavioral health care providers is of paramount importance for a successful program. PCPs do not always have the confidence to prescribe and titrate behavioral health drugs, such as antidepressants.
The lessons learned in the mental health integration pilots helped guide the evolution of Medicaid mental health policy and target statewide training and technical assistance more effectively. Build practice infrastructure to incorporate the behavioral health needs of patients in the primary care provider office setting.
Increase the number of primary care practices who use evidenced-based screening tools to identify patients. Seek to develop and implement an agile therapeutic model with enhanced referral processes for more complex patients to specialty mental health services.
Three behavioral health providers and three partnering primary care practices participated in a reverse co-location model in which the PCP worked within the specialty behavioral health clinic. Demonstrate that patients receive the preventative care services in accordance with the U.S. Community Care co-location pilots work in partnership with The ICARE Partnership to maximize resources and avoid duplication of effort.
Recognizing the value and importance of behavioral health integration in managing individuals with chronic conditions, the central office and networks began hiring psychiatrists in 2010 to lead a comprehensive statewide effort. The term “informatics” encompasses all aspects of electronic data use within the Community Care program, including the collection, processing and representation of health care data from multiple sources for multiple stakeholders. A steady principal source of information about the enrolled population is Medicaid claims data. Self-management as a component of a chronic care model is extremely important in the Medicaid population due to the percentage of individuals with multiple chronic conditions, co-morbid behavioral health concerns, higher social and economic barriers, lack of ability to navigate the system, cultural differences and increased levels of defensiveness.
Many networks are testing and implementing strategies of coordinated care that enhance patients’ self-management abilities. Teach patients about proper self-care and to recognize symptoms that need to be addressed by health professionals. Use coaching styles that are best able to address treatment adherence and lifestyle changes.
Important Note: The content of this website is not intended to be a substitute for professional medical advice, diagnosis or treatment. Novo Nordisk is a global healthcare company with more than 90 years of innovation and leadership in diabetes care. Headquartered in Denmark, Novo Nordisk employs approximately 41,600 people in 75 countries and markets its products in more than 180 countries.
Clipping is a handy way to collect and organize the most important slides from a presentation. My sister uses this ad as a way to describe how easily distractible both she and my niece are. An outline of the primary components of Community Care’s chronic care model will be described and tools will be shared. Community resources were identified and integrated into the chronic care program and these new relationships and collaborations strengthened our chronic care model. Community Care partnered with those providers and other community professionals to improve how care is organized and delivered and to ensure accountability for managing target populations. In the chronic care initiative, the networks are expected to provide a comprehensive and integrated package of screening and assessment, care management and care coordination, in addition to the primary, preventive and medical coordination and treatment provided to all enrollees. The networks have reorganized the delivery of care to those with chronic needs in ways that enhance appropriate access, increase service delivery options, improve efficiencies in the identification, assessment and care planning processes, support transitions in care, reduce the rate of hospitalization, and reduce the unnecessary inefficiencies and expenses inherent in the current system. At that point, networks had adopted evidence-based practice guidelines for asthma, diabetes, congestive heart failure, and chronic obstructive pulmonary disease. First, Community Care developed a community-based approach to identify individuals who might benefit most from targeted care management interventions. The chronic care program has created the infrastructure for the quality demonstration project with CMS (646; see mini-module A, “Managing Other Populations,” for additional information). The average annual recipient cost for an ABD patient is more than five times the average annual recipient cost for families and children.
The networks have established local care teams led by a PCP (primary care provider) to support the management and evaluation of care plans for those chronic care patients at highest risk. The blueprint addresses network infrastructure, population stratification to target the most impactful patients, transitional support processes, clinical and care management interventions and processes, enrollment and outreach processes, and quality improvement. The networks received lists of practices that had large discrepancies between eligible and enrolled members that they could use to determine how best to increase enrollment. Division of Medical Assistance began sending “opt-out” letters to potentially eligible patients who were assigned to medical homes based on historical claims data. Within Community Care, the entire population is grouped into high-risk and high-cost categories based on Medicaid historical claims data.
