The faces
of homelessness we see or hear about
do not usually include images or stories
of elderly persons who are homeless.
Homeless elders, although increasing
in numbers, continue to be a forgotten
population. In an attempt to bring to
the forefront the very real and growing
existence of elder homelessness, this
paper discusses the special health care
and service needs of elderly homeless
people and the barriers that they encounter
when trying to access services. It also
presents service-delivery models from
communities that are addressing the
multiple health care and social service
needs of this frail and vulnerable population.
In addition to the elderly who are facing
homelessness for the first time or are
at risk of becoming homeless, there
are also chronically homeless adults
who are aging on the streets and are
often multiply diagnosed, i.e. suffer
from a range of complex health, mental
health, and substance abuse issues.
Both face unique health care and service
needs that require a multidisciplinary-team
approach with minimal barriers in order
to achieve optimum health and housing
stability.
Health Issues
Physical Health Problems
Elderly people who are homeless are
more likely to experience multiple medical
problems and chronic illnesses that
may have gone untreated for years. In
addition to illnesses common to aging
such as diabetes, cardiac disease, circulatory
problems, and hypertension, the health
of an elderly person who is homeless
is also compromised by the harsh environment
of homelessness (e.g., exposure, hypothermia,
frostbite). For an elderly person who
is homeless in a “survival mode”
and trying to find a safe place to sleep
every night, addressing his or her health
care quickly loses priority.
Elderly people who are homeless or recently
homeless and lack social supports are
especially prone to depression, dementia,
and other mental health problems. An
elderly demented person may present
with significant memory problems, cognitive
impairments, poor judgment and poor
comprehension. Dementia, as well as
depression, makes it very difficult
to provide follow-up, which is necessary
to secure housing. Both conditions may
also threaten an elderly person’s
stable housing (e.g., non-payment of
rent because of cognitive difficulties
and memory loss) or create a dangerous
environment in the home, often leading
to loss of housing (e.g., leaving water
running or forgetting to turn off the
stove).
Critical Service Needs
Case Management
For both those elderly persons experiencing
homelessness for the first time, as
well as those who have been living in
the streets or shelters for many years,
intensive case management services are
an integral part of the transition into
permanent housing. Along with this is
a requirement to establish other much
needed services such as health care
and behavioral health services. Good
case management allows for continuity
of care, coordination of services, and
follow-through, while maintaining the
dignity of each individual and addressing
his/her unique needs.
Once in a stable housing situation,
previously homeless elderly persons
may benefit from on-going case management
services. The on-going involvement of
social workers or case managers may
help to ensure that the elderly person
maintains his or her independence in
the community for as long as possible.
The case manager may coordinate supportive
services such as in-home care, meal
deliveries, transportation to medical
appointments, medication monitoring,
and visitors, which help to improve
the quality of life for the elderly
person. The case manager and support
network may also monitor potentially
dangerous situations such as risks for
eviction (e.g. for non-payment of rent)
or self-neglect.
Housing Assistance
A stable living environment is important
for an elderly person in order to allow
for the identification and resolution
of their neglected health care and other
needs. Due to the transitory nature
of an emergency shelter, which often
provides only a bed for the night, it
is usually not an appropriate placement
for an elderly homeless person. For
example, it is rare that one is allowed
to securely store belongings at the
shelter and a bed is not always guaranteed
every night. Thus stability and security
are lacking.
Housing options for elderly homeless
persons are limited. Complete medical,
mental health and case management assessment
are important in determining the appropriate
housing needs of an elderly homeless
individual. An elderly person found
wandering on the streets and presenting
with dementia, chronic medical conditions,
poor hygiene and self-neglect may be
deemed incapable of living independently
in the community. However, after intensive
medical and case management intervention,
the same person may be able to thrive
in a permanent housing situation with
supportive services and social networks
in place. Collaboration between case
managers, health care providers, substance
abuse counselors, and mental health
providers are integral in developing
a housing plan that takes into consideration
the specific needs and wishes of the
elderly person.
Board & Care homes or Residential
Care Facilities (RCF) exist for older
adults who need a minimum level of supervision.
Housing and meals are provided in a
communal living situation and medical
supervision is available. Unfortunately,
in some communities, some Board &
Care homes or RCFs that will not accept
a resident whose only income comes from
Supplemental Security Income, making
this option unavailable for seniors
on a fixed, limited income.
