Special Instructions. Intermountain Healthcare is a Utah-based, not-for-profit system of 33 hospitals (includes "virtual" hospital), a Medical Group with more than 3,800 physicians and advanced practice clinicians at about 385 clinics, a health plans division called SelectHealth, and other health services. The goal of these visits is for the RFL team to gain a deeper understanding of both the methodology and evidence behind Intermountains CPMs, and to get tactical education on how to familiarise clinical staff on methodology and help show them how to socialise these models for widespread adoption. Care Process Model AUGUST 2013 !is care process model (CPM) and accompanying patient education were developed by a multidisciplinary team including primary care physicians (PCPs), mental health specialists, registered dietitians, and eating disorder specialists, under the leadership of Intermountain Healthcares Behavioral Health Clinical Program. Six Steps to Mass Customization in Healthcare Rather than rely solely on guidelines, healthcare systems should use a clinical management method to develop shared baseline protocols. 0000170459 00000 n Intermountain Healthcare convened a team consisting of executive leadership, the enterprise initiative office and internal medicine leaders to design the RPC. 0000007762 00000 n It was created by general pediatricians at the University of Utah in collaboration with Intermountain Health pediatric . 0000050304 00000 n endstream endobj 1661 0 obj <>/Metadata 177 0 R/Names 1662 0 R/Outlines 155 0 R/PageLayout/SinglePage/Pages 176 0 R/StructTreeRoot 179 0 R/Type/Catalog/ViewerPreferences<>>> endobj 1662 0 obj <> endobj 1663 0 obj >/PageWidthList<0 612.0>>>>>>/Resources<>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/Thumb 171 0 R/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 1664 0 obj [1665 0 R 1666 0 R 1667 0 R 1668 0 R] endobj 1665 0 obj <>/Border[0 0 0]/H/N/Rect[131.157 415.338 170.914 404.138]/StructParent 17/Subtype/Link/Type/Annot>> endobj 1666 0 obj <>/Border[0 0 0]/H/N/Rect[460.652 162.428 475.529 151.48]/StructParent 1/Subtype/Link/Type/Annot>> endobj 1667 0 obj <>/Border[0 0 0]/H/N/Rect[509.976 162.428 537.031 151.48]/StructParent 2/Subtype/Link/Type/Annot>> endobj 1668 0 obj <>/Border[0 0 0]/H/N/Rect[187.84 256.725 212.127 244.468]/StructParent 18/Subtype/Link/Type/Annot>> endobj 1669 0 obj <> endobj 1670 0 obj <> endobj 1671 0 obj <> endobj 1672 0 obj <> endobj 1673 0 obj <> endobj 1674 0 obj <>stream 0000059703 00000 n 0000226180 00000 n 0000008686 00000 n %%EOF 0000028071 00000 n 0000025382 00000 n 0000005250 00000 n 0000005756 00000 n 0000048189 00000 n 0000071295 00000 n 0000226561 00000 n Because of its unique size and scope, Royal Free London was concerned with reducing variation across its venues of care while increasing quality and decreasing costs. All rights reserved. 0000056204 00000 n 6346 95 Acronym: CPM Targeted Populations: Ages 6-18; both males and females; for children who have experienced a wide range of traumas. by Cerner UK There are aspects of Royal Free care that Intermountain can learn from, said Dr Chris Wood, vice president, Cerner and medical executive for iCentra development at Intermountain Healthcare. under the leadership of Intermountain Healthcare's Behavioral Health Clinical Program. Although realigning care at RFL is still a work in progress, the introduction of the CPG concept and its adaptation to the Trusts culture and needs is having an impact. 0000079460 00000 n Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery. There can be reticence to learn from others and there can sometimes be the resistance to adopting something that was someone elses idea. Choose a state from the dropdown to add local service providers. Additional assistance with risk assessment: iCentra order algorithm, Score Line 801-50-SCORE ( providers only ), and Connect Care 801-442-4457. hUiPG~=";.^qv12%&e-Kg.^OPxx7(w~X]"`~g 0000079372 00000 n startxref Intermountain used this philosophy to organise its most common care processes under the direction of an operations structure called clinical programmes. 