Examining variables related to successful collaboration on the hospice team.
Although social work participation on interdisciplinary teams is
long-standing, little research has been done to examine its
effectiveness. This study used the Index of Interdisciplinary
Collaboration to explore relationships between selected variables and
teamwork in the hospice setting. The findings indicate that hospice
social workers report a high level of interdisciplinary collaboration
with colleagues. Whereas education, hospice census, the presence of
other social workers, and quality of care were found to be unrelated to
overall levels of collaboration, individual items measuring
collaboration proved to be linked with hospice census, the presence of
other social workers on the team, and quality of care. Further research
is required to investigate other possible related variables and their
impact on successful interdisciplinary collaboration and service
KEY WORDS: hospice; Index of Interdisciplinary Collaboration; interdisciplinary collaboration; interprofessional teams
Physicians (Social aspects)
Social workers (Management)
Social workers (Services)
Bronstein, Laura R.
|Publication:||Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2005 National Association of Social Workers ISSN: 0360-7283|
|Issue:||Date: Nov, 2005 Source Volume: 30 Source Issue: 4|
|Topic:||Event Code: 360 Services information; 290 Public affairs; 200 Management dynamics Computer Subject: Company business management|
|Product:||Product Code: 9124500 Health Care Financing Admin; 8011000 Physicians & Surgeons NAICS Code: 92312 Administration of Public Health Programs; 621111 Offices of Physicians (except Mental Health Specialists) SIC Code: 8011 Offices & clinics of medical doctors|
|Organization:||Government Agency: United States. Centers for Medicare and Medicaid Services|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Social workers have a long tradition of collaborative practice with
other professionals. Interdisciplinary teams in health care originated
with Richard Cabot, a well-known physician, in the early 1900s. Working
for Massachusetts General Hospital, he proposed the idea of teamwork,
suggesting that the social worker, doctor, and educator work together on
patient issues (Cabot, 1929). For the better part of a century, input
from the social worker has been viewed as helping the physician gain a
broader perspective on patient care (Baldwin, 2000).
Health care teams, consisting of different professionals combining resources to deliver care to a specific population (Rubin & Beckhard, 1972), manifest in unique ways depending on the delivery system and the philosophy of the particular setting. In some settings teams are simply groups of various practitioners coming together to "report" on what they are each planning with a specific patient, working side by side but not necessarily together (Lee, 1980). Other teams choose to work together and discover that it requires great effort and investment. Interdisciplinary collaboration is defined here as an interpersonal process leading to attainment of specific goals that are not achievable by one team member alone (Bruner, 1991). This definition focuses on the synergy, which emerges from collaboration, identifying it as an active, ongoing, productive process.
Hospice was built on the interdisciplinary team model. Cicely Saunders, founder of the modern hospice movement, serves as a role model for interdisciplinary work because she was trained as a social worker, nurse, and physician (Saunders, 1978). In hospice, teamwork is critical to the service and management of the entire person and his or her environment and is essential in providing a "good death" for the hospice patient. Saunders' commitment to dying individuals resulted in a social model of care that advocates a holistic perspective, reflecting social work values and standards at its heart (Torrens, 1985). Management of pain for the dying person requires attention to the physical, spiritual, financial, and psychosocial needs of the patient and his or her family, none of which can be accomplished by only one "kind" of professional (Skobel, Cullom, & Showalter, 1997). Social work is a vital component of hospice care, formalized in the Medicare Conditions of Participation as a core service requirement (Health Care Financing Administration [HCFA], 1983).
Although a required component and integral part of hospice care, social workers have encountered problems in these interdisciplinary team settings. Ironically, the close ties between social work and hospice often make the social work role challenging. The social work perspective and values are so inherent in hospice that roles among hospice professionals can become inappropriately blurred (MacDonald, 1991). Competition between social workers and both nurses (Ben-Sira & Szyf, 1992) and chaplains (Lister, 1980) has been found in various practice settings. In a nationwide study of hospice professionals, social workers reported frustration as they perceived that nurses were assuming social work duties (Sontag, 1996).