Based on research and Community Care’s experience, we know that 18 percent of Medicare patients nationally are readmitted to the hospital within 30 days, and 50 percent of these patients did not see a physician before readmission. The importance of managing poly-pharmacy and poly-prescriber concerns in this population cannot be overstated.
The pharmacy home’s foundation comprises four key pharmaceutical care providers: the central office pharmacist, network pharmacist, care manager and primary care provider.
In addition to providing a portable and legible medication list, such interactions can improve medication adherence. But it is the application of the care management model that is most able to affect care pathways and patient outcomes. The care management support and coordination efforts help the PCPs care for the most complex and vulnerable patients. Additionally, mental health delivered in an integrated setting can help minimize the stigma and discrimination that often accompany such diagnoses while simultaneously increasing opportunities to improve overall health outcomes.
Further, although it takes time to develop these relationships, once they are built both communication and referrals are enhanced.
Having psychiatric telephonic consultation readily available helped increase the PCP’s knowledge and comfort.
These early pilots led to the development of another pilot effort in mental health integration: the co-location project in which a behavioral health provider worked within a PCP’s practice to provide onsite care to patients with both physical and mental health needs.
ICARE (Integrated, Collaborative, Accessible, Respectful and Evidence-based) is a project focused on statewide education about and assistance for integrated collaborative care, local model development, and process and policy change. As of third quarter 2010, the initiative is in its final phases and has demonstrated that sustainability is much easier in a pediatric rather than an adult setting. This initiative seeks to build the capacity and infrastructure needed to improve quality of care and contain the costs of that care while simultaneously increasing the ability to identify patients with behavioral and physical health care needs. A centralized Informatics Center affords the chronic care program access to meaningful information, and networks are able to set common goals, share performance data and provide comparisons to each other and to national benchmarks. Often, it is the patient’s ability to make the appropriate behavior change that determines whether they achieve optimal health outcomes. The goal of self-management support is to help patients improve their health outcomes and reduce or avoid costly crises.
Patients and healthcare professionals had greater confidence in correct and complete dose delivery with FlexTouch®.
Do not disregard your doctor's advice or delay in seeking it because of something you have read in this website. This heritage has given us experience and capabilities that also enable us to help people defeat other serious chronic conditions: haemophilia, growth disorders and obesity. This would be a useful tool for all patients, but would be especially appealing to a visual learner. It is helpful for these patients to participate in groups with conversation and idea-sharing.
Both have tactile kinesthetic learning preferences.These learners should be well-rested, and well-fed. Now we've learned that there's a new non-profit organization on the block aimed specifically at serving those diabetes educators who already have the "certified" tag behind their names.It's called the Academy of Certified Diabetes Educators (ACDE), and as the name suggests, it's all about training and connecting CDEs working "in the trenches" with PWDs. NCBDE understands the increasing need for educators to support a growing population of people with diabetes, but also feel it's important to balance access with ensuring a level of quality to that educational process.


Frankly, I think the diabetes community is looking for a certification for non-health (formally) educated experts.
All three of these professions require their members to log a certain number of continuing medical education (so-called CME) hours to maintain their licenses. Department of Health and Human Services in 2005 to “expand the scope of Community Care of North Carolina’s care management model to recipients of Medicaid and dually eligible individuals with chronic conditions and long-term care needs…” This effort began with nine networks piloting a chronic care model and creating a model for replication and adoption across the state. The Community Care Chronic Care Model aims to incorporate these system changes into the program components that will be defined in this module. For example, many of the networks developed relationships with the Aging, Disability and Resource Centers, with local organizations representing the elderly and disabled communities, and with home and community-based providers. In addition, enrollees who are dually eligible for both Medicaid and Medicare are eligible to participate on a voluntary basis. In addition, they had integrated targeted care management initiatives to help physicians manage and care for the most frail and costly patients. That approach comprised performing an assessment, identifying individual needs and developing an appropriate plan of care. Through the chronic care program, Community Care has partnered with community providers to improve how care is organized and delivered and to create local accountability for managing target populations. In addition, the care team reviews the Personal Care Services (PCS) and Home Health (HH) services ensuring that patients receive what is medically necessary. Some practices were willing and able to create educational materials encouraging their patients to choose a medical home. The Informatics Center produces quarterly Chronic Care Reports with more than 70 data elements providing information on all ABD enrollees regarding cost, utilization and diagnosis data to help define a sub-set of the population for further screening.
