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Your family member, sick and in pain, is in a hospital or nursing home and no one is available to help because the person is the next room is in critical condition and the entire floor staff is rushing around to help this person. You empathize thinking that if you were in a similar situation you would want everyone rushing around to save you. What you really do not know is that this emergency is due in some cases to financial self interest or lack of staff education regarding critical or end of life care. Most individuals do not fear death as much as the experience of a painful death and many nursing homes and assisted living facility staff do not have the training or desire to educate family members about hospice and palliative care services.

How can we make the stress of having a sick loved one, piled on top of daily stress easier for all involved when hospitals, nursing homes and assisted living locations often provide end of life care? Whether you recently experienced the loss of someone you know or are currently experiencing the decline of a loved one there are steps that can be taken to ease the journey but you must be the one to ask questions because many facility staff lack training in hospice and palliative care.

According to research by Lisa Welch, Ph.D. few nursing homes or assisted living facilities have written procedures for regularly assessing residents’ terminal disease status or eligibility for hospice care. Instead, many staff members base their timing and referral of hospice based on their ability to recognize decline, their personal beliefs about hospice services and their initiative in raising hospice as an option. What happens when facility staffs have little or no education relative to palliative or hospice care and family members rely on their level of experience to help their loved ones? The result is often family frustration, little or no pain assessment or management for the loved one and a painful death.

In my work, I have been personally told by facility staff that their administration does not want them recommending outside hospice services because that means that money leaves the building. Or, as the research mentions, if there is no family requiring support, hospice is not recommended and is instead provided by their own staff, lacking hospice background. In these cases, offering hospice becomes a territorial issue founded by concerns over money and staffing. How can family members trust health care providers when the concern for money and self interest overrides the care needs of their family members at an especially critical time of life? This choice should not be a decision made by facility staff but the decision of the individual or family member involved.

“Additionally, timing of hospice referrals is often delayed because staff members believe that hospice is appropriate only for the very end of life. There was often a discrepancy of weeks or months between when staff reported recognizing terminal decline and when referral to hospice occurred.” It is clear that training needs exist for staff relative to recognizing declines and understanding the benefits of hospice services. In defense of facility staff, I have experienced instances where fear of breaking rules or regulations or chastisement by a superior prevents staff from doing the right thing. However in these cases mysteriously a phone call or recommendation is made and I become involved to help families navigate the situation.

Until the level of palliative and hospice care education catches up with the need, family members will have a greater level of responsibility navigating the care of loved ones experiencing declines in health. It’s never too early to ask about palliative or hospice care; however it can be too late. Too late is when a loved one is days away from passing and has already likely experienced a high degree of pain and discomfort. In the instance you ask and it is not quite time for palliative or hospice care, at least you have been proactive in your own education and when the time does come you’ll be more prepared and less reliant on others to recognize the signs or request assistance.

Welch, Lisa C. Ph.D. et. al. Referral and Timing of Referral to Hospice Care in Nursing Homes: The Significant Role of Staff Members. The Gerontologist. Vol 48, No. 4, 477-484.

Pamela D.Wilson, The Care Navigator, specializes in consulting, planning and education for families and individuals experiencing transitions in health care. Contact her at The Care Navigator or visit The Care Navigator Blog for free information

There are approximately 37 million people over the age of 65 and 5.3 million people over the age of 85. Each year millions of older people start requiring some sort of assistance to carry out their routine daily activities. Family members (family caregivers) provide most of the help.

It is not always easy to know when to intervene. It may seem like your loved one is in a gray area somewhere between competency and incompetence.

Your loved one can have a behavior that is not life threatening but still very serious. Making an assessment is the very step.

Here are some clues that your loved one may need some extra help:
1. Disheveled clothes
2. Stained or dirty clothes The same outfit worn everyday
3. Unkempt hair
4. Poor hygiene
5. Bad breath
6. Body odor
7. Having trouble walking
8. Having trouble sleeping
9. Dangerous driving
10. Extreme clutter in the home
11. Can’t do light housekeeping
12. Items not returned to drawers or cupboards
13. Clothes strewn about or left on floor
14. Medication bottles left open
15. Medications taken out of original containers and mixed up
16. Not much food in house
17. Spoiled or rotten food
18. Unpaid bills
19. Penalties for overdue bills
20. Unopened mail
21. Put on or lost a lot of weight that is unexplained
22. Signs of confusion
23. Signs of forgetfulness
24. Signs of isolation
25. Signs of depression
26. Drastic mood swings
27. Extreme sadness or loneliness
28. Loss of interest in favorite hobby
29. Stopped doing things they used to enjoy like gardening, reading, going to church, seeing friends
30. Can’t cope with everyday stress
If you do not live near your aging parents, ask a neighbor or friend to keep an eye on your parents and notify you if they notice any changes in their behavior.