Using an array of intervention strategies in which social work professionals have expertise, social workers can stimulate positive change within their teams. It has been suggested that hospice social workers enhance their identity by correctly assessing and responding to identified needs of teams, recognizing opportunities to enhance effectiveness and collaboration, and capitalizing on the resulting synergy, for the benefit of both the team members and the patients (MacDonald, 1991). One study found that some families of deceased hospice patients felt that better communication among hospice team members would have improved the delivery and effectiveness of hospice services (Archer & Boyle, 1999). The keys to successful social work collaboration on interdisciplinary teams and the possible link to improved quality of care remain obscure and need to be explored, articulated, and translated into action. The purpose of this project was to explore the variance in successful interdisciplinary collaboration within hospice teams in an effort to improve teamwork and hospice care.
The conceptual framework for this project relies on a model (Bronstein, 2003) developed from four theoretical perspectives: a multidisciplinary theory of collaboration, services integration, role theory, and ecological systems theory. The model is designed to identify components of successful collaboration between social workers and members of other disciplines. This framework is composed of interdisciplinary processes in five core areas: (1) interdependence; (2) newly created professional activities; (3) flexibility; (4) collective ownership of goals; and (5) reflection on process (Bronstein, 2003).
The synergy that defines successful collaboration begins with the team members' reliance on interactions among each other to be successful with necessary tasks. This interdependence is combined with newly created professional activities or collaborative acts, programs, and structures, allowing for accomplishment that would not be possible without the other members. The success of interdependence and these newly created professional activities requires flexibility in traditional roles, leading team members to deliberately and appropriately blur roles on the basis of their team identity and knowledge. In addition, this collaborative process requires collective ownership of the goals of the team, including shared responsibility for the design, definition, development, and achievement of goals. Finally, integral to successful collaboration is a reflection on the collaborative process by the team members, focusing on the process of their work together and the outcomes of their efforts (Bronstein, 2003).
Solid collaborative interdisciplinary teamwork has been found to affect patient care in positive ways. Nurse and physician collaborative practice in intensive care units has been found to improve patient outcomes and nurse satisfaction (Baggs, Ryan, Phelps, Richeson, &Johnson, 1992). In a study on collaborative physician office practice, teamwork among physicians, nurses, and social workers reduced readmission to the hospital, reduced physician office visits, and helped older adults with chronic illnesses maintain their health status (Sommers, Marton, Barbaccia, & Randolph, 2000). In addition, collaboration among social workers and psychologists, physical therapists, and other health providers has been found to enhance the ability of these providers to meet clients' service needs, to better understand clients, to solve complex problems, and to successfully implement treatment plans (Sands, 1989).
This study used the Index of Interdisciplinary Collaboration (IIC) (Bronstein, 2002) developed from the conceptual framework mentioned earlier, along with selected demographic questions to examine the following three research questions: (1) What do hospice social workers see as the extent of their interdisciplinary team collaboration? (2) Does the type of social work degree (BSW or MSW), hospice census, or type of practice (group or solo) correlate with social workers' perceptions of their collaboration? (3) Is there a relationship between social workers' perception of their level of interdisciplinary collaboration and quality of care?
In an effort to reach all practicing social workers in one state, a mailing list of social workers and their respective hospice programs was obtained from the Missouri state hospice association. The list included all hospice programs licensed in the state in 2001. Although individual social workers do not join the association, individual names and addresses were provided by the hospices. Letters of introduction and explanation were sent to each of the 146 hospice social workers on the list, with demographic questions and a copy of the IIC. Only one letter of introduction was returned as undeliverable. In recognition of participation, a letter offered all workers responding to the study an opportunity to enter a lottery drawing for a $100 gift certificate to any future educational event sponsored by the state hospice association. Instructions for the study encouraged participants to return the survey using fax or mail. A fax number and an address were both supplied. Envelopes were not included in an effort to encourage the fax-back option. The fax-back option was used because one of the authors had experienced good response rates using this method in another survey project with hospice programs (Parker-Oliver, 2002). The University of Missouri Institutional Review Board approved the study.
Variables and Instruments
Demographic variables included the program name, social work degree, hospice census, individual caseload, and number of social workers in the hospice program. The individual social worker caseload question was eliminated from data analysis because it was reported inconsistently. The numbers of social workers in the agency was recoded into a dichotomous variable of "one" or "more than one" because respondents included part-time and fulltime social workers.
