```
Older Americans Act: The National Eldercare Campaign (Letter Report,
02/23/94, GAO/PEMD-94-7).

In April 1991, the Administration on Aging (AOA) launched a multiyear
initiative called the National Eldercare Campaign.  AOA used about $14
million of $26 million in title IV discretionary funds to support the
campaign's various components.  The largest portion of these funds went
to a new community outreach effort, Project CARE.  Under this national
coalition-building demonstration program, each state was required to
establish three local coalitions.  At the end of 15 months, virtually
all states had three local coalitions in place.  A majority of
coalitions had generated some resources, and about 70 percent of the
coalitions were providing a service to the elderly.  The campaign
differs from earlier AOA initiatives in that its seeks to expand not
only the Aging Network but also the resources available to them.
Usually, AOA initiatives were of 12- to 24-months duration and limited
to research, demonstration, and technical assistance.  By the end of
fiscal year 1992, about 200 coalitions had joined the Aging Network and
had developed programs and services for the elderly.  Although this is a
significant change in both the mission and structure of the Aging
Network, the success of this campaign ultimately depends upon the
coalitions' ability to sustain themselves beyond the three-year funding
period.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  PEMD-94-7
     TITLE:  Older Americans Act: The National Eldercare Campaign
      DATE:  02/23/94
   SUBJECT:  Elder care
             Federal/state relations
             Elderly persons
             Agency missions
             Aid for the elderly
             Public assistance programs
             Technical assistance
             State-administered programs
IDENTIFIER:  AOA National Eldercare Campaign
             AOA Aging Network
             AOA Project CARE
             Medicaid Program
             AOA Eldercare Connections Project
             AOA Eldercare Locator Project
             
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Cover
================================================================ COVER

Report to the Chairman, Subcommittee on Human Resources, Committee on
Education and Labor, House of Representatives

February 1994

OLDER AMERICANS ACT - THE NATIONAL
ELDERCARE CAMPAIGN

GAO/PEMD-94-7

A Description of the National Eldercare Campaign

Abbreviations
=============================================================== ABBREV

  AOA - Administration on Aging
  CARE - Community Action to Reach the Elderly
  OAA - Older Americans Act

Letter
=============================================================== LETTER

B-254985

February 23, 1994

The Honorable Matthew G.  Martinez
Chairman, Subcommittee on Human Resources
Committee on Education and Labor
House of Representatives

Dear Mr.  Chairman: 

In your letter of July 16, 1992, you requested that we address a
series of questions about the National Eldercare Campaign, a
multiyear initiative being funded by the Administration on Aging
(AOA).  In response, this report examines the three questions:  (1)
What is the National Eldercare Campaign?  (2) What has been the
progress, thus far, in implementing the Campaign?  and (3) What
changes in the Aging Network as a result of the Campaign are
discernible at this time? 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

In April 1991, AOA launched a multiyear initiative, called the
National Eldercare Campaign, drawing heavily on AOA title IV
discretionary funds to strengthen the existing Aging Network by
broadening the base of support and increasing public awareness.\1

AOA used about $14 million of almost $26 million title IV
discretionary funds to support the various components and activities
of the National Eldercare Campaign (see table 1).  The largest amount
of these funds was allocated to a new community outreach effort,
Project CARE (Community Action to Reach the Elderly), which is a
national coalition-building demonstration program.  Each state was
required to establish three local coalitions.  Even though additional
monies were not available to establish optional statewide coalitions,
32 state units did so.  Additional monies were available to establish
volunteer corps activities, and 30 state units did so. 

At the end of 15 months, virtually all states had three local
coalitions in place.  A majority of coalitions had generated some
resources.  Seven out of ten of the coalitions (107 of 151) were
providing a service to elderly persons. 

We found that the Campaign, particularly its Project CARE component,
is different from earlier initiatives fostered by AOA in that it is
targeted to expand not only the Aging Network, but also the resources
available to them.  Usually, AOA initiatives were of 12- to
24-months' duration and limited to research, demonstration, and
technical assistance.  By the end of fiscal year 1992, about 200
coalitions had become part of the Aging Network, and they have
developed programs and services for older individuals.  This, then,
is a significant change in both the mission and the structure of the
Aging Network.  However, it is important to note that the ultimate
measure of the success of this Campaign depends upon the coalitions'
ability to sustain themselves beyond the 3 years' funding. 

