The system of care definition also included a description of core values and principals to guide service delivery to children and families.

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2 Mental health or emotional problems can develop at any age. These problems can have a serious negative impact on children and their families, and the consequences can be costly and sometimes tragic. Many children and youth experience emotional disorders like attention deficit, depression, anxiety, conduct and eating disorders. Studies cited by the President s New Freedom Commission on Mental Health in 2002 showed that 1 in 5 children are affected by mental health problems, and that 1 in 10 youth have a serious enough emotional or behavioral disorder that causes significant disruption at home, in school or in the community. In Minnesota, 9 % of school age children and 5% of preschool children have a serious emotional disturbance. That means an estimated 91,000 children in Minnesota are in need of treatment for mental health problems. The national Institute of Mental Health s National Advisory Mental Health Council (2001) stated that no other illnesses damage so many children so seriously. 2

3 Despite the high numbers of children and youth who have a diagnosable mental disorder, there is an extremely high level of unmet need. It is estimated that about 75% of children with emotional and behavioral disorders do not receive specialty mental health services. When you consider the risks involved with mental health problems (see power point) it is unbelievable to think that we have failed to develop a national comprehensive, systematic approach to children s mental health. Former Surgeon General David Satcher stated at his National Conference on Children s Mental Health back in 2000, that growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. Unbelievably, the inadequacy of the children s mental health system has been repeatedly documented. As far back as 1969 the Joint Commission on the Mental Health of Children said that only a fraction of children in need were actually receiving mental health services, and that the services provided were mostly ineffective. 3

4 As a result of the Joint Commission s report and other federally legislated reports, the Child and Adolescent Service System Program was created by the National Institute of Mental Health in The purpose of this program was to help states or communities develop a system of care by building their capacity to serve children with complex needs who were involved with multiple services like mental health, special education, child welfare and juvenile justice. The framework for this was through individual grants and the criteria for getting the grant award was that the community or state had to develop a system of care that was a comprehensive spectrum of mental health and other services and supports organized into a coordinated network to meet the complex and changing needs of children and their families (Stroul & Friendman, 1986). 4

5 The system of care definition also included a description of core values and principals to guide service delivery to children and families. The core values specified that services should be community based, child centered and family focused and culturally appropriate. 5

6 The key principals specified that services should be (a) comprehensive and include a broad array of services and supports, (b) be individualized to meet the specific and unique needs of each child and family, (c) be provided in the least restrictive and most typical setting possible, (d) be coordinated at both the system and service delivery levels (e) include early intervention and (f) include families and youths as full partners in recognizing service needs and how to get those needs best met. These principles were based on an understanding of the diverse and multiple needs of children with serious emotional disturbances and their families. 6

7 Minnesota recognized the need for a system of care for children, youth and families in our state who were dealing with unmet mental health and behavioral needs. PACER Center, a Parent Training and Information Center for families of children and youth with disabilities worked with Children s Mental Health at the Department of Human Services to propose a CAASP grant to the National Institute of Mental Health to develop infrastructure and support for children and youth with mental health needs in Minnesota. As a result of the award of that grant, a law was passed in 1989 to create a mental health system for children and youth. This law was called the Minnesota Comprehensive Children s Mental Health Act. 7

8 The Minnesota Comprehensive Children s Mental Health Act was created by the legislature to develop a statewide system of care. This law was one of the first in the nation to be passed as a result of the CAASP grants. Today, almost every state or a local community within a state has received a grant. A national evaluation of the program by the Center for Mental Health Services showed a reduction in mental health problems and costly out ofstate residential placements and an increase in behavioral and emotional strengths. In a 2001 report from CMHS, residential stability, school attendance, and school performance improved, and contacts with law enforcement and substance use decreased as a result of the efforts from these grants. In Minnesota, the Children s Mental Health Division at the Department of Human Services was able to move ahead with strategic initiatives to more successfully meet and treat the needs of children struggling with or at risk for mental health issues as a result of these system of care grant awards to Minnesota. 8

