2014-17 Multi-Sector Service Accountability Agreement (M-SAA)

An Overview

Presentation to: HNHB LHIN Health Service ProvidersJanuary 15, 2014

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2014-2015 HNHB LHINIntegrated Service Delivery Landscape

2014-201555 - Community Support Service Agencies33 - Community Mental Health and Addiction Agencies7- Community Health Centres1 - Community Care Access Centre

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What is an M-SAA?

• Prior to providing funding for the provision of services to its local health system, the Local Health System Integration Act, 2006 requires that the LHIN and the Health Service Provider (HSP) enter into a service accountability agreement.

• The Multi-Sector Accountability Agreement (M-SAA) is a multi-year agreement.

• It supports a collaborative relationship between the LHIN and the HSP to improve the health of Ontarians through better access to high quality health services, to co-ordinate health care in local health systems and to manage the health system at the local level effectively and efficiently.

• The HSP and the LHIN agree that the provision of services to the local health system by the HSP will be funded as set out in this Agreement

For a Summary of Key Changes between Current and new M-SAA, see Appendix 1

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M-SAA ComponentsThe M-SAA has two components:

The Terms and Conditions and the following Schedules that relate to program planning, reporting and evaluation:

•Schedule A: Description of Services

•Schedule B: Service Plan (HSP’s Operating Plan and Budget)

•Schedule C: Reports

•Schedule D: Directives; Guidelines and Policies

•Schedule E: Performance (including Performance Indicators)

• Schedule F: Project Funding Agreement Template

• Schedule G: Compliance

-See Appendix 4 and 5 for more details-

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LHIN/HSP Accountability Relationship

Community Accountability

Planning Submission

(CAPS)

Multi-sector Service

Accountability Agreement

(M-SAA)

Quarterly Report (Ontario

Healthcare Report Standards (MIS)

Remediation Negotiation,

Implementation of Consequences

NegotiationsNegotiations/Consultations

Planning AdjustmentCommitment Measurement

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LHIN/Sector Responsibilities

LHINs are responsible for:

•Training and supporting HSPs through the Community Annual Planning Submission (CAPS) and M-SAA processes•Negotiating performance targets within the context of a provincial framework•Monitoring the achievement of specific performance goals under the M-SAA and ongoing performance management

HSPs are responsible for:

•Ensuring their governance and operations support high quality care•Promoting leading performance improvement approaches•Providing access to high quality health services and coordinated health care in an effective and efficient manner•Identifying integration opportunities and engaging the public and stakeholders in any planned service changes

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THE M-SAA PROCESS

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2014-17 M-SAA Approach• In May 2013, the M-SAA Advisory Committee was established (Members of the

Advisory committee include LHIN staff, Ministry staff, sector representatives and sector Association representation)

• In July 2013 the mandate and scope of authority of the Committee was established by the LHIN CEOs and was confirmed as follows:

Work with LHIN Legal Services, identify opportunities to revise language that either requires updating or would benefit from greater clarity

Work with community sector representatives, invite and review sector feedback (175 sector comments were received and individually addressed)

Finalize a three year M-SAA by the end of 2013 to enable local execution by March 31, 2014.

• On December 17, 2013 the M-SAA Advisory Committee endorsed the 2014-17 M-SAA and Schedules

• The Committee will continued to meet throughout the life of the agreement to advance M-SAA related priority issues

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M-SAA Development Principles

• The M-SAA Advisory Committee was guided by the following principles:

The process is to be undertaken with a spirit of trust and collaboration among the province’s community HSPs, sector associations and the LHINs.

The M-SAA will align with provincial health system priorities and be consistent with Ministry of Health and Long-Term Care (ministry) policy, legislation and regulations.

The M-SAA will strive to streamline processes, minimize administrative burden and provide clarity for HSPs where possible.

