Home Health & Hospice Articles by Topic: Quality care

Wound care process will be more important in PDGM, improve now

• Homecare Direction, Issue 12, December 6, 2019

  Agencies should consider implementing a solid wound care program or improving upon any existing...

Don't let OASIS-D1 changes reduce the quality of your comprehensive assessments

• Homecare Direction, Issue 7, July 8, 2019

  While OASIS-D1 will make responses to 23 existing items optional, agencies must keep in mind that...

Create a clinical documentation improvement program to achieve PDGM success

• Homecare Direction, Issue 6, June 6, 2019

  Strong documentation is key in home health, and implementation of the Patient-Driven Groupings...

Improve your score on new drug regimen review measure

• Homecare Direction, Issue 6, June 6, 2019

  Ensure clinicians fully understand how to respond to M2003 (Medication follow-up) when filling out...

Home Health Compare update released after weeks-long delay

• Homecare Direction, Issue 6, June 6, 2019

  The number of agencies earning five stars in the quality of care star ratings ticked upward in the...

Home Health Compare scores involving value-based purchasing data elements

• Homecare Direction, Issue 6, June 6, 2019

  Agencies continued to improve in several Home Health Compare measures included within value-based...

In your mind, should my agency's long-term PIP goal be to reduce hospitalizations to the national average?

• Homecare Q&A, Issue 5, May 31, 2019

  I personally don’t like national averages.

Can you provide me info on ACH measure on CASPER?

• Homecare Q&A, Issue 5, May 31, 2019

  You note that when looking at the AHC measure on CASPER, you have data that is risk-adjusted and...

Why do agencies struggle on Home Health Compare with hospitalizations?

• Homecare Q&A, Issue 4, April 18, 2019

  You note agencies' struggles with hospitalizations.

Why is M1033 (Risk for hospitalization) going to be part of functional case-mix adjustments?

• Homecare Q&A, Issue 4, April 18, 2019

  You note that the importance of OASIS-D item M1033 (Risk for hospitalization) increases even more...

Thoughts on CMS' proposed rule to alleviate burden and when it will be finalized?

• Homecare Q&A, Issue 4, April 18, 2019

  A couple years ago, the new administration came in with a desire to simplify life for providers.

In the coming year, how do you think survey targets will change?

• Homecare Q&A, Issue 4, April 18, 2019

  We’re going to keep seeing agencies cited for issues involving organization and...

How can we keep our eyes on the ball on hospitalizations as we move to the next PIP?

• Homecare Q&A, Issue 3, March 22, 2019

  Root cause analysis still needs to be done at every hospital transfer because agencies will be able...

What are the most common, easily fixable issues you see when it comes to agencies with high hospitalization rates in home health?

• Homecare Q&A, Issue 3, March 22, 2019

  One is going to be the scheduling aspect. Getting out to the home within 24 to 48 hours is vital.

Why is Acute Care Hospitalization noteworthy for agencies outside VBP states?

• Homecare Q&A, Issue 3, March 22, 2019

  Those that are not in the value-based purchasing states really should pay attention to what...

Staff trainer quiz on malnutrition

• Homecare Direction, Issue 3, March 6, 2019

  Test staff knowledge on malnutrition.

Any advice for best practices to add emerging infectious diseases into emergency prep?

• Homecare Q&A, Issue 2, February 25, 2019

  You note that CMS is adding “emerging infectious diseases” to the current definition of...

I have a question about therapists submitting a list of patient medications for the nurse to review.

• Homecare Q&A, Issue 2, February 25, 2019

  You say that your agency just learned that according to the revised CoPs, in rehabilitation...

Reducing hospitalization rates will be a key goal for many agencies in 2019

• Homecare Direction, Issue 2, February 5, 2019

  More agencies plan to focus on improving the rate of acute care hospitalizations than any other...

Quality of care star rating measure(s) agencies will work to improve in 2019

• Homecare Direction, Issue 2, February 5, 2019

  About 70% of agencies will work to improve performance on acute care hospitalization in 2019.

For PDGM, agencies will need to change how they handle case conferencing

• Homecare Direction, Issue 2, February 5, 2019

  Case conferences will take on increased importance when the Patient-Driven Groupings Model (PDGM...

What strategies would you advise rural agencies use in 2019 to help withstand the phase-out?