Assisted living facilities provide housing
and personalized care for elderly persons
who need help with activities of daily
living such as bathing, eating, dressing,
and housekeeping. Assisted living facilities
allow a senior to remain in his/her
community while providing necessary
supportive services on-site. In Boston,
the Committee to End Elder Homelessness
(CEEH) is currently developing an assisted
living facility specifically for elderly
homeless persons. The new CEEH program
will provide affordable housing and
services such as laundry, health care,
medication monitoring, and meals.
Finally, there are subsidized senior
housing programs that usually have long
waiting lists. Residential hotels or
single room occupancies (SROs) often
become the housing of choice for many
low-income seniors faced with homelessness
and waiting to get into subsidized senior
housing programs. Unfortunately, there
has been a steady trend of diminishing
SRO housing stock in many urban areas
due to conversion into more high-rent
condominiums, apartments, or tourist
hotels (Minkler and Ovrebo, 1985).
Many elderly persons face evictions
because of ever-increasing rents in
many communities, which also have tight
housing markets, thereby creating a
need for eviction prevention assistance.
Elderly persons need to be aware of
their rights as tenants and of legal
eviction procedures. In conjunction
with general case management, eviction
assistance, availability of emergency
rental funds, and advocacy may prevent
many elderly persons from losing their
homes. An additional obstacle to finding
other housing can be the inclusion of
an eviction history on one’s housing/rental
record, making eviction prevention assistance
critical.
Financial Management
Determining an elderly person’s
eligibility for financial benefits and
securing a stable income is necessary
to obtain permanent housing. The elderly
person may be unaware of benefits such
as Social Security, Supplemental Security
Income, VA pensions, and private retirement
pensions. In some States, very low-income
older adults may be eligible for food
stamps and/or State-funded public assistance.
In addition, many seniors are unaware
of their eligibility for Medicare upon
reaching 65 years of age. Lastly, very
low-income and/or disabled seniors may
be eligible for the State-supported
Medicaid program and therefore be dually
eligible for Medicare/Medicaid. Following
through with the application process
necessary to secure such benefits requires
paperwork and long waits for filing
this paperwork that an elderly person
(or anyone else for that matter) may
find discouraging. Elderly persons with
cognitive disabilities or elderly immigrants
faced with changing immigration policies
and language and cultural barriers may
require even more assistance.
In addition to assistance with securing
a stable income, elderly persons, especially
those with significant mental health
problems, cognitive impairments, or
substance abuse problems, may need assistance
with money management or benefit from
participation in representative payee
services. Such services ensure that
the participant’s rent is paid
or that the limited income lasts through
the month to support the senior’s
need for food, prescription co-payments,
and transportation.
Nutritious Meals
A well-balanced, nutritious meal is
crucial for an elderly person with ailing
health, chronic medical conditions,
and living in a harsh environment on
the streets and in shelters. Elderly
persons may utilize community soup kitchens
and senior nutrition sites available
in many cities to provide meals exclusively
for persons age 60 and older. Senior
meal sites provide what may often be
the only hot, nutritious meal an elderly
person will have for the day. In addition,
mealtime may also serve as a significant
place for socialization and interpersonal
contact.
Elderly persons who are homeless encounter
barriers to services similar to those
that younger homeless persons experience
(e.g. lack of transportation, long application
processes to obtain services, lack of
awareness of resources). However, they
often find these barriers more difficult
to overcome because they are frequently
burdened by poor health and chronic medical
conditions, frailty, poor mobility, and
physical limitations common to aging such
as loss of hearing or sight. In addition,
for some seniors, aging may come with
cognitive impairments and changes in mental
status such as dementia. The barriers
homeless seniors face can be grouped into
external or real barriers and internal
or perceived barriers. External barriers
are those obstacles encountered in the
physical world, while perceived or internal
barriers refer to an individual’s
perceptions or beliefs regarding his or
her environment which may prevent him/her
from seeking much needed services. In
order to make an already overwhelming
social service system more accessible
and to provide services that effectively
address the needs of elderly persons who
are homeless, one must look at both external
and internal barriers.
A. External Barriers
Difficulty Utilizing Shelter System
The emergency shelter system, which
generally lacks sensitivity to sub-groups
among homeless persons, can be an especially
harsh environment for an elderly person.
