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Кровать Ким 160х200 Дуб кари белый Сан-рено (с ламелями) Мебель Сервис (. 7 см) (com)

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см) (com)

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см) (com)

Компания осуществляет возврат и обмен этого товара в соответствии с требованиями законодательства.

Сроки возврата

Возврат возможен в течение 14 дней после получения (для товаров надлежащего качества).

Обратная доставка товаров осуществляется по договоренности.

Статьей 9 действующего Закона Украины «О защите прав потребителей» предусмотрено право потребителя обменять непродовольственный товар надлежащего качества на аналогичный, если купленный товар не подошел по форме, габаритам, фасону, цвету, размеру или по другим причинам не может быть использован по назначению, если данный товар не использовался и если сохранен его товарный вид, потребительские свойства, пломбы, ярлыки и расчетный документ, выданный продавцом вместе с товаром. Продавец не имеет права отказать в обмене (возврате) товара, не включенного в перечень, если он соответствует всем требованиям, предусмотренным ст. 9 Закона (сохранен товарный вид, ярлыки, пломбы, имеется расчетный документ и т.д.).

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см)

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см)

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см)

Кровать Ким 160х200 Дуб кари белый + Сан-рено (с ламелями) Мебель Сервис (168.8х208.8х98.7 см)

*Внимание, не забудьте приобрести 👉 матрас 👈 размером 160х200 см .

Комод "Ким" 0,91 х 0,85 метра

 Комод "Ким" 0,91 х 0,85 метра

ВенгеВенге
Дуб молочныйДуб молочный

«Ким» Ко мод. Высота комода — 91 см, ширина — 44,6 см, высота — 85 см. Магазин «Мебель-Рик» имеет в ассортименте дополнительные модули данной серии, что поможет собрать красивый спальный гарнитур: кровати, пенал, шкафы, прикроватная тумба, зеркало .«Ким», п олностью соответствует своему названию: вся мебель этой серии красива и изящна и удовлетворит вкусы самых требовательных клиентов.

Сушилка для посуды хромированная 80см

Сушилка для посуды хромированная 80см

Спальный гарнитур "Ким"

Спальный гарнитур "Ким"

Зеркало "Ким"

Зеркало "Ким"

Тумба прикроватная "Ким"

Тумба прикроватная "Ким"

Шкаф "Ким" 2-ств МДФ 0,9 метра

Шкаф "Ким" 2-ств МДФ 0,9 метра

Шкаф "Ким" 3-ств МДФ 1,5 метра

Шкаф "Ким" 3-ств МДФ 1,5 метра

Кровать "Ким" 1,6м с подъемным механизмом

Кровать "Ким" 1,6м с подъемным механизмом

Тумба под ТВ Ким

Тумба под ТВ Ким

Угловой шкаф "Ким" 0,87 метра

Угловой шкаф "Ким" 0,87 метра

Пенал "Ким" 0,5 х 2.23м

Пенал "Ким" 0,5 х 2.23м

Материал
Цветбелый глянец/венге
МатериалМДФ
Размеры
Высота, см91
Длина, см85
Ширина, см44,6

Сборка мебели

  • Сборка мебели для Москвичей и жителей Ближайшего подмосковья (в пределах 100 км.) производится в день доставки (в случае если сборщики свободны), либо в любое удобное для покупателя время.
  • Предположительная стоимость работ по сборке:
  1. Любая Кухня 2,0м. (только собрать все шкафы + повесить на стену), без врезки мойки, подключения кранов и т.д. — 2500руб
  2. Спальня "Зиля" — 3000руб
  3. Спальня "Фиеста" — 3000руб.
  4. Прихожая — от 1500руб

Дополнительные работы по сборке (сверление отверстий,подгонка столешниц по стене, установка стеновых панелей, врезка моек, установка кранов, посудомоечных и стиральных машин, подключение подсветок, и др. виды дополнительных работ) оплачиваются отдельно.