• Homecare Q&A, Issue 1, January 16, 2019

  You explain that your  agency is based in a rural area, and beginning this year the rural...

Do agencies have a responsibility to train staff to identify whether patients are addicted to opioids?

• Homecare Q&A, Issue 1, January 16, 2019

  You asked whether agencies have a responsibility to train staff to identify whether patients are...

Faster documentation will be crucial to success under PDGM: Take time to prepare now

• Homecare Direction, Issue 1, January 4, 2019

  Make completing documentation in the home a requirement for all clinicians. Doing so will improve...

Understand, combat common reasons patients refuse to get a flu shot

• Homecare Direction, Issue 12, December 5, 2018

  As flu season ramps up, it’s vital to ensure patients get vaccinated. Agencies should work to...

Changes in final rule could indicate another version of OASIS is on the way

• Homecare Direction, Issue 12, December 5, 2018

  While agencies hustle to prepare for the Jan. 1, 2019, implementation of OASIS-D, changes to the...

Our agency is considering investing in telehealth solutions. Do you have any recommendations for important questions to ask of potential vendors?

• Homecare Q&A, Issue 16, November 20, 2018

  Here are some of the questions to ask.  

Improve your agency's efficiency by implementing quality cycle management

• Homecare Direction, Issue 11, November 5, 2018

  Establish procedures, set benchmarks and hold staff accountable to increase efficiencies as part...

What recommendations would you have when it comes to caring for patients who have lice or scabies?

• Homecare Q&A, Issue 15, October 19, 2018

  Staff should use contact precautions with a contact precaution kit. In general, wear protective...

In the following scenario, should my agency write an order stating the patient is in compliance of taking medications as ordered?

• Homecare Q&A, Issue 14, September 21, 2018

  In the scenario you describe, your agency admitted a patient when she was discharged home from the...

Educate aides about steps they can take to keep patients out of the hospital

• Homecare Direction, Issue 9, September 1, 2018

  Aides can be an integral part of preventing hospitalizations, but they are often left out of an...

Removing measures among proposed quality reporting changes

• Homecare Direction, Issue 8, August 1, 2018

  Changes to the Home Health Quality Reporting Program outlined in the 2019 proposed PPS rule would...

How should I act in the following scenario involving power of attorney (POA)?

• Homecare Q&A, Issue 12, July 25, 2018

  First determine if the POA is medical and if the patient is incapacitated.

New MedPAC report warns that most patients don't pick the best agency in their area

• Homecare Direction, Issue 7, July 2, 2018

  In its latest report to Congress, the Medicare Payment Advisory Commission (MedPAC) points out...

CMS seeks to modify star ratings, adding a drug measure and removing another

• Homecare Direction, Issue 7, June 29, 2018

  Step up efforts to educate clinicians about M2020 (Management of oral medications). The measure is...

When is it necessary to conduct an oxygen safety assessment for home health patients?

• Homecare Q&A, Issue 10, June 11, 2018

  All O2 patients need to at least be assessed on a comprehensive assessment for safety.

Early survey results show individualized plans of care are a major target

• Homecare Direction, Issue 5, May 2, 2018

  Break your agency’s clinicians of their mentality to rely solely on generic language or...

Home Health Compare update shows jump in transferring, total 5 star agencies

• Homecare Direction, Issue 5, May 2, 2018

  More agencies have achieved 5-star status than ever before, and scores for transferring saw the...

Review, correct quality measure data to ensure accuracy on Home Health Compare

• Homecare Direction, Issue 5, May 2, 2018

  Incorporating a review of this assessment-based outcome measure data into the quality review...

Train intake to gather more detail, ensure patient rights process is efficient

• Homecare Direction, Issue 4, April 12, 2018

  To help comply with the new patient rights requirements in the revised Home Health Conditions of...

How can we best determine areas for a program ac-tivity for a QAPI project?

• Homecare Q&A, Issue 7, April 3, 2018

  The data an agency’s QAPI program collects will be de-termined by the program activities...

New online training for surveyors highlights the importance of a detailed plan of care

• Homecare Direction, Issue 3, March 29, 2018

  CMS’ newly posted surveyor training reiterates the need for home health agencies to ensure...

