Thursday, November 7, 2019

Fall (Sept/Oct) 2019 Research Roundup for the HH Project

keywords:  research literacy

  • Community survey on integrative oncology
  • Community discussion articles: oncology acupuncture, general acupuncture scientific evidence, ED acupuncture, the "whole system paradigm"
  • Metrics: Interested in measuring your work?
  • Reviewing some research basics
  • Research conference notes and recording availability
  • funding announcements
  • NAM new book, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being
  • The Gold Foundation's Research Roundup--highlights from

The Fall (Sept/Oct) 2019 Research Roundup

Review of the "Research and Metrics Thursdays" theme from the public Facebook Page and newsletter

At the Hospital Practice Handbook Project, we encourage practitioners to cultivate mentor-relationships and practice research literacy.

Community Survey: What Does Success Look Like in an Integrative Oncology Program?
The survey is now closed for processing.

Community Discussion Articles, Research this Autumn
2.      This original research article recommended by colleague Bobbee Vang, is out of Memorial Sloan Kettering Cancer Institute and about Hematopoietic Stem Cell Transplantation. Why this research and published work is important, “As you know, oral mucositis from high-dose chemotherapy causes severe acute pain with folks doing stem cell transplant. They burn from the inside out. Opioids help but they are also drying which sometimes makes the healing time worse. Acupuncture appears to significantly reduce the need for pain medications during transplant.” -Bobbee Vang, LAc.
a.      Citation: Gary Deng, Sergio Giralt, David Chung, Heather Landau, Jonathan Siman, Qing S, Li MS, Kaitlyn Lapen, Jun Mao. “Reduction of Opioid Use by Acupuncture in Patients Undergoing Hematopoietic Stem Cell Transplantation: Secondary Analysis of a Randomized, Sham-Controlled Trial”. Pain Medicine, 0(0), 2019, 1–7 doi: 10.1093/pm/pnz190
b.     I (Megan) watched Dr. Deng present this work at the SAR conference in June 2019. For my related notes on the talk, including some photos, please go to this lecture in the SAR conference notes. You have access to this entire Notes course by belonging to the membership site.  Here’s the link to the specific lecture.
Acupuncture, general
3.      “Overview of Treatment Guidelines and Clinical Practice Guidelines that Recommend the Use of Acupuncture: A Bibliometric Analysis”. The Journal of Alternative and Complementary Medicine. Vol.24(8). 6.18.2018. published online ahead of print.
a.      This article is behind a paywall. For how to access peer-reviewed journal articles through your workplace, see our recent blog post on this process and resource:  Your Medical Library and Professional Journal Access: An Employee Benefit *
                                                    i.     This blog post is also available as a pdf with a separate document example of “how to request a new journal/article from your medical reference library” in the New Employee Resource
c.      “Acupuncture: An Overview of the Scientific Evidence” from Evidence-based Acupuncture is available at their website
d.     “Acupuncture Evidence-based Summary: Pain” by Evidence-Based Acupuncture
e.      The Acupuncture Evidence Project – A Comparative Literature Review 2017 with pdf download is available at the link noted
Acupuncture in the Emergency Department
4. Interview with Dr. John Burns about his program and his ED acupuncture feasibility research project.
Burns JR, Kram JJ, Xiong V, Stark Casadont JM, Mullen TA, Conway N, Baumgardner DJ. Utilization of acupuncture services in the emergency department setting: a quality improvement study. J Patient Cent Res Rev. 2019; 6:172-8. 10.17294/2330-0698.1688