Up to 30 percent of readmissions occur at different hospitals, and the second hospital frequently has no useful patient data from the first hospital.
In 2007 an increase in the PMPM enabled each network to hire a pharmacist (PharmD) to support the medical homes and networks in the pharmacy management programs. The team works closely with all physician practices to coordinate each patient’s pharmaceutical care.
The PCPs know the care managers and can communicate with them one-on-one; in some instances, the care managers may be located in the medical home (especially in large volume practices).
Successful integration requires the support of a strengthened primary care delivery system as well as long-term commitments from policymakers at the federal, state, private and local levels. Some networks held “brown-bag lunch-and-learns,” or evening socials for primary and behavioral health providers to interact and share best practices. Useful information such as training opportunities, validated screenings tools, clinical algorithms, referral information, community linkages and job postings can be found on the ICARE website.
Evidence-based best practices in managing behavioral health conditions will be identified and implemented, and the program will monitor and report on identified performance metrics. Further, the Informatics Center has enabled Community Care to use and share performance data to drive improvement, identify target populations and support the providers and care managers in optimizing best practices.
For example, a patient with diabetes must adhere to an appropriate diet and take their medications to manage elevated sugar levels.
In addition, this tool allows the patient demonstrate understanding by calculating the correct dosage. Unfortunately, I do not have a nursing degree, nor an MSW, nor am I a registered dietician. The organization has made a number of changes over the past few years regarding eligibility that people might not be aware of and we hope people will visit our web site (ncbde.org) for the most current information.
I know there are constraints about offering that type of certification, but it can be done. Physicians and practices received regular feedback on their ability to improve both the processes and outcomes of care.
Through their partnerships with community hospitals, network staff members get real-time information that identifies patients who are admitted to the hospital or emergency room; these relationships also allow the networks to participate in discharge planning and help ensure a safe transition back into the community. The patients signed enrollment forms that then were faxed to DSS for entry into the Medicaid enrollment system. The screening tool helps the care managers prioritize outreach and interventions for individuals at the highest risk and with the greatest potential to benefit. The report identifies approximately 17 percent of the population for screening and designates the top five percent as the highest priority. Further, nearly 40 percent of patients are discharged with one or more test result(s) pending, and more than one-third of prescriptions provided at discharge are never filled. In addition, the central program office has a PharmD who leads this effort and works with all network pharmacists to create standardized expectations and processes. The Community Care program emphasizes the importance and flexibility of face-to-face interactions between patients and their care managers that also include home visits to perform environmental assessments, fall prevention screenings and medication reconciliation. We expect more information on this effort to be available on Community Care’s website in 2011. In addition, the Informatics Center allows providers to share patient-specific data across the health care team and help coordinate care for patients for whom they share responsibility.
This tailored platform has evolved into a Web-based portal accessible to all networks that allows care managers to maintain health records and single care plans that stays with patients as they move from one area of the state to another. The networks and care managers have integrated patient-centered education and coaching interventions into their population-management activities with favorable results.
We don't want to reinvent the wheel, but we have to bring all of these resources together so they're more well-publicized, affordable and accessible," Day says.AADE itself appears to be blindsided and somewhat disgruntled about this.
Here are some important facts: 1) the professional practice aspect of the eligibility requirements for the CDE credential is not 2000 hours of diabetes education within 2 years. The first person perspective is so valuable to us PWDs, NCBDE would be re-miss and is certainly missing an opportunity to meet this need. Each network then established a local inter-disciplinary team to help evaluate and manage the needs of individuals with chronic conditions.