Even if you determine that your loved one needs some assistance, keep in mind that they may be resistant to your help. Be gentle and compassionate when asking them to accept help.

It may take several tries before they start to accept your help. There is a big difference in offering help and completely taking away all of their independence.

However, if your parent’s life is in danger and you can’t find a way to intervene, call Adult Protective Services, which is a part of the Department of Social Services. They will send a nurse or social worker to your parent’s home to determine the risks and find ways to protect your parent.

The caregiver role is complex and differs for everyone depending on the needs of the care-receiver. Many times, in the beginning, there may only be a few needs, such as providing transportation or helping with shopping or cooking. Over time, needs increase, requiring additional services, until the care-receiver is fully dependent on the caregiver.

Rebecca Colmer is an Eldercare Advocate, Author, Speaker, Publisher, and Caregiver Expert. You can find more caregiving tools and resources at her website:
Caregiving Tools

Whether your family member is in a nursing home or rehabilitation facility short or long term it is extremely important to be vigilant about their care. While many assume this is the responsibility of the facility providing care, do not become complacent and assume this is what actually occurs. Reality is often different. Many family members overlook or excuse the small things. A person not bathed frequently, a dirty room, increasing confusion or anxiety. There are so many things that can and do happen and if left unchecked continue to progress and become critical.

Consider the case of a father who had surgery and went for short term rehab. As a result of the surgery, this individual because anxious and extremely depressed. His daughter, knowing that dad had episodes of mental illness all of his life discussed this with the facility staff who mentioned it to the on call physician. The physician, having no background in mental health, prescribed ativan, a medication typically prescribed to calm anxiety. This worked for a brief matter of time until dad became increasingly depressed, a risk to self and according to the facility required 24-hour supervision which the family was forced to pay for privately if they wanted their father to continue to receive care.

More concerns were expressed by the daughter. The physician, again having no background in mental health, requested that a mental health social worker visit and make recommendations. The social worker proceeded to recommend an anti-psychotic medication that the physician prescribed. Unfortunately, dad had an immediate psychotic reaction from the medication and was transported to the local hospital emergency room for medication issues. In spite of the daughter requesting that the hospital emergency staff find a way to have her father evaluated from a psychological standpoint, they simply sent him back to the nursing home under 24 hour supervision.

This is a clear case of a daughter recognizing the needs of her father and the system failing to respond. The daughter, highly educated and intelligent, had no idea how to work within the system to achieve the desired result for her father. Fortunately I was contacted the evening of the hospital emergency room event and spent the next day having her father complete the requisite admission tests for acceptance into a psychiatric evaluation center.

It is important for families to understand that the health care system has limitations; that skilled nursing and rehabilitation facilities have limitations to the care they can provide. Even physicians, many who are general practitioners, are limited in their expertise. And that eventually the time comes to consult individuals versed in the situation with access to a wide range of resources. It is easy to assumewhat we know; yet more difficult to admit we lack the expertise to care for a family member. Many individuals experience panic in failing a family member because they do not know what to do. The best course of action is to admit help is needed and contact a professional who can help navigate the system.

Pamela D. Wilson, specializes in consulting, planning and education for families and individuals experiencing transitions in health care. Contact her at The Care Navigatoror visit The Care Navigator Blogfor free information.

As citizens age, loneliness becomes a very real issue and concern. They may be in need of help from their loved ones to determine how they, in their golden years, can still make a difference in the world. Here are some specific steps to help senior citizens lessen the chances of falling prey to the ravaging effects of loneliness.

There are many factors that lead to a senior citizen’s feeling isolated: death of a spouse or intimate friends, chronic illness, and an inability to drive a car, to name just a few. The most common effect of perpetual loneliness is depression, and it can lead to dire consequences.