Adam S. Reinstein, Lauren O. Erickson, Kristen H. Griffin, Rachael L. Rivard, Christopher E. Kapsner, Michael D. Finch, Jeffery A. Dusek; Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot StudyPain Medicine, Volume 18, Issue 1, 1 January 2017, Pages 169–178, 
The following are new citations, recommended by Sandro Graca.
East Asian Medicine/Acupuncture as a “whole system paradigm”
5.      East Asian Medicine as a “whole system” paradigm for wellness and improving the social determinants of health. I started a new thread on this in the discussion groups. Please feel free to add citations related to the subject. 
Why this subject is important to hospital-based practice: it is useful when talking about healthcare culture change and when discussing the issues related to decreasing the overall cost of healthcare by addressing chronic health conditions and social determinants of health (SDOH).
a.      Related subjects include social determinants of health (SDOH), acupuncture changes in patient perception (aka improves self-awareness) which thereby increases patient involvement in their own behavior change (lifestyle modifications, patient therapy compliance, increase in practicing self-care activities), which improves SDOH of patients and their communities. (culture change, chronic health conditions)
b.     This is an important subject/discussion topic for federal qualifying health centers (FQHC) and VHA work (directly related to their Whole Health Program).
c.      Recommended article on the subject:
                                                    i.     McPherson, F et al (2016) Health Perception and Wellness Behavior Survey among Military Beneficiaries. Ann Psychiatry Ment Health 4(2): 1060.
d.     If you have similar articles on the subject of acupuncture/East Asian Medicine and patient perception of health, please add the link or citation in the comments section. Thank you.

Interested in Measuring Your Work?
  • Are you tracking your patient outcomes? If you want to learn or review how to use a validated pain scale, check out our short course with pdfs and videos, How to Use a Validated Pain Scale in Your Chart Note 
  • Learn more about the importance of metrics in your work by following the Hospital Handbook Project. We are currently tagging blog posts related to metrics with "metrics". You can use the search feature in the blog and type in "metrics" to find related posts.
  • If the term "metrics" and/or "performance management metrics" are new to you, sign up for our new series, Basics of Being an Employee in a Healthcare System: Performance Metrics. We have finished recording the series. Just doing the slow work of video editing and note-taking. If you sign up, you will be notified when any of it is next published. More information about that here.

Reviewing Some Research Basics
Research Conferences

SAR Conference Notes
My notes from attending The Society of Acupuncture Research Conference and links to related articles and blog posts are available for about the cost of taking me for coffee at this link. If you are already enrolled in the membership site, you already have access.

NCCIH at 20: A Catalyst for Integrative Health Research, a One Day Conference with the NCCIH Stephen E. Straus lecture

Research Funding Announcements from NCCIH
Source: An October 2019 NCCIH electronic newsletter edition, NCCIH Update: new tools for clinical researchers...
For those of you working with your research team or are program leads and program managers, here's the list of new funding announcements from NCCIH. All seem to be related to the HEAL initiative:

More about these funding HEAL initiatives that are related to work with chronic pain and the opioid crisis: 
NIH Rolls Out Large Wave of NIH HEAL Initiative Funding -NCCIH’s Ongoing Role” from the Director’s Page of Dr. Helene Langevin, published 9.26.2019.
"Among the NIH HEAL initiative awards announced today are a combined $86.9 million over 6 years, pending the availability of funds, for initatives that NCCIH is leading or coleading. This includes, Pragmatic and Implementation Studies for the Management of Pain to Reduce Opioid Prescribing (PRISM), Behavioral Research to Improve Medication Assisted Treatment (BRIM), and the NIH Back Pain Consortium (BACPAC) Research Program."
"NIH HEAL Initiative research will develop non-addictive medications and nondrug treatments for pain and test new models of care in real-world settings. This includes a controlled trial of acupuncture under PRISM for chronic low-back pain in adults 65 years and older, and NIH is working with the Centers for Medicare & Medicaid Services (CMS). The results of this study will inform CMS coverage decisions. While some nondrug treatments of pain have been found to be effective, patients often do not have access to these treatments in their health care systems. The trials supported by the PRISM program will assess whether making these treatments directly available to patients with pain conditions improves their symptoms and ability to function." [highlight added for emphasis]
"Working together, I am confident that we can address the national opioid and pain crises and save lives." --Dr. Helene Langevin, NCCIH director

Metrics: Clinician Employee Burnout & Employee Well-Being
Are you interested in measuring burnout or well-being?
Learn more about the NAM Clinician Well-Being Series at our concise blog post here

New publication from NAM on Clinician Burnout
The National Academy of Medicine has a new publication on clinician burnout, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. **This is a consensus study report. The pdf download is free and available as of late October 2019. It will be available in paperback December 1st.
For more information and the pdf download, go to this NAM webpage.