A dichotomous variable to measure quality of hospice care was included in the analysis to assess its relationship to team collaboration. Quality of care was operationalized using annual certification survey reports filed by the Missouri Department of Health and Senior Services, Unit of Home Care and Rehabilitation Standards. The variable noted whether the hospice program had deficiencies in compliance documented in its recent certification report (2001-2002). This quality measure reflects how each hospice program delivers care in accordance with a set of practice standards identified through regulations and assessed annually by out-side regulators. The compliance audits include a review of records, interviews with staff and patients, and direct observation of care (HCFA, 1983; Missouri State Certification Law, 1992, 2001).
The IIC was used to measure the extent of collaboration as perceived by social workers in relation to their other interdisciplinary team members. The IIC items are rated on a five-point Likert scale. The instrument defines collaboration as an effective, active, and purposeful activity, rather than a neutral activity. Lower scores on the IIC denote higher levels of collaboration. The instrument has strong face validity based on its connection to the literature and modification based on previous testing (Bronstein, 2002). The instrument was originally designed as a 49-item scale; however, seven items did not contribute to the reliability of the instrument's subscales and were dropped (Bronstein, 2002). We used the modified 42-item scale to measures the five components of collaboration mentioned earlier. The index has been found to have internal consistency and moderate support for measurement of the identified subscale components (Bronstein, 2002). The 42-item scale was published with a .92 alpha coefficient, indicating reliability. The subscales' reliability on the 42-item scale was moderate, with the following alpha coefficients: interdependence, .78; newly created professional activities, .75; flexibility, .62; collective ownership of goals, .80; and reflection on process, .82. Bronstein (2002) proposed combining the flexibility and interdependence subscales because they conceptually overlap and because the combined score alpha coefficient is .80. For this project these subscales were combined.
Of the 146 surveys mailed, 48 were initially completed and returned. A follow-up mailing resulted in an additional 26 surveys, for a total of 77 returned surveys and a response rate of 52.7 percent. Twenty-nine (38 percent) were returned by mail, and 48 (62 percent) were received by fax. The sample included social workers from 51 different providers, representing 77 percent of the licensed hospices in the state. The majority (58 percent, n = 45) of the sample held a graduate social work degree (MSW), and 31 percent of respondents (n = 24) were the only social worker in their hospice program (solo practice) (Table 1). The size of the hospice program varied between four and 226 patients, with an average census of 56 patients per day.
Responses to the IIC were entered into an SPSS 10.0 program for analysis. Twelve statements were inversely worded (designed to minimize response sets) and recoded. Data were screened for missing variables and normality. Five missing data points for the IIC variables were replaced with the mean score recorded for the individual respondent. All data were normally distributed as defined with kurtosis and skewness statistics (Tabachnick & Fidell, 1996).
Descriptive statistics for the four subscales and the 42 individual items are summarized in Table 2. The overall mean for the entire instrument was 1.92, with 1.0 being the highest perception of collaboration and 5.0 being the lowest possible perception. Although not statistically significantly different, the most positive mean perception of collaboration was in the subset scale related to interdependence and flexibility (2.18), followed by newly created professional activities (2.32), collective ownership of goals (2.38), and reflection on process (2.41). The subscale on newly created professional activities had the largest variance in responses, with a standard deviation of .6527, indicating there was less agreement among social workers on different teams for this set of questions. The subscale average for the combined interdependence and flexibility item showed the lowest standard deviation, indicating the most agreement with statements related to interdependence and flexibility among hospice social workers. Totals for the entire IIC and each subscale were normally distributed, indicating the expected range in collaboration among hospice social workers.
Analysis of individual item scores found the most positive question response mean related to question 4, "Teamwork with professionals from other disciplines is important in my ability to help clients" (1.26). The second most positive response was with question 11, "Cooperative work with colleagues from other disciplines is a part of my job description" (1.30) and question 1, "I utilize other (non-social work) professionals for their particular expertise" (1.31). The most negative mean response was to question 34, "My colleagues from other disciplines and I often discuss different strategies to improve our working relationships" (2.55).