9 As part of the comprehensive system for children s mental health, this law ordered the commissioner of human services to create and ensure a unified, accountable, comprehensive children s mental health service system that is consistent with the provision of public social services for children. Identification and prevention services needed to be available to all children. Access to services meant that the community needed to be educated about the mental health needs of children and that they were coordinated with the range of social and human services provided to children and their families by the Departments of Education, Human Services, Health and Corrections, and were appropriate to their developmental needs and sensitive to cultural differences. Providing services to children and their families in their communities and schools was another important mission of the act, as well as making certain that families had access to private and public insurance coverage for their children. Implementation of the act was a mandate for counties. Minnesota is a state supervised, county run state. So counties were responsible for developing systems that would meet the mission of this act, and develop services to help families and their children get their needs met. 9

10 Eligibility for children and youth is from birth to age 18, or up to 21 if the youth had received services prior to age 18, had SED and had either been admitted within the last 3 years or is at risk of being admitted to inpatient treatment or residential treatment for SED. Some youth may not have met criteria for SED until their late teen years, and even early twenties. Those young adults would have to enter through adult mental health. 10

11 For a child to be determined eligible for services, they must have met the criteria by a licensed mental health professional for a psychosis or clinical depression, or have been at risk of hurting themselves or others, or have been a victim of physical or sexual abuse that constituted trauma for them within the past year, and that has lasted at least one year. 11

12 Another criteria could be that the child has had great difficulty at home, at school or in the community for at least one year or lasting at least one year, and a mental health professional has documented that significant impairment. 12

13 Because Minnesota is a state supervised, county run state, each county has the mandate to provide a gateway to services for children and youth with serious emotional disturbance. Some counties have stand alone children s mental health collaboratives, others have children s mental health and family services within their social services agencies. The 7 county (Hennepin, Anoka, Carver/Scott, Dakota, Ramsey and Washington) metro area has multiple access to services through collaboratives. Hennepin county alone has 13 different collaboratives strategically located throughout the county area. Anoka county has one, Carver/Scott has one in Carver and one in Scott, Dakota has one, Ramsey has 3 and Washington has one). In Greater Minnesota most collaboratives or family service agencies are specific to the county, and in some cases several counties (Like PACT for Families Collaborative in Willmar) covers Kandiyohi,Yellow Medicine, Renville and Meeker counties. A full directory of these mental health and family service collaboratives can be found on the DHS website in children s mental health. You can also go to your county on the web and find those contacts. 13

14 Everything costs money. Now, more than ever, it can be a struggle to be able to have the resources to pay for services. Families, agencies, counties and the state are all struggling with managing their money appropriately. Some families have the resources to be able to pay for services up front. Other families may have private insurance or an insurance plan through their employer that can help to pay for services. Others may have no insurance or resources to pay for services, and need to look for another way to get those services paid. In Minnesota for a family of a child under 18, TEFRA (Tax Equity and Fiscal Responsibility Act) provides Medical Assistance eligibility to some children with disabilities who live with their families. While this program allows for a child to be eligible for MA without counting parents income, parents may still be required to pay a fee based upon income. MOST COUNTIES REQUIRE THAT THE CHILD HAVE SOME FORM OF PUBLIC INSURANCE TO ACCESS COUNTY MENTAL HEALTH SUPPORT. (refer to the 3 handouts in their packets). Grants are another way families can get specific services and supports for their children. Counties often write for and receive grants that allow them to offer specialty supports like respite, mentoring or other activities that help support that child at home. 14

15 It is important to understand your private health insurance coverage. When you enroll in a health insurance plan, you are given a certificate of coverage. You can call your insurance customer service department at any point during your coverage and ask for a written copy of your certificate of coverage. This should be provided free of charge. This document explains the health benefits you and your dependents have under the plan. It details the services and providers that will and will not be covered. Services that are not covered are called exclusions. The actions you have to take to receive the health benefits such as paying a copay, meeting a deductible, or using particular health care providers are called conditions. The certificate outlines your obligations. It explains: when you will be required to make copayments and pay deductibles and how much you will have to pay when you will need to obtain a referral from one provider to another when you will need to call the insurance company to obtain approval before you receive a service The certificate also details the process for appealing decisions made by the insurance company. It is important to keep the certificate available, because it should be the first place you look when you have a question about coverage. It includes the phone numbers to call if you have any questions, including the number for the insurance customer representative. Every plan has a different certificate because the benefits under each plan are different. It is also important to know if you plan is a fully or self insured plan. Your rights regarding 15

