Attention Deficit Hyperactivity Disorder (ADHD): Policies and Practices to Identify and Treat ADHD on University Campuses

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1 STUDENT AFFAIRS LEADERSHIP COUNCIL Attention Deficit Hyperactivity Disorder (ADHD): Policies and Practices to Identify and Treat ADHD on University Campuses Custom Research Brief March 4, 2011 TABLE OF CONTENTS RESEARCH ASSOCIATE Karishma Furtado RESEARCH MANAGER Aashna Kircher I. Research Methodology II. Executive Overview III. ADHD Policies and Practices IV. Alternative Treatments V. Case Study: University C s Center Y VI. ADHD Trends and Plans for the Future THE ADVISORY BOARD COMPANY WASHINGTON, D.C.

2 I. Research Methodology Project Challenge: A member institution approached the Council with the following questions about ADHD treatment policies and practices: What policies have institutions developed that address treating students with ADHD? What were the key considerations in the formulation of these policies? What other support and resources exist for students in the surrounding area? What is the process for students to seek assistance for ADHD? What additions and alternatives to pharmacological treatment do institutions provide (e.g., screening components, referral resources, group therapy)? How were they developed and implemented? What options are provided for students concerned that they might have ADHD but ultimately are not diagnosed as such? What options are provided for students who would prefer non-pharmacological treatments? How have other institutions measured and tracked the efficacy of treatment options (traditional-pharmacological and behavioral, as well as non-traditional)? What, if any, trends are institutions witnessing or predicting among the population of students with ADHD? What are possible explanations for these trends and how do institutions react to them? Research Parameters The Council interviewed directors of psychological and psychiatric services at large, public, four-year research institutions. Institution A Guide to the Institutions Profiled in this Brief Geographic Location Carnegie Classification Approximate Enrollment (Total / Undergraduate) University A Midwest Research Universities (high research activity) University B South Research Universities (high research activity) University C Southwest Research Universities (very high research activity) University D Midwest Research Universities (very high research activity) University E Northwest Research Universities (very high research activity) University X* *This institution requested that all identifying and descriptive information pertaining to geographic location and student population size be omitted. 17,000 / 15,000 29,000 / 24,000 39,000 / 31,000 29,000 / 21,000 46,000 / 33, The Advisory Board Company 2

3 II. Executive Summary Key Observations Contact institutions maintain a variety of policies regarding official testing for ADHD. Those institutions that do offer evaluations do so through three models: o o o Services through a training clinic: The graduate school of psychology hosts the clinic and uses it as an opportunity to train clinical psychology graduate students while providing services for a fee to students and the surrounding community. Suggestive diagnostic services: A phone screening and more comprehensive evaluation can provide a suggestive diagnosis; if the staff psychiatrist agrees with it, students can receive medical treatment. Official evaluations through student counseling or health services: students can receive full evaluations through Counseling Services at a significantly subsidized price. Institutions that do not offer formal evaluations, along with those that do, provide students with phone, electronic, or in-person screenings. These screenings provide students with information about the ADHD diagnosis and treatment process while helping to manage the volume of students seeking services. All institutions attempt to serve their students by providing them with alternative treatments. These treatments are generally behavioral in nature and fall into five distinct buckets: o One-on-one sessions: Students work with a counselor on a recurring basis to learn how to organize, manage, and take accountability for their work. Providing this service is highly resource-intensive. o Group sessions: Interactive sessions that serve a dual educational and counseling function. Emphasis is placed on developing small cohorts of students who can help support each other both during the sessions and after. o Workshops: Modules that address learning strategies, behavioral habits, and health and wellness techniques. o Electronic Options: A growing set of options that provide students with resources electronically (e.g., online screening modules, webinars and podcasts on various aspects of being a college student with ADHD, virtual check-ins with doctors, etc.). o Tutoring: Provided through learning centers or other academic support centers. Some institutions train tutors to work with students who have learning disabilities and differences. Many contacts explain that assessment of strategies has been difficult in the past due to a lack of collection of data across the field of ADHD diagnosis and treatment in the higher education setting. This process is changing at some institutions that hope to perform more rigorous assessment of treatments in the near future. Contacts agree that higher education providers are experiencing a significant increase in numbers of students presenting with ADHD both undiagnosed and previously diagnosed. As a result, contacts describe a growing need to train faculty and staff across the university on how best to identify and assist students who might have ADHD. Some contacts also describe plans to integrate their services into those provided to the general student body The Advisory Board Company 3