                           Table 1
           
              Funding for the National Eldercare
                Campaign for Fiscal Year 1992

Component                                           Amount\a
--------------------------------------------------  --------
Project CARE                                           $4.80
Public awareness                                        0.76
Outreach to national organizations                      1.27
Other                                                 7.17\b
============================================================
Total                                                 $14.00
------------------------------------------------------------
\a In millions. 

\b The category "Other" includes the National Eldercare Institutes
($3.55 million), a contract with a private firm assisting AOA with
logistics (Empire, $1.1 million), the optional Volunteer Corps
Program ($0.9 million), special smaller activities in selected
locations ($1.47 million), and dissemination within the Aging Network
($0.15 million). 

--------------------
\1 This network consists of 10 federal regional offices, 57 state
units and 670 area agencies (substate units) on aging, and nearly
25,000 local service providers.  The Aging Network, as an
organization, has been instrumental in developing and delivering
social, nutritional, and other services to the elderly. 

   OBJECTIVES, SCOPE, AND
   METHODOLOGY
------------------------------------------------------------ Letter :2

Much of this report is based on our survey of officials from state
units on aging in all 50 states, regarding Campaign operation and
activities from October 1991 to December 1992 (the first 15 months of
Campaign awards).  Some of the data were collected on a calendar-year
basis; some on a fiscal-year basis.  Our survey was conducted between
March 4, 1993, and April 21, 1993, and we had a 100-percent response
rate.  In addition, we collected information from:  (1) 14 site
visits of area agencies on aging and local coalitions as well as
visits to 4 state units on aging; (2) directors of each of the 13
National Eldercare Institutes; (3) officials in the AOA central
office, regional offices, state units, and area agencies, as well as
experts on aging issues nationwide; and (4) a review of AOA agency
documentation.  We performed our work between September 1992 and
September 1993, in accordance with generally accepted government
auditing standards. 

   BACKGROUND
------------------------------------------------------------ Letter :3

The Older Americans Act (OAA) of 1965 was established to provide
assistance by developing a set of programs to support the nation's
elderly (all persons 60 and over).  Over the years, amendments to the
act have greatly expanded the mission of AOA and the Aging Network
beyond the initial focus on community planning and coordination,
demonstration programs, and the training of personnel in gerontology,
to provide supportive services to the elderly, such as in-home care
for the frail elderly, nutritional services, and legal assistance. 
At the same time, the level of federal funding has not kept pace in
real terms with this expanded mission (as we pointed out in a recent
report\2 ).  Further, as a result of budgetary constraints at state
and local levels of government, the Aging Network is now under severe
fiscal duress.  Accordingly, service cutbacks are occurring, and
other service curtailment options are being reviewed.  In addition,
structural changes have occurred, and others are being considered,
such as a plan to cut the number of area agencies in Michigan from 14
to 7. 

Additional pressures from two other sources are constraining the
Aging Network.  First, there has been a significant increase in the
number and proportion of the elderly in the United States,
particularly those 85 and older.  Second, many states, among them
Oregon and Wisconsin, have assigned additional responsibilities to
the Aging Network to administer programs beyond the scope of the
Older Americans Act, such as administering the elderly component of
Medicaid programs. 

It is in this context, that one must assess the current efforts of
AOA.  In April 1991, AOA launched a multiyear initiative, called the
National Eldercare Campaign to augment the resources and capacities
to provide supportive services to vulnerable, at-risk elderly in the
United States.\3

--------------------
\2 See Administration on Aging:  Harmonizing Growing Demands and
Shrinking Resources (GAO/PEMD-92-7, Feb.  12, 1992). 

\3 Title IV of the Older Americans Act authorizes discretionary
funding which the Administration on Aging (AOA) employs to support
efforts in three areas:  research, training, and demonstration. 

   FINDINGS ON EVALUATION QUESTION
   1:  WHAT IS THE NATIONAL
   ELDERCARE CAMPAIGN? 