Some seniors may attempt to numb their sadness with alcohol; this could lead to a range of problems from decreased liver function to out and out alcoholism.

They may begin hoarding prescription or over the counter drugs, taking them improperly, and abusing their bodies as a result.

Statistics regarding suicide for senior citizens are bleak indeed: never assume that age and feebleness will prevent seniors from taking their own lives. Many see drastic action as the only release from their isolation and anguish.

There are ways for senior citizens to still feel like contributing members of society, fill their lives with meaning, and fend off isolation. Quite often, it is up to the senior’s children or other loved ones to help the senior find and implement activities that will work.

Volunteering is a great way to get out in the world and feel a part of things again. Elementary schools are always looking for grandparent figures to read to and give some on one attention to children. Of course, schools are not the only venue for volunteering: a loved one should sit down with the senior and help him or her sort out her feelings and interests. Once a range interests are narrowed, the internet can provide a list of volunteering activities in the community to choose from.

Active seniors who still live at home can visit local senior centers and make new friends there. You’re never too old to meet someone new and enjoy the friendship of companions the same age. Join a bowling league or go dancing! Since ability to drive is often an issue, loved ones could arrange for rides and help keep their senior on the move.

Seniors with limited mobility or chronic illness may enjoy regular visits from a community volunteer. Volunteers are trained to do errands, give rides, bring in meals, or simply sit and listen when they come to a senior citizen’s home. An older person who is still developing relationships and feels a kinship and responsibility toward the volunteer is less likely to feel isolated or forgotten, and will have something to look forward to.

Fighting senior citizen isolation and accompanying depression requires careful thought, planning, and follow through by everyone.

If you or a senior citizen you love is interested in high quality California assisted living centers, contact the good people at Heritage Senior Care, Inc. (http://heritageseniorcare.com/). Art Gib is a freelance writer.

Are You Okay? That was the name of the automated computer system that saved an elderly 88-year old woman from Surprise, Arizona from a possibly fatal bathroom fall. The “Are You Okay” or RUOK system is an automated program that makes reassurance calls to check on participating individuals that are homebound and elderly or those with physical and medical disabilities. Participants from Arizona can choose the time of day when these automated calls will be made, and if for some reason the automated call was not answered, Police or Citizens Patrol personnel will immediately be dispatched to the residence to check on the participant’s condition.

For this octogenarian who lives at the Happy Trails RV Resort, the failure to answer the scheduled 9:30am call triggered a welfare check conducted by a Citizens Patrol member. The responding patrol member found the woman lying on the floor with a fractured arm and in need of immediate medical attention. The woman has been lying there for some undetermined amount of time, and was clearly not able to get up from her injuries to make emergency calls. The patrol member who got there on time was able to call in paramedics who brought the Arizona woman to a local hospital and treat here from her injuries.

Surprise is a progressive city in Maricopa County in the state of Arizona. With a population of 103,000 (2007 census), Surprise is the second fastest-growing municipality in the Phoenix metropolitan area and the sixth among the towns and cities in the whole of Arizona. The city was founded in 1938 by a real estate developer and an Arizona state legislator named Homer C. Ludden. Naming it after his hometown in Nebraska, the town started out with a few houses and a gas station. As a real estate expert, Ludden transformed the land into residential subdivisions with low cost houses intended for agricultural workers, and was eventually proclaimed a city in 1960.

Surprise slowly became a retirement capital for Arizona when tens of thousands of retirees flock to the city to live in the resort-like community of Sun City Grand that is restricted for these retirees only. This resort community contributed to the tremendous growth in population that Surprise enjoyed. And with these residential demographics, the RUOK system is a perfect reassurance system that would cater to Sun City Grand’s residents.

The RUOK system has been in place for almost two years and has served more than 20 Surprise, Arizona residents already. The system was paid for by the Rotary Club, which raised the $3,000 fund to cover for the cost of the system. It has been incorporated to the city’s police and Citizen’s Patrol network. These personnel will be called in for any abnormalities in the routine calls generated by the system.

The Arizona police was quite satisfied and happy regarding this concrete evidence of the system’s benefits to the city’s residents, particularly those who are homebound and with physical disabilities. The outcome would have been different for the elderly woman if she had not participated in the program.