Most shelters, when developing shelter
rules and regulations, do not take into
consideration the physical limitations
and multiple medical conditions many
elderly persons face. For instance,
in addition to having to stand in long
lines in order to “sign-up”
for a bed, elderly persons often have
a particularly hard time using a general
shelter system that requires a late
entry (sometimes as late as 9:00 p.m.)
and very early morning exit. Normally,
shelters do not allow for adequate hygiene
and self-care. Not only is it difficult
to maintain one’s personal hygiene,
but elderly persons also undoubtedly
have a difficult time maintaining their
health and following up on medications
while staying in a shelter. Medications
are at risk of being lost or stolen
in a crowded shelter where there is
usually a lack of private, personal
space. In addition, shelters located
up or down stairs may not be accessible
to those with limited mobility.
Elderly persons who are homeless, especially
those who are homeless for the first
time and may lack “street smarts”,
are easy targets for assault and robbery
by the younger residents staying at
the shelter, particularly if the elderly
person is under the influence of alcohol,
drugs, or medications. Many seniors
may feel unsafe in shelters and avoid
staying in them altogether, only to
expose themselves to equally dangerous
elements on the streets.
Lack of Respite Services and Transitional
Housing Programs
Elderly persons who are homeless often
have compromised immune systems related
to aging, poor nutrition, and chronic
medical illnesses. They are often hospitalized
and may be prematurely discharged from
hospitals or discharged without a housing
placement, making it difficult, if not
impossible, to adequately recuperate
and regain their health. This only exacerbates
existing medical conditions and likely
leads to repeat hospitalizations. Elderly
persons who are homeless need recuperative
care or respite services that allow
for the time necessary to heal.
Sometimes persons in substance abuse
treatment programs, hospitals, or jails
are thrust into homelessness after being
prematurely discharged into the streets
or shelters. It is not unheard of for
an elderly person, for instance, to
lose his/her housing after an extended
hospital stay especially in cities where
there is a tight housing market. In
urban areas where high rental market
rates persist and affordable housing
has long waiting lists, transitional
housing programs may be necessary to
immediately stabilize an individual’s
situation. Elderly persons who are faced
with homelessness need a stable place
to stay while receiving case management
services and awaiting permanent housing.
Especially for persons who are being
discharged from substance abuse treatment
programs or jails, timely follow-up
with supportive services and stability
is necessary to decrease risks for relapse
or return to incarceration.
Conflicting Service Hours
During a consumer focus group conducted
for the preparation of this paper, a
67 year old senior who had been homeless
for about a year summarized one of the
access barriers that many homeless people
encounter: “Do I line up so that
I can get a bed for the night, or do
I get my foot taken care of?”
Homeless persons find that the business
hours when essential medical care, shelters,
or meals are available can overlap and
interfere with one another, forcing
the homeless person to neglect some
of the assistance that they require.
Lack of Transportation
There are two factors that, when combined,
compound people’s difficulty in
access services: conflicting service
hours (discussed above) and a lack of
available transportation. Lack of transportation
may especially be difficult for elderly
persons who, due to poor mobility, cannot
get around as easily or as fast as their
younger counterparts. Even in areas
where sufficient public transportation
may exist, an elderly person with poor
cognitive capacity will have a difficult
time following directions and utilizing
available public transportation.
Lack of Awareness of Resources
and Benefits
As with other age groups experiencing
homelessness, lack of information about
resources and eligibility requirements
is a significant barrier to accessing
services. Many seniors may not be aware
of what benefits they are eligible for
or they may not know how to begin applying
for benefits (e.g. SSI, food stamps).
The daunting paperwork procedures, and
extensive follow-up needed may be intimidating
and prevent some persons from applying
for benefits or assistance altogether.
Elderly persons, especially those with
physical limitations and/or changes
in their mental status, require extensive
assistance when applying for benefits
or housing, a process that often requires
supplementary documents and personal
interviews. Not only is it important
to make persons aware of their eligibility,
but it is essential to make certain
that there is follow-through with appointments
and completing paperwork.
Inadequate Substance Abuse and Mental
Health Services
Annie is the shelter director of the
Lazarus Day Center, a daytime drop-in
center for seniors 50 and older located
in Seattle, WA. In working with chronically
homeless elderly persons, many of who
have a history of substance abuse or
are often dually diagnosed, she states,
“We need to get them [homeless
seniors] into a program as soon as they
say they’re ready.”