  • Вынос упаковочного материала сборщиками не производится.
  • Помните, товар подлежит возврату ТОЛЬКО в разобранном виде, в заводской упаковке, без следов попыток сборки.
  • Сохраняйте упаковку до момента полной уверенности в том, что Ваш заказ пришел в нужном цвете и комплектации.
  • При самостоятельной сборке, Покупатель обязан проверить комплектацию до начала сборки! Претензии по количеству и качеству после начала сборки не принимаются. (в случае некомплекта мебели, доставка до покупателя брака, либо недостающих частей осуществляется в кратчайшие сроки и за счет продавца)
  • Бракованные детали со следами сборки не меняются.
  • Все отсутствующие или испорченные детали покупаются и меняются за счет Покупателя.
  • Срок замены таких деталей составляет срок от 10 дней.

Гарантия на товар:

Гарантия на товар предоставляется заводом изготовителем и составляет 1 год с момента продажи товара при условии нашей сборки, либо сборке сторонней организации имеющей необходимые сертификаты на осуществление сборочных работ.

Доставка по Москве

Стоимость доставки по городу в пределах МКАД — 1000руб (независимо от количества товара и веса)

Стоимость доставки за пределами МКАД до 10 км — 1500руб, далее 30ркм (независимо от количества товара и веса)

Доставка осуществляется до подъезда, в доставку не входит подъем на этаж, сборка, установка, вывоз старой мебели и т.д. — данные услуги оплачиваются отдельно.

Доставка осуществляется в пределах Москвы ежедневно с 10.00 до 23.00. Также возможна доставка в день заказа без доплаты.

Заказ на сумму свыше 80 000 рублей доставляется бесплатно в любое удобное для клиента время!

Стоимость бесплатной доставки рассчитывается от суммы заказа с учтенной скидкой. В случае если сумма заказа после применения скидки менее 80 000р,осуществляется платная доставка.

Пример:

  • кухня 2.0 метра в прелах МКАД, доставка будет стоить 1000руб, за МКАД в пределах 10км. 1500р (ДАЛЕЕ 10КМ — 30ркм)
  • Спальный гарнитур с матрасом в Пределах МКАД — 1000р, за МКАД в пределах 10км. — 1500р. (ДАЛЕЕ 10КМ — 30ркм)

Самовывоз

Удобный и быстрый способ получения заказа.

Адрес офиса + склада: Москва, 2-й Южнопортовый проезд д.10., мы находимся на территории "Южного речного порта".

Для Въезда необходимо заказать пропуск, обязательно необходимо звонить перед выездом и уточнить наличие товара и заказать пропуск!!

Внимание!! Въезд на территорию платный, составляет 70р. за легковой транспорт и Газели. Для прохода на территорию необходимо взять с собой документы: Паспорт или права.

Доставка в регионы с помощью транспортных компаний

Удобный и быстрый способ доставки в крупные города России. Посылка доставляется в терминал любой транспортной компании Москве. Для получения необходимо предъявить паспорт и номер грузовой декларации(сообщит наш менеджер после отправки).

Все заказы которые отправляются в регионы оплачиваются по 100% предоплате только в случае наличия товара на складе.

Доставка до Транспортной компании осуществляется нашими силами БЕСПЛАТНО (это бонус покупателю)!! При получении товара клиент оплачивает только стоимость самой перевозки.

Срок доставки и стоимость Вы можете рассчитать на сайте транспортных компаний:

и др. удобные для Вас компании

Подъем на этаж

  • от 600 р при наличие лифта
  • без лифта от 200 р за этаж (+600р. до подъезда)

Пример:

Кухня 2.0 метра — 600 р при наличии лифта

Спальня — 800 руб при наличии лифта

Гостинная от 2 — 3 метров — 600руб. при наличии лифта

Оплата товара:

Оплата товара Осуществляется непосредственно при получении товара клиентом. Оплата производиться наличным расчетом.

Взамен водитель выдает Вам Товарную накладную (форма торг 12) по которой необходимо сверить товар и затем поставить свою подпись в графе "товар принят".

Предоплата (но не более 5% от суммы заказа) возможна только в одном случае — если Ваш товар заказывается с индивидуальными размерами под заказ.

Как собрать кровать ким

Calling all early birds: Save up to 25% when you give a holiday gift subscription!

taraxacum officinale

What is a Dandelion?

The word dandelion, meaning “tooth of lion” because of the shape of their leaves, actually refers to more than 250 species in the Taraxacum genus. The most common one that you might have in your garden is aptly named the “common dandelion,” or Taraxacum officinale. One of the many other species, Taraxacum californicum, is native and endemic only to the San Bernardino mountains of California.