0000011106 00000 n 0000004060 00000 n | Dr Chris Streather 0000062915 00000 n 0000258879 00000 n When we visit Intermountain, we bring senior-level executives, but we also take people who are directly involved in care, said Dr Streather. Cerner Corp. and Intermountain Healthcare announced recently the implementation of iCentra, a model electronic health record (EHR), practice management and revenue cycle system, at two Intermountain hospitals and 24 clinics across northern Utah. 0000062870 00000 n 0000050331 00000 n 0000017396 00000 n The partnership has provided value to RFL on many levels. Fact Sheet Published in 2021 Printer-friendly version 0000005093 00000 n 0000013265 00000 n Contribute to Intermountain by participating in one of our charitable events, Find fresh ideas to manage your health, enjoy better quality of life, and LiVe Well, Learn more about Intermountain's mission: Helping people live the healthiest lives possible, Search and apply for volunteer opportunities at Intermountain. Go to my One Account. Franklin G. Miller, Ph.D., and Ezekiel J. Emanuel, M.D., Ph.D. 0000037253 00000 n 0000014102 00000 n . 0000086035 00000 n SEEK is an effective model for prevention of abuse / neglect in early childhood. CARE PROCESS MODEL JANUARY 2021 Chronic Obstructive Pulmonary Disease (COPD) Diagnosis, Treatment, and Resources ALGORITHM NOTES ALGORITHM: DIAGNOSIS OF COPD . If this is an emergency please go to the nearest emergency room or call 911. 0000086396 00000 n 0000034112 00000 n 0000005788 00000 n 0000176436 00000 n Care Process Model JUNE 2019 2019 Update GOALS & MEASUREMENTS The goal of this CPM is to improve the . 3175 0 obj <> endobj Ive rarely seen in the NHS such buy-in from the clinical community, he said. The formalised nature of the partnership agreement has also allowed for knowledge sharing on a granular and practical level that might not have been possible if RFL had passively observed Intermountains processes one or two times. 0000015322 00000 n 0000016722 00000 n 0000066109 00000 n 0000025573 00000 n trailer following: (1) modifying Intermountain data on any of Intermountain information systems; 0000179023 00000 n Each visit is centred around a single theme to allow for a focused deep dive into that specialty. 0000016606 00000 n This CPM includes two processes to address child traumatic stress across the pediatric lifespan. 0000002571 00000 n 0000007949 00000 n 0000005131 00000 n 0000084783 00000 n 0000010599 00000 n 0000002990 00000 n 0000029472 00000 n 0000002048 00000 n 0000022254 00000 n 0000015005 00000 n trailer 0000008093 00000 n 0000002281 00000 n 0000053054 00000 n 0000038439 00000 n 0000011885 00000 n 0000071068 00000 n Nope. 0000055101 00000 n 0000176512 00000 n @G 0000023486 00000 n 0000110685 00000 n 0000050364 00000 n 0000177088 00000 n 0000075636 00000 n Its good to see that even after 18 months of introducing a complex programme, we see the general enthusiasm growing daily.. 0000075971 00000 n 0000023543 00000 n 0000057953 00000 n 0000011732 00000 n Care Process Model AUGUST 2016 The inside pages of this tool provide an algorithm and associated notes and can be folded open and posted in your office or clinic. 0000006783 00000 n It is extremely important to screen patients until there are no further limitations on testing capacity. startxref bPatients who had at least 1 outpatient visit with a primary care physician (family medicine, internal medicine, geriatric, or pediatric specialty) during the period of 2003-2005 and a continuous service encounter from an Intermountain delivery location (either acute, ambulatory, radiologic, or laboratory services) at least once a year for each 0000004309 00000 n 0000087852 00000 n 0000038376 00000 n Only authorized users with an appropriate business need and legal right may use these resources. Of all the approaches leaders can leverage to address these issues, reducing unwarranted clinical variance is receiving increased attention. height, weight, OFC, care process model data, etc.). 0000004039 00000 n 1660 0 obj <> endobj The CPM also guides family decision making, links at-risk children to evidence-based trauma therapy, and encourages providers' use of in . 0000002947 00000 n 0000072266 00000 n 0000006375 00000 n Box 581289 Salt Lake City, Utah 84158, A Short History of the Medical Home Portal, Pediatric Patient Summary-Medical Home Portal Project, Nevada Pediatric Mental Health Care Access Program (PMHCAP), Rhode Island Pediatric Psychiatry Resource Network (PediPRN), University of Utah Pediatric Resident Writing Elective, University of Utah Writing & Career Development Group, Utah Children's Care Coordination Network, Anxiety Disorders & Attention Deficit Hyperactivity Disorder (ADHD), Attention-Deficit/Hyperactivity Disorder (ADHD) & Disruptive 0000050398 00000 n 0000008395 00000 n 7 September 2022 The Royal Free Hospital provides the only high-level isolation unit of its kind for the care of patients with the Ebola virus and other infectious diseases. 