4 IV. Alternative ADHD Treatments at Contact Institutions ADHD Policies at Contact Institutions Institution Policy Medication University A University B University C University offers a phone screen, an Attention Problem Evaluation that can deliver a suggestive diagnosis, and a counseling (psychiatric) evaluation for medication purposes. Students are referred off campus for official evaluation. All students requesting treatment must participate in an ADHD workshop. University offers an inperson ADHD screening, which can offer a suggestive diagnosis. Students are then referred off campus for a full psycho-evaluation. No screening or evaluation, formal or informal, is offered. Yes. Campus psychiatrist will prescribe if he/she agrees with suggested diagnosis. Yes. Campus physician will prescribe once student has an official diagnosis. Yes. Campus psychiatrists will prescribe if: Previously diagnosed students have their psychological tests and summary letters from prescribing physician. Undiagnosed students have psychological testing as well as evaluation and three months of medication from a psychiatrist, all approved by campus psychiatrist. Disability Accommodations Yes, if students have an official diagnosis and documentation (i.e., the suggestive diagnosis from the Attention Program Evaluation is not sufficient). Yes, if student has an official diagnosis and documentation. Yes, if student has an official diagnosis and documentation. Fees Phone Screen: Free Attention Problem Evaluation: $30 (2012) Counseling Evaluation: $30 ADHD Workshop: Free ADHD Screening: Free N/A 2011 The Advisory Board Company 4

5 IV. Alternative ADHD Treatments at Contact Institutions Institution Policy Medication University D University E University X University offers an initial screening as well as full, formal evaluations. University offers, through Clinic Z, a brief evaluation, a focused evaluation, and a comprehensive evaluation that renders an official diagnosis. The main clinic also offers a brief evaluation. University offers an online screening module, inperson screening, and referrals to external providers for formal evaluations. If a student is diagnosed with ADHD and he or she seeks assistance understanding the disability, specialists will work with the student to read through the diagnostic evaluation and understand its implications. Yes. Campus psychiatrist will prescribe medication if student has official diagnosis and documentation. If they do not, psychiatrist will refer student for a formal evaluation. Yes. Mental Health Clinic physician will medically treat if student has the appropriate documentation. Unavailable Disability Accommodations Yes, students can use either the report generated by campus psychiatrist and intern after the formal evaluation; or, if they were not evaluated on campus, outside documentation. Yes, if student has an official diagnosis and documentation. Yes, if student has an official diagnosis and documentation. Fees ADHD Screening: free Full Evaluation: $75 (materials cost) Main Clinic Brief Evaluation: $150 Clinic Z Brief Evaluation: $500 Focused Evaluation: $1700-$2100 Comprehensive Evaluation: $2000-$3000 Online Screening Module: Free In-Person Screening: Free 2011 The Advisory Board Company 5

6 Common Points of Inquiry Services for a Fee IV. Alternative ADHD Treatments at Contact Institutions Different Models of Providing ADHD Services Contacts describe several models of providing ADHD evaluation and diagnosis services: 1 Partial Services through a Training Clinic 2 Suggestive Diagnosis Services 3 Full Services on Campus Institutions that do not operate under one of these models do not offer evaluative services; students are instead referred to resources in the surrounding community. University X and University B offer an initial screening after which students are referred to psycho-evaluation services off campus. ADHD Screenings Most contact institutions offer a screening for students who believe they might have ADHD. Screenings usually take 20 minutes to an hour and cover a check list of symptoms, either developed by a third party or by medical staff at the institution. The screening also informs students of the ADHD treatment process and offerings at the institution and any next steps. Contact institutions offer different varieties of initial screenings: University A phone screening University D in-person screening University X online screening module and in-person screening sessions University B in-person screening University X s online screening module was developed in 2010 in response to increased demand for screenings and diminished staff capacity. Administrators will assess the number of students using the module at the end of the year. Contacts note that many students visiting the Learning Center with ADHD-related concerns have watched the module. 1 Services through a Training Clinic: University E Description: Clinic Z at University E provides learning and behavioral assessments for a fee to children, adolescents, and adults both on campus and off. The Clinic is hosted within University E s Psychological Services and Training Clinic. A self-sustaining specialty unit, the clinic aims to provide training in psychological assessment to clinical psychology graduate students and to provide assessment services to the community at large. Learning Center Counseling Student Health Center Clinic Z Brief Evaluation Focused Evaluation Comprehensive Evaluation Services: Comprehensive evaluations addressing learning, attention, and behavioral problems 2011 The Advisory Board Company 6

