BILL ANALYSIS                                                                                                                                                                                                    



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          Date of Hearing:  April 28, 2015 


                           ASSEMBLY COMMITTEE ON JUDICIARY


                                  Mark Stone, Chair


          AB 1193  
          (Eggman) - As Introduced February 27, 2015


          SUBJECT:  MENTAL HEALTH SERVICES: ASSISTED OUTPATIENT TREATMENT


          KEY ISSUES: 


          1)GIVEN THAT A NUMBER OF COUNTIES HAVE OPTED TO FULLY IMPLEMENT  
            THE ASSISTED OUTPAITENT TREATMENT PROGRAM (AOT), ALSO KNOWN AS  
            "LAURA'S LAW," SHOULD ALL COUNTIES IN THE STATE BE REQUIRED TO  
            OFFER AOT, UNLESS THEY OPT OUT OF THE REQUIREMENT TO DO SO?


          2)SHOULD ALL COUNTIES BE REQUIRED TO ADOPT THE AOT PROGRAM  
            WITHOUT HOLDING ANY PUBLIC HEARINGS, UNLESS THEY DECIDE NOT TO  
            OFFER THE PROGRAM?


          3)SHOULD THE JANUARY 1, 2017 DATE, WHEN THE INVOLUNTARY  
            OUTPATIENT MENTAL HEALTH TREATMENT PROGRAM DEMONSTRATION  
            PROJECT IS SCHEDULED BY STATUTE TO EXPIRE, BE EXTENDED UNTIL  
            JANUARY 1, 2022, FIVE YEARS AFTER ITS CURRENT SUNSET DATE?


          4)SHOULD ANY SUPERIOR COURT JUDGE BE ABLE TO INITIATE THE  
            PROCESS FOR OBTAINING A COURT ORDER FOR ASSISTED OUTPATIENT  
            TREATMENT OF A PERSON APPEARING BEFORE THE JUDGE, EVEN THOUGH  








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            THE JUDGE MAY NOT BE FAMILIAR WITH EITHER THAT PERSON'S MENTAL  
            HEALTH HISTORY, OR ALL OF THE OPTIONS FOR LESS INTRUSIVE  
            MENTAL HEALTH TREATMENT PROGRAMS THAT MAY BE AVAILABLE IN THE  
            COUNTY?


                                      SYNOPSIS


          The Involuntary Assisted Outpatient Mental Health Treatment  
          Program (AOT), also known as "Laura's Law," was initially  
          adopted in 2001, reauthorized in 2006, and reauthorized again in  
          2012.  The law allows any county that wishes to provide  
          "assisted outpatient treatment services," as defined, to do so,  
          but requires the county wishing to offer the program to make  
          certain findings, including that no voluntary mental health  
          program serving adults, and no children's mental health program,  
          will be reduced as a result of the implementation of AOT.  The  
          program has been authorized for over 10 years and a number of  
          small and large counties have either implemented AOT, or  
          approved implementation: Nevada, Yolo, San Diego, Orange, San  
          Francisco, Los Angeles, Contra Costa, Placer, and Mendocino.   
          Given the positive, but somewhat limited "on the ground"  
          experience with AOT in California, the bill proposes three  
          significant changes to the program.  First, it makes AOT an  
          opt-out program, allowing a county that does not wish to  
          implement the program to pass a resolution of the county board  
          of supervisors stating the reasons for opting out and any facts  
          or circumstances relied on in making that decision.  Second, it  
          extends for five years the date when the program is set to  
          sunset, from January 1, 2017 until January 1, 2022.  Third, it  
          allows any superior court judge to request that the mental  
          health director evaluate the person for AOT.   This bill is  
          sponsored by the California Psychiatric Association and  
          supported by California Chapter of the American College of  
          Emergency Physicians, California Hospital Association, NAMI  
          Contra Costa County, and the National Association of Social  
          Workers.  It is opposed by the California State Association of  
          Counties (Oppose unless amended), California Association of  








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          Social Rehabilitation Agencies, County Behavioral Health  
          Directors Association of California (Oppose unless amended),  
          Disability Rights California, and Urban Counties Caucus (Oppose  
          unless amended).


