Barry's Blog

The ‘Age Wave’ is Here

This article appeared in the 4th quarter 2014 issue of the Journal of Employee Assistance

Aging Parents is Vital EAP Issue

“As the American population ages, employee assistance professionals have an opportunity to become advocates of proactive planning as opposed to simply providing interventions when needed.”

By Barry D. Epstein, J.D.

Our aging parents face enormous challenges struggling to navigate the complicated health care maze. Their adult children, many in their prime working years, share this struggle regardless of whether they are caregivers. The stress, distractions and demands of helping an aging parent frequently undermine both personal health and job performance. Both employees and employers are important stakeholders in the care of our elders.

Early interventions, particularly planning services, are preferable to “emergencies”, which arise largely because families do not adequately discuss and plan for issues related to aging. As the American population ages, employee assistance professionals have an opportunity to become advocates of proactive planning as opposed to simply providing interventions when needed. In other words, the challenges of aging parents are inviting early EAP interventions. More specifically:

* What should be the role of EAPs as the need for proactive planning increases?

* How can EAPs and their employer clients help increase job performance and return on investment while workers struggle in their relationships with aging parents?

Unique Aspects of the ‘Age Wave’

Renowned aging theorist, Ken Dychtwald, Ph.D. has studied the effects of the aging population, the “Age Wave”, on not only consumers and markets but also on families, elder care, and the health care system. Dychtwald’s 2010 study for Genworth Financial found the “vast majority of families have not had a comprehensive discussion regarding long term care.” From my hands-on experience I know this is still the situation today.  His study includes findings that EAPs should take into account:

1. Most elders prefer and are receiving long-term care at home;

2. The vast majority (80%) of home care is by unpaid caregivers;

3. Families significantly underestimate the financial and emotional demands of caregiving; and

4. Even though two-thirds of the population will require caregiving assistance, a minority (35%) of those surveyed believed they would.

Adapt or Perish

EAP providers regularly face the challenges of employer clients torn between their desires to support staff embroiled in elder care issues with their need to protect the bottom line.  There is a potential win-win strategy here.

In his book, Marketing to Leading-Edge Baby Boomers (2003), Brent Green cautions that industries that ignore these types of seismic demographic shifts and their sociological context will suffer lost market opportunities. In recent years I have noted that several major industry players have shifted their focus to begin offering different elder care solutions than what they provided previously.

For example, Morgan Stanley recently announced a strategic partnership with a medical case management firm due to the fact that their brokers do not have the expertise to properly handle key elder care issues.  A number of major banks and trust companies are now offering “holistic” wealth management strategies that include elder care service referrals.

In addition, many long-term care providers have created call centers to respond to families struggling with elder care challenges. The “take-away” for EAP is that if EA professionals do not assume a leadership role in addressing these challenges, another industry will.

Proactive interventions and provider collaboration in senior care solutions can offer significant cost-saving opportunities for families and employers alike.  However, waiting to discuss care options and preferences until a parent falls or is diagnosed with a terminal disease triggers emergency-based decisions that, over time, are less effective and more expensive. This is also a result of the myth that remaining in one’s home is always a senior’s best option. This myth fosters “volunteer” spousal and/or family caregiving without adequate, objective evaluation. My own family made this same misstep relative to my mother’s disease path as she declined due to the ravages of Alzheimer’s and Parkinson’s.

A survey of various EAP websites reveals an industry dilemma about which specific solutions for elder care issues should be offered. The minimal end of the spectrum, such as a senior resource list, is tempting given elder care complexities, but it also may represent lost opportunities for more impactful interventions with a better ROI. Resource lists and countless Internet sites without qualitative assessments often leave families intimidated and confused. Alternatively, full-service offerings raise equally compelling issues for companies:

* What are the provider screening criteria?

* Who created it and what is their level of expertise?

* What are or should be the credentials of the “specialists” who assist the employee?

* What ethical dilemmas arise when the referring EA professional faces conflicts between the interests of the employee, employee’s parents, and the employer?

If an employee is understandably preoccupied with or committed to the care of an aging and ailing parent, a certain degree of absenteeism, presenteeism (employees distracted at work), and leave of absence requests are predictable. This can strain performance and a sound employer/employee relationship. EAPs can assume a leadership role by working side-by-side with managers to jointly solve this problem.

