August 7, 2019

Evaluation of the Medicaid Value Program: Health Supports for Consumers with Chronic Conditions

The Center for Health Care Strategies’ (CHCS) Medicaid Value Program (MVP) sought to test interventions seeking to improve care for adult Medicaid beneficiaries with multiple chronic conditions. The program was funded by a grant from Kaiser Permanente, with additional funding from the Robert Wood Johnson Foundation. This report provides Mathematica […]
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The Center for Health Care Strategies’ (CHCS) Medicaid Value Program (MVP) sought to test interventions seeking to improve care for adult Medicaid beneficiaries with multiple chronic conditions. The program was funded by a grant from Kaiser Permanente, with additional funding from the Robert Wood Johnson Foundation. This report provides Mathematica Policy Research’s (MPR) evaluation of the MVP program and the estimates of program effects produced by the programs themselves. This study was funded by CHCS to identify best practices and lessons for future replication or testing. This report is composed of two parts—a cross-cutting analysis of findings, and case studies for each of the 10 interventions tested through the MVP program.
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http://www.chcs.org/usr_doc/Exec_Summary.pdf

August 7, 2019

Improving Geriatric Care by Reducing Potentially Avoidable Hospitalizations

Background • Current financial incentives in the Medicare fee-for-service program foster the overuse of diagnostic tests and interventions that do not benefit many elderly patients, and can result in morbid and costly complications • Care can be improved at reduced costs: Savings can be reinvested to improve care • One […]
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Background • Current financial incentives in the Medicare fee-for-service program foster the overuse of diagnostic tests and interventions that do not benefit many elderly patients, and can result in morbid and costly complications • Care can be improved at reduced costs: Savings can be reinvested to improve care • One major example in the geriatric population is potentially avoidable acute care hospitalizations and hospital readmissions
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http://www.americangeriatrics.org/files/documents/annual_meeting/2010/handouts/friday/painting/F0215P_J_Ouslander.pdf

August 7, 2019

Quality Matters Newsletter: In Focus: Toward a System of Coordinated Care

Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching […]
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Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching and tracking of high-risk groups, but widespread reform will require changes to the financing of care delivery and other system-wide changes
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http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june

August 7, 2019

Chronic Care Coordination

Chronic Care Coordination is a nurse-based model with consultation from licensed clinical social workers, for providing clinical and educational support to complex patients
Chronic Care Coordination is a nurse-based model with consultation from licensed clinical social workers, for providing clinical and educational support to complex patients
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http://www.innovativecaremodels.com/care_models/13

August 7, 2019

Pharmacy Team Providing Enhanced Services to a Transitional Care Unit.

Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One […]
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Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One of the team's most important contributions is the virtual elimination of medication errors following the implementation of computerized transfer orders.
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http://www.medscape.com/viewarticle/555610_1

August 7, 2019

Evercare Care Model

Evercare Care Model is a primary care team model in which nurse practitioners provide intensive primary and preventive care to individuals with long-term conditions or disabilities.
Evercare Care Model is a primary care team model in which nurse practitioners provide intensive primary and preventive care to individuals with long-term conditions or disabilities.
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http://www.innovativecaremodels.com/care_models/17

August 7, 2019

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients

This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
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http://hin.3dcartstores.com/Retooling-Care-Transitions-to-Reduce-Hospitalizations-in-Medicare-Patients_p_3925.html

August 7, 2019

Effect of a Hospitalist-Care Coordinator Team on a Nonteaching Hospitalist Service.

O’Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to […]
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O'Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to evaluate the impact of a hospitalist-care coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency. DESIGN AND PARTICIPANTS: During each of 12 weeks, hospitalists on a nonteaching hospitalist service were randomly assigned to work with a hospitalist care coordinator (HCC) or to work independently. MEASUREMENTS: Each week hospitalists completed a survey to assess their satisfaction and perceived work efficiency. Patient satisfaction with hospital discharge was assessed by telephone interviews. Hospital efficiency was analyzed with multivariate linear regression using log-transformed length of stay (LOS) and cost as dependent variables. RESULTS: The 356 patients cared for by hospitalist-HCC teams were similar to 337 patients cared for by control hospitalists. Twenty-eight of 31 hospitalists (90%) who worked with an HCC responded that the HCC improved their efficiency and job satisfaction. Seventy-one of 196 eligible patients (36%) completed the postdischarge interview. The mean ratings of overall satisfaction with hospital discharge on a scale of 10 were similarly high in both groups (8.57 vs. 8.37; P = .94). In multivariate regression analyses, LOS was 0.28 days shorter and cost was $585.62 lower for patients cared for by hospitalist-HCC teams; however, these results were not statistically significant (P = .17 and .15, respectively). CONCLUSIONS: Hospitalists working in a team approach with an HCC reported improved efficiency and job satisfaction compared with hospitalists working independently. These findings are important in light of growing concerns about hospitalist workload and job satisfaction.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract

August 7, 2019

Hospital Readmissions as a Measure of Health Care: Advantages and Limitations; Archives of Internal Medicine

Benbassat J, Taragin M. Hospital Readmissions as a Measure of Health Care: Advantages and Limitations. Arch Intern Med. 2000;160(8):1074-1081. http://archinte.jamanetwork.com/article.aspx?articleid=415392. Accessed December 11, 2014. We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic […]
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Benbassat J, Taragin M. Hospital Readmissions as a Measure of Health Care: Advantages and Limitations. Arch Intern Med. 2000;160(8):1074-1081. http://archinte.jamanetwork.com/article.aspx?articleid=415392. Accessed December 11, 2014. We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic disease. However, from 9% to 48% of all readmissions have been judged to be preventable because they were associated with indicators of substandard care during the index hospitalization, such as poor resolution of the main problem, unstable therapy at discharge, and inadequate postdischarge care. Furthermore, randomized prospective trials have shown that 12% to 75% of all readmissions can be prevented by patient education, predischarge assessment, and domiciliary aftercare. We conclude that most readmissions seem to be caused by unmodifiable causes, and that, pending an agreed-on method to adjust for confounders, global readmission rates are not a useful indicator of quality of care. However, high readmission rates of patients with defined conditions, such as diabetes and bronchial asthma, may identify quality-of-care problems. A focus on the specific needs of such patients may lead to the creation of more responsive health care systems for the chronically ill.
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http://archinte.ama-assn.org/cgi/content/abstract/160/8/1074

August 7, 2019

Promising Models of Care Coordination/care Management For Beneficiaries With Chronic Illnesses

Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
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http://socialwork.nyam.org/mwg-internal/de5fs23hu73ds/progress?id=1/DIeJ7cnT

August 7, 2019

Organizing the U.S. Health Care Delivery System for High Performance

The Commonwealth Fund. Organizing the U.S. Health Care Delivery System for High Performance. http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf. Published August 2008. Accessed December 11, 2014. This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our health care delivery system and offers policy recommendations to stimulate greater organization—established […]
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The Commonwealth Fund. Organizing the U.S. Health Care Delivery System for High Performance. http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf. Published August 2008. Accessed December 11, 2014. This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our health care delivery system and offers policy recommendations to stimulate greater organization—established mechanisms for working across providers and care settings. Fragmentation fosters frustrating and dangerous patient experiences, especially for patients obtaining care from multiple providers in a variety of settings. It also leads to waste and duplication, hindering providers’ ability to deliver high-quality, efficient care. Moreover, our fragmented system rewards high-cost, intensive medical intervention over higher-value primary care, including preventive medicine and the management of chronic illness. The solutions are complex and will require new financial incentives, changes to the regulatory, professional, and educational environments, and support for new infrastructure. But as a nation, we can no longer tolerate the status quo of poor health system performance. Greater organization is a critical step on the path to higher performance.
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http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf

August 7, 2019

Administration On Aging

The mission of AoA is to develop a comprehensive, coordinated and cost-effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities.
The mission of AoA is to develop a comprehensive, coordinated and cost-effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities.
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http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/index.aspx