          SUMMARY:  Delete the provisions in current law that authorize,  
          but do not require counties in the state to participate in the  
          Assisted Outpatient Treatment Demonstration Project Act of 2002,  
          known as Laura's Law, extend the repeal date of January 1, 2017  
          until January 1, 2022, and allow any superior court judge to  
          refer a person appearing before the judge for AOT evaluation.   
          Specifically, this bill:  


          1)Deletes the provisions that authorize a county to participate  
            in the Assisted Outpatient Treatment Demonstration Project Act  
            of 2002, and instead requires all counties with available  
            funding to implement the program, unless they opt out of  
            implementation.  
           2)Extends the January 1, 2017, repeal date for the Assisted  
            Outpatient Treatment Demonstration Project Act of 2002 until  
            January 1, 2022, thereby extending the program for an  
            additional five years.  


           3)Authorizes a judge in a superior court to request that the  
            county mental director investigate whether it would be  
            appropriate to file a petition seeking a court order for AOT  
            relating to a person who appears before that judge. 


          EXISTING LAW:  


          1)Permits counties to provide AOT for people with serious mental  
            illnesses when a court determines that a person's recent  
            history of hospitalizations or violent behavior, and  
            noncompliance with voluntary treatment, indicates the person  








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            is likely to become dangerous or gravely disabled without the  
            court-ordered outpatient treatment.  (Welfare and Institutions  
            Code Section 5346.  All further statutory references are to  
            this Code, unless otherwise indicated.)


          2)Requires the board of supervisors of a county, in order to  
            authorize an AOT program in the county to adopt the program by  
            resolution or through the county budget process and make a  
            finding that no voluntary mental health program serving  
            adults, and no children's mental health program, may be  
            reduced as a result of its implementation.  (Section 5349.)


          3)Allows a court, after finding that an individual meets the  
            criteria for assisted outpatient treatment, and there is no  
            appropriate and feasible less restrictive alternative, to  
            order the individual to receive assisted outpatient treatment  
            for an initial period not to exceed six months.  If the  
            director of the assisted outpatient program determines that  
            the individual requires further assisted outpatient services,  
            requires that director, prior to expiration of the time period  
            of the treatment, to apply to the court for an extension of  
            the services, not to exceed 180 days.  (Section 5346(d), (g).)


          4)Sunsets this authorization on January 1, 2017.  (Section  
            5349.5(a).)


          5)Grants any person subject to a petition for an order of  
            assisted outpatient treatment the right to legal counsel at  
            all steps of the hearing process.  (Section 5346(d)(4)(C).)


          6)Requires the Department of Health Services to submit a report  
            and evaluation to the Governor and the Legislature of all  
            counties implementing an assisted outpatient treatment program  
            by July 1, 2015.  (Section 5349.5(b).)








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          7)Establishes the Lanterman-Petris Short Act (LPS Act), which  
            authorizes a person to be involuntarily detained for inpatient  
            mental health treatment when, as a result of a mental  
            disorder, the person is a danger to him or herself or to  
            others, or is "gravely disabled".  Defines "gravely disabled"  
            to mean a condition in which a person, as a result of a mental  
            disorder, is unable to provide for his or her basic personal  
            needs for food, clothing or shelter. (Sections 5008 (h)(1)(A)  
            and 5150.)


          8)Allows, under the LPS Act, a person who is gravely disabled to  
            be involuntarily detained for further inpatient mental health  
            treatment for an additional 14 days, as provided, which can be  
            extended for 14 days if the person presents an imminent threat  
            of taking his or her own life or 30 days if the county has  
            authorized the program and the person remains gravely  
            disabled.  (Section 5250, 5257, 5260.)


          9)Allows, under the LPS Act, a court to order an imminently  
            dangerous person to be confined for further inpatient  
            intensive health treatment for an additional 180 days, as  
            provided.  (Section 5300 et seq.)