Dandelions are usually yellow and have a “composite” head, made up of a bunch of flowers, as opposed to a “disk” head, making them a favorite for butterflies who can’t fit in more closed-face flowers. They have an exceedingly long history of traveling around the world with and for humans.

dandelion heads

Foraging

After watching some videos from Alexis Nicole, a social media celebrity who teaches people to appreciate and eat the plants growing in their neighborhood, I decided to try foraging. After much effort and a failure to get anything good from cattails, I turned to dandelions. I already knew how to identify this weed, for the most part, considering how common they are around humans. And I knew I could find them all over the neighborhood, from parks to yards.

“Dandelions are more like beginner-level foraging,” says Jesse E.D. Miller, who researches plants and landscape ecology at UC Davis. That’s pretty appealing to me, as calling myself a beginner-level forager is a stretch.

“When it comes to foraging, dandelions are one of the healthiest, healthiest, healthiest things you could collect,” says Tracy Thatcher, a garden and nature educator, and San Francisco Botanical Garden docent.

I met Thatcher at Mitchell Canyon, one of her spots at which she regularly trail runs. It’s hard to imagine she gets any running done at all for two reasons. One, because she frequently stops to point out facts and uses of all sorts of plants, ever present and aware of what’s happening with the plants on the trail. Two, because she once broke her back and was bedridden for seven years. Now, she runs on Bay Area trails multiple times a week and teaches plant-based cooking.

The health benefits of foraging dandelions are consistent across many different cultures. Various Native American groups considered dandelion to be, for instance, an all-over wellness tonic. The Cafe Ohlone, which plans to reopen in Berkeley early next year, offers dandelion soup on the menu.

Early Europeans and practitioners of Traditional Chinese Medicine also used dandelions to treat a wide variety of ailments. Ultimately, Europeans brought the common dandelion to the United States as a salad green. Thatcher juices the greens, sautés them, and uses them in salads. You can use the yellow heads in baking, wine, and tempura snacks.

Many dandelion benefits have been confirmed in a lab as well. A 2016 Study published in the journal Romanian Biotechnological Letters found that dandelions are filled with antioxidants, vitamin C, chlorophyll and carotenoids. Scientists have also found that Dandelion Root Extract (DRE) kills 95 percent of colorectal cancer cells in a petri dish, and 90 percent in mice.

There are just a few dangers to watch out for. For instance, any plant that lives so close to humans can be exposed to pesticides and herbicides, so it’s important to wash your haul. Also, while diuretics can be useful in many circumstances, this quality has also gained the flower the nickname “wet-the-beds.”

Want even more stories about Bay Area nature? Sign up for our weekly newsletter!

As a Part of Nature

Dandelion is “a really useful plant to have around both from an ecological perspective but also because we can use the plant,” says Miller, the UC Davis botanist.

Miller categorizes some invasive plants, such as dandelions, as “exotic but benign.” They can, like any plant, crowd out whatever other plants live in their environment, and for that reason, Thatcher, a fellow dandelion lover, will cut off the seed heads before they overpopulate her yard. Miller says that dandelions aren’t usually much of a problem to native plants because they prefer the type of soil that most other plants hate anyway. Still, the flower can be obnoxious in its coverage of some domestic plants, competing for sun and soil in fields of crops like alfalfa.

Humans tend to compact soil, which makes it hard for many plants to grow. As the plants with more sensitive roots leave, dandelions take root, with their strong, deep taproots penetrating the earth. “You could think of it almost as helping to repair compacted soils very slowly,” says Miller. They also help fertilize your yard by fixing nitrogen levels.

Pollinators drop pollen into the flowers, which goes down into the ovary of the plant, fertilizing the seeds. When that doesn’t happen, the plant can simply fertilize itself. Then, the fuzzy inside of the flower emerges, pushing away the yellow portions, and forming into a fuzzy parachute or papus. These papuses form a “blowball,” which children pluck and wish on, blowing the seeds away to settle down in someone else’s yard.

“You can’t really blame a plant that’s good at dispersing long distances and finding these opportunities,” Miller says.

dandelion seeds

A Time and A Place

While Thatcher and Miller both like these flowers as well, what I noticed is that their affection was not unconditional or absolute. Both admit that too many dandelions can be a problem. While they are overall pretty healthy for humans, any food or medicine can be misused.