16 your health insurance plan depend on whether the plan is fully insured or self insured. To advocate for your rights, it is important that you understand your insurance plan and know what your rights are. With a fully insured plan, the employer pays all or part of the premium to an insurer, and the insurer pays claims from the pool of premiums it collects from everyone it insures. Under a self insured plan, the employer is responsible for collecting or funding a pool of premiums and paying all health care claims out of company assets. To find out if your plan is fully or self insured contact your employee benefits administrator in your employer s human resources department. Self insured plans are regulated by federal law, not by state law, which means state laws that apply to fully insured benefit plans do not apply to self insured plans. Many states have laws requiring that insurance plans offer specific benefits. Federal law may not require those same benefits; therefore self insured plans do not have to offer them. The appeal process for self insured plans are also governed by federal law rather than state law. The federal law that regulates self insured plans is The Employee Retirement Income Security Act (ERISA). These plans are under the jurisdiction of the U.S. Department of Labor. 15

17 Medical Assistance is Minnesota s Medicaid program and provides services to low income senior citizens, families, children, and people with disabilities. There are income limits to qualify for this program, and you can apply through your local county human services office. YOU CAN HAVE BOTH PRIVATE AND PUBLIC INSURANCE. OFTEN IT IS THE ONLY WAY TO OBTAIN COVERAGE FOR ALL THAT IS NEEDED. TEFRA is a Medical Assistance (MA) program that provides services to children with disabilities who live at home with their families and meet ALL the following eligibility criteria. To receive TEFRA, children must: live with at least one parent be under age 19 be determined to have a disability by the State Medical Review Team, with information provided by the child's parent and doctors, including certification of disability by Social Security, if applicable need a certain level of home health care to stay at home which compares to the level of care provided in a hospital, nursing home or an intermediate care facility persons with developmental disabilities need home care that does not cost more than the cost for care in a medical institution Under TEFRA, families may have to pay a parental fee based on income and family size. 16

18 Home and community based waiver services are for Minnesotans with disabilities or chronic illnesses that are enrolled in Medical Assistance and need care or services beyond what MA covers. These programs are designed to support children and adults with a disability or chronic illness in their home who might otherwise be in a hospital, nursing facility or intermediate care facility if they did not have this program. Usually, these services are for people with specific needs or diagnosis. There are some differences in the services and amount of money available in each waiver. Developmental Disability (DD) Waiver, is for children and adults with developmental disabilities or related conditions who need the level of care provided in an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) Community Alternative Care (CAC) Waiver is for children and adults who are chronically ill and medically fragile who need the level of care provided in a hospital Community Alternatives for Disabled Individuals (CADI) Waiver is for children and adults with disabilities who require the level of care provided in a nursing facility Brain Injury (BI) Waiver is for children and adults who have a traumatic or acquired brain injury who need the level of care provided in a nursing home or neurobehavioral hospital PCA Eligibility Requirements: To qualify you must be assessed as having : a dependency in 1 Activity of Daily Living and/or level 1 behavior is required to qualify for 30 minutes per day for PCA services; or a dependency in 2 ADLs is required to receive more than 30 minutes of PCA services per day under the home care rating system in effect since January of Definition of Dependency and ADL: Dependency requires hands on physical assistance, cuing, or constant supervision to complete the task. Activities of Daily Living (ADLs) include: Grooming Dressing Bathing Transferring Mobility Positioning Eating Toileting Definition of Level 1 Behavior: Level I Behavior is behavior that requires the immediate response of another person, has occurred in the last 12 months with supporting documentation from professionals such as doctors, nurses, teachers, therapists, etc., and involves at least one of the following: Physical aggression towards self Physical aggression towards others 16

19 Destruction of property 16

20 In order for MA to pay for residential treatment the county must be involved with the placement. Some counties might access adoption and foster care funds to help pay for the cost of room and board for the residential treatment center. If the county pays for any of a child's care the parents will need to go through a voluntary foster care process and sign an agreement with the county. This gives the county legal authority for placement, care and supervision of the child. Legal authority is different than legal custody. Parents do not need to give up, or relinquish custody of their child and make their child a ward of the state in order for the county to pay for treatment. 17