Lack of access to adequate mental health
and substance abuse services poses a
challenge to providing comprehensive
behavioral health evaluations and treatment.
Elderly persons who are homeless or
are in jeopardy of homelessness are
at great risk for depression. Chronic
mental illness and/or substance abuse
that remain undiagnosed and untreated
can be a factor leading to homelessness
or prolonged homelessness. Proper mental
health evaluation is an important component
in long-term case management planning
toward stabilizing an elderly person’s
homeless situation.
Lack of Affordable Housing
One of the dilemmas faced by homeless
persons who are elderly is the long
waiting list for affordable senior housing.
In most urban areas, the waiting list
for subsidized housing can be as long
as 3 to 5 years. This is especially
true in areas where the rental market
tends to be most expensive and elderly
persons with limited incomes who becomes
homeless are unable to find alternate
housing that is within his or her economic
means. Compounding this lack of affordable
housing are the stringent and often
extensive criteria for acceptance into
many existing affordable housing programs.
Most housing programs seek applicants
who have clean housing histories with
no prior evictions. In addition, they
are often hesitant to accept applicants
who have a history of mental health,
substance abuse problems, or past criminal
records.
Lack of Economic Resources
The amount of financial assistance an
elderly person receives from Social
Security is dependent on the number
of years or quarters they have worked
and contributed to the Social Security
system. Currently, if one retires at
the age of 65, the individual will receive
the maximum benefit each month. However,
if one retires before reaching the age
of 65 years, the amount they are entitled
to receive every month is decreased.
In some States, Social Security can
be supplemented with Supplemental Security
Income (SSI) for seniors who are 65
years or older and whose monthly income
is below the SSI limit. For many elderly
persons 65 years or older who do not
have a work history with Social Security,
SSI becomes the primary source of income.
The cost of living, including housing
and other expenses, is often not sufficiently
covered by SSI.
One of the barriers which Twyla Smith,
Health Care for the Homeless nurse practitioner
in Seattle, WA, observes is the reluctance
and hesitance of many elderly homeless
persons to accept any housing that will
significantly deplete their Social Security
or SSI check. She states, “The
[homeless] seniors are aware of their
need to accept certain services such
as housing, but when it comes down to
parting with the very little money they
have, they are adamant about not wanting
to.”
Some elderly persons find it necessary
to obtain employment in order to supplement
their limited monthly income to meet
the costs of basic housing and living.
However, elderly persons may have medical
and physical conditions that may make
it difficult to work. Many others encounter
difficulty in obtaining employment,
not because of any physical limitations,
but because of their age. While some
seniors may access employment training
and placement in part-time work through
National Council on Aging programs,
others may face the discriminatory practice
of ageism in the job market, which may
defeat their attempts to establish or
improve their income.
B. Internal Barriers
Lily Cabeza, nurse case manager for
the San Diego Health Care for the Homeless
Program in San Diego, CA, has found
that elderly people who are homeless
tend to be more difficult to work with
than her younger patients because of
the greater distrust that elderly people
experiencing homelessness have toward
service providers. She shares that many
of her elderly patients who are homeless
have a “fear of the system”
and a fear of “being put in a
home”. An elderly person, afraid
of losing his or her independence, may
think that seeking help from a social
service agency will lead to institutionalization.
Unfortunately, the lack of trust in
providers and fear of social service
agencies prevents elderly persons, either
homeless or at risk of becoming homeless,
from receiving the services they need.
The pride and self-perception an elderly
person carries may also be a barrier
that prevents him or her from seeking
much-needed services. Case managers
at St. Anthony Foundation in San Francisco,
CA, observed among many of their elderly
homeless clients, a resistance to accept
services because “they [homeless
seniors] do not want to rely on anybody.”
To some of the elderly people who are
homeless, accepting services may equate
to admitting that they are aging and
are no longer as independent as they
had been previously
Risk of Victimization
Elderly persons who are homeless are
at greater risk for victimization and
injury than their younger counterparts.