------------------------------------------------------------ Letter :4

      DESCRIPTION OF THE CAMPAIGN
---------------------------------------------------------- Letter :4.1

AOA launched the National Eldercare Campaign with three goals.  These
included (1) building coalitions among organizations in ways that
will achieve a nationwide commitment to action; (2) raising public
awareness and support through media outreach; and (3) encouraging
organizations to adopt an eldercare agenda.  To accomplish these
goals, AOA adopted the following strategy: 

  Project CARE sought to enlist state and local coalitions to
     identify the target population, their needs, and generate
     resources to meet their needs. 

  Public Awareness Campaign was a multifaceted initiative using
     public service announcements, newspaper articles, videos, a
     magazine, brochures, and press kits to make the public aware of
     the needs of at-risk older persons. 

  Outreach to National Organizations was designed to enlist the
     support of nonaging national organizations to promote an agenda
     that enhances community capacities to serve older persons at
     risk of losing their independence. 

Together, these three components were expected to raise public
awareness of aging issues and generate additional resources to meet
the needs of at-risk elderly persons.  The largest amount of these
funds ($4.8 million) was allocated to a new community outreach
effort, Project CARE, which is a national coalition-building
demonstration program.  Since Project CARE and related support
activity accounted for most of the funds allocated to this Campaign
(60 percent in the first year, for example), as agreed with the
Subcommittee staff, we focused our analytical attention most heavily
on this component of the Campaign. 

         PROJECT CARE
-------------------------------------------------------- Letter :4.1.1

The intent of Project CARE was to demonstrate that coalitions that
widen their base of support at the state and local levels can enhance
a community's ability to provide needed services for an increasing
population of aging persons who are at risk of losing their
self-sufficiency.  Project CARE was to recruit groups that have not
traditionally focused on aging issues.  They would provide new
advocates, ideas, and approaches to mobilizing community resources. 

Project CARE had both mandatory and optional components.  The three
local coalitions per state were mandatory.  The statewide coalitions
and volunteer corps were optional.  AOA aimed to fund 150 Project
CARE local coalitions (3 in each state) through awards to the state
units on aging and area agencies on aging.  AOA envisioned that state
units and area agencies would select three local coalitions dispersed
across the state to represent an inner city neighborhood, a medium or
small city, and a rural area.  AOA further specified that "several of
the selected communities should have a high concentration of older
persons in greatest economic need, especially low-income minorities,
including Native American elders."\4

The 42 state units on aging that have area agencies on aging received
$100,000 each for fiscal year 1992 to start and maintain three local
coalitions.  These funds were distributed as follows:  the state unit
received $10,000, each of the three area agencies received $10,000,
and each of the three lead organizations for the local coalitions
received $20,000.  (AOA anticipated that this funding would remain
constant for each year of the 3-year pilot.) These funds were used
largely to retain a part-time person to coordinate efforts among the
units involved (that is, the state unit, the area agency, and the
lead organization) and for administrative costs supporting coalition
activities.  For the remaining 8 states with no area agencies on
aging (Rhode Island, New Hampshire, Delaware, North Dakota, South
Dakota, Wyoming, Nevada, and Alaska), each state unit received
$15,000, and each of the three coalitions was allocated $20,000
annually. 

--------------------
\4 See Department of Health and Human Services, "Program
Instructions," AOA-P1-06, p.  8. 

         PUBLIC AWARENESS CAMPAIGN
-------------------------------------------------------- Letter :4.1.2

In its first year, the National Eldercare Campaign sought to expand
public awareness at the national, state, and local community levels. 
AOA officials told us that through the collective efforts of the
components of the Campaign (Project CARE, Public Awareness, and
Outreach), various public information activities were undertaken in
the first year. 

At the national level, the following examples of products were
developed to build awareness: 

  a variety of posters, information kits, brochures, and exhibits for
     public use, and

  a new quarterly magazine, Eldercare Today, which highlights the
     accomplishments of the Campaign. 

AOA officials could not tell us who the various target audiences
were. 

         OUTREACH TO NATIONAL
         ORGANIZATIONS
-------------------------------------------------------- Letter :4.1.3

For the period October 1, 1991-February 28, 1993, AOA allocated $1.8
million to support outreach activities to 18 national organizations. 
(Each organization received about $100,000.) This effort was designed
to build the awareness and commitment of national and regional
organizations to an agenda that will, in turn, enhance community
capacities to serve older persons at risk of losing their
independence.  Our review of agency documents suggests that AOA was
successful in recruiting many national organizations that were not
previously committed to aging issues.  Twelve of the 18 awardees were
nonaging organizations; the remaining 6 were organizations that
focused on the elderly (see table 2). 