Reminder for hospices: Submit timely HIS and CAHPS data

• Homecare E-News, Issue 13, March 26, 2018

  To comply with the Hospice QRP (HQRP) requirements, hospices must successfully submit timely...

MedPAC encourages Medicare beneficiaries to use higher-quality PAC providers

• Homecare E-News, Issue 12, March 19, 2018

  During the Medicare Payment Advisory Commission’s (MedPAC) public meeting on Thursday, March...

IMPACT Act, improving care coordination special open door forum planned March 28

• Homecare E-News, Issue 12, March 19, 2018

  Learn about the development and testing of standardized patient assessment data elements mandated...

How can we better collaborate on OASIS?

• Homecare Q&A, Issue 6, March 17, 2018

  Agencies must abide by certain regulations in order to participate in the Medicare program, as...

Improve on medication management in your performance improvement project

• Homecare Direction, Issue 3, March 12, 2018

  Agencies gearing up for the performance improvement project (PIP) requirement under the revised...

How should we interpret the information regarding measurable outcomes and goals? Are agencies to use timeframes for their goals and outcomes or are we just doing improvement in symptoms/function etc.?

• Homecare Q&A, Issue 5, March 3, 2018

  In the current draft of the CoP interpretive guidelines it says: “A goal is defined as a...

What should we be looking for when assessing a nurse's critical thinking during care for a patient?

• Homecare Q&A, Issue 4, February 19, 2018

  Strategies and attributes of critical thinking during the treatment process include the following...

How can we achieve better medication management?

• Homecare Q&A, Issue 3, February 2, 2018

  Agencies that select medication management as their Performance Improvement Project, or PIP, should...

VA, HHS announce partnership to strengthen prevention of fraud, waste and abuse efforts

• Homecare E-News, Issue 5, January 29, 2018

  On January 23, the U.S. Department of Veterans Affairs (VA) and HHS announced a partnership to...

Attending doctors' visits can be key to value-based improvement and Five-Star success

• Homecare Direction, Issue 1, January 22, 2018

  The amount of money at stake in CMS’ value-based purchasing demonstration for home health...

What data do we need to collect for QAPI?

• Homecare Q&A, Issue 2, January 17, 2018

  After defining the scope of an agency’s QAPI program, the CoPs outline how the quality...

Our agency looks at the PEPPER reports, but what pieces of information are most important?

• Homecare Q&A, Issue 2, January 17, 2018

  Note PEPPER’s six target areas: Average case mix. This target area calculates average case...

What documentation should we have for QAPI?

• Homecare Q&A, Issue 24, December 17, 2017

  The documentation surrounding your QAPI program should include:

CMS plan to drop flu measure would add weight to other star ratings measures

• Homecare Direction, Issue 11, November 20, 2017

  CMS’ plan to eliminate “Influenza im-munization received for current flu...

Update coordination of care, plan of care practices to comply with new CoPs

• Homecare Direction, Issue 11, November 2, 2017

  Restructure clinical managers’ positions so they function more like case managers. Doing so...

How can we prevent readmissions related to pain?

• Homecare Q&A, Issue 20, October 17, 2017

  Have clinicians follow up the next day when patients have a change in pain medications or...

How can we use electronic clinical pathways to improve outcomes?

• Homecare Q&A, Issue 20, October 17, 2017

  Consider adopting clinical pathways to increase nursing visit efficiency, decrease...

CMS forum will discuss algorithm changes to star ratings

• Homecare E-News, Issue 38, October 9, 2017

  CMS is hosting an open door forum 2 p.m. to 3 p.m. EST Oct. 10 to discuss modifications and...

Protect patients during hurricanes by identifying their need for immediate care

• Homecare Direction, Issue 10, October 2, 2017

  The way Texas and Florida agencies reacted to the recent catastrophic hurricanes should serve as a...

Focus on starting care timely to impact star ratings, meet QAPI requirement

• Homecare Direction, Issue 9, September 29, 2017

  Updating the referral date for all patients who experi-ence a delay in discharge from inpatient...

Educate patients and staff on CABG care to improve rehospitalization rates, get referrals

• Homecare Direction, Issue 9, September 25, 2017

  The rehospitalization rate for coronary artery bypass graft (CABG) surgery patients receiving...

Home health agency helps elderly displaced by Harvey find homes

• Homecare E-News, Issue 35, September 18, 2017

  A Texas-based home health agency is teaming up with the Red Cross to help senior citizens forced...