0000132822 00000 n *kxVQQ6]9@{B%+/Q9a6Q_~Kx1 RX@QF p+h=52hf4f3#`33e{f|@gHXS'U`*}lts}=>;tPJfi5C&L^cI_2I7l8-G-mLvp +y" oE$qy(b9yz|~{kt;a| ~%1e8PKo*>7%T[.4jp+Gq}. A 2012 report from the Institute of Medicine found that inefficiencies in the U.S. healthcare system resulted in up to $750 billion of wasted spending in 2009, roughly 30 percent of total healthcare spending in that year. Published on 8 March 2019. 0000072789 00000 n 0000018335 00000 n H\@. 0000031239 00000 n He brought with him a background in medical research, having previously held positions at the National Cancer Institute and the Harvard School of Public Health, as well as an interest in the theory and methods of W. Edwards Deming. 0000081921 00000 n by Treesa Carter | James Hitter 0000008535 00000 n 0000049258 00000 n 2:1b``AY0 tbg(8/C3n0=~ 0000041107 00000 n 0000012798 00000 n 0000005751 00000 n 0000007723 00000 n 0000066307 00000 n 0000009925 00000 n Administers screening tests to . 0000000016 00000 n 0000073354 00000 n One of the best features of the child traumatic stress care process model is that it can be administered by people who don't have a clinical background. The multidisciplinary team is tasked with asking how they can improve the care processes within the programme. 0000004208 00000 n Mot de passe (8 caractres ou plus) . 0000002834 00000 n 0000005596 00000 n 0 0000045274 00000 n Click the following URL which is the closest match we can find to the one you entered: Use the left navigation or the tabs above to browse the site, Perform a search using the search box at the top of the page. Intermountain Healthcare in Salt Lake City, Utah, recognised the link between variance, quality and cost early on thanks in part to Dr Brent James. P.O. Special attention is also paid to who attends each visit to ensure all stakeholders are involved. 0000069140 00000 n We recommend that child or caregiver complete the child traumatic stress screener while in the waiting room, prior to their appointment. 0000005140 00000 n 0000007513 00000 n C-suite leadership has been overwhelmingly supportive of the project, furthering the message that the Trust is serious about reducing variance and improving care. 0000045385 00000 n Published February 21, 2008, Harming Through Protection. 0000177145 00000 n 1660 60 1425 0 obj <> endobj <<5BE851667CC40543996F5A9ED21E16D8>]/Prev 646447/XRefStm 3820>> 0000026834 00000 n 1506 0 obj <>stream 0000010273 00000 n 0000012415 00000 n >iDTPTTqbZ]w;$zm3{! Dr James was hired by Intermountain in 1986 as the director of medical research and continuing medical education. 0000008709 00000 n Important features included creating meaningful alignment around value, building teams to drive the transition and implementing supportive workflows and technological innovations. Amy Bowen and Kaye Coholan share their thoughts on how North Central London (NCL) has taken a different approach to managing NHS waiting lists for their Integrated Care System (ICS). CPM020 - 01/21 3 COPD CPM JANUARY 2021 TABLES TABLE 1. This is not like an IQ test or psychological testing where the results could be skewed. monitored, audited, and stored. 0000009576 00000 n 0000069327 00000 n hb``0f``d`e` l,x70y7Yc[%Lq|cO 'rX)!2[HQ(WVE 0khhDGG; J@(}=bw&5_R 0000079537 00000 n 0000023593 00000 n It turns out that clinical process management and improvement is our core business strategy.. %PDF-1.7 % 0000004089 00000 n 0000087649 00000 n 0000014401 00000 n by Amy Bowen | Kaye Coholan 0000013362 00000 n It takes humility to recognise that you dont have all the answers and seek out people who are leaders in their field, he said. 0000060798 00000 n 0000176241 00000 n 0000016011 00000 n 0000118904 00000 n 0000019018 00000 n 0000176282 00000 n 0000045478 00000 n The FSI Academy is focused on the onboarding of new hires who will be trained as interface engineers; responsible for implementing the technical mechanisms that allow the exchange of information between solutions and external systems. 