                           Table 2
           
            Participating National Organizations,
                       Fiscal Year 1992

                                                  Principal
Organization                                      focus
------------------------------------------------  ----------
American Bar Association                          Nonaging

American Institute of Architects/Association of   Nonaging
Collegiate
Students of Architecture

American Medical Association                      Nonaging

American Red Cross                                Nonaging

American Society on Aging                         Aging

Asociacion Nacional Pro Personas Mayores          Aging

Catholic Charities USA                            Nonaging

Health Insurance Association of America           Nonaging

National Association of Counties                  Nonaging

National Association of Social Workers            Nonaging

National Black Caucus of State Legislators        Nonaging

National Caucus and Center on Black Aged          Aging

National Hispanic Council on Aging                Aging

National Council of Negro Women                   Nonaging

National Easter Seal Society                      Nonaging

National Title VI Directors Associations          Aging

Public Health Foundation                          Nonaging

SOS (Save Our Social Security) Education Fund     Aging
------------------------------------------------------------
Source:  AOA. 

AOA officials told us that each of the 18 organizations had started
to work on a project tailored to its particular interest.  For
example, the American Bar Association, in the first year, started to
develop an educational program to help social workers and religious
organizations become more informed about legal issues critical to
at-risk elderly persons.  The American Medical Association sponsored
a project to increase the awareness of physicians of the role that
community resources play in geriatric care.  AOA officials, however,
could not tell us whether these organizations succeeded in reaching
their targeted audiences. 

      SUPPORT ACTIVITIES
---------------------------------------------------------- Letter :4.2

         NATIONAL ELDERCARE
         INSTITUTES
-------------------------------------------------------- Letter :4.2.1

To support the activities of Project CARE, AOA obligated
approximately $3.55 million for 13 Eldercare Institutes in fiscal
year 1992 to help the local coalitions mobilize community
participation and develop effective service initiatives.  The purpose
of these institutes was to analyze important issues related to
eldercare; provide training and technical assistance to state units,
area agencies and local coalitions; and serve as a resource to
organizations involved in the Campaign.  The 13 Institutes were
specified by subject area, including long-term care, elder abuse,
transportation, and so on (see table 3).  Each of the Institutes
received from $250,000 to $329,000 for the first year of operation. 
These Institutes replaced the former National Resource Centers. 

                                     Table 3
                     
                        Eldercare Institutes and Sponsors

Institute                                Sole Grantee or Lead Organization
---------------------------------------  ---------------------------------------
Income security                          Families USA

Employment and volunteerism              Center on Aging, University of Maryland

Housing and supportive services          Ethel Percy Andrus Gerontology Center,
                                         University of Southern California

Transportation                           Community Transportation Association of
                                         America

Multipurpose senior centers and          National Council on Aging
community focal points

Health promotion and aging               American Association of Retired Persons

Nutrition                                National Association of Nutrition and
                                         Aging Services Programs

Long-term care                           National Association of State Units on
                                         Aging

Long-term care and Alzheimer's disease   Suncoast Gerontology Center, University
                                         of South Florida

Elder abuse and state long-term care     National Association of State Units on
ombudsman services                       Aging

Older women                              National Council of Negro Women

Human resources                          Brookdale Center on Aging, Hunter
                                         College

Business and aging                       Washington Business Group on Health
--------------------------------------------------------------------------------
Source:  AOA, Compendium of Active Grants Under Title IV of the Older
Americans Act (Washington, D.C.:  October 1992). 

         ELDERCARE CONNECTIONS
-------------------------------------------------------- Letter :4.2.2

Eldercare Connections was to provide participating organizations
access to a comprehensive repository of information concerning the
Eldercare Campaign and summary information about products produced
for the Campaign.  In addition, the project was funded to publish and
distribute a bimonthly update of all products received, maintain a
computerized bulletin board for quick access to information in the
database, and publish and distribute a calendar of events of
important eldercare meetings around the country.  In fiscal year
1992, this activity was funded by AOA for $156,700. 