In an attempt to explain the variance in IIC scores, several statistical procedures were used. Bivariate correlations for instrument and subscale averages, demographics, and quality of care variables were analyzed to assess possible relationships. No statistically significant relationships were found in the total or subset responses. Using each demographic variable as a factor and the total and subset scores of the IIC as dependent variables, we conducted a series of one-way analyses of variance to explore significant differences in the means between groups based on the demographic variables. Finally, we used multiple regression equations to see if any of three demographic variables (professional degree, census, solo practice) or the quality of care variable (deficiencies) were predictive of IIC total or subscale scores. Five regression models using the total IIC score and each subscale score as dependent variables and the demographic variables and the dichotomous deficiency variable as independent variables were explored. The regression analysis showed no support for any of the demographic variables as predictive of either total interdisciplinary collaboration scores or subscale measures. Therefore, there is no statistical evidence that the social work degree (BSW or MSW), hospice census, type of practice (group or solo), or deficiencies with state audits are related to perceived overall level of social worker collaboration or components of collaboration: perceived levels of interdependence and flexibility, newly created professional activities, collective ownership of goals or reflection on process, on the hospice interdisciplinary team.
Individual question analysis, however, revealed some interesting correlations. Education was not correlated with any individual question responses. Solo practice was negatively correlated (p < .04) with the first question, "I utilize other (non-social work) professionals for their expertise," indicating that an individual who is the only social worker in the hospice is more likely to use non--social workers as a resource. This is a logical conclusion when no other social worker is available. Given that nearly one-third (31 percent) of the respondents were the only social workers in the agency, it appears that a significant number of social workers rely on professionals from other disciplines on their teams.
Quality, as defined by the absence of documented deficiencies, was significantly correlated with three individual questions. The responses were positively correlated with question 27, "My colleagues from other disciplines work through conflicts with me in efforts to resolve them" (p < .030) and question 17, "I am not aware of situations in my agency in which a coalition, task force, or committee has developed out of interdisciplinary efforts" (p < .03) and finally, question 10, "My colleagues from other disciplines refer to me often" (p < .042). These correlations were in the expected direction, as clean audits were associated with stronger agreement (after recoding where indicated) with the statements. This indicates a possible link between these aspects of interdisciplinary collaboration, as perceived by social work team members, and the quality of hospice services. Further exploration of links between collaboration and quality is indicated.
Two individual questions were negatively correlated with the hospice census: question 17, "I am not aware of situations in my agency in which a coalition, task force, or committee has developed out of interdisciplinary efforts" (p < .23) and question 19, "Creative outcomes emerge from my work with colleagues from other professions that I could not have predicted" (p < .017). The negative correlation indicates that task forces or committees and creative problem solving are less common in smaller programs. This finding may be a reflection of the lack of need for such groups in small programs and less opportunity for creative problem solving. Further research is required to better understand these issues.
This research reveals that the extent of interdisciplinary collaboration as perceived by the majority of social workers in Missouri hospices is high, with a mean IIC score of 1.92, indicating overall agreement with the items said to constitute collaboration. Whereas the variance (range of 1.0 to 2.9) between IIC scores cannot be explained by the variables in this study, the results justify further exploration to learn more about what does account for this variance. These data suggest that overall differences in collaboration on hospice teams is not a result of the education of the social worker, the hospice census, the number of social workers on the team, or the quality of care delivered by the hospice program as measured by certification audits. However, because individual components of collaboration did correlate with these variables, more research is warranted to examine whether greater impact on these discrete aspects of collaboration can improve overall levels of collaboration and ultimately improve service delivery.
Although numerous barriers to interdisciplinary collaboration in hospice settings have been identified (Kovacs & Bronstein, 1999; MacDonald, 1991; Reese & Sontag, 2001), no barriers were found in these data. Rather, these data indicate an overall positive perception of the level of interdisciplinary collaboration by hospice social workers. Although normally distributed, indicating that not all social workers experience was the same, the positive overall perception was unexpected. The results of this study may indicate that collaboration is so strong within hospice teams that there may not be a need to study its variance among hospices. Perhaps the positive experiences reported are because hospice offers unique teamwork experiences based on the strong collaborative history within the hospice movement. Finally, the unexpected results may be due to the limitations of this particular study. These limitations include the fact that the sample in this project is small and represents only one Midwestern state and therefore generalization of the results is not possible, and that the study only examined a small number of demographic variables and one measure of quality of care.