0000002361 00000 n 0 0000018590 00000 n 0000066218 00000 n Intermountain has created care process models (CPMs) within each clinical programme that use a combination of existing evidence-based practice guidelines and historical EHR data. 0000193542 00000 n 0000002797 00000 n 0000177340 00000 n Users are prohibited from doing any of the 0000045545 00000 n 0000015259 00000 n 0000057819 00000 n 0000014285 00000 n I think one of the problems in health systems is that good practice happens in a lot of places, but were not very good at learning from excellence in other places, said Dr Streather. In the 5 phase III alvimopan efficacy trials, a simple standardized accelerated postoperative care pathway was used rather than a comprehensive, multidisciplinary colon surgery care process model that is used by Intermountain Healthcare. 0000065975 00000 n What resources are available to get children into therapy? 0000009340 00000 n 0000014978 00000 n What if the child or parent asks me a question about the screener while they are filling it out? 0000178370 00000 n 0000079241 00000 n 0 The Child Traumatic Stress Care Process Model (CPM) offers an approach to be used in children's advocacy centers and pediatric primary care to identify children and families at risk of traumatic stress. 0000048319 00000 n <]/Prev 276186/XRefStm 2368>> 0000066042 00000 n 0000004256 00000 n 0000005644 00000 n 0000065951 00000 n 0000041187 00000 n 0000058433 00000 n xref 0000021255 00000 n 0000225797 00000 n There is quite a lot of admiration in the United Kingdom for some of the system-wide approaches for improving quality in the United States, said Dr Streather. 0000168976 00000 n 0000063228 00000 n 0000007263 00000 n (2) removing Intermountain data from any Intermountain information system; or 0000021043 00000 n 0000005286 00000 n 0000008994 00000 n 0000000016 00000 n ALL RIGHTS RESERVED. First, primary care providers and care teams can meaningfully respond to family needs that may prevent trauma exposure in children (0 5 years) through the use of the SEEK questionnaire and Road Map of Care for Pediatric Trauma Prevention. 0000056318 00000 n Its purpose is to summarize and promote evidencebased approaches to lifestyle and weight management, and to facilitate implementation in routine . Within a health system, unwarranted clinical variance is understood as the difference in clinical practices and services that do not derive from unique patient needs and that may involve the overuse, underuse or misuse of medical services. The partnership with Intermountain has allowed us to learn the positive things, and the things theyve found difficult, the pitfalls and bear traps theyve discovered, and thats made it easier to be open to the perspective of people that have walked the journey before us.. During development of the care process model, the authors found many aspects of ICU care that required substantial change. The power of building relationships is not just what can be done today, but what we can work on tomorrow, he added. 0000010567 00000 n The really great benefits of the relationship between Intermountain and Royal Free are in the future of working together to apply what we already know in newer and better ways., Senior executive medical director for the Healthcare Delivery Institute, Vice president at Cerner and medical executive for iCentra development at Intermountain Healthcare. 0000017260 00000 n 0000029880 00000 n 0000055034 00000 n %PDF-1.7 % 0000076267 00000 n 0000021193 00000 n 0000059623 00000 n Ping Identity Corporation. 0000000016 00000 n 0000033836 00000 n 9-FCr-+| E+dJgx!Ck 0000020531 00000 n CPM uses several different tools to look for trauma exposure (recent and remote events), suicidality and self-harm, and traumatic stress symptoms. 0000006843 00000 n 0000088537 00000 n 0000005534 00000 n 0000022401 00000 n We already have resource guides developed for many counties in Utah. 0000080004 00000 n Partnering with and adapting the methodology of an internationally recognised leader like Intermountain signalled to staff that RFL was serious about improving care and has helped create buy in, Dr Streather believes. 0000003093 00000 n 0000032530 00000 n At Salt Lake City-based Intermountain Healthcare, ensuring the alignment of all these things to provide extraordinary care requires a constant regimented focus across our 23 hospitals, 170. Intermountain monitors use of the Information Systems resources. 