Richard Barthallo is an article writer for Phoenix Arizona Water Damage Restoration and Phoenix Arizona Flood Damage Cleanup

Due to the remarkable advances in health care and better living habits, many senior citizens are living alone in their own homes longer than ever before. Although seniors are usually perfectly capable of taking care of themselves, their loved ones often worry about what might happen if something goes wrong. Here are a few things to look out for when a senior citizen is living alone.

– Maintaining proper lighting in a home is essential to safety. So many seniors fall in their own houses simply because they couldn’t see where they were going! Making sure light switches are near doorways will prevent having to venture into a darkened room.

Windowless hallways may be a hazard at any time of day, so consider having permanent nightlights kept on in these kinds of areas. There should always be a lamp on a bedside table and a flashlight for emergencies at hand.

– To prevent bathtub falls, make sure it has a non-skid surface and have safety railings installed. There are seats available for both bathtubs and showers for people who struggle with standing for prolonged periods of time or who may suffer from occasional imbalance.

– Although throw rugs are beautiful, they can be a serious tripping hazard for seniors. Hallway runners should especially be avoided if the rugs end near the top of a stairway. Even rubber backings on rugs are no guarantee against slippage. It’s safest just to get rid of them altogether.

– Make up your own system of organization. Keep important numbers on speed dial or in the same spot by your phone at all times. Keep medications in the same place and establish a routine for taking them in the right dosages at the same time every day.

Routines for other daily activities are a great idea also: let your family members know what your schedule is. Then, if you are not where you are supposed to be, they will know something may be wrong.

– Know your neighbors! When people are looking out for each other’s welfare, everyone is safer. Good neighbors watch for trouble and will know a senior’s routine also. Install a security system for greater peace of mind, or wear an emergency pendant in case of accident.

– Keep a cell phone in your pocket whenever going outdoors, even for a minute. You will have an instant connection to your loved ones should something happen.

Following a safety conscious lifestyle brings peace of mind to both seniors and those who love them.

For expert, friendly advice on medical alert systems for senior citizens, contact the professionals at Accel, Inc. (http://ezmedicalalert.com/). Art Gib is a freelance writer.

The American economy, it seems, is just getting worse and worse. Unemployment rates are up, and fewer jobs are available than even a year ago. It’s a scary time to be looking for work, and even people who have jobs now may not have them in a year or two. There are other options. If you want job security for the foreseeable future, you should train for a career with the help of companion homemaker training. The DVDs and pamphlets available give you the information you need.

Take a moment and think about it; our country won’t soon be coming out of the recession we are in, without a miracle that is! In the meantime, more jobs will be cut or lost in the finance sectors, manufacturing, even the seemingly impervious retail sales and service fields. About the only area of employment that won’t experience serious contractions are medicine and home health care. In fact, home health care is practically guaranteed to keep growing in the next three to four decades as the Baby Boomer generation continues to age and requires medical attention at home and in hospitals or clinics. Will you be ready for these opportunities when they arise?

One way to guarantee that you will is by doing your research now, and becoming well versed in the healthcare industry. The least expensive route is deciding to do your own training from home, instead of going to a University or vocational college. If you have an ailing relative you will be able to learn while assisting them with their activities. There are always opportunities to volunteer your time at rest homes and hospitals, which you can use as additional training after you complete your DVD curriculum. The more experience you have the better prepared you will be to take care of a family member when they are in ailing health, or if you choose to make it your career.

If you’re interested in being a companion homemaker, you’ll need to work on your people skills, including positive communication skills, professional medical ethics and how they apply to the field of home health care. Even basic support skills like telephone etiquette in a client’s home are important to know. Training will include answers to all your questions including the best ways to escort and transport your client when you’re going outside the home, what to do if and when a medical emergency occurs, and how you can save a life by taking quick action and thinking on your feet. Through companion caregiver training you will be prepared for most situations.

Learning to communicate with your family member or patient that is in ailing health is a large part of the resources you will find in standard programs or curriculum. Alzheimer’s disease is a disease that affects a large part of the elderly community. Dealing with someone that is confused about who you are, is combative, and isn’t aware of their surroundings can be extremely difficult. Becoming well versed in communication techniques is essential to the overall standard of care given to an ailing senior. Understanding the disease and knowing how to interact accordingly is something that can be the hardest task to accomplish.