Quotes from the NAM webpage:
"Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care." 
"Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being and recommendations for the field."  -NAM webpage
National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press.

What is a NAM consensus study report?
Any "Consensus Study Report" from the National Academies of Sciences, Engineering, and Medicine is the documentation of the "evidence-based consensus on the study's statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee's deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task."

The National Academy of Medicine has a lot of resources on clinician burnout. In fact, their recorded sessions on the topic are a recommended Lunchtime Listen. Learn more about these resources at this blogpost. 

Humanism in Healthcare: Patient-Centered-ness and Clinician Resilience
  • The September edition of the Jeffrey Silver Humanism in Healthcare Research Roundup includes these relate-able articles:
    • Researchers looking at how to measure the change when you ask patients to stop and reflect on a question before answering it.  “Reflective pause.”
      Reflecting on shared decision making: a reflection-quantification study Free full-text Kunneman M, LaVecchia CM, Singh Ospina N, Abu Dabrh AM, Behnken EM, Wilson P, Branda ME, Hargraves IG, Yost KJ, Frankel RM, Montori VM. Health Expect. 2019 Aug 14. 
      "Shared decision-making (SDM) refers to the collaborative nature of clinicians and patients in making decisions about health and care. It is considered an important component of healthcare, but assessing it accurately can be difficult. After testing the three versions of this questionnaire on 107 patients, they pursued further modifications to emphasize “stop-and-think” reflection. In this second study, they distributed a second version of the questionnaire to 212 patients. Overall, they found that that the “stop-and-think” emphasis did not significantly alter the ratings. Still, the authors conclude by noting that “other ways to induce a reflective pause” should be considered when studying SDM in these sorts of challenging settings."
    • Mentoring and Professionalism in Training (MAP- IT) programs
      Humanistic topics are emphasized…appreciative inquiry, enhancing well-being, and mindfulness and self-care.
      “graduates continued to use these practices and skills in their professional and personal lives. To their surprise, self-care, which was not designed to be an outcome..emerged as a major theme.”  "MAP-IT exercises with the greatest staying power was the participant's selection of a "third thing."
      “The authors conclude that there is durability in humanistic faculty development programs and that they may help to foster cultures of medical education and practice that promote wellness, community, and social support.”

      The long-term impact of an interprofessional humanistic faculty development programme: a qualitative investigation Tortez LM, Quinlan PS, Makaryus AN, George C, Caruso V, Gilman S, Ricardo A, Fornari A.   J Eval Clin Pract. 2019 Sep 3.
      Faculty development programs are important components of professional growth among academic clinicians once they have completed formal training, and constitute opportunities for building skills necessary for humanistic care.
    • "A Third Thing". Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events Gaufberg E, Olmsted MW, Bell SK. J Med Humanit. 2019 Jul 24. 
    • “Third things” are objects, images, or texts that serve as reflective triggers or conversational mediators to help create a safe space for sharing stories and perspectives. They can be used to approach sensitive topics that may otherwise cause emotional harm. Elizabeth Gaufberg and colleagues examined whether visual reflective triggers could serve as 'third things' to foster useful dialogue about the emotional impact of harmful events and medical errors. At an Agency for Healthcare Research and Quality conference called 'Healing After Harm,' the authors engaged 41 participants in a visual reflective trigger exercise to formulate domains and themes associated with medical injuries."
    • Teaching empathy to nursing students: a randomised controlled trial  Bas-Sarmiento P, Fernández-Gutiérrez M, Díaz-Rodríguez M; iCARE Team. Nurse Educ Today. 2019 Sep;80:40-51.
      "Empathy is a touchstone of humanistic healthcare, but can it be acquired as part of health pro
      fessions education?" "They measured outcomes before and after the intervention using standardized measures like the 
      Jefferson Scale of Empathy (JSE), the Consultation and Relational Empathy (CARE) Measure, and a 10-point Likert scale on student perception of learning. They determined that experimental groups had higher post-test scores and that there was an increased perception of learning and understanding compared to control groups. The authors noted that certain elements of empathy can be developed through training, but follow-up over longer periods of time and more rigorous studies controlling for other variables are necessary before establishing more definitive conclusions." [highlight added to metrics noted]
    • Compassion fatigue and compassion satisfaction among multisite multisystem nurses
      Kawar LN, Radovich P, Valdez RM, Zuniga S, Rondinelli J. Nurs Adm Q. 2019 Oct/Dec;43(4):358-369.
      Compassion fatigue is defined as “emotional exhaustion due to severe and prolonged interaction with clients, use of self and exposure to stress.”  This is a major occupational hazard among inpatient nurses and is associated with burnout. The converse of this is compassion satisfaction, which refers to when “a nurse gains fulfillment through helping clients.”  
      "However, there was low variability accounted for by these factors, suggesting that there are other factors, which could include unit culture and management support, that could mitigate the risk of compassion fatigue, and consequently burnout. Overall, these results point to the need for interventions designed for specific specialties and for less-experienced nurses." [highlight added for emphasis]  