Caring for Aging Parents and Impact on the Workforce

The 2013 World EAP Conference included a presentation on “Caring for Aging Parents and Impact on the Workforce.” The co-presenters were Nina Cohn, Senior Vice President for Sunrise Senior Living and Sharon O’Brien, Senior Vice President for Ceridian. Cohn explained that the tsunami-like “age wave” that is engulfing employers and employees alike is not just an American phenomenon, it also exists in Canada and Europe. This is due to demographic factors that date back to World War II and its corresponding impact on subsequent birth rates.

However, there appears to be less EAP demand for aging-related issues outside of these nations, due largely to cultural differences. Simply stated, these societies have a more firmly imbedded extended family support system. In addition, EAP is not yet a fully developed concept in some countries and cultures.

Despite growing awareness of the age wave and its consequences, even innovative companies like Sunrise and Ceridian acknowledge there is a long way to go in closing the gap between need and EAP utilization. O’Brien acknowledges that “it is the human condition to be reactive and wait.” Cohn similarly laments that there is a “dearth of elder care option awareness” specifically and even “extremely limited awareness of EAP generally.”

I believe the solution is both simple and complex at the same time… that is, raise employee awareness through EAP-driven initiatives with a corresponding “permission” by employers to seek assistance free of stigma before workplace performance suffers.

The following are some best practices for EAPs to consider implementing:

• Include parental elder care and planning as an employee wellness or work/life balance issue within an EAP’s influence. This is an area where employers should want high utilization rates.

• Adopt proactive educational programs and interventions for employers and employees beyond traditional referrals. (Savvy Aging is among the organizations that employs a facilitation process to identify issues and help create an action plan.)

• Evaluate service offerings with equal attention to quality management and return on investment by outside program assessment and future specific utilization tracking.

• Include a holistic approach to the aging maze by partnering with health insurance carriers, clients and providers to increase both program effectiveness and ROI. Employee follow ups to gauge participation and their perception of referral value is important.

Summary

Preventative resources are already standard practice in many areas, and aging is no different. It’s true that decline of a loved one’s health, disease, dementia and family dysfunction are topics we understandably try to avoid.

However, as in most areas of business and life itself, I’ve found that reflection, discussion and planning eases the journey. To provide greatest value to your employer and employee clients I urge readers to explore and implement novel ways to promote proactive elder care solutions.

Barry D. Epstein is the President of Savvy Aging (www.savvyaging.com). He is a nationally recognized long-term health care attorney, educator and mediator. He has served on Colorado’s Assisted Living Advisory Council, the Legal Advisory Committee of the Assisted Living Federation of America (ALFA) and as President of the Alzheimer’s Association–Rocky Mountain Chapter. 

References:

Age Wave. Our family, our future: The heart of long-term care planning, a national examination. Genworth Financial. (November 2010).

Ceridian newsletter, Are your employees “sandwiched?”(January 2014). Retrieved from: http: www.ceridian.com/resources/newsletters

Green, B. Marketing to Leading-Edge Baby Boomers. Paramount Market Publishing (2003).

MetLife Study of Caregiving Cost to Working Caregivers: Double Jeopardy for Baby Boomers caring for Their Parents[L1] -2011, AARP Livable Communities, (September 2012).

MetLife Study of Working Caregivers and Employer Health Care Costs, MetLife Mature Market Institute (February 2010).

Morgan Stanley Wealth Management Announces Health Advisory Alliance with Pinnacle Care Private Health Advisory – Relationship Integrates Health Management and Wealth Advisory Services, Including Eldercare Options, (May 2013).

National Alliance for Caregiving in collaboration with AARP. Caregiving in the U.S. executive summary. Retrieved from: http://www.caregiving.org/research/general.caregiving. (November 2009).

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Hospice: A Higher Calling

One of the fundamental premises of Savvy Aging is personal choice.  Wise choices, however, imply options.  The article Hospice: A Higher Calling that I recently co-authored and which appeared in the Huffington Post was motivated by a concern that industry, regulatory and federal budgetary forces were converging to create a risk to future hospice provider choices by consumers.  The public needs to be aware of this and voice their support for their future option to elect palliative rather than curative care when the time comes.  It is one of our most personal choices in life and in death.