7 IV. Alternative ADHD Treatments at Contact Institutions 2 Typical Session: diagnostic interview, individualized collection of psychological and neuropsychological tests, feedback session (summary of test results, impressions, and recommendations), comprehensive report documenting findings and recommendations Suggestive Diagnostic Services: University A Description: Students follow a series of steps, beginning with an initial screening, in order to access ADHD treatment. Services are provided through the Student Counseling Center and the Learning Center. Phone Screen Attention Problem Evaluation Psychiatric Screen ADHD Workshop Treatment Program A phone screening and more comprehensive evaluation can provide a suggestive diagnosis, and if the staff psychiatrist agrees with it, students can receive medical treatment. Treatment, both behavioral and medical, is organized through an academic calendar/planner, which can be purchased through the Learning Center. Students seeking treatment must also participate in a one-hour ADHD workshop that discusses comprehensive treatment a collaborative effort between the Learning Center and counseling service that consists of Weekly one-on-one life coaching sessions with specialists in the Learning Center Monthly meetings with the psychiatrist prescribing medication. Very strict medication management is a centerpiece of this program; if students do not abide by the guidelines provided for managing their medication, the psychiatrist can withhold medication. Contact Observations: Anecdotally, contacts note that the medication-control facet of the program has been highly successful and overall the program has been very well-received. 3 Full Service Diagnosis On-Campus: University D Description: Students at University D first undergo a 50 minute screening through the counseling center. If students seem to have ADHD, they receive a full evaluation through the counseling center. The full evaluation takes eight to ten hours and is spread across multiple short sessions and several weeks. The fee for the on-campus full evaluation is $75 (materials cost). If students do not want to wait for an evaluation (because there is a waiting list and the evaluation itself takes multiple weeks), they are referred to outside providers. The report generated by the evaluator is then passed on to disability services and the student health center, where a psychiatrist will discuss medical treatment options with the student. Screening Full Evaluation Disability Services Student Health Center Contact Observation: The future the full evaluation is under serious question. Currently one psychologist is delivering all the evaluations and the waiting list is extremely long. Contacts anticipate difficulty in finding a replacement for this individual when she leaves the university. Subsidizing the full evaluation so extensively is also expensive for the institution The Advisory Board Company 7

8 Resource Intensiveness IV. Alternative ADHD Treatments at Contact Institutions Alternative Options for Students with ADHD One-on-One Sessions Tutoring Group Sessions Workshops E-Options Prevalence One-on-One Sessions: Most contacts agree that one-on-one, recurring assistance is an effective model of providing students with non-pharmaceutical assistance. Contact institutions offer one-on-one services in slightly different ways: With an academic coach from Learning Services University A As a team, the learning coach and student put together a planner (purchased through the Learning Center) that incorporates class assignments, tests, and activities; the coach then helps students develop a plan to successfully manage their responsibilities Planners, as well as the work the students are doing with the coach, also inform students monthly meetings with the psychiatrists who prescribe their medication Students meet with a learning coach approximately once per week Offered through the counseling center; some coaching is offered through the Office of Disability Services Sessions provided by Counseling Services are not targeted to students with ADHD University B The Center for Teaching and Learning also has one-on-one services that focus on organizational and academic success strategies (for the student body at large) Contacts plan on developing an ADHD coaching program in the future by training one individual within the Student Health Center who will then train others Learning Specialists work with students with a learning disability or ADHD through Center Y University C Students meet once a week to develop an Individualized Learning Plan (ILP) The ILP serves as a dynamic framework within which the specialist and the student assess and re-assess what strategies and approaches work best 2011 The Advisory Board Company 8