21 If you have a complaint about your insurance coverage or services, then you have the right to file an internal complaint with the insurance provider. Complaints include appeals for denied claims. Fully insured plans are regulated by state law. Minnesota law requires all insurance providers to have a procedure for internal complaints. The procedure must have the following steps: (1) an initial review of your complaint, (2) an initial decision by the insurance provider, (3) a right to appeal if the decision goes against you, and (4) an appeal decision. Obtain a copy of the complaint procedure Your insurance provider must give you its complaint procedure in writing when you enroll; this is usually included in the certificate of coverage. You may also call your insurance provider s customer representative and ask for a copy of the complaint procedure. Start the procedure in writing In most cases, in order to start the insurance provider s review process you must make a written appeal or complaint to the insurance provider. You may submit an appeal letter or a completed complaint form provided by the insurance provider. 18

22 To appeal a decision made by a Minnesota Health Care Program you must request a hearing which is a very easy thing to do. Your request for a hearing must be in writing. You or someone who represents you must sign the request. You can fill out a request form by filling out an Appeal to State Agency Form (DHS 0033). The request for a hearing must be received within 30 days after getting written notice of the county's or state's decision. If you show good cause for not appealing within this time limit, you may appeal up to 90 days. After the state gets your request, it will set a date for a hearing. The state will tell you the exact date, time and place. You have the right to look at your case file and any other papers the agency will use at the hearing. It is a good idea to look at your file ahead of time. You have a right to free copies of any papers related to your hearing. Call the agency to set up an appointment if you want to see your file. If you have trouble getting this information, you can call or write the human services judge assigned to your case and ask for an order enforcing your rights. The agency cannot use information at the hearing if they did not give you a chance to see it first. If you are scheduled for a telephone hearing and prefer an in person hearing you have the right to a face to face hearing, if you ask for one. If you want a face to face hearing, you should call the human services judge and tell him/her that is what you want. The human services judge may have to schedule the hearing for a different day and time. the Minnesota Disability Law Center typically recommends in person hearings. 19

23 It can take up to 90 days from the date you appealed to receive the decision. 19

24 Under the MCCMHA there are 13 specific services that each county is responsible for developing and sustaining. Because this is a county run state, each county gets to determine the amount of resources they put into the development of these services but ALL MUST BE AVAILABLE IF THE FAMILY AND CASE MANAGER AGREE THEY ARE NEEDED IN ORDER TO KEEP THE CHILD OR YOUTH AT HOME, IN THE COMMUNITY and SAFE. 20

25 Unfortunately, there still remains a stigma around mental illness. Historical perspective has a vision of mental illness as a chosen disorder, a disorder born out of bad parenting, or a disorder that could have been prevented if other choices had been made. There has been research for years that connects mental illness with genetic disorders, abnormalities in the brain, and other physiological abnormalities. Environment can certainly impact a person s mental health, but environment alone is rarely the sole cause of mental illness. How we respond to behaviors, how we manage our lifestyle and how we prevent unhealthy choices is definitely key to managing mental health needs and mental illness. By providing education about mental health, it s causes and implications, as well as decreasing the stigma associated with mental illness through public forums, trainings and development of other resources (such as community based recreation activities that include persons with disabilities, etc), counties can help their residents who have children and youth with mental health needs stay in their homes, in their neighborhood schools, and in their communities successfully. 21

26 Counties have the mandate under this statute to also make available to all children and their families mental health identification and intervention services. They must have a process in place to identify children at risk of needing these services whether that be through a family request, a social worker or other service provider or even the school. While screening and assessments are voluntary and consent must be given by the parent or legal guardian unless they are court ordered, there must be a process in place so that early identification can be made. The county is also mandated to offer intervention services to each child who is identified at risk of needing mental health services. 22

27 County boards must provide for enough mental health emergency services within the county to meet the needs of their children, and the children s families when clinically appropriate, who are experiencing an emotional crisis or emotional disturbance. In the 7 county metro area, there are mobile crisis service teams available 24/7. (see handout with numbers) In greater Minnesota, the crisis response may be designated through the 911 emergency line. The county can require the family to pay a fee for the service, however emergency service providers may not delay services due to inability or unwillingness to pay the fee. Emergency services are meant to stabilize the crisis, minimize future crisis, and prevent placement in settings are are more intensive, costly or restive than necessary and appropriate to meet the child s needs (such as juvenile detention, shelters or hospitals). (See separate handout: Metro County Mobile Crisis Services) 23