Hospice: A Higher Calling

Posted: Updated:

Governmental Overreaction May Jeopardize Patient Choices for Compassionate Services that Spare Terminally Ill Patients and Families Needless Suffering

By Barry D. Epstein, J.D., and Brent Green

A recent Washington Post article exposed dubious hospice business practices, including alleged Medicare fraud. The controversial article focused on several large, for-profit companies that today dominate an industry historically served by nonprofits and religiously affiliated organizations.

Governmental entities, taxpayers, and law-abiding hospices should justifiably feel betrayed by any proven fraud. But regulatory overreaction could sacrifice the vital purpose and proven benefits of hospice care.

Misguided regulation could squeeze out historically successful nonprofits. Hospices could be penalized for accepting patients with more complex terminal diseases, those who do not die soon enough in the view of authorities.

All stakeholders in end-of-life (EOL) care need to reconsider the higher calling of hospice. Otherwise, terminally ill patients may soon have fewer options to facilitate their passage to the most pain-free and peaceful death possible.

A Matter of Choice More than Money

In 1983, hospice became a Medicare option for eligible persons, defined as those who have been diagnosed with a terminal condition and certified by two physicians to have six months or less to live. Terminally ill patients are thus entitled to a range of pain management and therapeutic services.

The Medicare hospice benefit has a humanistic underpinning, as championed by Dr. Elisabeth Kubler-Ross, author of On Death and Dying, a bellwether book published in 1969. Palliative care can ease pain and discomfort associated with terminal conditions without attempting to cure the patient. Services embrace the whole person and family and can provide relief from physical, emotional, and even spiritual suffering.

Further, curative procedures and therapies deemed ineffectual can sometimes cause unneeded distress while having adverse financial impact on families. Over-treating terminally ill patients also inflates national health care expenditures.

Today, Medicare pays for a major percentage of hospice care in the United States, but the regulations contain explicit rights and restraints. An expenditure cap has always been part of the authorizing statute. A patient making this choice must also voluntarily relinquish a claim for Medicare coverage of curative procedures for the same terminal illness.

The hospice benefit or election includes an initial 90-day period, a second 90-day re-certification period, and “an unlimited number of subsequent 60-day periods.” Services must be delivered with informed consent and can be revoked or reinstated upon a patient’s request, subject to certain qualifying conditions.

Both an attending physician and a hospice medical director must confirm patient eligibility, provide documentation, sign this certification, and, as of 2011, provide a supporting written narrative. A newer regulatory precaution requires an in-person assessment prior to a third period.

Caught in the Middle of Budget Balancing and Fraud Fighting

The Washington Post article presents a picture of the hospice benefit as vulnerable to abuse by providers and therefore rightfully targeted by governmental officials for scrutiny. Oversight comes primarily from the Centers for Medicare and Medicaid (CMS) and state survey agencies as well as the Office of Inspector General if criminal conduct has been implicated. But to accept recently elevated scrutiny as a sweeping denunciation of the entire hospice industry would be an imprecise understanding.

The explosive growth of hospice providers since 2000 can be attributed to for-profit enterprises, according to the 2012 Report to Congress by MedPac, the independent commission created to oversee all federal health care expenditures.

The for-profit sector also accounts for much of the alleged fraudulent billing attributed to longer periods of care for patients who never initially met eligibility requirements. Not all or even most for-profits engage in falsified billing, but some have, and this dark shadow has been falling on the nonprofit sector as well.

Mary Labyak, the late CEO of Suncoast Hospice in Clearwater, Florida, the nation’s largest nonprofit hospice, often made clear through her remarks that there are noteworthy differences between for-profit and nonprofit hospices worth consideration, from financial management practices to standards of care.

Nevertheless, MedPac reports that between 2000 and 2012 the median length of hospice stay “remained stable at approximately 17 or 18 days.” This typical length of stay is dwarfed by a qualified patient’s full legal entitlement of up to 180 days (and sometimes beyond).

Likewise, Medicare profit margins reported by hospice providers across-the-board for 2012 were projected at 5.1 percent. These modest margins hardly point to egregious profiteering. Yet MedPac and CMS decry long hospice lengths of stay without drawing sufficient distinction between appropriate and inappropriate usage.