          FISCAL EFFECT:  As currently in print this bill is keyed fiscal.


          COMMENTS:  The AOT Demonstration Project allows courts in  
          participating counties to order a person into an AOT program if  
          the court finds that the individual either meets existing  
          involuntary commitment requirements pursuant to Section 5150 (is  
          gravely disabled, or is a danger to self or others), or the  
          person meets non-5150 criteria, including that the person has  
          refused treatment; their mental health condition is  
          substantially deteriorating; and AOT would be the least  








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          restrictive level of care necessary to ensure the person's  
          recovery and stability in the community.  The law is only  
          operative in those counties where the county board of  
          supervisors, by resolution or budget action, authorizes its  
          application and makes a finding that no voluntary mental health  
          program serving adults, and no children's mental health program,  
          will be reduced in order to implement the law.


          According to the author, "Assisted outpatient treatment is a  
          community-based treatment program to assist individuals who, as  
          a result of their severe mental illness, are unable to access  
          community mental health services voluntarily.  In fact, AOT is a  
          less restrictive alternative to involuntary hospitalization,  
          where an individual suffering from a severe mental illness is  
          detained for up to 72 hours if they have presented a danger to  
          themselves or others."


          Indeed, studies of involuntary outpatient programs have shown  
          that the programs have impressive results.  For example, a Duke  
          University/North Carolina State University study in the 1990s  
          showed that "subjects who underwent sustained periods of  
          outpatient commitment beyond that of the initial court order had  
          approximately 57% fewer readmissions and 20 fewer hospital days  
          than control subjects."  That same study, however, showed that  
          "sustained outpatient commitment reduced hospital readmissions  
          only when combined with a higher intensity of outpatient  
          treatment" and concluded that "use of outpatient commitment is  
          not a substitute for intensive treatment; it requires a  
          substantial commitment of treatment resources to be effective."


          Counties have a financial incentive to implement AOT programs,  
          according to other recent studies.  For example, a 2013 study  
          showed that New York state's AOT law, "Kendra's Law," resulted  
          in substantial cost savings.  "In the New York City sample, net  
          costs declined 43% in the first year after assisted outpatient  
          treatment began and an additional 13% in the second year. In the  








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          five-county sample, costs declined 49% in the first year and an  
          additional 27% in the second year."  (Swanson et al, Am J  
          Psychiatry 2013; 170:1423-1432.) 



          County Experience with implementation of AOT.  The AOT  
          Demonstration Project was first implemented in Nevada County.   
          According to the treatment provider that provides AOT services  
          in Nevada County, Turning Point Community Programs, initiating  
          the AOT process begins with a referral submitted by family  
          members, relatives, cohabitants, treatment providers or their  
          supervisors, or peace officers.  If the person meets the AOT  
          eligibility requirements, a preliminary care plan is developed.   
          If the individual voluntarily engages with the treatment after  
          initial contact, a petition is no longer necessary and the  
          patient no longer meets the criteria for AOT referral.  However  
          if the client declines the preliminary care plan, the AOT team  
          proceeds with a petition and a public defender is assigned to  
          the client.  The court must be notified within 10 days of the  
          intervention, and a hearing must be set within five days of the  
          filing of the petition and the judge either grants or rejects  
          the AOT petition.  If ordered, AOT is valid for up to 180 days.



          According to Nevada County, in the seven years the county has  
          implemented Laura's Law, 37 AOT commitments have been ordered by  
          the court, and six individuals have failed to complete their  
          orders due to hospitalization, incarceration, or death.  Nevada  
          County indicates that the number of hospitalization days for  
          program participants has been cut in half, and no patient has  
          encountered problems with law enforcement since their  
          commitment. In Orange County, two individuals have been ordered  
          to fulfill an AOT commitment. The other county programs have  
          been recently implemented and do not yet have any court ordered  
          AOT commitments.