The dictionary defines weeds as “a wild plant growing where it is not wanted and in competition with cultivated plants.” On the one hand, you can de-list a plant from the “weed” category by simply choosing to want it.

On the other hand, maybe “want” and “don’t want” are the wrong questions. A gardener might want dandelions to fix nitrogen levels, but not to grow out of control and crowd out other flowers. A chef might want the young leaves for salad, but not the bitter ones if it doesn’t fit the dish. And a person might want the diuretic properties of the plant — or it might be inconvenient.

Instead of trying to appreciate dandelions as a whole, perhaps we should ask, are they growing — or being consumed — at the right place and the right time for your needs?

Personally, as someone with no lawn to worry over and a penchant for free food, I love them unconditionally. But maybe that will change with time.

Creator Candace Bushnell: ‘SATC’ wasn’t feminist & Mr. Big isn’t worth it

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Reese Witherspoon made plenty of money selling her media group

‘Door is open’ for Kim Cattrall return for ‘Sex and the City’ revival

Kim Cattrall is making her way back to sitcom television.

The “Sex and the City” alum, 65, is joining Hilary Duff in the “How I Met Your Mother” sequel series for Hulu, “How I Met Your Father.”

Cattrall is set to play the future version of Duff’s character, Sophie. The series will be Sophie telling her son the story of how she met his father.

The series takes a page out of the original show’s book — much like Josh Radnor and Bob Saget’s Ted Mosby telling his son how he met his mother.

Sophie’s plotline will take place in the year 2021 as she and her posse of millennial pals are trying to figure out their lives.

The friend group includes Jesse (Chris Lowell), Valentina (Francia Raisa), Charlie (Tom Ainsley), Ellen (Tien Tran) and Sid (Suraj Sharma).

“How I Met Your Mother” ran on CBS from 2005 to 2014 and also starred Neil Patrick Harris, Cobie Smulders, Jason Segel and Alyson Hannigan.

Duff, 34, is also producing the upcoming series, which has no premiere date as of yet.

Hilary Duff

Duff is both producing and starring in the “HIMYM” sequel.

Cattrall was last seen on TV in the drama series “Filthy Rich” and “Tell Me A Story.”

The “Ice Princess” star will not be returning to the HBO Max “Sex and the City” revival, “And Just Like That,” which is set to air next month. She famously played brash, fabulous and sex-obsessed Samantha Jones.

Nicole Ari Parker will join original stars Sarah Jessica Parker, Cynthia Nixon and Kristin Davis in the show instead.

The 51-year-old admitted in October that she was yelled at by “SATC” fans for seemingly replacing Cattrall. “When it first came out that I was replacing the Samantha character — which is not true at all, so please write that — I have been yelled at,” she told The Hollywood Reporter.

“I’ve been photographed in places I should never be photographed,” she added. “The fans are so excited and over the top. I had some idea of that because I am one of those fans but I had no idea [the extent of it].”

How Amazon’s ‘Fairfax’ Humanizes the Hypebeast Experience: “It Is the Obsessive Need to Get Something”

The animated comedy’s creators and animator talk about centering the search for clout on a group of 13-year-olds and aesthetic inspirations including Tyler, the Creator.

Evan Nicole Brown

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Fairfax

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Fairfax, the new original series from Amazon Prime Video, is an animated comedy starring Skyler Gisondo, Kiersey Clemons, Peter S. Kim and Jaboukie Young-White as four middle school best friends on a passionate quest for clout on Los Angeles’ famous Fairfax Avenue, a block known for its winding lines of young streetwear aficionados waiting to buy the newest sneaker release.

Created and executive produced by longtime friends and Los Angeles natives Matthew Hausfater, Aaron Buchsbaum and Teddy Riley, Fairfax humanizes the hypebeast experience by finding humor in the fundamentally relatable desire to be part of a community.

Episode one follows the earnest, outdoorsy Dale (voiced by Gisondo) who’s just moved to the Fairfax area from Oregon as he joins the “Gang Gang” (a crew of 13-year-old friends) who spend their days hunting down the latest Latrine clothing release: the Dr. Phil Box Tee. THR‘s review of the series calls it “visually energetic, humorously frantic and populated by an exceptional voice cast.”

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The characters, designed by artist Somehoodlum, were created on spec “before they were voiced,” he said, adding: “I never think about how my art is going to be animated so it was really cool to think about how a hoodie was going to look from the back, from the other side.”