Further inquiry is warranted in the hospice setting exploring characteristics that previously have been found to influence interdisciplinary collaboration, including professional role (that is, allegiance with profession and agency), structural characteristics (that is, time and space for collaboration to occur), a history of collaboration, and personal characteristics of the collaborators (Bronstein, 2002, 2003). Further measurement of hospice quality of care is justified in that a relationship between collaboration and quality of care is indicated in three individual questions. Other measures of quality should be explored, including client satisfaction with services, given that preserving quality of life is a major hospice goal. Finally, adaptation of the IIC to measure the perspectives of the entire hospice interdisciplinary team could yield interesting results and comparisons among disciplines in various programs and within the same program.
IMPLICATIONS FOR SOCIAL WORK
This study bears implications for social work research, practice, and education. Although normally distributed overall, hospice social workers in this study reported a high level of interdisciplinary collaboration, which does not seem to be affected by the worker's level of education, agency size, number of workers, or quality. Further research might look to substantiate if, indeed, high levels of interdisciplinary collaboration routinely prevail in hospices. These research studies might include focus groups and individual interviews with social workers and other members of the hospice team to lend greater depth to our understanding of collaboration in these settings. Such qualitative studies could be longitudinal and follow hospice social workers over time to track and understand the process of the development of collaboration on the hospice team. Interviews and focus groups might also be conducted with clients and families to ascertain their experience with the hospice team and the perception of collaboration from the perspective of the recipients of service. As we learn more about collaboration in the hospice setting, it might come to light that hospice teams are indeed ideal models of interdisciplinary teamwork. If such is the case, hospice teams can be used as models for teaching social work students and current practitioners about teamwork.
Further research is needed to ascertain the impact of collaboration on client outcomes and quality service delivery. This study identifies some individual aspects of collaboration (working through conflict together, establishing structures to support collaboration, and making interdisciplinary referrals) that correlate with an indicator of quality, but this is only a beginning. Other indicators of quality need to be examined for their relationship with collaboration. If there does prove to be a link between service delivery and collaboration, then the hospice approach might serve as a model not only of interdisciplinary practice, but also of a setting that uses social work values and methods to promote quality and healing for the clients we serve.
Original manuscript received May 28, 2003
Final manuscript received December 15, 2003
Accepted March 8, 2004
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Debra Parker-Oliver, PhD, MSW, is assistant professor, School of Social Work, University of Missouri, Columbia, 719 Clark Hall, Columbia, MO 65211; e-mail: oliverdr@ missouri.edu. Laura R. Bronstein, PhD, ACSW, is associate professor, Division of Social Work, School of Education and Human Development, Binghamton University. Lori Kurzejeski, MSW, is a graduate research assistant, School of Social Work, University of Missouri. An earlier version of this article was presented at the National Hospice and Palliative Care Organization meeting, March 25, 2004, Las Vegas, NV.
Table 1: Demographics of Social Workers Responding to IIC (n = 77). Variable Result Educational level (%) BSW 38 MSW 58 Other 4 Agency census (daily average) 56 Solo practitioner in agency (%) 31 Different agencies responding (A) 51 Agencies with survey deficiencies (%) Yes 74 No 26 Note: IIC = Index of Interdisciplinary Collaboration (Bronstein, 2002). Table 2: Summary Statistics for Subscales and Individual IIC Questions (n = 77) Individual Question Mean Range SD Subscale: Interdependence and flexibility 2.18 1.28-3.78 .5098 Subscale: Newly created professional activities 2.32 1.17-4.17 .6527 Subscale: Collective ownership of goals 2.38 1.13-4.13 .5873 Subscale: Reflection on process 2.41 1.10-4.0 .5689 1. I utilize other (non-social work) professionals for their particular expertise. 1.31 1-3 .54 2. I consistently give feedback to other professionals in my setting. 1.51 1-4 .58 3. Other (non-social work) professionals in my setting utilize social workers for a range of casks. 