Whether you want more information on the home healthcare industry for professional or personal reasons, it’s a great time to study online and do your research. The best companion homemaker training courses are available from a multitude of resources. Generally the cost is low to purchase these materials, but overall its worth any amount of money. You can’t put a price on the health and welfare of your ailing family members or patients.

Andy west is a writer for Medifecta, providing programs and information, in English and in Spanish, on companion homemaker training and elderly homecare. For more information please visit Medifecta.com.

We are a nation that is aging rapidly, with the largest generation, Baby Boomers, growing near to retirement age. Because of this, there will be many Americans in need of medical care in the next three or four decades, more so than in previous years. This means that more and more children and other relatives will be called upon to take care of their aging relatives. The economy in its current state has financially ruined hundreds of thousands of people, and this will undoubtedly affect the retirement of our Baby Boomers. In home health care and family caregiving, some predict that many of us will become do-it-yourselfers. That doesn’t have to be a daunting prospect if you have the right outlook and family caregiver training.

Nurturing those who nurtured you during your early years will give you pride in your familial relationships, not to mention the fact that you will be spending the last days caring for your relatives. The bonds shared during this time will give you memories for a lifetime after they’re gone. You’ll be helping your family in one of the best ways imaginable. It’s a noble calling, but you’ve got to be prepared in order to do it right. One of the best ways to prepare is by purchasing and watching training DVDs on the subject of elderly home care. Some of the material on training DVDs may already be common knowledge to most, but much of the material may be new to family members who’ve never had to care for a parent, disabled friend or elderly relative. A variety of videos are available on the market that will assist you in everything from the very basic to the very detailed and concise.

For instance, it’s vitally important to know what to do in cases of emergency, such as a home fire, or if the person you’re caring for has a heart attack, a stroke, a seizure, or a fall. Falls can have devastating consequences for the elderly, so you need to know what to do so that you can act quickly and calmly. Some efforts taken within the first five minutes of a serious event can safe a life. Knowing what to do in family emergencies will enable you to take appropriate action quickly. You will be prepared and know not to panic, or just make plain bad choices. Getting the proper training in family care giver techniques will help you to preserve the life and health of your important loved ones for years to come.

It’s not only important to know how to cope with emergencies; you must also know how to assess a person’s quality of life and know how you can assist. You may be required to carry out the common day-to-day tasks that caring for an elderly and infirm person demands. Some of them are simple things like knowing how to do laundry efficiently, iron, clean, help with showers and general hygiene. It’s also important to understand the value of good nutrition. Your needs may be completely different from your 90 year old aunt. She may need calcium, low sodium, low fat, nutrient enriched supplements, just to name a few. Being able to prepare a variety of different, tasty, nutritious meals is essential to caring for another person, especially when appetites are low. It is essential that the person you are caring for eat regularly, so they can maintain a good quality of life.

Being a good housekeeper, a good cook, and good training all make a great caregiver. With the current prices of medical care and the state of our economy, it’s no question that caring for your family will soon be more of a responsibility for the younger generations. Be prepared with family caregiver training, and get your siblings and cousins to join your efforts. You won’t soon be disappointed.

Andy west is a writer for Medifecta, is dedicated to enhancing the well-being and knowledge of professionals through family caregiver training. For more information please visit Medifecta.com.

Individuals who are interested in the healthcare industry and employment positions can enjoy the benefits of home care training. The care giving industry is one of the fastest growing in the United States. There is a consistent need for individuals who are interested in assisting others. As a result, not only are professionals potentially promised work, they may also be able to vie for higher salaries since the demand for such individuals is so high in today’s society.

For those who are interested, it is possible to enjoy training from a structured, classroom setting, in an online environment and through simulators. All forms of learning can help specialists brush up on and improve the processes in their everyday tasks.

Training is always important in order to become good at what you do. It is especially important when the lives of individuals, especially, the elderly, are resting in the hands of these professionals. It is important that caregivers be properly trained and educated in order to ensure the best possible care for those who need it. Families need to implement high standards when it comes to their medical care; the more extensive and prestigious a caregivers training, the more these individuals will adhere to the standards in general medicine.

While some healthcare professionals are not as educated in certain areas, they are also not paid as much as their more educated counterparts. As a result, education is integral to career advancement. In addition to education, healthcare workers can enjoy training as a means to instill confidence in their work. Increased confidence can lead to improved success for not just healthcare professionals, but professionals in any field.