While pitching the show, Hausfater, Buchsbaum and Riley had a clear vision of who they wanted each of the four main protagonists to be, but conceptualizing those archetypes was not without challenge. “It was really hard to encapsulate all aspects of ‘hypebeasts’ in four characters, that was something we struggled with,” Somehoodlum explained. “All I did was represent a style.”

Somehoodlum’s aesthetic is influenced not only by satire but by the distinct colors and textures of Los Angeles, creating an atmosphere for the show that is equal parts grit and saccharine illusion. “L.A., in general, is the land of opportunity; it feels like anyone can come as a fan and leave as a legend,” he said. “This is where a fan becomes an actual contributing member to the culture: I’m just inspired by Tyler, the Creator — that’s what my pastels are all based off of — the Golf Wang look books back in the day from 2012 … It comes from the love of this community.”

On Tuesday, Nov. 2, the cast, creators and special guests gathered on the avenue at the pop-up “Latrine Store,” which is based on Latrine, a fictional streetwear brand created within the universe of the show. The pop-up is open to the public through Nov. 6 and sells merchandise like fanny packs, bucket hats, yo-yos, skateboards and salad tossers.

All eight episodes of the first season, which premiered on Oct. 29, are exclusively available to watch on Amazon Prime Video, and production for the show’s second season is already underway. THR spoke to Hausfater, Buchsbaum, and Riley about the Los Angeles that raised them and inspired the site-specific series.

Lazy loaded image

What role has Fairfax Avenue played in broader Los Angeles culture? And why did it feel like the right environment to set a new animated comedy?

TR: Fairfax played a huge role in our formative years. We’re all from L.A., and we all grew up loitering the block, eating challah french toast at Canter’s at two in the morning and watching Fairfax evolve from this block full of Jewish delis and bakeries into this incredible mecca of streetwear and pop culture.

MH: We went to great lengths with our animation studio Titmouse to make the show feel authentic in that when you see the block or when you see incidentals, as the background characters are called, they are from every single walk of life, socio-economic background, and it’s really as diverse as Fairfax in real life.

How would you define a hypebeast, and what does the streetwear subculture mean to you?

MH: I think hypebeast is just a shiny new word for saying you love and admire and are a fan of something … It really just means that you are a huge fan of streetwear and that you will do anything — short of death — to get your hands on a pair of sneakers, or a box tee or, you know, a sweater.

AB: I think every teenager is a hypebeast at some point in their life. It is the obsessive need to get something and that’s just baked into what it’s like being a kid. It’s the stuff. It’s like a hot item that is advertised on TV and baked into your brain and you just need to have it, or else.

Why does Amazon Prime feel like a good home for the show and your audience?

TR: We came up loving animated shows like Recess, Hey Arnold, Rocket Power, Animaniacs and South Park. We wanted to make a show that felt like a 2021 version of those with our own sensibility and humor involved. Whether you’re 13 or 35 or older, you’ll find something to connect with, whether it’s a joke, or an emotion, or a storyline. We wanted to find that balance between making a really specific show that felt contemporary, while also telling stories that you could connect with whether you’re from Fairfax or not.

How do you handle ‘clout’ and the quest for fame differently in Fairfax, in a way we haven’t seen before? I know these are middle schoolers, but how do these themes extend beyond that stage of life?

AB: Every story we told boiled down to what we felt was a universal, relatable theme. So, for instance, Episode 106 is about making a varsity team; everyone can connect to what it feels like to want to be on a team and wanting to be the champion of that varsity team. So, the hope is that an audience can still see and connect to this story, even though it doesn’t necessarily resonate in their life at that moment.

TR: What’s funny to us is that there are so many people our age and older who behave just like the kids in our show, if not more immature [laughs]. Whether you’re 13 or our age, we know people who are trying to get a fit off, or who are trying to make content on social media and brand themselves. I think adults can watch the show and laugh at themselves a little bit. Because whether they realize it or not, I think everybody is trying to kind of find their place in this weird game of the internet.

Lazy loaded image

How has working as three friends and collaborators informed the creative process from when you first began developing the show to now?