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          In the past ten years that AOT has been authorized, eight  
          counties - Nevada, Yolo, San Diego, Orange, San Francisco,  
          Contra Costa, Placer, and Mendocino -- have chosen to fully  
          implement the program.  (A ninth county, Los Angeles, has  
          implemented AOT on a limited basis).  In addition, according to  
          the author, there are formal processes in motion that may lead  
          to adoption before the Board of Supervisors in the following  
          counties: El Dorado, Contra Costa, San Mateo, Kern, Santa  
          Barbara, and Ventura.


          County hearings - one person's bureaucratic hurdle is another  
          person's public process.  According to the author, the  
          procedural requirements in current law are an obstacle for  
          counties that wish to implement AOT programs.  The author  
          states: 


               Since Assisted Outpatient Treatment (AOT) was approved by  
               the legislature in 2002, only nine counties have  
               implemented it.  . . . The current opt-in process makes AOT  
               implementation difficult for counties to participate in,  
               evidences [sic.] by the fact that only a fraction of  
               counties have implemented AOT.  Implementing AOT statewide  
               will ensure that those at highest risk for hospitalization  
               can obtain the necessary treatment services to keep them in  
               the community.  While this bill implements Laura's Law  
               statewide it does provide for counties to retain control by  
               allowing them to opt out of participation in Laura's Law if  
               they so choose.  


          While it is true, as the author contends, that only a small  
          percentage of the counties in the state have gone through the  
          process to approve AOT, it is unclear why others have not done  
          so (i.e. an issue of procedure or policy).  As the Duke Study  
          shows, AOT programs require "a substantial commitment of  
          treatment resources to be effective."  It could be that counties  








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          do not have the personnel or financial resources to implement  
          AOT in a manner that would be successful.  If so, then it is  
          appropriate for counties not to adopt the program.


          Many counties may have considered and rejected implementation of  
          AOT.  This bill would force those counties to either implement a  
          program they have previously rejected, or to hold another public  
          hearing to reject adoption of the program they have already  
          rejected in a public process.  As the Urban Counties Coalition  
          writes in opposition to the bill (unless it is amended to revert  
          to the opt-in system in current law): 


               [W]e are opposed to the provision which would make it  
               mandatory for every county to adopt Laura's Law unless the  
               county elects not to participate through a resolution.  
               Since the enactment of Laura's Law, it has been permissive  
               due to the potential additional costs and policy issues  
               that can vary among counties. In urban counties, 5 counties  
               have adopted Laura's Law in the past two years (Contra  
               Costa, Los Angeles, Orange, San Diego, and San Francisco),  
               therefore, we do not believe this section of the bill is  
               necessary. In addition, this bill would mandate counties  
               adopt Laura's Law which would create a new burden on  
               counties that may have already heard this issue recently in  
               public hearings.


          Opt-in versus opt-out.  Despite the fact that AOT remains  
          controversial in some communities and certainly some advocacy  
          groups, the author seeks to remove the provision in current law  
          which makes the program optional ("upon adoption of a resolution  
          or budget act by the board of supervisors of a county and a  
          finding that no voluntary mental health program serving adults,  
          and no children's mental health program will be reduced as a  
          result of its implementation").  Instead, this bill would make  
          the program mandatory, unless the county board of supervisors  
          adopts a resolution opting out of the program.  While the  








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          author's goal of statewide adoption of AOT is admirable, clearly  
          not all counties wish to adopt the program.  In light of the  
          author's well-meaning desire to encourage counties to consider  
          adoption of the program while acknowledging the right of  
          counties to reject the program, perhaps it would be appropriate  
          to require a county that has not yet held a public hearing to  
          consider adoption of AOT to do so.  This would promote county  
          consideration of the program, while taking into consideration  
          the fact that some counties have already determined that AOT is  
          inappropriate and should not be forced to reopen their  
          decisions.  Based upon these concerns, the following amendment  
          is suggested to the author:


               Page 14, at lines 14 - 17: strike out in their entirety





               Page 14, at line 18, strike out "circumstances relied on in  
               making that decision." And insert the following:





                This article shall be operative in those counties in which  
               the county board of supervisors, by resolution or through  
               the county budget process, authorizes its application.  