9 IV. Alternative ADHD Treatments at Contact Institutions University D University E University X Academic advisors, as well as staff from academic support service offices, offer one-onone options for students Advisors focus on coaching; academic support staff offer academic skill training Staff across campus from several student service offices may offer individualized services Students can work with ADHD/LD specialists and specialists from the Learning Center Two ADHD/LD specialists who are a part of the Academic Success Program (which works solely with students with ADHD) are certified life coaches; sessions tend to focus on helping students organize their academic lives Life Coaching University D, University B, and University X all offer or plan to offer life coaching as a variety of one-on-one session. This type of coaching focuses on executive functioning (e.g., planning, cognitive flexibility, abstract thinking, rule acquisition, etc) deficits and for that reason is an attractive option for students with ADHD who know how to do their work but have difficulty becoming more structured and accountable. Coaches help students set very specific, short-term goals within the framework of larger goals and design plans that will help them accomplish those goals. University X is assessing the efficacy of life coaching through an ongoing pilot group. Contacts from University X offer several life coaching training providers: JST (Jodi Sleeper-Tripplett) Coaching: college and high school-age students specifically; primarily training for individuals who want to be private coaches in the community; affordable; tele-meetings; training takes six months Edge Foundation: non-profit provides institutions with tele-counseling; eager to form relationships with colleges; just completed a large, gold-standard study on the efficacy of coaching Inside Track: coaching at colleges; not targeted to students with learning disabilities or ADHD; in the past have focused on improving retention 2011 The Advisory Board Company 9

10 IV. Alternative ADHD Treatments at Contact Institutions While contacts cite anecdotal evidence of the success of individual sessions (formal assessment is in its nascent forms at most contact institutions), they stress that such services are highly resource intensive. As more students request services as a result of better advertising and a growth in the student population affected by ADHD, it will, contacts predict, become increasingly difficult to provide one-on-one services. As a result, institutions are developing more efficient methods of outreach: Group Sessions: Group sessions are interactive and serve a dual educational and counseling function. Emphasis is placed on developing small cohorts of students who can help support each other both during the sessions and after. The Skills Groups sessions offered at University E were initiated by an interested graduate student. Modules focus on different pieces of understanding and managing life with ADHD (topics include goal management, ADHD and relationships, secondary symptoms, time management, etc). Success with the Skills Group is anecdotal, though contacts anticipate formal assessment in the near future. Contacts do plan to continue offering the sessions if resources are available. University B is also considering group sessions. Contacts explain that the economics of group offerings are too attractive to not consider. Contacts at University B do worry that it will be difficult to recruit students to participate in group sessions because students may not be comfortable discussing their situations within a group of peers. Workshops: Most contact institutions offer workshops that address learning strategies, behavioral habits, and health and wellness techniques. The University C and University A specifically offer workshops for students with ADHD. Workshops at University D, University B, and University X offer learning strategy and success workshops to all students. Integrating sessions in such a way inhibit customization to ADHD student needs, but also can accommodate more students. Resources that are actively utilized by a significant portion of the student body tend to have greater longevity, contacts at University X explain. For these contacts, integration into broader student and academic affairs programming is a concerted strategy. Electronic Options: Similar to the online screening module developed by University X, other contact institutions aim to create assistive resources in the electronic space. University B currently offers online medication management check-ins with psychiatrists. University B also has plans to develop a series of pod and webcasts that discuss ADHD symptoms, treatment options, and strategies. University X is working on a series of animated videos discussing the top five learning strategies for students with ADHD. Tutoring: All contact institutions offer tutoring through learning centers or other academic support centers. University C and University X train their students on how best to work with students who have specific learning needs The Advisory Board Company 10

11 V. Case Study: University C s Center Y Center Y at University C was founded thirty years ago as a program within the Student Resource Center. It eventually grew to become a fee-based unit with the Division of Campus Life. Its mission is to serve students with learning disabilities or ADHD. The safe space environment is, contacts explain, critical to the Center s success. Organizational Overview of Services and Resources Students have access to unlimited recurring or drop-in tutoring Tutors are primarily upperclassmen certified through the College Reading and Learning Association New tutors undergo training on the neurobiological basis of learning disabilities Tutors complete their training by observing and being observed by more experienced tutors Tutors also offer Weekly Intensive Study Sessions (WINSS): Preempt a large assignment or test Cover the subject matter and practice learning strategies Focus on troublesome freshman courses Center Y students receiving tutoring in the subject are invited to the sessions The Center Y Psychologist helps students with anxiety, depression, coping with stress, managing life in college, grief and loss, substance abuse, and sleep disorders Center Y Learning Specialists Tutors Learning Strategy Workshops Psychological Services Masters-level counselors work with a roster of students weekly With the students, counselors develop an Individualized Learning Plan (ILP) each semester o ILP plots the students upcoming assignment o Applies learning strategies Specialists help students understand what strategies work well and provide support Hosted by learning specialists Tutors may help facilitate For younger students, workshops are as close to mandatory as possible. Series of workshops are targeted at certain groups of students (e.g., those on academic probation) Sample workshop topics include: Skills Workshops Organization Workshops Time Management Workshops Test-Taking Workshops Health and Wellness Workshops Leadership Opportunities Ambassador Program consists of a diverse group of current Center Y students who answer questions and relate their own experiences as incoming freshmen to University C and Center Y Center Y students have exclusive access to a Computer Resource Lab (CRL), equipped with software packages and assistive technologies Technology Assistance 2011 The Advisory Board Company 11