1.75 1-4 .75 * 4. Teamwork with professionals from other 1.26 1-5 .59 disciplines is not important in my ability to help clients. * 5. My colleagues from other professional 1.43 1-3 .55 disciplines and I rarely communicate. 6. The colleagues from other disciplines with whom I work have a good understanding of the distinction between my role and their role(s). 2.29 1-5 .98 7. My colleagues from other disciplines make inappropriate referrals to me. 2.08 1-5 1.0 8. I can define those areas that are distinct in my professional role from that of professionals from other disciplines with whom I work. 1.60 1-3 .54 9. I view part of my professional role as supporting the role of others with whom I work. 1.43 1-3 .55 10. My colleagues from other disciplines refer to me often. 1.92 1-5 .77 * 11. Cooperative work with colleagues from other disciplines is not a part of my job description. 1.30 1-4 .65 * 12. My colleagues from other professional disciplines do not treat me as an equal. 2.05 1-5 1.15 13. My colleagues from other disciplines believe that they could not do their jobs as well without the assistance of social workers. 2.05 1-4 .86 14. Distinct new programs emerge from the collective work of colleagues from different disciplines. 2.13 1-4 .89 15. Organizational protocols reflect the existence of cooperation between professionals from different disciplines. 1.99 1-4 .83 16. Formal procedures/mechanisms exist for facilitating dialogue between professionals from different disciplines (i.e., at staffings, inservice, rounds, etc.) 1.74 1-4 .71 * 17. I am not aware of situations in my agency in which a coalition, task force, or committee has developed out of interdisciplinary efforts. 2.39 1-4 1.07 18. Working with colleagues from other 1.39 1-3 .52 disciplines leads to outcomes that we could not achieve alone. 19. Creative outcomes emerge from my work with colleagues from other professions that I could not have predicted. 1.77 1-4 .71 20. I am willing to take on tasks outside of my job description when that seems important. 1.57 1-4 .68 * 21. I am not willing to sacrifice a degree of autonomy to support cooperative problem solving. 1.73 1-4 .72 22. I utilize formal and informal procedures for problem solving with my colleagues from other disciplines. 1.62 1-4 .63 * 23. The professional colleagues from other disciplines with whom I work stick rigidly to their job descriptions. 2.19 1-4 .86 24. My non-social work professional colleagues and I work together in many different ways. 1.70 1-4 .67 25. Professionals from other disciplines with whom I work encourage family members' participation in the treatment process. 1.84 1-4 .63 * 26. My colleagues from other disciplines are not committed to working together. 1.75 1-4 .78 27. My colleagues from other disciplines work through conflicts with me in efforts to resolve them. 2.31 1-5 .80 28. When colleagues from different disciplines make decisions together, they go through a process of examining alternatives. 2.21 1-4 .86 29. My interactions with colleagues from other disciplines occur in a climate where there is freedom to be different and to disagree. 2.06 1-4 .80 30. Clients/patients/students participate in interdisciplinary planning that concerns them. 2.10 1-5 .94 31. Colleagues from all professional disciplines take responsibility for developing treatment plans. 1.82 1-4 .76 * 32. Colleagues from all professional disciplines do not participate in implementing treatment plans. 1.81 1-4 .78 33. Professionals from different disciplines are straightforward when sharing information with clients/ patients/students. 2.06 1-4 .66 34. My colleagues from other disciplines and I often discuss different strategies to improve our working relationships. 2.55 1-5 .98 35. My colleagues from other professions and I talk about ways to involve other professionals in our work together. 2.51 1-5 .93 * 36. My non-social work colleagues do not attempt to create a positive climate in our organization. 1.77 1-4 .72 37. I am optimistic about the ability of my colleagues from other disciplines to work with me to resolve problems. 1.81 1-4 .71 38. I help my non-social work colleagues to address conflict with other professionals directly. 2.25 1-5 .78 39. My non-social work colleagues are as likely as I am to address obstacles to our successful collaboration. 2.34 1-5 .94 40. My colleagues from other disciplines and I talk together about our professional similarities and differences, including role, competencies, and stereotypes. 2.49 1-5 .94 * 41. My colleagues from other professions and I do not evaluate our work together. 2.48 1-5 1.05 42. I discuss with professionals from other disciplines the degree to which each of us should be involved in a particular case. 2.31 1-5 .92 Overall average response. 1.92 1.05-2.90 .4290 Notes: IIC = Index of Interdisciplinary Collaboration (Bronstein, 2002). * denotes inversely worded statement that was recoded for comparison of averages.
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