DACA will affect older Americans, reports New York Times

• Homecare E-News, Issue 34, September 11, 2017

  Last week, the Trump administration announced a move to end the Deferred Action for Childhood...

Hospice Provider Preview Reports Available

• Homecare E-News, Issue 34, September 11, 2017

  Hospice providers are encouraged to preview their quality measure results based on Quarter 1- 2016...

How do you overcome barriers of health literacy?

• Homecare Q&A, Issue 17, August 31, 2017

  Health literacy is a set of skills needed to read, understand, and act on basic health...

Hospice Compare released; hospices must step up efforts on pain assessments

• Homecare E-News, Issue 32, August 21, 2017

  Hospice Compare’s launch Aug. 16 confirms that, for the most part, hospices already perform...

How can our agency get started on implementinga clinical documentation improvement (CDI) program? We already have a CDI specialist/committee to lead the effort. How can we rally in external sources of better documentation?

• Homecare Q&A, Issue 15, August 3, 2017

  The first decision for the CDI committee is to establish which CDI program model to adopt. The...

Agencies' payments will drop in 2018

• Homecare E-News, Issue 29, July 31, 2017

  While the HHGM is the most significant long-term change for agencies’ payments, in the short...

New PEPPER available for home health agencies, CMS updates to Home Health Compare

• Homecare E-News, Issue 28, July 21, 2017

  New Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) through CY 2016 are...

Very few 5-star agencies in quality of care have been on top since the beginning

• Homecare E-News, Issue 28, July 21, 2017

  Only a select group of 43 agencies that earned 5 stars in quality of care July 12 have remained on...

We are looking to decrease our rehospitalization rate but we do have a decent number of patients with multiple chronic conditions. What can we do? Can telehealth help? Some of our patients are so frail.

• Homecare Q&A, Issue 14, July 17, 2017

  It’s true that you will struggle. A study of hospitalizations using a national all-payer...

What does a psychosocial assessment need to include?

• Homecare Q&A, Issue 14, July 17, 2017

   The CoPs make clear that the plan of care will continue to be based on the comprehensive...

How can we improve on timely initiation of care?

• Homecare Q&A, Issue 14, July 17, 2017

  As part of a monthly or quarterly quality assurance review, agencies should closely monitor...

Implement a strong performance improvement project as part of QAPI

• Homecare Direction, Issue 7, July 10, 2017

  Your agency has gone through the quality assessment piece of QAPI and identified areas that need...

Turn the Trump transition into success for your agency

• Beacon Institute On-Demand Webcast Library, Issue 2, February 28, 2017

  Turn the Trump transition into success for your agency

Approximately one million fewer Americans suffering from dementia

• Homecare E-News, Issue 45, November 28, 2016

  Between 2000 and 2012, dementia rates among U.S. seniors show a significant decline, dropping from...

Physical activity for patients with chronic illnesses

• Homecare E-News, Issue 44, November 21, 2016

  Physical activity is a cornerstone of health, even for people with multiple chronic conditions...

IMPACT Act comments due on new measure for home health

• Homecare E-News, Issue 44, November 21, 2016

  The call for public comment on the IMPACT Act of 2014’s cross-setting quality measure on...

In Focus: Authors of study suggest framework for optimizing home health value

• Homecare E-News, Issue 40, October 24, 2016

  The final report from the Alliance for Home Health Quality and Innovation (AHHQI)’s Future...

Is skilled nursing administering allergy injections sub-q twice a week or weekly to a patient (due to no willing or available caregiver) a covered skill under CMS guidelines?

• Homecare Q&A, Issue 18, September 17, 2016

  Medicare will pay for administration of these injections with the proper circumstances and with...

Question on physician interactions and medication reconciliation...

• Homecare Q&A, Issue 17, September 3, 2016

  Remember, as an agency, you must follow the strictest of the guidelines, including your agency...

Do only CWCN credentials give you necessary authority/scope to answer OASIS questions differently than the scope of a registered nurse with no wound training?

• Homecare Q&A, Issue 16, August 22, 2016

  Our agency is in the process of evaluating wound certification courses for our nursing staff. We...

We just want to confirm that a patient coming to us from a SNF who then goes back to the SNF does not count in hospital readmission data.