28 Once a family has requested an intake for children s mental health services, the county is responsible to notify and determine case management eligibility within 5 working days after receiving the request. Case management services are eligible for reimbursement under the medical assistance program. If a diagnostic assessment is needed to make a determination if the child has a serious emotional disturbance, the county must offer to assist the child and their family in obtaining one. If the child is not found eligible, or refuses case management services, the county must notify the family of the appeal process and offer to refer them to a mental health provider or another appropriate service provider and assist them in making an appointment with the provider of the family s choice. For each child, the case manager must develop an individual family community support plan that incorporates their individual treatment plan. 24

29 Day Treatment is a structured program of therapeutic support that is community based and only offered during the day. There are many kinds of day treatment programs throughout our state. Some are for part of the day (requirement is at least 4 hours), and only offer therapy. Others are full days programs and include an educational component to the program. Minnesota has several statutes and laws that cover school aged children and youth who are in Day Treatment programs. For the most part, Day Treatment is voluntary, unless court ordered. The mental health component is considered therapeutic and not education, so either private insurance, public insurance private pay, or private pay with a sliding scale fee cover the cost. The school district is required to provide education, and can either pay for the educational costs of the program, if the Day Treatment has an educational component, or can educate the child in another setting, when appropriate. Special education services, according to IDEA define that special education must include students in the classroom, in the home, in hospitals and institutions and in other settings (34C.F.R. 300/.39(a)(i). That includes Day Treatment. Districts are also required to provide transportation to Day Treatment settings, per Minnesota Statute 125A.15. The Minnesota Department of Education has decided that best practice is to include the resident school district, when possible, in the decision of what Day Treatment is the best to place the child or youth so that excessive transportation costs are not incurred. 25

30 Children and youth can be referred to Residential treatment voluntarily through family and other caregivers, private providers, the county or the court system. The county is required to show effort that they have used less restrictive services to prevent placement, and length of stay is subject to a 6 month review process. The purpose of residential treatment is to promote family re unification by providing intensive clinical help that includes development of family living and social interaction skills for both the child and their family. Residential treatment programs have to provide special education services for students in this setting. If the child or youth is not receiving special education services, they must be screened to determine if there is a need for an appropriate educational evaluation, and parents must be included in that evaluation decision and process. 26

31 Acute care hospital inpatient treatment services are necessary for children or youth who are not responding to community based treatment plans, or who are having immediate safety needs due to their mental health. For children or youth who are unsafe, calling the county crisis number may not be enough. Some need immediate and restrictive interventions to be kept safe. Counties must have access to hospital treatment services and must provide access to admission, continued stay, discharge criteria and discharge planning. These facilities must also assist families and children in the transition from inpatient services to community based services or home setting, and provide notification to the child s case manager, if any, so that the case manager can monitor the transition and make arrangements for the child s appropriate follow up care in the community. 27

32 Family community support services must be designed to improve the ability of children with SED to (1) manage basic activities of daily living; (2) function appropriately in home, school and community settings, (3) participate in leisure time or community youth activities, (4) set goals and plans, (5) reside with the family in the community, (6) participate in after school and summer activities, (7) make a smooth transition among mental health and education services provided to the child, and (8) make a smooth transition into the adult mental health system as appropriate. Overall, these services must be designed to improve family functioning and reduce the need for more intensive placement. They must be available for a child who is at risk of out of home placement, or who is returning to the home from out of home placement. 28

33 Foster families caring for children with severe emotional disturbance must receive training and supportive services, as necessary, and at no cost to the foster families within the limits of available resources 29

34 When a child or youth is at the point of needing referral or admission to a treatment foster care setting or a residential treatment facility, there must be a determination of whether there were services first provided to that child in a lesser restrictive setting, and if the child failed to make progress toward their treatment goals in that less restrictive setting. This level of care decision must be based on a diagnostic assessment that includes a functional assessment which evaluates family, school and community living situation, and an assessment of the child s need for care out of the home. If a child is admitted to a treatment foster care setting, residential treatment facility or given emergency care by a regional treatment center, the level of care determination must occur within 5 working days of admission and must be completed by a mental health professional. 30