For more on the topic of research

Other monthly research summary blogposts
Research Review posts
Research Resource Websites & Journals

Did you find this information useful or interesting?
You can request a pdf copy of this blogpost via the website for the cost of a cup of coffee. All proceeds go toward basic operating costs to keep this HH Project work going. Thank you.

Subscribe to our email list for the latest updates and follow us
for "research and metrics Thursdays" on the public Facebook Page.

You can support this community-wisdom-sharing work by buying me a coffee or sponsoring a newsletter via our website.  Thank you.

Tuesday, November 5, 2019

Survey: Preparing for a Joint Commission Visit

keywords and phrases: hospital-based acupuncturists, community surveys, wisdom-share, quality assurance, federally qualified health centers (FQHCs), preparing for a Joint Commission visit, resources for learning more about The Joint Commission

Community Survey this Season: 
Preparing for a Joint Commission Visit

For all acupuncturists working at a Joint Commission-accredited facility (or facility eligible for TJC accreditation) and their hospital sponsors (admin)

TJC = The Joint Commission, a non-profit accrediting body for healthcare facilities that focuses on safety and quality assurance measures.

Please share the survey link with colleagues who can add their wisdom.

Survey Link

Suspense Date: respond by Jan. 1st, 2020
Since we go through several rounds of this every year, I decided it is time I write something on this subject for the community.

Goal: Learn about the community's current questions and concerns about preparing for a Joint Commission visit. Share your "lessons learned" for a Joint Commission visit. Share any standard operating procedures (SOPs) or other advice that was helpful to you in preparing for a Joint Commission visit. Share any other advice or questions you have on this subject. Continue the discussion in the community on this topic.

How will this info be used?
  1. Continue the discussion in the community about the topic
  2. When enough information gathered, will create a summary document(s) available to the discussion community and a public blog post summary via the blog 
  3. Follow up interview potential about specific programs for those interested in participating, part of the "issues in hospital practice" community webinar/interview series. For more about this special Project series, go here.  
  4. I will have the survey open through the holidays with a suspense date of 1.1.2020. I will compile responses received up to that time period. However, I can keep the survey open or re-open in the future and then compile notes received about every 6 months for the community. *Waiting to hear in this first round of information what the community would like as a resource.*

Why this survey
  • In the U.S., every hospital-based acupuncturist will come across The Joint Commission preparation and visit. And so will every acupuncturist who works in a Joint Commission accredited facility, including FQHC community health clinics. In an ideal situation, you had an awesome program manager/hospital admin who set up the whole program, from position description to credentialing to SOPs, to fly with sailing colors of quality assurance through the TJC process. And, that person has kept everyone up to par on all the quality assurance measures to stay compliant. However, that is an ideal situation. Many acupuncturists are new employees and might be encountering TJC prep rounds for the first time. This is an opportunity to connect with your community to wisdom-share with those who have set up programs, those in the process of setting up programs, and those who love the Metal Element of quality assurance. Because we need our Metal colleagues and their talents to round out all of us. When it comes to TJC visits, they shine. :) 
  • The Hospital Handbook Project is about connecting people to each other and sharing wisdom. This is an important topic for us to start a more structured discussion on. I am looking forward to your feedback. 
  • However, the Project is not a substitute for finding mentors in your own facility. The Project can connect you virtually with others dealing with the same or very similar issues and their solutions. For more about how much we value mentor-relationship building, please see the First Steps resources, available on the website.