12 V. Case Study: University C s Center Y Center Y and the University: a Dynamic Relationship Collaboration Contacts stress that collaboration among student service units across campus is critical for the Center s success and for ADHD services in general. Contacts maintain open lines of communication and good working relationships with contacts in the Disability Resource Center, Counseling and Psychological Services, Academic Advising, and Career Services. Contacts are also kept apprised should Center Y students be involved in any residential issues. The director also actively recruits for both the University and the Center. Training Training sessions encourage staff across campus to engage with LD and ADHD students. Training opportunities include: RA training in the Fall Training of recruitment and admissions staff in the summer Speaker series with ADHD/LD experts for all faculty and staff Sessions for specific units as requested Admission and Fees Students are required to apply for admission to Center Y and are encouraged to do so alongside their application to University C at large (demand for services is large enough that students who wait are usually placed on a waiting list). In addition to essays and recommendations, students are encouraged to submit documentation of a learning disability or ADHD though students do not need to be diagnosed in order to be admitted. If students do not have documentation, they must submit an additional essay describing their learning challenges. Center Y Fees Lower-Division Undergraduates* (fewer than 60 credits) Upper-Division Undergraduates (60+ credits) Graduate Students Part-Time Students $2,450 per semester (access to everything) $1,050 per semester (tutoring is charged at an additional $20 per hour; students can choose to remain at the lower division rate, in which case tutoring is not charged per hour) $1,000 per semester (no access to tutoring) Fees are per semester regardless of student s enrollment status Pre-, Summer, and/or Winter $20 per hour (tutoring services only) Session Students *Contacts note that most Center students are underclassmen as they need to most help with acclimating to university life as a student with a learning disability or ADHD. Assessment Center Y leaders recently launched an effort to increase assessment. Assessment is now a part of the Center s strategic plan. In addition to assessing satisfaction, administrators aim to assess learning objectives through pre- and post-service surveys, focus groups, and interviews with alumni. Different educational and instructional strategies are also being tested with pilot groups of Center students The Advisory Board Company 12

13 VI. ADHD Trends and Plans for the Future Centers for Disease Control (CDC) Reported Trends in ADHD Prevalence 1 Notable Statistics from the CDC 1 Approximately 9.5 percent or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD, as of Rates of ADHD diagnosis increased at a greater rate among older teens as compared to younger children from 1997 to Rates of ADHD diagnosis increased an average of three percent per year from 1997 to 2006 and an average of 5.5 percent per year from 2003 to The percentage of children with a parentreported ADHD diagnosis increased by 22 percent between 2003 and Analysis of data collected by the CDC/NCHS National Health Interview surveys shows that the percentage of students diagnosed with ADHD (in two distinct age cohorts: years, and 6-11 years) seems to be increasing. Contact-Observed Trends Contacts almost unanimously agree that the number of students with ADHD diagnosed and undiagnosed arriving at institutions of post-secondary education is increasing. Contacts offer these observations: As a country, the United States has made an increased commitment to other minority groups. Contacts from University X explain that efforts to include minority, first generation, and other students who, decades ago, might not have felt entitled to pursue post-secondary education are increasingly encouraged to do so. Contacts point out that having a learning difference is not included as a variety of diversity and as a result, students with ADHD at the postsecondary level do not receive as much support as they should. Students across the country have access to ADHD resources from a younger age. As a result, more students with ADHD are able to apply and get into universities. High performing students who have managed to work around their attention disorders in the past are not able to when placed in a more intense academic environment like college. As a result, these students are seeking assistance later in life. Despite the increasing volume of students with ADHD, state and private institutions are facing extreme budget cuts that trickle down to ADHD support services. Contacts from 1 Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, National Center for Health Statistics. Vital Health Stat 10(237) The Advisory Board Company 13