Because most seniors receive a regular
monthly income (e.g. VA pension, Social
Security, and SSI checks), and are less
likely to be able to defend themselves,
they are perceived as easy targets for
robbery (Hudson, et al, 1990). Because
of their limited physical mobility,
frailty, and often, cognitive impairments,
elderly persons are extremely vulnerable
both on the streets and in the shelters.
They may also be less likely to report
an incident and more likely to be ignored
by law enforcement. In addition, an
elderly person with poor mental status
and impaired judgment may be at risk
for being abused financially. Because
they are particularly vulnerable to
victimization and abuse, special awareness
and attention should be given to the
protection and safety of elderly persons
who are homeless.
Recommendations from Providers
Who Serve Elderly People Who Are Homeless
Community Models (What is working?)
Multidisciplinary Team Service-Delivery
Model
Elderly persons who are homeless often
present with multiple, chronic medical
and social service needs that may be most
effectively addressed using a multidisciplinary
team approach. A multidisciplinary team
service delivery model brings together
services and providers under one roof.
At North of Market Senior Services
(NOMSS) in San Francisco, CA, homeless
seniors age 55 and older who walk in immediately
have access to primary health care, case
management, substance abuse counseling,
social programs, referrals to emergency
shelters, assistance with permanent housing,
and a hot, nutritious meal. The homeless
case manager collaborates with substance
abuse counselors and primary health care
providers on-site in objectively assessing
the needs of the client and assuring quality
care.
For an elderly person who has been homeless
for many years, transitioning into permanent
housing may be difficult. NOMSS continues
to provide support to previously homeless
seniors and assists in their transition
into permanent housing through long-term
case management. Case managers work with
seniors by coordinating support services
which allow the senior to continue to
live independently in the community and
remain in stable housing for as long as
possible.
For more information on NOMSS, contact
Gay Kaplan, Executive Director, at (415)
885-2274.
Emergency and Transitional Shelters
for Elderly People Who are Homeless
St. Martin de Porres
in Seattle, WA was founded in 1984 as
an emergency shelter for homeless men
age 50 and older. The shelter accommodates
212 persons every night. Forty-five percent
of shelter users are in their 50s while
fifty-three percent are in their 60s.
A large segment of the population served
are veterans who are elderly and homeless.
Twyla Smith is a Health Care for the Homeless
nurse practitioner who provides clinic
services on-site five times a week and
establishes primary care for the clients
at the shelter. She states that the shelter
provides an especially safe and secure
place for the older homeless men who increasingly
are becoming targets for assault and robbery.
In addition to health care, the shelter
provides an evening meal, shower and laundry
facilities, a library, and a respite program
for participants with medical recovery
needs.
For more information about St. Martin
de Porres in Seattle, WA, contact Twyla
Smith, Health Care for the Homeless nurse
practitioner, at (206) 323-6341.
Shelter of the Cross, Inc.
located in Danbury, CT is a transitional
housing program for elderly people who
are homeless ages 58 and older. The founder,
Karen Messina, observed in her community
a growing number of seniors living on
the streets and an emergency shelter system,
which was difficult for the seniors to
access. Receiving referrals from churches,
nursing homes, relatives, and emergency
shelters, Shelter of the Cross works with
up to 12 homeless seniors at a time, providing
supportive services and housing for up
to 2 years. During this period, the participants
have a stable place to live while being
placed on the waiting list for more permanent
and affordable housing. They also have
the opportunity to address neglected medical
conditions, receive podiatry care, attend
AA meetings, and, with the support and
assistance of a case manager and staff,
to consider reunification with their family.
For more information about Shelter of
the Cross, Inc. in Danbury, CT, contact
Karen Messina, Director, at (203) 791-1050
or visit the website www.shelter-cross.org.
Day Shelters and Drop-in Centers
Most emergency shelters open their doors
after 6:00 p.m. to a long line of people
seeking a bed for the night and then require
everyone to leave as early as 6:00 a.m.
the next morning. For a frail, elderly,
homeless person, finding a place to stay
during the hours when the emergency shelters
are closed may be an extreme challenge.
Lazarus Day Center in
Seattle, WA serves homeless adults 50
years old and older by providing a safe
place for them to stay during the day.
The center, which is open 365 days a year,
also offers a hot meal at lunchtime, showers,
a clothing bank, computer and Internet
access, restrooms, laundry facilities,
telephones and a mailing address for their
clients to use. For some, the center serves
as a starting point for connecting with
community resources and social services.