Depending on where an individual is located in the United States, they can be right around the corner from a learning facility and not even know it. Many universities and colleges offer classes that are related to healthcare education. By performing a school search of an individual’s local region, they will be able to discover what institutions are located nearby and how close by home care training classes or courses are. However, in today’s day and age, a more popular choice is to look on the Internet. Many schools and training courses are available outside the confines of a classroom. Not only do these programs offer individuals the convenience of learning at their own rate, they are also competitively priced. Financial aid and grants are available to those who quality.

Many online courses you may find are apart of a program or are individualized. Such courses may be completed in a quick or lengthy period of time, depending on the preference of the individual taking the class. Online courses do not interrupt the every day lives of students, as you can pick up and complete assignments as you are available. For example, if you work during the day, you can perform training tasks and courses at night after the kids have gone to bed. This allows you to keep your job while receiving an education to help you advance in your career. Online distance education makes learning more convenient for the busy American person. We all want the ability to succeed and advance, but sometimes there isn’t enough time to go to school. This option is open to just about everyone.

Once training is completed, there are a number of ways to practice the home care training procedures you’ve learned. If you are still feeling like you need practice then check out a number of home care training simulators which can be purchased for your individual use. Many of these simulators are available online. With so many resources, there is no reason why you can’t advance yourself in your current healthcare career.

Andy west is a writer for Medifecta, a retailer of the best home care training DVDs and pamphlets, as well as an online resource for valuable information. Please visit Medifecta.com.

Elder abuse resources are designed in to assist those who have fallen victim, or know a relative who has fallen victim, to elder neglect. There are a number of situations which would qualify as such. Abuse can occur not only through another’s actions, but also through lack of actions, or neglect, when it comes to caring for a partially or fully incapacitated person. Every year, tens of thousands of individuals in the United States alone are subjected to abuse, if not more. Authorities are made aware of hundreds of thousands of reports, while it is estimated that as many as half a million more cases are not reported to authorities annually.

Elderly individuals can make easy targets due to their general fragility and the fact that they are less likely to fight back against their attackers. Additionally, many do not see or hear as well as they once did. It is possible that they may question what is occurring to them, but they may not be able to vocalize their abuse or neglect to others. They are, generally speaking, less likely to stand up for themselves when compared to younger individuals who may experience being bullied. In most cases, individuals who are mistreated are done so by the very person or persons who are in charge of their care. It most often takes place where the individual lives, such as in their home or at an assisted living facility. If mistreatment is suspected, there are resources that may be utilized to assist in helping catch the culprit(s) and stop the mistreatment.

Maltreatment can take many different forms. However, if you understand the type there are more specific resources to be considered. Such ill-treatment can take the form of physical, emotional, or sexual abuse. There is also neglect or abandonment on the part of the caregiver(s), financial exploitation, and healthcare fraud or healthcare cruelty. While general signs of mistreatment include frequent arguments between the affected individual and their caregiver or changes in the personality of the affected person.

There are also more specific signs of elder cruelty as categorized by each potential form of abuse. Many online resources offer a complete listing of symptoms on their websites, broken down by the type of mistreatment which may be taking place. Identifying suspected violence is the first step to getting the victim help, which makes online resources very valuable.

Some help is readily available. For example, it is important to report suspicions to the effected victim’s family, physician or a personal friend who may be able to help. It is suggested that if an individual suspects mistreatment, they should inform, at the very least, one other person. Ignoring or attempting to rationalize it away will not help the person in danger. State information pamphlets can be helpful in your time of need. Generally an organization can be contacted nationally on an 800 number. U.S. Administration on Aging offers several resources and guidelines to helping determine and deal with violence and neglect.

In many states throughout the US, the first agency that is designed to respond to situations such as these is Adult Protective Services. The power and scope of actions which Adult Protective Services can offer varies from state to state, since there is no federally structured organization in place. Each state has its own phone number to contact APS.

Once violence is found to have occurred, there are a number of agencies which can assist in the aftermath of such trauma. If you find yourself in the position of taking care of an older family member or friend, then it is wise to gather your elder abuse resources. You never know when you might need to call upon others recommendations and advice.

Andy west is a writer for Medifecta, dedicated to providing a varied curriculum to teach about elderly care and can provide you with a list of elder abuse resources. For more information please visit Medifecta.com.