So, without further ado! Would you fill out this survey to share your questions or wisdom?
Thank you. 🏥🦋🙂☕️

If you are a student or practitioner in the field and are interested in connecting to mentors or programs,
  1. First, check out our Hospital-based Practice Learning Opportunities Directory.
  2. Then, if the options in the directory don't fit your needs, you can contact me via the website with your query. 
  3. For free and low-cost resources already available for prospective hospital-based practitioners, go to the First Steps resources at our website, stay connected to this blog, and sign up for the email list.  
  4. For the New Hospital Employee, here is a new resource landing page for you.
  5. The current resource landing page for the Program Lead and Hospital Sponsor is here.
  6. Welcome to the community!

Blog posts related to The Joint Commission and Acupuncturists 

All blog posts are also available as pdfs for about the cost of taking me for coffee ☕. Just send me a message via the website contact page with which blog post(s) you would like in pdf form.

Other Community Survey Blogposts

Did you find this information useful or interesting?
Subscribe to our email list for the latest updates and follow us
for "Leadership and Workplace Mondays" on the public Facebook Page.

You can support this community-wisdom-sharing work by buying me a coffee or sponsoring a newsletter via our website.  Thank you.

If you are interested in a pdf copy of an article/post on this blog,
send me a message via the website with which post you are interested in.
A pdf copy is available for about the cost of a cup of coffee. ☕ All proceeds from the website go directly toward helping offset the basic operating costs of The Hospital Handbook Project. Thank you.

Thursday, September 26, 2019

Your Medical Library and Professional Journal Access: An Employee Benefit

keywords: research literacy, professional practice, employee benefits for healthcare professionals, workplace, new hospital employee

As A Hospital-Based Healthcare Professional, You Have Medical Library and Professional Journal Access as an Employee Benefit

Did you know? 
You can look up journal citations at your healthcare institution’s online library.

Today's mission: Learn how to access your healthcare facility’s library and how to request an article or journal related to your work

At the Hospital Practice Handbook Project, we encourage practitioners to cultivate mentor-relationships and practice research literacy.

Contributors: Megan Kingsley Gale, Helen Ye

CINAHL = the Cumulative Index to Nursing and Allied Health Literature. Its focus is on nursing and allied health and has a broad range of topics. A product of EBSCO.
EBSCO = a private company that is the largest provider of research databases, e-journals, and more to libraries.
MedlinePlus = focus is on answering health questions. It is a service of the National Library of Medicine. Has information from the National Institutes of Health, other government agencies and health-related organizations.
National Cancer Institute = The National Cancer Institute is the U.S. federal government’s lead agency for cancer research.[i]
PubMed® = a government site. PubMed is a service through the U.S. National Library of Medicine and the National Institutes of Health.[ii]

Hospital-based clinicians! Does your system or facility have one of these?
1.       Graduate studies department
2.       A teaching hospital or hosts graduate school residents
3.       A library

Did you know a common hospital employee benefit is access to healthcare journals?
If your workplace does not have #1-3 above, you likely still have access to an online professional journal databases like EBSCO, CINAHL, or PubMed through your work.
Learn About Your Facility’s Library Benefits
Whether you are a new employee or have been there a few years, if library access is news to you, here’s a basic outline to learn more.
(1)    Look up your local medical library. Take a visit at your next break and learn more about it, what journals they have, and ask the librarian about online access to journals and how to access it. Sometimes these libraries are also called "reference libraries". Or, if the library is large and at an academic center, you will want to talk to the reference librarian.
(2)    If you can’t find a medical library on your workplace map but you do have a graduate studies department, you probably have some version of a medical library. Start with the graduate studies department. You can call or email them or stop by on your break and casually ask them about their medical library or online access to journals.
(3)    If you are in a satellite clinic that is associated with a larger medical center, your medical library may be a long drive away. In that case, it is more likely you have easiest access to journals via an online access point.
a.      Ask your supervisor how to access your system’s medical library, stating you need to review some journal articles for work-related study.
b.     If your supervisor doesn’t know, ask the physicians in your team. Ask the physicians how they access journal articles for work-related study. If the physicians are buying all their own subscriptions (none through work or an academic medical library), ask your hospital workers’ union about this. It should be a common question.