         ELDERCARE LOCATOR
-------------------------------------------------------- Letter :4.2.3

The Eldercare Locator project, which predated the Campaign, was a
collaborative effort among AOA, National Association of Area Agencies
on Aging, and National Association of State Units on Aging.  The
purpose of this project was to establish a national 800 (toll-free)
number to assist families and friends in finding information about
community services for older persons and help identify the most
appropriate organizations to call for help.  The Eldercare Locator is
now in operation.  This activity was begun in fiscal year 1990, with
funding at $311,300 in that year, $403,700 in fiscal year 1991, and
$473,500 in fiscal year 1992. 

   FINDINGS ON EVALUATION QUESTION
   2:  WHAT HAS BEEN THE PROGRESS,
   THUS FAR, IN IMPLEMENTING THE
   CAMPAIGN? 
------------------------------------------------------------ Letter :5

      STATUS OF IMPLEMENTATION
---------------------------------------------------------- Letter :5.1

At the time of our data collection (spring 1993), all components of
the Campaign (Project CARE, Public Awareness, and Outreach) were in
place and operating nationwide.  AOA urged state units on aging, to
the extent possible, to develop new coalitions and diversify the
location of the three mandatory ones to have one in an inner city
neighborhood of a large city, one in a medium or small city, and one
in a rural area.  We found, however, that the local coalitions
operated somewhat differently than expected, based on the above
description, in two ways.  First, we found that 24 percent of
respondents to our survey described their coalitions as having
existed prior to the National Eldercare Campaign.  We do not know
whether area agencies simply were not successful in recruiting
"nontraditional" organizations or whether they made a decision not to
recruit these organizations. 

Second, we found that coalition locations did not match program
guidelines:  inner city, small city, and rural area.  The coalitions
tended to be in smaller places; half of them in areas with a
population of 20,000 or less.  Many area agencies located in very
large cities--in New York and California, for example--did not even
apply for funding.  They may have already expanded their base of
support, or a $10,000 grant may not have been large enough for them
to apply. 

In the first year, AOA expected the local coalitions to

  select a target population of vulnerable, at-risk older persons,

  identify a need,

  select a service,

  generate resources to support that project, and

  develop a project that delivers the service to meet the need. 

AOA officials provided information indicating that, at the end of the
first year, approximately 80 percent of the coalitions had identified
a target population and a need and had selected a priority service. 

      GENERATION OF RESOURCES AND
      SERVICES
---------------------------------------------------------- Letter :5.2

With regard to the generation of resources, a majority of coalitions
responding to our survey reported generating the following types of
resources:  funds (63 percent), services-in-kind (75 percent),
donations of materials (55 percent), and volunteer labor (71
percent).  The level of funds being generated was relatively low
(only 14 percent obtained amounts over $10,000); however, among those
not raising funds to date were a small number of coalitions (fewer
than a dozen) that were incorporating so as to facilitate their
fund-raising. 

Finally, based on our survey results, we found that 71 percent of the
coalitions (107 of 151) are providing a service.  About half of those
coalitions providing a service (56 of 107) are delivering one and
only one service; but the rest (51 out of 107) are delivering two or
more services.  For those coalitions not providing services (44 out
of 151), the state unit officials reported four reasons why those
coalitions were slow in organizing and delivering a service:  (1)
turnover or illness of the part-time local coalition coordinator; (2)
lack of necessary organizational or needs assessment skills of the
local coordinator; (3) insufficient support from the local coalition
lead organization, and (4) slowness on the part of the state in
processing the necessary papers, inhibiting the rapid flow of funds
to the area agencies and local coalitions. 

We found that the coalitions were providing four major categories of
services.  First, 56 coalitions were delivering access to services,
providing information and referral, transportation, outreach
activities, and the publication and distribution of service
directories.  Second, 30 coalitions were providing in-home services,
providing housekeeping and other chores, grocery and errand services,
telephone reassurance, and visits to the homebound.  Third, 22
coalitions were providing housing repair and maintenance activities,
including the installation of ramps for facilitating the access of
wheelchair users as well as outdoor security lights.  Finally, 21
coalitions were delivering health, nutrition, and meal services,
including eye and ear screening, wellness clinics, and publications
(see table 4). 