Unintended Consequences

MedPac’s report offers more forceful commentary: “…with very short hospice stays, the concern is that patients enter hospice too late to fully benefit from all that hospice has to offer…Of course, there will always be some very short and very long stays in hospice because of uncertainty in predicting life expectancy and unforeseen events…”

An aggressive push to bring health care expenditures under control while combating fraud is understandable. But one unintended consequence of nonflexible oversight and enforcement could be to diminish the number of hospice providers and scope of services so valued by patients and families.

Hospice care embraces the inherent imprecision of science when it comes to predicting the course of a terminal disease or the exact moment of death. Yet, because of alleged abusive practices, governmental regulators are turning their backs on this key premise while demonizing lengthy stays as suggestive of fraud.

To the contrary, more rather than less hospice utilization should be the goal for a rapidly aging society. All stakeholders benefit from hospice care that begins earlier rather than later, regardless of whether the focus is quality-of-life or cost containment.

Given recent studies showing the cost savings of hospice care, why not defer to the higher calling of personal choice when it comes to death and dying? Hospice is an alternative that must not be unduly shackled by spreadsheets, length-of-stay metrics, and budgetary micromanagement.

Congress honored palliative care for terminally ill patients at the behest of American citizens, thus enabling Medicare and Medicaid funding. The higher, humanistic calling of hospice must not be regulated or prosecuted out of existence.

2014-02-10-BarryEpsteinBW-thumbBarry D. Epstein, J.D., President, Savvy Aging. During his 25+ year career as a health care attorney, educator, author and retirement community Executive Director, Mr. Epstein has counseled numerous providers, allied professionals, associations, staff and families on legal, operational and real life aspects of long-term care, including hospice. He has served on Colorado’s Assisted Living Advisory Board, the Legal Advisory Committee of the Assisted Living Federation of America (ALFA) and as President of Colorado’s largest Alzheimer’s Association Chapter.

2014-02-10-BrentGreenBW-thumbBrent Green is a creative director, author, speaker, social commentator, trainer, and marketing consultant focused on Baby Boomers, the generation born between 1946 and 1964. He has spoken for National Hospice Work Group, New Mexico Association for Home & Hospice Care, Florida Hospices and Palliative Care, Community Hospice in California, and has provided in-depth commentary for a PBS hospice documentary produced by Hospice of Michigan, entitled Except for Six.

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Aging Parent Challenges Invite Early EAP Intervention

Our aging parents face enormous challenges struggling to navigate the aging maze.  Their adult children, many in their prime working years, share this struggle whether or not they are caregivers.  Frequently the stress, distraction and demands of helping an aging parent undermine both personal health and job performance.  Both employees and employers are important stakeholders in the care of our elders.  Early interventions, particularly planning services, are preferable to “emergencies” which arise largely because families do not adequately discuss and plan for aging issues.  As the American population ages, employee assistance professionals and their industry have an opportunity to become advocates of proactive planning versus just providing interventions when needed. What should the role of EAPs role as the need for proactive planning increases?  How can EAPs and their employer clients help increase job performance and return on investment while workers struggle in their relationship with aging parents?

Renowned aging theorist, Ken Dychtwald, Ph.D. has long studied the effects of the aging population, the “Age Wave”, on not only consumers and markets but also on families, elder care, and the healthcare system.  Dychtwald’s 2010 study for Genworth Financial found the “vast majority of families have not had a comprehensive discussion regarding long term care.”  From my hands-on experience I know this is still the situation today.  His study has several findings that EAPs should take into account:

1.    most people prefer and are receiving long-term care at home;
2.    80% of home care is by unpaid caregivers;
3.    families significantly underestimate the financial and emotional demands of caregiving; and
4.    although two-thirds will need care, only 35% of those surveyed believed they would.

Adapt or Perish

EAP providers regularly face the challenge of employer clients conflicted between their desire to support staff embroiled in elder care issues and the need to protect the bottom line.    There is a potential win-win strategy here.

In his book, Marketing to Leading-Edge Baby Boomers (2003), Brent Green cautions that industries who ignore these types of seismic demographic shifts and their sociological context will suffer lost market opportunities.   In recent years I have noted that several major industry players have shifted their focus to beginning to offer different elder care solutions than those they historically provided.