Another strategy included individual outreach by care managers to educate patients about the importance of the medical home.
This standardized approach helps determine acuity level and the best plan of care for each patient.
In addition, a large proportion of patients with chronic diseases have significant overlap between physical health and behavioral health issues. Because of the challenge of managing behavioral health medications, the program office has added a PharmD with this expertise to support the networks. Have patient “teach back” the information to you.As Dawn said in lecture, it doesn’t always make sense to teach in a logical sequence. I am hoping I can become a dietician, but wonder if I will ever be able to accrue the necessary 2,000 hours. It's 2 years of general experience (not necessarily diabetes) and a minimum of 1000 hours doing diabetes education over a maximum window of 4 years. Community Care’s existing infrastructure of provider networks, case management services, Web-based case management information systems, and capacity for claims-based quality and cost data feedback provided valuable support to the networks as they launched their programs.
In any case, a point I would like to make here is that while I have met a handful of CDE's who really seem to understand what it is like to really live with this disease, I have met many who do not.
Nelson, at first glance, seems an odd choice to teach diabetes educators about PWDs and depression. The only true way to recognize those in diabetes education is through certification," says Dr. I am not saying that just living with Type I diabetes successfully should be enough to make a person a CDE, but this disease is so very complex that only those truly qualified to advise patients (and their caregivers, if they are children, or their spouses, if they are married) should ever endeavor to enter the field of diabetes education. But Nelson spent 19 years in our trenches working at the International Diabetes Center in Minneapolis, from 1984 until 2003, when he went into private practice. Since that time he has worked with PWDs on both sex issues and garden variety depression, been a speaker at many TCOYD events, and has written for the Diabetes Self-Management blog .
The ACDE operates as a "virtual" organization but has a mailing address in the Chicago area, where the group can meet in a geographically-central spot.Status QuarrelThe NCBDE certification process has long been criticized as a barrier to bringing new blood into this profession. Rather, the current model that is being used when promoting licensure includes a pathway where a health professional can become licensed without passing a psychometrically valid examination verifying their diabetes knowledge.
To become certified, one must be a licensed healthcare professional and then rack up 2,000 hours of experience over two years working directly with diabetes patients (without yet having certification to do so) to be eligible to sit for an extensive exam. However, people with diabetes need to be assured that an individual who is licensed by their state as a diabetes educator has proven that they have a certain level of diabetes knowledge. Without the hours of work experience, hopefuls are not eligible for the exam, which is clearly a hurdle to many.
With a pathway that allows licensure without an examination, the current model does not address this need. Also, as Pihos notes, some educators may work in facilities where research is the priority, rather than hands-on patient care, and some folks in rural areas may not have access to a center where the NCBDE exam is given.So AADE has been working in recent years to be more inclusive of educators who do not have certification, and to afford them a tiered-level status of state licensed educator (FAQ here).
Note that a little over 60% of AADE members are CDEs, but you don't have to be a CDE to be a member.The new ACDE rejects this approach. Limited access to these programs is the other beef that ACDE aims to address.During her time as an auditor for ADA programs in the past, Day says she'd noticed that many small D-education programs have been cutting back on their continuing education.
There's likely going to be an increasingly steep decline in CDEs over the coming decade, especially as more and more of those professionals opt for higher-paying corporate jobs over clinical practice.One way to counteract that CDE drain is to focus more on the aspiring educators and students, Day says.
That's something the existing organizations haven't been doing effectively, and the shortage of CDEs will become critical if more work isn't done to usher a new generation into the profession. And the academy plans to make its website a "one-stop shop" for CDEs to get low-cost (or even free) access to webinars and resources to help them in their jobs.Already, the academy has a career center on its site where CDEs or those entering the field can post a resume and look for job opportunities. And to help recruit new members, the ACDE is offering free membership for the first two years.Patient VoicesWith six initial board members, Day says they're planning to recruit more later this year and they'd like to include student and patient voices in that group (which we applaud).



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