                           Table 4
           
              Most Frequent Services Provided by
               Project CARE Local Coalitions\a

Type of service                             Number   Percent
----------------------------------------  --------  --------
Access                                          56        27
Information and referral                        17
Transportation                                  13
Outreach                                        11
Service directories                             10
Miscellaneous                                    5
In-home service                                 30        14
Housekeeping chores                              9
Telephone reassurance                            5
Visiting homebound                               5
Grocery shopping and errands                     4
Miscellaneous                                    7
Housing and related services                    22        11
Repair and maintenance                          12
Miscellaneous                                   10
Health, nutrition, and meals                    21        10
Meals                                            7
Health screening                                 4
Wellness                                         3
Miscellaneous                                    7
Other\b                                         80        38
============================================================
Grand total                                    209       100
------------------------------------------------------------
\a A preliminary estimate as of December 31, 1992. 

\b Includes, for example, services focusing on education, recreation,
crisis intervention, seasonal activities, public safety, among
others. 

   FINDINGS ON EVALUATION QUESTION
   3:  WHAT CHANGES IN THE AGING
   NETWORK ARE DISCERNIBLE AT THIS
   TIME? 
------------------------------------------------------------ Letter :6

      CHANGE IN MISSION AND
      STRUCTURE OF THE AGING
      NETWORK
---------------------------------------------------------- Letter :6.1

Recognizing that OAA resources were never going to be sufficient to
meet the service needs of all elderly persons, the Congress
envisioned that AOA would serve as an effective and visible advocate
for the elderly.  In this role, AOA would coordinate and assist local
public and private entities in planning and implementing community
services for the elderly.  However, AOA never allocated any money
specifically to implement this aspect of their function. 

In the past, AOA title IV initiatives have consisted of 12- to
24-month projects to provide research and demonstration programs and
technical assistance to the Aging Network.  By launching the National
Eldercare Campaign, AOA made a substantial, multiyear commitment to
implement a formal mechanism to broaden the base of the Aging
Network. 

The National Eldercare Campaign is a creative effort to expand the
structure of the Aging Network to include new coalitions and national
organizations that were traditionally not primarily involved in aging
issues.  About 200 coalitions were established in year 1 as part of
the Aging Network, and their function is not only to serve as
advocates for the elderly, but also to work on developing programs
for older individuals.  In addition, AOA reorganized and redirected
the focus of the Institutes to provide support specifically to
strengthen the coalitions, organizations, and other components of the
Campaign.  This, then, is a significant change in both the mission
and the structure of the Aging Network.  One effect of the Campaign
on the expansion of the Aging Network is that in the first year, the
coalitions have started to generate new resources.  Whether they will
be able to sustain themselves beyond the 3-year funding level is too
early to tell. 

      SUMMARY
---------------------------------------------------------- Letter :6.2

In summary, the National Eldercare Campaign is designed to broaden
the impact of the Older Americans Act, which calls for community
involvement in meeting the needs of the elderly population,
especially those with greatest economic and social needs, including
low-income minorities.  By setting aside a critical mass of funding
for this purpose (about $14 million of the $26 million total title IV
discretionary funds), AOA has succeeded in expanding the Aging
Network and thereby is enhancing local level capabilities to organize
and deliver services to meet the needs of at-risk elderly. 

   AGENCY COMMENTS
------------------------------------------------------------ Letter :7

We requested written comments from officials of the Administration on
Aging, but none were provided.  We did obtain their views during an
exit conference.  They were in general agreement with our findings. 

We are sending copies of this report to the Secretary of Health and
Human Services, the Assistant Secretary for Aging, and others.  We
will also send copies to interested parties upon request. 

If you have any questions or would like additional information,
please call me at (202) 512-2900 or Robert L.  York, Director of
Program Evaluation in Human Services Areas, at (202) 512-5885.  Other
major contributors to this report are listed in the appendix. 

Sincerely yours,

Eleanor Chelimsky
Assistant Comptroller General

MAJOR CONTRIBUTORS TO THIS REPORT
==================================================== Appendix Appendix

   PROGRAM EVALUATION AND
   METHODOLOGY DIVISION
-------------------------------------------------- Appendix Appendix:1

Sushil K.  Sharma, Assistant Director
Harold C.  Wallach, Project Manager
Brian Keenan, Survey Methodologist
Venkareddy Chennareddy, Senior Economist
Elaine Vaurio, Project Staff

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