14 VI. ADHD Trends and Plans for the Future University X note that in the 1990s five full-time staff members worked with students with ADHD. Today two full-time staff members manage students with ADHD. Support staff across campuses have become better at directing students to ADHD support services. This compounds the number of students with which services must work. Future Directions for ADHD Resources at Contact Institutions Integrate with broader student services: Contacts from University X plan to integrate the needs of students with ADHD with the needs of all students. The emotional wellbeing of all students is a growing concern and student affairs programming is responding accordingly. If ADHD service offices align with broader initiatives, the newly created programming will help students with ADHD though they may not be advertised as such. Train faculty and staff across campus: Contacts note that ADHD support services as many support services have suffered disproportionately in the current budget crisis because administrators want to buffer in-class offerings. As a result, contacts at most contact universities plan on increasing the pool of effective support staff by training staff who monitor some of the common entry points for students seeking assistance (e.g., student health, learning centers, tutoring services, etc.) This training would be sufficient for staff members to feel more comfortable recognizing some of the symptoms of ADHD and putting students in touch with resources across campus. Contacts also share a desire to train more faculty to identify the learning differences of students with ADHD and account for them in their design plans. ADHD Policies and University Leadership Contacts note that while most university leaders understand the important role of ADHD services, they still are not considered a high priority. Contacts list the following reasons: ADHD staff do not rigorously assess the impact of their services and therefore do not effectively convey as much to leaders According to contacts from University X, students with ADHD do not suffer from lower retention rates, which is a primary metric leaders consider Minimal evaluation of student success and graduation rates for students with ADHD occurs in large part because there is little demand from leadership for this information Contacts do not report university-wide policies that greatly affect ADHD support staff s workload with the exception of those policies that mandate that students complete their degree in eight semesters. Contacts from University X explain that students with ADHD tend to do better when taking 12 vs. 15 hours. Contacts do believe, however, that strong ADHD services can be an attractive feature at an institution. Contacts from University C attest to the recruiting power of well-developed support services for students with ADHD. Key to making this case, contacts maintain, is data-driven proof of impact. Develop a culture of storing and using data: Contacts at University X report that institutions must use data to assess, grow, and modify ADHD student services. Collecting and storing data in this field of study is not, contacts observe, a common practice, and this must change in the near future. University X, University E, and University C are all laying the groundwork for and seeing the benefits of such changes The Advisory Board Company 14

15 VI. ADHD Trends and Plans for the Future Leverage graduate student populations: Many institutions have a graduate school of psychology and/or psychiatry and those graduate students can be trained to provide ADHD screenings and evaluations (though perhaps not official evaluations). University E currently hosts such a program through its Clinic Z. University D is also considering this option. Grow into virtual offerings/ group sessions: While contacts are split as to the efficacy of virtual and group support sessions, some institutions do plan to explore this area. University X, University E, University C currently offer group sessions and plan to expand upon those offerings. University B currently offers virtual check-ins with the psychiatrist who prescribes students ADHD medication. Utilize Student Leaders: University X has incorporated into its strategic plans efforts to conduct more outreach with student leaders. Student leaders can, contacts predict, help change the tone surrounding support services. Many students perceive a stigma associated with receiving assistance and contacts argue that the impetus to modify that perception must come from within the student body The Advisory Board Company 15

16 PROFESSIONAL SERVICES NOTE The Advisory Board has worked to ensure the accuracy of the information it provides to its members. This project relies on data obtained from many sources, however, and The Advisory Board cannot guarantee the accuracy of the information or its analysis in all cases. Further, The Advisory Board is not engaged in rendering clinical, legal, accounting, or other professional services. Its projects should not be construed as professional advice on any particular set of facts or circumstances. Members are advised to consult with their staff and senior management, or other appropriate professionals, prior to implementing any changes based on this project. Neither The Advisory Board Company nor its programs are responsible for any claims or losses that may arise from any errors or omissions in their projects, whether caused by the Advisory Board Company or its sources The Advisory Board Company, 2445 M Street, N.W., Washington, DC Any reproduction or retransmission, in whole or in part, is a violation of federal law and is strictly prohibited without the consent of the Advisory Board Company. This prohibition extends to sharing this publication with clients and/or affiliate companies. All rights reserved The Advisory Board Company 16

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