               (a)    Any county which has not held a public hearing by  
                 January 1, 2017 to determine whether this article shall  
                 be operative shall do so by January 1, 2018.  At the  
                 hearing, the board of supervisors shall consider the  
                 options available in the county for providing services to  
                 persons whose  recent history of hospitalization or  
                 violent behavior, and noncompliance with voluntary  
                 treatment, indicate that they may be likely to become  








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                 dangerous or gravely disabled, including but not limited  
                 to the following:

                    1)          Options for providing services other than  
                      court-ordered outpatient treatment.

                    2)          Whether any voluntary mental health  
                      program serving adults, or any children's mental  
                      health program, may be reduced as a result of the  
                      implementation of this article.   

                


          Extension of the sunset provision.  The AOT program was  
          originally scheduled to expire by law on January 1, 2008, but  
          was reauthorized in 2006, and reauthorized again in 2012.  The  
          2012 legislation, Assembly Bill 1569 (Allen, Chapter 441,  
          Statutes of 2102) was controversial.  It was opposed by all of  
          the groups that oppose this bill, but also many others that do  
          not oppose this bill that removes the sunset in its entirety,  
          including the American Civil Liberties Union of California,  
          California Council of Community Mental Health Agencies,  
          California Mental Health Planning Council, Mental Health America  
          of California, and the National Association for Rights  
          Protection and Advocacy.  Based upon the fact that fewer groups  
          oppose this much more far-reaching bill, it appears that the AOT  
          program is more widely accepted and less controversial that it  
          was at one time, but is not without critics.  


          Disability Rights California has "concerns about AOT programs  
          and we believe that voluntary services are more effective and  
          should be expanded, we believe that the sunset provision is  
          important to protect the rights of people with mental health  
          disabilities in California."  Meanwhile, the California  
          Association of Mental Health Peer Run Organizations questions  
          whether AOT is as effective as less coercive alternative  
          treatments and writes:








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               Clearly it is the services that make the difference and  
               produce positive results. Through the MHSA (Prop 63),  
               California has put its money into a voluntary network of  
               community services that are person centered and holistic  
               and based on the recovery model.  The results of a 2012  
               UCLA study of MHSA Full Service Partnerships found that  
               every dollar spent on mental health services in California  
               saved roughly $0.88 in costs to the criminal justice and  
               health and housing services by reducing the number of  
               arrests, incarcerations, ER visits, and hospitalizations.  
               These same kinds of results were found in the Petris Center  
               Evaluation, May 2010; a large reduction in homelessness, a  
               rise in the proportion of consumers living independently,  
               less use of mental health related emergency services, less  
               incarcerations, and a rise in employment.  AB 34 and 2034,  
               the pilot programs that the full service partnerships are  
               modeled on, produced the same kind of positive results. 


          Given these concerns and the importance of receiving more data  
          about the implementation successes and failures, the Committee  
          may find it prudent to reauthorize this program for another  
          relatively short period, such as the five years suggested by the  
          author.  


          Additional portal necessary for entry into AOT via the county  
          courts?  Current law allows specific individuals to request that  
          the county mental health director file a motion for a court  
                                                     order requiring a person to participate in AOT: 


             (a)  Any person 18 years of age or older with whom the person  
               who is the subject of the petition resides.

             b)   Any person who is the parent, spouse, or sibling or  
               child 18 years of age or older of the person who is the  








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               subject of the petition.

             c)   The director of any public or private agency, treatment  
               facility, charitable organization, or licensed residential  
               care facility providing mental health services to the  
               person who is the subject of the petition in whose  
               institution the subject of the petition resides.

             d)   The director of a hospital in which the person who is  
               the subject of the petition is hospitalized.

             e)   A licensed mental health treatment provider who is  
               either supervising the treatment of, or treating for a  
               mental illness, the person who is the subject of the  
               petition.

             f)   A peace officer, parole officer, or probation officer  
               assigned to supervise the person who is the subject of the  
               petition.  (5346(b)(2).)