August 7, 2019

Shared Care Plan

Shared Care Plan.Sharedcareplan.org. [Tool]. https://www.sharedcareplan.org/OtherPages/Phms.aspx. Published [No Date Specified]. Updated 2013. Accessed December 11, 2014. The Shared Care Plan is a free, easy-to-use, Shared Care Plan record that lets you organize and store vital health information. You can share this information with your family, physicians and others you feel should […]
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Shared Care Plan.Sharedcareplan.org. [Tool]. https://www.sharedcareplan.org/OtherPages/Phms.aspx. Published [No Date Specified]. Updated 2013. Accessed December 11, 2014. The Shared Care Plan is a free, easy-to-use, Shared Care Plan record that lets you organize and store vital health information. You can share this information with your family, physicians and others you feel should have access to this information. The Shared Care Plan is also much more — it is a self-management care plan, improving your understanding of your own health. It can help you manage chronic conditions, coordinate the care of others, and improve your health. Whether you are living with a chronic condition or are a healthy athlete, the Shared Care Plan can benefit you.
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https://www.sharedcareplan.org/OtherPages/Phms.aspx

August 7, 2019

Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program

The hospital discharge is nonstandardized and marked with poor quality. One in five hospital discharges is complicated by an adverse event (AE) within 30 days, many of which lead to emergency department visits and rehospitalizations. Methods: Using an iterative group process, we developed the principles and components of the ReEngineered […]
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The hospital discharge is nonstandardized and marked with poor quality. One in five hospital discharges is complicated by an adverse event (AE) within 30 days, many of which lead to emergency department visits and rehospitalizations. Methods: Using an iterative group process, we developed the principles and components of the ReEngineered Discharge (RED), a set of 11 distinct components designed to prepare patients for discharge. Three tools were created: a training manual used to train discharge nurses to provide the RED; an individualized, patient-friendly “After Hospital Care Plan” (AHCP), a booklet used to prepare patients for discharge; and a workstation to integrate all pertinent discharge information used to electronically create the AHCP. Outcomes: The RED was adopted by the National Quality Forum (NQF) as one of their “Safe Practices.” Among the intervention subjects, 89 percent were provided with an AHCP at discharge; it required approximately 1 hour for the discharge advocate to provide the RED intervention. Implications: Use of the AHCP tool can effectively prepare patients for discharge, as recommended by NQF 2006 Safe Practice number 11. These results have important implications for quality of care at discharge and for lowering costs.
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http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Jack_28.pdf

August 7, 2019

PtC3: Patient-Centered Coordinated Care

The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in […]
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The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in America will soon become unsustainably expensive. The answer may be Patient-Centered Coordinated Care (PtC3). PtC3 is an assessment-based interdisciplinary approach to integrating health care and social support services in which a patient’s individual needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored through a high touch approach.
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http://www.medicarepatientmanagement.com/issues/04-03/mpmMJ09-CareCoordination.pdf

August 7, 2019

ABIM Summer Forum: Coordination of Care: Is There a Missed Opportunity?

ABIM. Coordination of Care. Missed Opportunity? The 2007 ABIM Foundation Summer Forum. http://www.abimfoundation.org/~/media/care_coordination.ashx. Published 2007. Accessed September 24, 2014. The 2007 ABIM Foundation Summer Forum , August 4 – 7, 2007, convened more than 130 healthcare leaders who addressed the topic Coordination of Care: Missed Opportunity? Presented here are illustrations […]
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ABIM. Coordination of Care. Missed Opportunity? The 2007 ABIM Foundation Summer Forum. http://www.abimfoundation.org/~/media/care_coordination.ashx. Published 2007. Accessed September 24, 2014. The 2007 ABIM Foundation Summer Forum , August 4 – 7, 2007, convened more than 130 healthcare leaders who addressed the topic Coordination of Care: Missed Opportunity? Presented here are illustrations to each of the Forum’s sessions. The illustrations graphically capture the key insights, observations and commentary shared by facilitators, moderators and participants during each of the Forum’s sessions.
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http://www.abimfoundation.org/~/media/care_coordination.ashx

August 7, 2019

Project Boost: Reducing Unnecessary Readmissions and So Much More

Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a quality improvement toolkit, backed by evidence-based research, to enhance the care of patients transitioning from the hospital to home. Project BOOST helps hospitals better manage patient discharge—a chaotic process at most facilities— leading to better patient care by […]
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Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a quality improvement toolkit, backed by evidence-based research, to enhance the care of patients transitioning from the hospital to home. Project BOOST helps hospitals better manage patient discharge—a chaotic process at most facilities— leading to better patient care by reducing readmission rates, improving patient and family preparation for discharge, enhancing patient satisfaction, and much more.
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http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/BOOST_Presentation_St_Mary's_Handout.pdf

August 7, 2019

Transitional Care Planning (PDQ): Supportive Care-Patient Information [NCI]-What is Transitional Care Planning?