For example, Morgan Stanley recently announced a strategic partnership with a medical case management firm due to the fact that their brokers do not have the expertise to properly handle key elder care issues.    A number of major banks and trust companies are now offering “holistic” wealth management strategies including elder care service referralsMany major long-term care providers have created call centers to respond to families struggling with elder care challenges. The “take-away” for your industry is that if you do not take a leadership role, another industry will.

Proactive interventions and provider collaboration in the realm of senior care solutions offer significant cost saving opportunities for families and employers alike.   Waiting to discuss care options and preferences until a parent falls or is diagnosed with a terminal disease triggers emergency-based decisions that, over time, are less effective and more expensive. This is also a result of the myth that remaining in one’s home is always a senior’s best option. This myth can and does foster “volunteer” spousal and/or family caregiving without adequate, objective evaluation.  My own family made this same mis-step relative to my mother’s disease path as she declined due to the ravages of Alzheimer’s and Parkinson’s.

A survey of various EAP websites reveals an industry dilemma about what service solutions for elder care issues should be offered.  The minimal end of the spectrum, such as a senior resource list, is tempting given elder care complexities, but it also may represent lost opportunities for more impactful interventions with a corresponding ROI. Resource lists and countless internet sites without qualitative assessments often leave families intimidated and confused.  Alternatively, full service offerings raise equally compelling issues for companies: What are the provider screening criteria? Who created it and what is their expertise? What are or should be the credentials of the “specialists” who assist the employee?  What ethical dilemmas may arise when the referring employee assistance professional faces conflicts between the interests of the employee, his/her parent(s), siblings, and the performance demands and benefit limits set by the employer?

If an employee is understandably preoccupied with or committed to the care of an aging and ailing parent, a certain degree of absenteeism, presenteesism (employees distracted at work), and leave of absence requests are predictable.  This can strain performance and a sound employer/employee relationship.   EAPs can take a leadership role working side-by-side with managers to jointly solve this problem utilizing state-of-the-art employer-sponsored resources.

Below I have included some best practices to consider adopting.

  • Consider parental elder care and planning as an employee wellness or work/life balance issue within an EAP’s influence.  This is an area where employers should want high utilization rates;
  • Implement proactive educational programs and interventions for employers and employees beyond traditional referrals (e.g. Savvy Aging employs a facilitation process to identify issues and co-create an action plan before the referral phase that is analogous to SBIRT principles).  Aging parent issues may lurk in the background of other presenting issues or not be raised due to limited awareness of service offerings.
  • Evaluate service offerings with balanced attention to quality management and return on investment by outside program assessment and future specific utilization tracking;
  • Include a holistic approach to the aging maze by partnering with health insurance carriers, clients and providers to increase both program effectiveness and ROI. Employee follow ups to gauge participation and their perception of referral value is important.

It is already a standard of practice to apply resources preventatively in many areas of EAP practice and aging is no different. Decline, disease, dementia and family dysfunction are topics we understandably avoid. However, as in most areas of life and business, I’ve found that reflection, discussion and planning eases the journey.  To provide greatest value to your employer and employee clients I urge you to explore and implement novel ways to promote pro-active elder care solutions.

Copyright 2013 Barry D. Epstein

You may download the pdf here: Colorado EAPA Chapter Newsletter Nov/Dec

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The Recycling of Parental Wisdom

How many times has your aging mother or father frustrated you by being, in your opinion, stubborn?  How often has the simple solution to a delicate and maybe health-threatening living situation been beyond grasp because Mom or Dad simply refused your advice?

  • Driving when unsafe.
  • Mixing up medications but not accepting help.
  • Insisting on doing their own laundry even if it means a risky path down concrete steps to the basement.
  • Claiming they are “independent” when in reality, they are alone most of the time and seemingly depressed.

Need I say more?  Take a deep breath.  Try to relax.  Now visualize a time while growing up your parents shared with you a pearl of wisdom.  It could have been a saying, a parable, a real family story with an important message, or simply straight forward parental advice.  For how long and how hard did you resist the obvious common sense of what was being offered?  Did you ever “accept” the free advice?  What was the result of accepting or declining what you later learned was sage advice?