• Homecare Q&A, Issue 16, August 22, 2016

  All acute care hospitalizations are “counted;” however, a SNF admission would not be...

How can I teach my staff to avoid unprofessional behavior?

• Homecare Q&A, Issue 15, August 3, 2016

   To start, define unprofessional behavior for them. Most employers consider some behaviors...

Inside story | Star ratings

• Homecare E-News, Issue 29, August 1, 2016

  CMS created the five-star rating systems to assist patients, families, and caregivers in...

Weekly Roundup

• Homecare E-News, Issue 28, July 25, 2016

  In this week's roundup: New HHA PEPPER is now available. A new release of the Program...

We've begun a new robust reporting system, including incident reporting, and would like to take advantage and share our process and outcomes data with our staff. How do you suggest going about this, and what do we need to keep in mind?

• Homecare Q&A, Issue 12, June 17, 2016

  Now that leadership has the data, what to do with it? First and foremost, give the data to the...

In Focus: Senators introduce Compassionate Care Act

• Homecare E-News, Issue 21, May 23, 2016

  United States Senators Richard Blumenthal (D-CT) and Shelley Moore Capito (R-WV) recently...

Weekly Roundup

• Homecare E-News, Issue 21, May 23, 2016

  In this week's roundup: Overtime laws could change the game for home health: The Department...

Inside story | Define quality

• Homecare E-News, Issue 20, May 16, 2016

  Editor’s note: This week’s Inside story is from Quality Care in Home Health: Improving...

In Focus: Strategies for fighting "quality fatigue"?

• Homecare E-News, Issue 19, May 9, 2016

  Is the constant haranguing about “quality” getting to you? You’re not alone...

Weekly roundup

• Homecare E-News, Issue 19, May 9, 2016

    DoJ: Thousands deprived of home care options: South Dakotans with disabilities do not...

Inside story | Ensure compliance with IC regulations

• Homecare E-News, Issue 15, April 11, 2016

  The home health Conditions of Participation outline CMS’s expectation that the agency will...

What are some standardized approaches to care planning?

• Homecare Q&A, Issue 7, April 4, 2016

  Although it plays an important role in care planning, delivery, and coordination, the care plan...

Weekly Roundup

• Homecare E-News, Issue 13, March 28, 2016

  The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has launched...

Weekly Roundup

• Homecare E-News, Issue 12, March 21, 2016

  The CMS Office of Minority Health last week unveiled a snapshot of chronic disease-related service...

I just learned I'm in one of the nine states required to abide by value-based purchasing (VBP)! What do I need to know?

• Homecare Q&A, Issue 6, March 18, 2016

  I just learned I'm in one of the nine states required to abide by value-based purchasing (VBP...

What are some plan of care pitfalls to avoid?

• Homecare Q&A, Issue 4, February 18, 2016

  What are some plan of care pitfalls to avoid?

Weekly roundup

• Homecare E-News, Issue 7, February 15, 2016

  CMS intends to start a Medicare Probable Fraud Measurement Pilot for home healthcare services...

What are the key aspects of medication reconciliation, and how can we improve?

• Homecare Q&A, Issue 2, January 18, 2016

  Although there are many ways to develop a medication reconciliation program at a particular...

Inside Story | Cerebrovascular disease (stroke) care

• Homecare E-News, Issue 2, January 11, 2016

  When working with stroke patients, you are responsible for several types of observations. First...

What are the legal risks with telehealth?

• Homecare Q&A, Issue 1, January 3, 2016

  Telehealth devices are becoming more common in the area of home healthcare. It is important for...

Patients who experience a decline in their condition upon their discharge from home health are impacting our outcome scores.

• Homecare Q&A, Issue 1, January 3, 2016

  You are correct, M1034 is risk adjusted. Please be sure clinicians are answering response “3...

Inside Story | Pain management for cancer patients

• Homecare E-News, Issue 50, December 21, 2015

  Chemotherapy drugs can damage nerves, which causes burning, numbness, tingling, or shooting pain...

Where do we begin with implanting best practices? What benefits come with doing so?

• Homecare Q&A, Issue 24, December 17, 2015

  In simplest terms, a best practice is a process or procedure that consistently produces superior...