          All of these individuals are very familiar with either the  
          person who is the potential subject of an AOT petition, or the  
          county's mental health resources, or both.  On the other hand,  
          this bill would authorize a "judge of a superior court before  
          whom the person who is the subject of the petition appears" to  
          request the county mental director to investigate whether it  
          would be appropriate to file a petition for AOT relating to that  
          person.  A judge (who could be presiding over a traffic, family,  
          juvenile, probate, or criminal matter) may not be familiar with  
          either the person and his or her mental health history, or the  
          resources available for mental health treatment of that person  
          in the county.  Therefore, the Committee may question whether  
          this language is too broad and whether it would be more  
          appropriate to limit this provision to judges who are familiar  
          with the mental health background of the individual appearing  
          before them and the mental health resources available in their  
          county.  









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          Disability Rights California writes, "Existing law provides a  
          list of individuals who may request that a county mental health  
          department file an AOT petition, based on the individual's  
          knowledge of and connection to the person who will be the  
          subject of the petition.  This bill would add to this list a  
          Superior Court judge before whom the subject of the petition  
          appears. A judge presiding over an unrelated legal matter would  
          not necessarily have sufficient information about the individual  
          who is subject to the petition to request that an AOT petition  
          be filed. Adding to the existing list of people who can request  
          a petition increases the possibility that the petitions may be  
          filed without adequate basis, therefore further limiting  
          individual rights."


          Based upon these concerns, the following amendment is suggested  
          to the current language in the bill:

               (G) A judge of a superior  court   court's mental health  
               court, reentry court, or other collaborative justice court  
               available for improving the mental health of the defendant,  
               or a probate court  before whom the person  who is the  
               subject of the petition  appears  as the subject of a  
               proceeding pursuant to Section 5352.

           Related pending legislation.  AB 59 (Melendez) Removes the  
          sunset on Laura's Law so that the program is indefinitely  
          extended and eliminates the requirement that the board of  
          supervisors in a county must find, prior to authorizing the  
          program, that other mental health programs, including but not  
          limited to children's mental health services will not be reduced  
          as a result of implementation of AOT, and allows the  
          professional staff of the facility where a person has been  
          detained for involuntarily inpatient treatment to recommend a  
          petition for AOT for that person.


          AB 193 (Maienschein) Allows probate courts to recommend a  








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          referral for an LPS conservatorship to the county officer  
          providing conservatorship investigations.  


          Previous legislation.  AB 2266 (Waldron, 2014) would have  
          increased the maximum period of imposed outpatient treatment  
          under the AOT Demonstration Project from six months to one year.  
          AB 2266 failed in the Assembly Judiciary Committee.


          AB 1265 (Conway, 2013) would have increased the maximum period  
          of imposed outpatient treatment under the AOT Demonstration  
          Project from six months to one year.  AB 1265 also failed in the  
          Assembly Judiciary Committee.


          AB 1569 (Allen), Chapter 441, Statutes of 2012, extended  
          authorization for "Laura's Law" to January 1, 2017 and required  
          DHCS to submit a report to the Legislature regarding the program  
          by July 1, 2015.


          AB 1421 (Thomson), Chapter 1017, Statutes of 2002, authorized  
          counties to provide court-ordered outpatient treatment services  
          for people with serious mental illnesses when a court finds that  
          a person's recent history of hospitalizations or violent  
          behavior, coupled with noncompliance with voluntary treatment,  
          indicate the person is likely to become dangerous or gravely  
          disabled without the court-ordered outpatient treatment.


          REGISTERED SUPPORT / OPPOSITION:



          Support


          California Psychiatric Association (sponsor)








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          California Chapter of the American College of Emergency  
          Physicians


          California Hospital Association


          NAMI Contra Costa County


          National Association of Social Workers




          Opposition

          California State Association of Counties (Oppose unless amended)


          California Association of Social Rehabilitation Agencies


          County Behavioral Health Directors Association of California  
          (Oppose unless amended)


          Disability Rights California


          Urban Counties Caucus (Oppose unless amended)




          Analysis Prepared by:Alison Merrilees / JUD. / (916) 319-2334









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