35 Remember, these services are voluntary and are family driven. That means you have the RIGHT to ask for help, and the RIGHT to decide if this works for your family. 31

36 Many unmet mental health needs look behavioral. A child with ADHD who is impulsive and acts unpredictably at school may look purposeful and aggressive. Actually, that child may just need help with learning replacement behaviors that help meet his need for movement or managing his response to unstructured situations. A youth who is consistently refusing to do work and gets belligerent when confronted may actually be very depressed and need positive interactions and support to get the work done. Anger is often a manifestation of depression, especially in boys. Because we historically think of responding to problem behavior with consequences, the connection between the manifestation of a mental health disorder and behavior is often ignored. It is imperative that we understand if the child won t or can t do the preferred behavior. The 504 Plan which provides for accommodations like back pocket passes to take breaks, preferred seating, shortened assignments, extra time, etc. can help a student with an anxiety disorder to better manage their day. A Special education plan which also gives accommodations, but also gives instruction in learning replacement behaviors to meet needs can help a student with ADHD to use his energy productively and keep task oriented throughout his day, rather than being disruptive to his peers as well as himself. 32

37 Having a crisis is not pleasant, and it certainly is not the time to come up with a plan for support. Minnesota has developed a place for children, families and even school staff to get mental health support in times of a mental health crisis. It is called MetrCCS or Metro Children s Crisis Response Services. Licensed mental health professionals are available 24 hours a day, 7 days a week to answer your questions over the phone and meet you in person to help evaluate and stabilize your immediate crisis. They can also help you develop a plan for not only managing the current crisis but also reducing future crises, help with short term care moving towards on going treatment support, and can connect you to other places for support. Mental health crisis response is provided regardless of ability to pay, but it is covered by most insurance plans. It is also helpful to have a working relationship with a specialist in your child s area of mental health diagnosis. While family doctors and pediatricians provide wonderful care and support they might not always have the most up to date information on treatment options, especially medication. Minnesota has now created a help line for family physicians to contact for consultation on mental health needs because it can take many months to get seen by a child and adolescent psychiatrist or specialist. The Ombudsman for Mental Health and Mental Retardation is a resource for persons who need help in understanding their rights, are looking for access to appropriate services, have questions or complaints about services, and may need general questions answered or need more information on services for persons with mental disabilities. They also assist consumer and their families on the Civil Commitment and Treatment Act and related laws including Child Protective Services. 33

38 Minnesota has been at the forefront of creating an infrastructure of support and services for children and youth with mental health needs and their families. Through the early CAASP grant, the System of Care grants, the creation of CMH Collaboratives and MetrCCS, we have gradually evolved into a system of coordinated services and supports. There are always challenges with everything however, and Minnesota is NOT immune from those challenges. Funding from the State has dwindled away for the CMH Collaboratives and counties are now charged with finding ways to fund the MCCMHA. Parents have the right to be heard, and in fact have the right to be active and vocal participants in the implementation of the MCCMHA. Each county is required to have a Local Advisory Council (LAC). This is a committee that meets to determine the service needs of families in their county. The state has a Mental Health Advisory Council that makes recommendations to the Governor on policies, laws and regulations and services relating to children s mental health. The Subcommittee on Children s Mental Health, part of that council, has a requirement to include parents on that committee. The Office of the Secretary of State, Open Appointments ( ) has more information. 34

39 The concept of school based mental health support has been a discussion for many years. Realistically, children and youth spend a majority of their day in school or are involved in school related activities (homework, sports, arts, etc). The vision of this program was to form public/private partnerships to deliver a broad continuum of high quality mental health services to students and families by: improving access to children s mental health services improving symptoms and functioning and school outcomes integrating a broad continuum of mental health services and supports into school and build capacity of school staff Minneapolis Public schools for example, has school mental health programs in 15 of their schools currently. They have served 8,422 students (55% male, 41% female), and for 48% of them it was the first time they had received MH services. 45% qualified as SED. They reported improvements in school functioning (decreased suspensions, reduced office referrals and improved attendance 35

40 Mental health matters at every stage of life and requires an integrated continuum of services ranging from prevention to recovery. Hopefully the efforts will result in better outcomes and build a statewide response to appropriate mental health care that is accessible and family centered. 36

41 37

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