In Focus | Understanding value-based purchasing in the final rule

• Homecare E-News, Issue 49, December 14, 2015

  Although the final rule contained several notable changes to the proposed VBP pilot set to launch...

Weekly Roundup

• Homecare E-News, Issue 49, December 14, 2015

  The Centers for Medicare & Medicaid Services (CMS) will host an open door forum on Thursday...

Weekly Roundup

• Homecare E-News, Issue 46, November 23, 2015

  Vets waiting, even dying, for home health care; telemedicine gains momentum After the Inspector...

In Focus | 2016 Home Health Final Rule Released

• Homecare E-News, Issue 43, November 2, 2015

  After receiving 118 comments from the public during the official comment period, the Centers for...

The Weekly Roundup

• Homecare E-News, Issue 43, November 2, 2015

  Final Rule Released After receiving 118 comments from the public, the Centers for Medicare &...

The Inside Story | Staff education on infection control

• Homecare E-News, Issue 40, October 19, 2015

  Care delivered according to infection control guidelines is the most effective tool available for...

What are some approaches patients may try to implement themselves to overcome swallowing difficulties, and what are more effective alternatives?

• Homecare Q&A, Issue 20, October 16, 2015

  What are some approaches patients may try to implement themselves to overcome swallowing...

What kind of events count as "potentially avoidable"? What will and should be in the CASPER Outcome-Based Quality Improvement Report?

• Homecare Q&A, Issue 20, October 16, 2015

  What kind of events count as "potentially avoidable"? What will and should be in the...

Can we provide two home health aides to provide care for a quadriplegic patient?

• Homecare Q&A, Issue 19, October 2, 2015

  Can we provide two home health aides to provide care for a quadriplegic patient?

Can you please explain what specifically needs to be under the supervisions of licensed professionals?

• Homecare Q&A, Issue 19, October 2, 2015

  Can you please explain what specifically needs to be under the supervisions of licensed...

What should be our frequency of visits?

• Homecare Q&A, Issue 18, September 17, 2015

   We have an 87-year-old woman who was referred by the wound care center for care of a wound...

We discharged a patient who then resumed services. Are we going to have troubles receiving reimbursement?

• Homecare Q&A, Issue 17, September 8, 2015

  If an agency discharges a patient and that patient resumes services, there may be questions about...

We are looking for a checklist for our case conferences within our agency. Any tips?

• Homecare Q&A, Issue 14, July 16, 2015

  Because there is no requirement to conduct case conferences, agency policy should...

What content would be in a best practice statement for homecare providers?

• Homecare Q&A, Issue 13, July 2, 2015

  AA best practice should identify clinical actions—assessment, teaching, procedures...

Homecare Q&A

• Homecare Q&A, Issue 13, July 2, 2015

  July 3, 2015

How will OASIS-C1/ICD-10 differ from the data set iteration currently in use?

• Homecare Q&A, Issue 0, June 9, 2015

   To accommodate the extended effectiveness of ICD-9 after the Protecting Access to Medicare...

Can a single physical therapy visit determine a need for occupational therapy that is covered under Medicare?

• Homecare Q&A, Issue 10, May 17, 2015

  Can a single physical therapy visit determine a need for occupational therapy that is covered under...

What does the proposed standard Patient Care 485.65: Quality Assessment & Performance Improvement mean for my agency?

• Homecare Q&A, Issue 9, May 3, 2015

  My agency has been reviewing the proposed Conditions of Participation (CoP). We are looking at the...

Is it an appropriate use of Medicare to do three weeks of assessment and venipuncture for a patient hospitalized with deep vein thrombosis (DVT)?

• Homecare Q&A, Issue 9, May 3, 2015

  Is it an appropriate use of Medicare to do three weeks of assessment and venipuncture for a patient...

Does the start of the VFOs for the HCA need to begin on the day of the new cert period, or can it begin the following week?

• Homecare Q&A, Issue 7, April 3, 2015

  You can write orders for when the services begin.

Any tips for preventing future legal fallout in such cases?

• Homecare Q&A, Issue 7, April 3, 2015

  Unfortunately, when a fall occurs in the presence of agency staff, people assume that it...

Will home health remain exempt from overtime compensation in most circumstances like it has for 40 years?

• Homecare Insider, Issue 1, January 5, 2015

  Will home health remain exempt from overtime compensation in most circumstances like it has for 40...