AB: It’s been a fantastic process that is ever-evolving; we are constantly learning and trying to make our process better. Obviously, three is an interesting dynamic — truthfully, like a marriage, it requires work. It’s a process and it’s a delicate balance, but it’s something that I think we have succeeded at doing, and frankly love doing.

MH: I don’t know if it is for these two guys, but it is a dream come true for me to work with them. Because, you know, we came up as writers together; Teddy and Aaron had a script on the 2012 Blacklist, I had a script on the 2012 Blacklist. I’ve read every single script they’ve ever written, and I’ve always been like, ‘Man if I could just find a way to work with those guys …’ because they’re so funny. And they have such good action comedy, whereas I’ve always been kinda like this rom com guy. And the alchemy in the recipe when you put us all together is truly what makes Fairfax. Teddy and Aaron are my two best friends, and I am incredibly lucky to get to do this with them because it’s really challenging and I’m sort of in awe of anybody that can do this as one person.

TR: It was a blessing in disguise because if there was something that we all loved, we knew it was strong. Matt always references The Voice, and how we have like a three-chair turn system. Whether it’s a song, or a design, or a storyline, everything gets the three-chair turn. And if it doesn’t, then we figure out a way to beat it so that we’re all really happy with what the final result is.

How did you approach casting the ensemble of characters?

TR: We wanted to cast people that felt new and different for an animated show, people that weren’t your regular usual suspects of voiceover actors. Some are and they’re incredible, but some are people that you go, ‘Oh, whoa, I didn’t expect to see this person in an animated show’ and that’s what we found to be so satisfying about working with them. It was all about actors that could bring authenticity and a voice and a personality to these characters, and everybody else was a combination of people that we’ve long admired or people we thought could bring just a hilarious voice to the show. I mean, John Leguizamo and J.B. Smoove voicing our pigeons was just a dream come true. We couldn’t have asked for better improvisers and funnier people. Everybody on our show did such a great job helping us build out that world.

How did Somehoodlum, who designed the animated characters, help your vision come to life?

AB: Somehoodlum is an incredible artist that we had been a fan of just through the internet; we really connected with their color palette and felt like it spoke to Los Angeles, and their visual style was just something that felt really unique and felt different from the other animated shows that we were familiar with. The process working with them was incredible. They’re incredibly collaborative and a dream to work with and just have such an understanding of the world of Fairfax. They are so in on the joke there. If you look at their Instagram, satire is kind of baked into everything they do. So tonally it really spoke to the voice of the show as well. It’s a perfect fit.

What’s your favorite, quintessential place to go on Fairfax?

AB: I’m a foodie so … Animal was one of my spots. I just think Animal was one of the best restaurants in Los Angeles. I love eating there. And obviously Jon and Vinny’s. I’m all about that grub.

MH: I also love food. I think Meals By Genet is one of the best meals you can have in Los Angeles. And then obviously, love and respect and a big shout-out to Tyler, the Creator and the Golf Wang store. As well as goo which is a hair salon where my wife sometimes gets her hair done. And Zak! Zak. is truly where I get my glasses.

Telehealth improves heart care for Veterans

Heart failure affects around 6.2 million adults in the United States and is one of the leading causes of hospitalizations nationwide.

VA cares for Veterans with heart failure through efforts such as specialized heart failure clinics, pharmacists, and the Remote Patient Monitoring – Home Telehealth (RPM–HT) program.

Veterans enrolled in RPM–HT receive remote monitoring technologies to track their weight, blood pressure and heart rate daily. Care coordinators (typically registered nurses) call the Veterans when these vitals go outside of specified parameters.

Quality improvement initiative brings disciplines together

This year, a group at Los Angeles VA integrated RPM–HT with support from cardiology and pharmacy staff to create an initiative that is optimizing care for Veterans with heart failure.

That group consisted of Dr. Kim Lynch, a general internist and VA advanced fellow in the National Clinician Scholars Program; her mentor, Dr. Shelly de Peralta; a nurse practitioner in cardiology; Dr. Donald Chang, a consultant cardiologist, and several RPM–HT nurses.

In 2020, Lynch identified an increase in the number of heart failure patients who had been admitted to the hospital two or more times in the past year. Further inquiry revealed issues related to care coordination.

These included the lack of a consistent provider, follow-up care, and the ability to track blood pressure and weight at home. It also revealed that issues with medications were the leading cause of readmissions.