For more information on Lazarus Day Center,
contact the Shelter Director at (206)
623-7219.
Housing Development
The Committee to End Elder Homelessness
(CEEH) was founded in Boston, MA in 1991
by a group of seven professional women
who, in their work as public health nurses,
social workers, and activists, became
aware of high-risk homeless elders in
their city. CEEH conducts outreach to
homeless seniors 55 years and older and
provides permanent housing and supportive
services through facilities it develops,
owns, and operates. To date, CEEH has
developed four residences, with a total
of 70 units, specifically for Boston’s
elderly people who are homeless.
CEEH collaborates extensively with city
agencies and other community-based organizations
to bring such supportive services as primary
health care to the residents of its buildings.
CEEH also collaborates with Elders
Living at Home Program that places
homeless seniors in transitional shelters
while awaiting permanent housing in one
of the residences operated by CEEH.
CEEH conducts vigorous outreach to those
at risk of becoming homeless and to chronically
homeless elders. They seek to house the
frailest seniors with the worst histories
of homelessness. Elizabeth Babcock, executive
director of CEEH, emphasizes that while
most housing programs have very stringent
rules for acceptance, CEEH seeks out homeless
seniors who may otherwise be considered
“difficult to house”, such
as those often having a history of evictions,
and those with substance abuse and/or
mental health problems.
CEEH not only recognizes the dire need
for development of affordable housing
for elderly people who are homeless, but
also the importance of providing comprehensive
supportive services necessary for maintaining
stable housing as well as a person’s
independence in the community.
For more information on CEEH, contact
Elizabeth Babcock, Executive Director,
at (617) 369-1550
Community Education, Outreach, and
Advocacy
One of the major barriers elderly people
who are homeless face in accessing services
is the lack of knowledge about resources
in their community. Navigating through
a social service system may be overwhelming,
especially for seniors who are experiencing
homelessness for the first time. Planning
for Elders in the Central City
(PECC), based in San Francisco, CA recognized
the need to provide educational outreach
to homeless elderly people in the community
and increase their awareness of potential
resources. Every year, PECC organizes
a week-long "Homeless Senior Survival
School" during which service providers
give presentations to diverse groups of
seniors, all experiencing homelessness.
While learning about such general information
as establishing primary health care and
obtaining benefits such as Medicare, Medicaid,
SSA, SSI, and VA pensions, the seniors
also learn about resources specific to
their own needs, such as shelters, housing
assistance, and case management. The seniors
are provided with practical information:
Which shelter is the best one for an elderly
person? Where can I store my belongings
during the day? Where can I go to eat?
How do I get on the waiting list for housing?
After participation in the weeklong program,
the seniors "graduate" and have
the opportunity to continue involvement
with PECC as members of an advocacy group.
The advocacy group meets with the San
Francisco Mayor's Office on Homelessness
every month with the goal of increasing
the city's awareness of elder homelessness.
For more information on PECC, contact
Jeanette Ilagan, Senior Survival School
Director, at (415) 703-0188.
The programs highlighted in this paper
are making significant contributions in
their communities to address the needs
of older adults facing homelessness, and
yet the problems associated with elder
homelessness will continue to grow as
the Baby Boomer generation ages. Someone
who has been homeless for most of his
or her adult life may “age into
elder homelessness”; or perhaps
one unexpectedly becomes homeless for
the first time during his or her “Golden
Years”. Either way, the needs of
the elderly homeless require special attention.
Measures to address these needs will require
multidisciplinary approaches that offer
age-sensitive services, have minimal barriers
to access, and are accommodating for the
frail and multiply diagnosed senior. While
this paper discusses the general health
care and service needs of elderly homeless
persons, individual communities will also
have to consider the specific needs that
may be encountered by seniors living in
different geographic regions or in rural
environments, and by seniors belonging
to special demographic populations, including
homelessness among the elderly in different
racial and ethnic groups.
This paper can be used as a tool for increasing
awareness about elder homelessness in
local communities and among homeless service
providers. As we continue to recognize
the existence of elder homelessness, we
are poised to ask questions about their
special health care and service needs.
Subsequently, we hope to implement recommendations
to create resources and housing, develop
prevention programs, and eliminate barriers
to accessing services for seniors facing
homelessness.
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