Hopefully you are smiling a little at this remarkable example of the cycle of life.  However, my message is NOT to confront your parents as they may have done with you.  Child-rearing with a “my way or the highway” approach was quite common in prior generations, whether for better and for worse.  Instead, consider a modern day spin: RECYCLE PARENTAL WISDOM.

Just as we are required to thoughtfully separate our recyclable materials into different bins, the best use of “recycled” parental wisdom requires some care for best effect.  The goal: a reduced “adult child carbon footprint” that does not pollute your relationship. Step 1: pick just one issue or source of conflict (preferably a modest one); Step 2: identify what parental wisdom best fits resolution the issue; Step 3: visualize the original context and how you realized the benefit of that wisdom, whether sooner or later; Step 4: practice your narrative about that experience in way that conveys insight not anger or control; Step 5: validate with a spouse, sibling or friend; Step 6: evaluate a fruitful time and place to share the narrative with the involved parent (with no overt goal other than sharing) and do it-then be quiet, listen and observe. Step 7: if Step 6 went well consider the next time you are with or speaking to your parent you simply comment along the lines of: “Ya know, Mom, when I think about how good the advice was when you told me X, I cannot help but wonder if that may apply to how we are struggling with this Y issue.  What do you think?”  Step 8: be patient, empower your parent as much as possible, enroll the help of allies (stakeholders, caregivers, etc.) and try to move issue forward at pace and with a degree of flexibility that fits the objective urgency, but do so as a “team.”

Recycling is the right thing to do and it feels good, too.

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When Does Help Arrive?

On April 15, 2013 the Wall Street Journal ran a front page article highlighting that: As America Ages, Shortages of Help Hits Nursing Homes.  The article proceeds to accurately point out how the historically high turnover rates in skilled nursing facilities is now compounded by not only our increasingly aging society, but also by direct care staff retirements and frequency of occupational injuries for certified nurse aides.  The alarm has been ringing for some time.  During the years 1997-2001, I lectured around the country to the American Society of Health Care Risk Management’s annual convention and health care associations in Colorado, California, Connecticut and Wisconsin about employee related risk and retention issues.  These seminars culminated in my article, “A New Model for Employee Relations,” published in Provider Magazine, August, 2000.  This article discussed how employment contracts for front line staff could reduce turnover which is a novel idea that to this date has not been undertaken.

The key point is that this situation is not just a nursing home problem.  This is a senior care industry-wide problem which all families dealing now or later with aging issues has to take heed of.  Staff shortages and turnover is not necessarily evidence of poor practices.  It is largely reflective of difficult work that offers comparatively low pay and limited benefits.  People who directly care for our seniors (e.g. certified nursing assistants, personal care aides, home-health aides, medication aides, etc.) deserve our deepest appreciation and most are caring and compassionate but the gap between supply and demand will likely widen.  This reality affects assisted living facilities, community care retirement communities and home health agencies as well.  How does this situation impact seniors who simply claim they will never need or allow a nursing home placement?

Well, for one, the choice is often not voluntary and we are not always the masters of our fate.  However, seniors can and should plan with these staffing challenges in mind.  Consider long term care insurance with a range of benefit options, including assisted living and home health.  But avoid thinking that any provider can guarantee full staffing all the time regardless of whether the setting is a nursing facility, assisted living, or at home care.  Yes, even home care.  There is somewhat of a myth about how comparatively “easy” it is to stay indefinitely in one’s own home and get care as and when needed.  This is not necessarily true, particularly in rural areas.  A word of caution, not criticism: the decision if and when to choose  home health over other options should include a serious evaluation of the available agencies, their historical staffing, and their ability to provide additional care or a substitute worker on short notice, if needed.  Your own advanced and careful planning is still the best “insurance” against this situation adversely impacting you or your loved ones.  This includes asking what staffing levels may be required by law, what staffing is set by contract or policy and lastly, what has historically been the actual staffing.  When evaluating a facility visit at different times and on different days.  A Savvy Aging shopper should also ask to see a two week staffing schedule that shows not only the staff scheduled but who actually showed up for work. A difference between the two should not necessarily sound the alarm but should prompt a request for an explanation.

The parting word of wisdom for consumers of senior care is never take the staff or staffing for granted.

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