Lynch and de Peralta conceived a quality improvement initiative to bring together the various disciplines — cardiology, pharmacy, and RPM–HT — to reduce hospitalizations and optimize care for those at-risk Veterans.

Idea came from helping her Veteran grandfather

For Lynch, this initiative hit home. When she was in medical school, her grandfather, an Army Veteran, confessed that he would occasionally miss a day of taking his diuretic medication. As a result, his ankles were swelling.

Dr. Shelly de Peralta

Lynch suggested taking an extra dose the day after any missed dose to relieve his symptoms and wondered why his VA care team hadn’t suggested that. She believed care teams should have the medications, the technology and the evidence to improve medication management for Veterans.

Lynch’s team got to work. In November and December 2020, they conducted a literature review of national care coordination programs for Veterans with complex conditions such as heart failure. The evidence indicated that these programs could reduce admissions for such conditions if the right providers delivered the right care at the right time.

Nurses developed template for signs and symptoms

In January 2021 the team began the pilot intervention. They identified the target group as all Veterans who had been admitted to the hospital twice or more in the last year. Three RPM–HT nurses would also take part.

The intervention had two objectives. The first was to engage RPM–HT nurses and VA pharmacists to improve home tracking of symptoms, vitals, and medication management. The second was to give each Veteran a consistent VA provider in the chronic heart failure clinic.

The provider would interact with the Veteran, RPM–HT nurses and pharmacists would provide timely, problem-directed interventions. VA staff members would communicate through secure messages to manage Veteran care.

The nurses who participated in the pilot collaborated with Lynch and de Peralta to establish a questionnaire, or “template,” about the signs and symptoms of heart failure since the Veteran’s last evaluation. The template is based on questions from the American Heart Association. It addresses diet, leg swelling, medication adherence, shortness of breath and more.

The pharmacists also designed a template to collect data on pharmacy-sensitive measures. The focus of this data collection and care was on heart failure-related, guideline-directed medical therapy initiation and optimization.

Weekly meetings to review best options

The process starts when the RPM–HT care coordinator calls a Veteran weekly and uses the template to assess for changes in symptoms. The care coordinator also initiates a call any time a Veteran’s device-recorded vital signs or symptoms are outside of provider-specified parameters.

The coordinator then communicates the clinical assessment with the Veteran’s cardiology provider through a secure message. The cardiologist reviews the information and decides on an appropriate intervention for the Veteran, which may include a medication adjustment. The pharmacist assists in processing any medications using the data obtained from the RPM–HT Care Coordinator’s calls.

The cardiologist and pharmacist meet weekly to discuss the Veteran’s clinical status. They also gather data and review the best options for adjusting medications based on medical therapy. The team’s timely interventions and ongoing medical therapy are crucial to stabilize the Veteran’s heart failure and prevent hospitalizations.

Pete and Blanca Perales

75% decrease in emergency room visits and hospitalizations

By mid-February, the initiative expanded to include six RPM–HT care coordinators and registered nurses. From April to July, the team collected data and tracked the progress of more than 30 Veterans.

The results of the program have been impressive. Among the 30 Veterans who are actively sharing vital signs weekly, there was a 75% decrease in emergency room visits and hospitalizations post-intervention, compared to pre-intervention. In addition to health benefits for Veterans, these results inform potential cost savings for both Veterans and VA.

“Being part of the program has been great,” said Pete Perales, a Veteran enrolled in the initiative. “I rely on my nurse to give me advice and remind me to take my medications. Because of her, I have not been admitted since last year.”

His wife, Blanca Perales, agreed. “This program keeps him on track. Pete looks forward to her calls. We are very happy with the program.”

A cardiology nurse practitioner noted the benefits to providers as well. “This is helping me a lot. I am now spacing out my patient appointments from once a week to once every two weeks. And I’m more comfortable doing phone appointments because I have the vitals and the template. And I can trust that the information is reliable.”

Multiple disciplines collaborating benefits Veterans

Lynch hopes other VA care teams can use this program as a model for bringing evidence-based practices to Veterans who are high-risk heart failure patients.

“This program really highlights the collaborative nature of multiple disciplines that can come together for the benefit of the Veterans,” de Peralta said. “People have said this could be a game changer in the management of high-risk heart failure patients.”

For more information on meeting with VA providers virtually and sending health data from home, check out the VA Telehealth Services website.

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