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M-SAA Committee Structure

M-SAA LEGAL COUNSEL SUPPORT: LHIN LEGAL SERVICES BRANCH

M-SAA INDICATOR SUPPORT: HEALTH SYSTEM INDICATOR INITIATIVE

M-SAA SECRETARIAT SUPPORT: LHIN COLLABORATIVE

LOCAL M-SAA IMPLEMENTATION: LHIN M-SAA LEADS

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*See Appendix 2 for all M-SAA Membership

2014-17 CAPS Approach

• The Community Accountability Planning Submission (CAPS) is a three-year planning document that facilitates the negotiation of the M-SAAs between the LHIN and each HSP.

• In the absence of definitive funding targets, CAPS will be based on a planning assumption of 0% base adjustment. CAPS should be prepared to maintain service levels within the 0% planning assumption

• The M-SAA Schedules will be refreshed in the fall of each year of the agreement to confirm the current year’s planning assumption and to update the agreement’s performance and explanatory indicators

• The provincial due date for the submission of a HSP Board approved CAPS was November 15, 2013.

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HNHB LHIN Engagement Strategy• Aug 30-Sept 9, 2013: HSPs from the HNHB LHIN were asked to assist in

testing of the CAPS file.

• Sept 10-15, 2013: HSPs were asked to contribute input into new Part A of the CAPS (Narrative) as well as feedback on past CAPS Narrative.

• Oct 1, 2013: HNHB and Province launches CAPS educational material including. Orientation presentation (taped), User Guide, Reference Manual.

• Oct 1-4, 2013: HNHB HSPs were invited to submit questions to the LHIN regarding CAPS Part A and B and on all educational material.

• Oct 3, 2013: HNHB holds HSP Question and Answer teleconference with LHIN Financial, Quality and Risk Management, Health System Transformation and Access to Care staff in attendance.

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HNHB LHIN Engagement Strategy continued.

• Oct 4 - Oct 10, 2013: General CAPS questions were sent to HNHB LHIN lead and response have been provided. Specific questions were directed to review teams.

• Oct 10, 2013: Provincial FAQ document is distributed to all HSPs throughout the province. Approximately 38 questions were received from across all LHIN engagement sessions between Oct 1-4, 2013.

• The HNHB LHIN also offered each agency in our LHIN an opportunity to meet with the LHIN staff face to face, or by telephone to discuss their CAPS prior to submitting their CAPS on Nov 15, 2013.

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2014-17 HNHB CAPS Reporting Compliance

Report %

CAPS 2014-17 Submission on Time (due date November 2013) 98%

CAPS 2014-17 Complete/ accurate Data at time of submission 11%

Board Approval Received On Time (due date November 15, 2013) 77%

Submission of No Deficit 100%

Source: Internal Reporting and Monitoring Results based on 96 CAPS Submission

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PERFORMANCE

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Performance Indicators

• In April 2010, the LHIN-led Health System Indicators Initiative (HSII) was established to create a coordinated, system-based approach to indicator identification, development, maintenance and reporting.

• Central to the mandate of HSII is the close collaboration with provincial and national partners in order to leverage their organizational expertise related to indicator development, benchmarking, data extraction, and analysis.

• In September 2013 a revised mandate provided a greater focus on alignment to system priorities, advancing system performance improvement through the SAAs and other mechanisms, and enabling monitoring and reporting.

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M-SAA Indicator Work Group Focus and Approach

• To review current indicators and develop recommendations to reduce the number of indicators

• To develop recommendations regarding the definition and target setting approach for the administrative indicator calculation

• To align existing indicators with pan-LHIN imperatives

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Performance Indicators (Schedule E)

The Performance Schedule E in the M-SAA contains the following two indicator sections:

1. Pan-LHIN Indicators:Core indicators that are relevant to all LHINs and all community sector HSPs and Sector-Specific indicators that are only relevant to a specified sector.

• Performance Indicators are measures of HSP performance for which a Performance Target is set; Technical specifications of specific

• Explanatory Indicators are measures of HSP performance for which no Performance Target is set. Technical specifications of specific.