WebMD. Cancer Health Center.[Web Site].http://www.webmd.com/cancer/tc/ncicdr0000062780-what-is-transitional-care-planning. Updated February 25, 2014. Accessed September 24, 2014. Transitional care planning helps the patient’s cancer care continue without interruption through different phases of the cancer experience. Transition means passage from one phase to another. Transitional care planning is the bridge between two phases of care. […]
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WebMD. Cancer Health Center.[Web Site].http://www.webmd.com/cancer/tc/ncicdr0000062780-what-is-transitional-care-planning. Updated February 25, 2014. Accessed September 24, 2014. Transitional care planning helps the patient's cancer care continue without interruption through different phases of the cancer experience. Transition means passage from one phase to another. Transitional care planning is the bridge between two phases of care. As the cancer patient's treatment goals change or the place of care changes, the patient may encounter problems during the transition. Patients will need to make decisions that balance disease status and treatment options with family needs, finances, employment, spiritual or religious beliefs, and quality of life. There may be practical problems such as finding an appropriate rehabilitation center, obtaining special equipment, or paying for needed care. There may be mental health problems such as depression or anxiety. Transitional care planning helps identify and manage these problems so the transition can go smoothly, without interruption of care. This can reduce stress on the patient and family and improve the patient's health outcome.
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http://www.webmd.com/cancer/tc/ncicdr0000062780-what-is-transitional-care-planning

August 7, 2019

Patient Care Link: State Action on Avoidable Rehospitalizations Initiative (STARR)

The PatientCareLink Mission: To help participating hospitals provide transparent staffing and patient safety information to the public and other healthcare stakeholders, and also offer valid and reliable information on quality and safety to patients and healthcare workers alike. A multi-state project involving 53 hospitals, STARR was launched by the Institute […]
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The PatientCareLink Mission: To help participating hospitals provide transparent staffing and patient safety information to the public and other healthcare stakeholders, and also offer valid and reliable information on quality and safety to patients and healthcare workers alike. A multi-state project involving 53 hospitals, STARR was launched by the Institute of Healthcare Improvement (IHI) in May 2009 with grant funding from The Commonwealth Fund. 22 Massachusetts hospitals are enrolled in the initiative. To date, participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates. Now they are busy determining how to improve the patient's transition from hospital to post-acute setting.
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http://www.patientcarelink.org/improving-patient-care/readmissions/state-action-on-avoidable-rehospitalizations-initiative-staar.aspx

August 7, 2019

Nursing Home Special Study: Reducing Avoidable Hospitalizations of Nursing Home residents—Framework for Pilot Testing Interventions to Reduce Acute Care Transfers of Nursing Home Residents

This pilot project is a part of a special study supported by CMS. The special study is being conducted by Georgia Medical Care Foundation (GMCF), the Medicare Quality Improvement Organization (QIO) for Georgia. The main goal of the special study is to develop and implement strategies and tools that will […]
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This pilot project is a part of a special study supported by CMS. The special study is being conducted by Georgia Medical Care Foundation (GMCF), the Medicare Quality Improvement Organization (QIO) for Georgia. The main goal of the special study is to develop and implement strategies and tools that will reduce potentially avoidable acute care transfers (ACT) from nursing homes. The INTERACT TOOL KIT (INTERventions to reduce Acute Care Transfers) will be implemented using a Collaborative Framework similar to the model developed by IHI. The tool kit will be refined as the result of this pilot project, and disseminated nationally to assist nursing homes in the U.S. to reduce potentially avoidable ACT.
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http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=3&ved=0CE0QFjAC&url=http%3A%2F%2Fwww.qualitynet.org%2Fdcs%2FBlobServer%3Fblobkey%3Did%26blobwhere%3D1228861423145%26blobheader%3Dapplication%252Fpdf%26blobheadername1%3DContent-Dispos