Requesting Access to a Journal or Article Your Library Doesn’t Have
Keeping up on literature in your field
How reference libraries and medical libraries work
As a clinician, you can go to your library (physical or just online) and request they subscribe to a peer-reviewed journal(s) in your field. Or, if there is a specific article that the library doesn’t have access to and you only need that article, not the full journal access, request to order a copy of that specific item.  You will need the full citation and to give the reason for the request. Examples: “necessary for a presentation I am working on” or “directly related to my professional practice.”

Before making a request for a new item, verify your item isn't accessible
Check to see if they (the library or your online reference system, depending on how your workplace is organized) already have a subscription to the journal you want. Verify what type of subscription it is. For example, subscription types may be physical, electronic, or both.

If they have it, learn how you can access it from work. Is it online through your web browser? Do you need to set up a username/account for access? Do you log in to a specific employee site? Or do you contact your library and order a print copy or pdf to be sent to you? 

If they don’t have access, you can request it.

If your clinical work is part of an academic institution, sometimes the medical library is connected to the medical school or the graduate studies building while your clinical space may be a long distance from the physical building. In that case, some institutions will do a modified “interlibrary loan” for a physical item request or (more likely) you will have electronic access.

"At Madigan Army Medical Center, I could go down the library, which was next to the graduate studies department, and review print journals and check some types of books or journals out. At my workspace, I had access through my computer to the library, a login, and the databases of journals the library subscribed to. I could also request journal access for journals in my field, as an employee benefit. It was up to the library’s process to decide if that subscription was electronic-only or electronic and print, etc.
"At Portsmouth Naval Medical Center, I could go to the library that had books and journals and many other items for perusal or check out. I could also work with the librarian to request items not available at that location or any other research help I may need." -Megan Kingsley Gale, MSAOM
 At the University of California San Francisco (UCSF), there are multiple library locations, as well as online access to journals.  The medical librarians are very helpful in providing support for specific requests you may have.  As a clinician you may be able to request full articles online through our access points with a username and password. If you are new to the [UCSF healthcare system] library, there are several classes to orient you to its resources and how to use them. These classes are extremely helpful and specific times and locations are posted.  Some classes are walk-ins, while others require registration ahead of time.  The library has its own mailing list, so you may also sign-up for this to receive its newsletter with updates of services and classes.” -Helen Ye, LAc, clinician at UCSF


  • You and your colleagues get access to it as an employee benefit
  • Easier to find references for your presentations or stay updated in current evidence-based practices in your field
  • Easier to quote citations and find the full article
  • Easier to share favorite articles with your hospital sponsors/advocates in your facility who also have access

Peer-reviewed journals unique to integrative health programs in hospitals

Research Resource Websites & Journals
For more on the topic of research
Research Review posts
More about Professional Practice and Basics of Being a Healthcare Professional Employee

[i] The National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine coordinates and enhances the National Cancer Institute’s activities in research on complementary health approaches. Contact information is 1-800-4-CANCER (1-800-422-6237)

[ii] It contains publication information and brief summaries of articles from scientific and medical journals. NCCIH has a guidance article on tips for searching PubMed® for articles on integrative health, “How To Find Information About Complementary Health Approaches on PubMed”.

Did you find this information useful or interesting?
You can request a pdf copy of this blogpost via the website for the cost of a cup of coffee. All proceeds go toward basic operating costs to keep this HH Project work going. Thank you.

Subscribe to our email list for the latest updates and follow us on the public Facebook Page.

You can support this community-wisdom-sharing work:
 buy me a coffee or sponsor a small Project via our website.  Thank you.