Performance and Explanatory Indicator descriptions can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document. On the HNHB LHIN website. 2014-17 MSAA Indicator Tech Specs

2. LHIN-Specific Performance Obligations: Each LHIN may add specific performance objectives and obligations for their HSPs. LHINs are committed to minimizing any undue burden placed on providers with respect to performance management by focusing on a limited number of indicators aligned with local priorities.

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Core (All Sectors) Performance Indicators

Balanced budget - Fund type 2

Proportion of budget spent on administration

Variance forecast to actual expenses

Percentage total margin

Service activity by functional centre

Variance of forecasted to actual units of service

Number of individuals served

Percentage of Alternative Level of Care (ALC) days

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Community Care Access Centres SectorPerformance Indicators

Access: Wait time 1. From Hospital Discharge to Service Initiation (Hospital Clients)

Access: 90th Wait time 2. 90th percentile Wait time from Community Setting to Community Home Care Services

* Percentage people registered with Health Care Connect who are referred (Retired)

Details:–Reporting obligations are already in place with the ministry

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Community Support Services SectorPerformance Indicator

• There are no Performance Indicators for 2014-15 in the M-SAA for the Community Support Services sector.

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Community Health Centres Sector Performance Indicators Cervical cancer screening Colorectal Screening rate Inter-professional diabetes care rate Influenza vaccination rate Breast cancer screening rate Periodic health exam Vacancy Rate (for NPs and Physicians) Access to primary care clinical service (New)* Individuals served by functional centre (Retired)

Details:– Already a Core indicator

The HNHB LHIN staff are engaging the Community Health Centres (CHCs) until January 15, 2014 to negotiate targets for these eight CHC specific indicators.

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Community Mental Health and Addiction SectorPerformance Indicators

• There are no Performance Indicators for the Mental Health and Addiction sector in 2014-15.

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HNHB LHIN-Specific Performance Indicators and Reporting Obligations

Community Support Services (CSS) and Community Mental Health and Addiction (CMH&A):

Quality Obligation:

•“CSS and CMH&A organizations will work with the HNHB LHIN to develop and have in place the following three components of the quality plan: 1) Board approved policy on quality; 2) Balanced scorecard; and, 3) A Quality Plan to track variances and outline strategies for improvement. The CSS and CMH&A will align quality strategies with the LHIN-wide Quality Plan as set out by the Quality Guidance Council. This will be submitted to the HNHB LHIN at the end of each fiscal year (2014-15, 2015-16 and 2016-17)”

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HNHB LHIN-Specific Performance Indicators and Reporting Obligations

Community Health Centres and CCAC:

Quality Obligation:

•“The [CHC/CCAC ] will work to develop a Quality Improvement Plan (QIP) with guidance from the Health Quality Ontario (HQO) quality framework and templates for submission by the [CHC/CCAC] to HQO on or before fiscal year end. The QIP will inform HQO’s review and feedback of the broader [CHC/CCAC] sector alignment with its quality framework. The [CHC/CCAC ] will also align its quality strategies with the LHIN-wide Quality Plan set out by the Quality Guidance Council and provide the HNHB LHIN with a copy of their QIP to HQO”

• % of clients registered with CHC diagnosed with diabetes who have had a foot exam within the last 12 months

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HNHB LHIN-Specific Performance Indicators and Reporting Obligations

All Providers:

Behavioral Supports Ontario (BSO) Obligation:

•LHIN providers were identified in 2013-14 as either an Integrated Community Lead (ICL) agency or a Participating BSO ICL Contributing agency.

•All agencies are expected to continue their roles in 2014-15.

•Each agency should refer to the HNHB LHIN’s website for information on the responsibilities of their agency.

BSO HNHB LHIN Site

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Performance Standards

• All performance indicators have an associated target and standard of performance. Variance outside of the standard triggers a performance management processes.

To complete the targets and standards for the performance indicators, the following principles will be employed:• Where provincial targets and corridors exist, the LHINs and HSPs will

take these into consideration.

• Where appropriate, use past experience from M-SAA and MLPA indicators.

• Incorporate analyses of historical variation to inform corridor recommendations.

• Use % range for financial and volume indicators.