0000132101 00000 n Two of the first clinical programmes developed were cardiovascular, and women and newborns. %%EOF 0000058232 00000 n We found that there was a great deal of unwarranted variation in the way we delivered care that created less than ideal quality care for patients, and there were operational inefficiencies baked into that, said Dr Chris Streather, chief medical officer at RFL. %PDF-1.7 % 0000004465 00000 n 0000042757 00000 n 0000079708 00000 n 0000009309 00000 n Working with Intermountain and redesigning their methods of care represents a considerable shift for RFL and leaders have been deliberate about how these changes are introduced to doctors, nurses and others who provide care. 0000023933 00000 n :x-)KYYY"3%C_hS! 0000023458 00000 n 0000008067 00000 n 0000005907 00000 n Members of each clinical programme regularly review the core care processes within it using evidence from literature and data from Intermountains own EHR. by Cerner UK 0000088156 00000 n 0000006531 00000 n If the child is younger than 10 or has developmental limitations, then the parent/caregiver can complete the screener for them. 0000072898 00000 n hSiPSW>#BBX-"m6 EM;b;N:N+D(n." Learning some of these differences has provided insight for Intermountain into what may be possible in the future. 0000041140 00000 n 1846 0 obj <>stream 0000008428 00000 n 0000084852 00000 n Second, primary care providers and care teams can intervene with children (6 18 years) who have experienced a potentially traumatic experience through the use of the Pediatric Traumatic Stress Screening Tool and Road Map of Care for Pediatric Traumatic Stress (see image below). Once we understood the science of process management techniques as derived and applied in the business world could be brought into healthcare, we had our secret sauce and we knew we needed to teach that science to our teams, said Dr Todd Allen, senior executive medical director for the Healthcare Delivery Institute at Intermountain. 0000022000 00000 n 0000166102 00000 n 0000013288 00000 n 0000005907 00000 n 0000035663 00000 n 0000045738 00000 n It helps primary care providers identify areas of potential high risk for the child and provide relevant information and support to the parents / caregivers. 0000179330 00000 n 3276 0 obj <>stream The FSI Academy is focused on the onboarding of new hires who will be trained as interface engineers; responsible for implementing the technical mechanisms that allow the exchange of information between solutions and external systems. 0000007942 00000 n 5-Step Model for Creating a Virtuous Medical and Financing System to Enhance the Health and Well being of Future Generations. 0000006687 00000 n 0000021074 00000 n 0000010300 00000 n RFL provides specialist services in liver and kidney transplantation, rare cancers, haemophilia, HIV, infectious diseases, plastic surgery, immunology, neurology, Parkinsons disease, vascular surgery, cardiology, amyloidosis and scleroderma. 0000009144 00000 n It is not a prescription for every physician or every patient, nor does it replace clinical judgment. 0000081734 00000 n 0000006063 00000 n At two of our sites, we were immediately able to capture data-driven outcomes from the newly digitised pathways, said Dr Streather. 0000008135 00000 n 0000072602 00000 n 0000011835 00000 n The Child Traumatic Stress Care Process Model (CPM) was developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare's Primary Children's Hospital. 113021080>ca`labefpe|$X)Cc+G>[.3A/20 0000009527 00000 n 0000050145 00000 n 0000008313 00000 n 0000038525 00000 n %2O92qx`x@7l* eLBX&4*p*x 9`%jX,/p*x2 aWbL dTK`rX/i-'bT Df`9D3hA9@@!N Hg1pfM_:+.y- iM=5{*g2msZ:G3Lrtwsut e5b1L & 0000021696 00000 n 0000006529 00000 n View wait times and save your place in line at an Intermountain InstaCare location near you. 0000088233 00000 n xref Intermountain Healthcare and Royal Free London are working toward a common goal of reduced clinical variance. 0 0000005795 00000 n They then work to continually refine and improve each care process. %%EOF In-office interventions (such as teaching guiding imagery, belly breathing, or progressive muscle relaxation) can be taught by any individual who is comfortable teaching these skills, clinical background not necessary. 0000039904 00000 n 0000052164 00000 n <<969DFD35F0E1574DA86361927245C514>]/Prev 975812/XRefStm 3817>> 0000008676 00000 n 0000009347 00000 n 0000226944 00000 n Fortunately Intermountain Healthcare (among others) publishes their Care. 0000006937 00000 n 0000006999 00000 n 0000002244 00000 n 0000076190 00000 n hSYPW>G&$B% i}(!IA|C;N3mJd1 @EbBBDQ(+ Care Process Model JUNE 2013 This care process model (CPM) was created by a multidisciplinary team of physicians and other healthcare providers at Intermountain Healthcare. 