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Proportion of Budget Spent on Administration

• The Proportion of Budget Spent on Administration indicator measures how much an organization spends on administrative services relative to total operating expenditures.

• The HNHB LHIN’s expectation is that a shifting of resources away from administration will:

• increase capacity to deliver services directly impacting client care • contribute to the sustainability of the local health system.

In 2013-14 the HNHB LHIN asked each HSP to review their functional center allocations and provided education to the HSP’s on how to calculate this indicator.

The LHIN has completed its CAPS review of the change in this indicator target from 2013-14 to 2014-15

Next steps include further engagement with HSP’s to determine the reasons why some HSPs still have high targets.

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Performance Management

• How the LHIN chooses to deal with an indicator outside the standard depends on a number of factors, including:

• What is the realized and/or potential impact on the clients served?• Is this the first blip on an otherwise clean performance record?• Is this a unique event and unlikely to recur?• Are other areas of the organization or other HSPs affected?• What is the LHIN’s confidence in the HSP’s ability to manage

performance going ahead?• Depending on the above, the LHIN could choose to start with a less formal

tact. The formal process is always available...and can be triggered at any point.

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NEXT STEPS

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Next Steps and Important Dates

The LHINs will work collaboratively with their HSPs to implement M-SAAs by March 31, 2014

HSP Education Session…………………………………………….January 15, 2014

Local Indicator target setting engagement…...Dec. 16, 2013 to January 15, 2014

M-SAAs sent to 96 HSPs………………………………………….January 31, 2014

96 HSPs signed M-SAAs returned to HNHB LHIN…………………March 1, 2014

2014-17 M-SAAs take affect………………………………………….…April 1, 2014

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A copy of this slide deck will be available on the HNHB LHIN website at the following location:

2014-17 M-SAA HNHB Presentation

Questions may be sent to the HNHB LHIN

until January 31, 2014 to:

hnhblhin.caps@lhins.on.ca

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APPENDICES

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Appendix 1: Summary of Key Changes between current and new M-SAA

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Appendix 1: Summary of Key Changes continued

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Appendix 1: Summary of Key Changes continued

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Appendix 2: M-SAA Advisory Committee Membership

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Appendix 2: M-SAA Advisory Committee Membership continued

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Appendix 2: M-SAA Planning and Schedules Work Group Membership

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Appendix 2: M-SAA Planning and Schedules Work Group Membership continued

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Appendix 2: M-SAA Indicators Work Group Membership

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Appendix 2: M-SAA Indicators Work Group Membership continued

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Appendix 2: M-SAA Indicators Work Group Membership continued

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Appendix 3: Core (All Sectors) Explanatory Indicators

Cost per individual serviced by program/service/functional centre Cost per unit of service by functional centre Client experience (New Category)

Details: – Client Experience was an explanatory indicator for the

Mental Health and Addiction sector only in 2013-14– Indicators Work Group identified need to enhance linkage

with quality and patient experience for all sectors

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Appendix 3: Community Care Access Centres Explanatory Indicators

Access: Wait time 1. From hospital discharge to service initiation (hospital clients) by population groups (short stay, short stay rehab, long-stay complex)

Access: Wait time 2. 90th percentile wait time from Community setting to community home care services by population groups (short stay acute, short stay rehab, long-stay complex)

Average monthly cost per episode (adult short stay, adult long-stay complex, end of life, children medically fragile)

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Appendix 3: Community Care Access CentresNew Explanatory Indicators

Clients with MAPLe scores high and very high living in the community supported by CCAC

Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed

Details:–Moved from CCAC performance indicator category –Indicators fit this category and provide valuable information about how the system is functioning and the opportunities for change –Indicators are not a good measure for performance as targets are set locally by each LHIN

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Appendix 3: Community Care Access Centres Developmental Indicators

* Percentage of clients with a new or existing pressure ulcer that failed to improve (Retired)

* Medication safety (Retired)* Percentage of home care clients who say they have fallen in the last 90 days

(Retired)

Details –Indicators retired as developmental –Indicators were not identified by HQO on the Common Quality Agenda

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Appendix 3: Community Support Services Explanatory Indicator

Number of persons waiting for service (by functional centre)

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Appendix 3: Community Support Services Developmental Indicators Average number of days waited for first service (by functional centre) (New

Category)Details:

–Moved from CSS Explanatory indicator category as the data is not yet available–Move to explanatory in years 2 or 3

* Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired)

* Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired)Details:

–Indicators are difficult to measure as cannot follow clients between the hospital and the community

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Appendix 3: Community Health Centres Explanatory Indicators Emergency visits best managed elsewhere (New) Client satisfaction – Access (New) Clinical support staff per primary care provider (New) Cultural interpretation (New) Exam rooms per primary care provider (New) New grads/new staff (New) Number of new patients (New) Non-Primary Care activities (New)

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Appendix 3: Community Health Centres Explanatory Indicators continued Number of registered clients (New) Specialized care (New) Supervision of students (New) Third next available appointment (New) Non-insured clients (New) * Repeat unscheduled emergency visits within 30 days for mental health

conditions (Retired)* Repeat unscheduled emergency visits within 30 days for substance abuse

conditions (Retired)Details:– Data is a challenge as the cell size is small

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Appendix 3: Community Health Centres Developmental Indicator CHC clients hospitalized for Ambulatory Care sensitive conditions

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Appendix 3: Community Mental Health and Addiction Explanatory Indicators

Number of days waited from referral/application to initial assessment complete

Average number of days waited from initial assessment complete to service initiation

Repeat unscheduled emergency visits within 30 days for mental health conditions (New Category)

Repeat unscheduled emergency visits within 30 days for substance abuse conditions (New Category)Details: both of the 2 indicators above were moved to Explanatory indicator in 2014-15

* Client experience (Retired)Details: Moved to Core indicator

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Appendix 3: Community Mental Health & Addiction. Developmental Indicator

OCAN/GAIN Indicator

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Appendix 4: M-SAA Content - ArticlesArticle 1 Definitions and InterpretationClarifies terminology used throughout the document.

Article 2 Term and Nature of the AgreementDefines the term of the service accountability agreement as April 1, 2014 to March 31, 2017.

Article 3 Provision of Services Describes how services will be provided in accordance with legislation, applicable policies,e-health/IT compliance and the terms of this agreement. Discusses subcontracting services and conflict of interest.

Article 4 FundingOutlines conditions of funding, payment and provision limitations. Procurement and disposition of goods and services are also described.

Article 5 Repayment and Recovery of FundingDefines circumstances under which funding may be adjusted and/or recovered.

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Appendix 4: M-SAA Content - Articles continuedArticle 6 Planning and IntegrationDiscusses multi-year planning CAPS requirements in alignment with LHIN IHSP and priorities.

Article 7 Performance Discusses the need for ongoing performance improvement and the mitigating process in the event of performance factors (non-performance).

Article 8 Reporting, Accounting and ReviewDescribes the obligations of reporting and record maintenance, French language requirements, disclosure of information, transparency and reviews.

Article 9 Acknowledgement of LHIN SupportHSP publications are required to note LHIN support, be approved by the LHIN, and indicate views do not necessarily reflect those of the LHIN or Government.

Article 10 Representations, Warranties and CovenantsConfirms the HSP’s ability to enter into the agreement and carry out the funded services with the appropriate governance, personnel and documentation.

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Appendix 4: M-SAA Content - Articles continuedArticle 11 Limitation of Liability, Indemnity and InsuranceOutlines the limitation of liability and indemnification for the LHINs and the required insurance provisions for the HSP.

Article 12 Termination of Agreement Describes the parameters for termination of the agreement by the LHIN and by the HSP.

Article 13 NoticeDetails how notices to a party must be provided.

Article 14 Additional ProvisionsIdentifies additional provisions to the agreement.

Article 15 Entire AgreementDefines the agreement as constituting the entire agreement, superseding all prior agreements.

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Appendix 5: M-SAA Content - Schedules

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