0000059863 00000 n 0000026052 00000 n 0000228696 00000 n 0000005681 00000 n How old does a child need to be to complete the traumatic stress screener? xref 0000005294 00000 n 0000005048 00000 n Choose a skill that you are comfortable teaching and share your knowledge with the families you see in clinic. endstream endobj 1718 0 obj <>/Filter/FlateDecode/Index[179 1481]/Length 57/Size 1660/Type/XRef/W[1 1 1]>>stream 0000009463 00000 n 3 September 2021 0000064797 00000 n 0000009984 00000 n 0000128388 00000 n For more information about Perspectives, gohere. Mary Ann Baily, Ph.D. 0000000016 00000 n 0000079927 00000 n 0000063674 00000 n The EHR data from every patient treated by CPMs offer further points to improve the next application of the CPM through a nearly real-time feedback loop. Providers and caregivers around the country are using the model to measure and improve key diabetic metrics, including A1C results, blood pressure control, and kidney . 0000110646 00000 n Pierre-Henri Brchat, Pascal Briot, Lucy Savitz, Ross Fulton. 0000076040 00000 n Each clinical programme is led by a doctor, nurse and administration triad, and is resourced with all those whose work affects the patients care and outcome. 0000086104 00000 n Copyright 2003-2020. 0000004712 00000 n 0000086355 00000 n 0000017996 00000 n Behaviors, Attention-Deficit/Hyperactivity Disorder (ADHD) & Mood Disorders, Fetal Alcohol Spectrum Disorder Distinguished from Autism, Mucopolysaccharidosis Type I & Motor Development, Mucopolysaccharidosis Type I (MPS 1) Genetics, Mucopolysaccharidosis Type I (MPS 1) Hematopoietic Stem Cell Transplantation & 0000003817 00000 n 0000043417 00000 n 0000023004 00000 n 0000011492 00000 n Intermountain will use a regional deployment strategy to bring all acute care facilities, ambulatory . xref Intermountain Healthcare is a Utah-based, not-for-profit system of 33 hospitals (includes "virtual" hospital), a Medical Group with more than 3,800 physicians and advanced practice clinicians at about 385 clinics, a health plans division called SelectHealth, and other health services. 0000005079 00000 n Modified Medical Research Council Breathleness Scale (mMRC) 0000015624 00000 n Although physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are a means for discovering improvements in patient care and expanding the knowledge base. 0000001979 00000 n It is based on expert opinion and clinical practice guidelines from the Infectious Disease Society of America (IDSA), the American Academy of Pediatrics (AAP), and the American Academy of Otolaryngology (AAO). 0000011998 00000 n 0000081400 00000 n 0000006220 00000 n %%EOF 1425 82 0000084446 00000 n * This CPM presents a model of best care based on the best available scientific evidence at the time of publication. 0000036974 00000 n 0000019646 00000 n Published August 9, 2007, Quality- Improvement Research and Informed Consent. 0000078906 00000 n 0000029608 00000 n 0000009724 00000 n 206 63 0000017276 00000 n trailer 0000051705 00000 n 0000003264 00000 n This care process model (CPM), produced by Intermountain Healthcare's Antibiotic Stewardship team, Community-Based Care, and Intermountain Pediatrics, is based on the American Academy of Pediatrics (AAP) Clinical Practice Guidelines. endstream endobj 207 0 obj <>>>/Metadata 204 0 R/Names 209 0 R/OpenAction 208 0 R/Outlines 197 0 R/PageLayout/TwoPageRight/Pages 203 0 R/Type/Catalog/ViewerPreferences<>>> endobj 208 0 obj <> endobj 209 0 obj <> endobj 210 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/Properties<>/XObject<>>>/Rotate 0/Tabs/W/Thumb 198 0 R/TrimBox[0.0 0.0 792.0 612.0]/Type/Page>> endobj 211 0 obj [212 0 R 213 0 R 214 0 R] endobj 212 0 obj <>/Border[0 0 0]/H/N/Rect[647.403 349.775 697.152 339.065]/Subtype/Link/Type/Annot>> endobj 213 0 obj <>/Border[0 0 0]/H/N/Rect[647.905 312.2 690.6 301.535]/Subtype/Link/Type/Annot>> endobj 214 0 obj <>/Border[0 0 0]/H/N/Rect[32.9 392.516 116.959 379.171]/Subtype/Link/Type/Annot>> endobj 215 0 obj <> endobj 216 0 obj <> endobj 217 0 obj <> endobj 218 0 obj <> endobj 219 0 obj [/ICCBased 246 0 R] endobj 220 0 obj <> endobj 221 0 obj <> endobj 222 0 obj <> endobj 223 0 obj <> endobj 224 0 obj <>stream