School Health Screeing Team: Quickest Vision Screeners in the State

State: FL Type: Promising Practice Year: 2019

The Department of Health in Collier County (DOH-Collier), located in southwest Florida, provides essential public health services to more than 346,805 residents and approximately 1.67 million visitors to the county annually. Collier county is the largest county in the state by land area, consisting of both rural and urban populations. Collier county is made up of a diverse population that includes a large minority population, a significant population of residents over the age of 65, and a school district serving over 48,000 students. 

School Health is one of many services that is provided by DOH-Collier. The School Health Services Program in DOH-Collier provides essential school health services in compliance with Florida Statute 381.0056. The statute outlines that the Department of Education (DOE) and Department of Health are responsible for the delivery of school health essential services. Although the Florida statute outlines the essential services that must be provided by school health programs, it does not specify how the services must be delivered. Therefore, it is up to each county's DOE and DOH to decide how best to deliver services based on the available resources in the community. In Collier county, the DOH school health program has taken on the responsibility of delivering mandated screening services.

Among the screening services mandated, the vision screening requirement makes up the largest and most complex screening service to deliver (based on service count, epidemiological findings of at risk students, complexity of visual system, and available screening equipment).  The vision system is critical to learning, and in many cases, visual health barriers to learning can be mitigated when the medical intervention is provided (i.e. examination and prescribed glasses). Furthermore, if a child is identified with a visual impairment that cannot be improved through intervention, screening services are essential to recognizing these children and providing documentation for school officials to modify learning plans and provide educational assistance.  Due to these factors, special focus is given to improving vision screening service delivery and achieving a model practice program worth replicating statewide.

The Collier county school health screening service delivery system made it their goal to be the Quickest vision screeners in the State of Florida”.  It was determined this would be the goal of the program for the following reasons:

1. Due to vision being the highest referral rate and the largest service delivered, it is essential that completing the screening” early is necessary to assure ample time for referral follow-up (another requirement of the program and best practice in service delivery)

2. Current technology that was available in the county for vision screening and experience with the equipment by program leadership, supported the goal and method of achieving a quick screening within the timeframe (less than 6 weeks) for the required population.

3. Partnership between the school district and nonprofit agencies: the Naples Children's Education Foundation1 and Florida Vision Quest2 (NCEF/FVQ), provided the necessary partnership with human and technological capital that enabled the entire vision screening system within the county to schedule and achieve the outlined goal.

4. Providing screenings is only the initial requirement, all children that fail screening need referral follow-up. State programs that offer vision examination to vulnerable and underserved populations not based in the county can be utilized, but scheduling services from these programs can be time consuming and require following additional protocols. By completing screening within 6 weeks, more time could be spent on accessing and ensuring delivery of these services in the county.

The NCEF/FVQ partnership outlined that vision screenings would be provided to specific schools throughout the district. This partnership reduced the total number of vision screenings that would be required of DOH screening teams by half. Based on previous experiences, and having defined the screening protocols and processes, the program scheduled all vision screening services in May 2018 for the month of September. In collaboration with the private partnership, the school health program would provide approximately 14,000 vision screening to students within the first 6 weeks of the school year.

As of September, of the current school year, the program achieved its goal of providing essential vision screenings services in all schools across the district and attaining it goal.  

Statement of the problem/public health issue.

If a child experiences poor or impaired vision, their readiness to learn in the classroom may be adversely affected. Visual health barriers to learning, if not caught and mitigated early in a child's educational development, can have lifelong implications for a child's inclusion and desire to be educated.  In addition, there exists a vulnerable and underserved population throughout the community that do not have regular access to a medical home. Children in this population may not receive the recommended screenings during early childhood development when various visual impairments can cause amblyopia and or limit normal visual development that is permanent and irreversible.  Screening in schools, for some children, is the earliest opportunity for them to receive services to mitigate these visual deficiencies or limit their progression.

What target population is affected by problem? (please include relevant demographics)

Although, disturbance to the visual system can affect anyone, the target population is school aged children. Research varies but prevalence of common conditions afflicting children's visual systems ranges from 2% to 50% depending on the condition and the age and ethnicity of the children being screened (Proctor, S.E. (2005). To See or Not to See: Screening the Vision of Children in School).

What is the target population size?

There are currently about 48,000 school aged children attending Collier County public schools. The Florida Administrative Code mandates kindergarten, first, third and sixth grade students have an annual vision screening. With these mandated grades and additional students who are new to the district and are referred for vision screening services, the screening system within the county will annually screen upwards of 14,000 children.

  • What percentage did you reach? What has been done in the past to address the problem?

The goal of the current project was to screen 100% of the mandated population (school year 2018-2019 included 13,880 children from state estimates) by the end of September, then have 50% of referrals for vision obtain a medical evaluation by a physician. Best estimates based on available data to the program is that 92% of the mandated population was screened using the vision screening system available in the county.  This data does not account for the thousands of students that were screened in addition to the mandated grade levels, but are left out of current data models used for state compliance reporting.

Why is the current/proposed practice better? Is current practice innovative? How so/explain?

The proposed practice builds upon the community resources that were available to the vision screening program in the 2018-2019 school year. The previous five years saw the improvement and streamlining of several best practices learned within the program and the leveraging of community partnerships and current technology. With the implementation of a proven screening protocol and vision screening services system, the program sought to increase the speed at which services were delivered to push the system to its possible limits.

 The Florida Heiken Children's Vision Program (Heiken) informed the DOH collier program of additional funding which would allow them to evaluate and provide glasses for any child referred by the DOH-Collier screening program. Additionally, the NCEF/FVQ partnership assures examinations for students in vulnerable and/or underserved populations referred by their screening program. The collaboration of our programs and opportunities for rendering services removes previous barriers to care (e.g. obtaining an eye examination after screenings) for nearly every student in the district. It was therefore imperative to screen quickly and move into the referral follow up part of the program. The school health program intended to schedule and ensure services from the Heiken program for its students as soon as possible.  This involved several planning process meetings with Heiken which is based in neighboring Miami Florida (scheduling with Heiken, obtaining permissions from schools and parents, and notification of parents that services would be provided and on what date).

The entire project was a desire to push the current vision screening system within the county and state to its limitation. Current requirements for school health program is 45% of vision screening for mandated populations be completed by December 31 of year, with 95% of screenings required to be completed by April 14th. These requirements are set to ensure service delivery, but do not test the ability to provide a service in a timely fashion. Nor does it correlate with best practice models that reiterate early identification and access to care.  

Is it new to the field of public health?

Screening services and school health services can be considered a specialty in public health systems.  Vision screenings are not new to school health services. In fact, most states have laws and requirements for vision screening services to be performed in schools. However, no uniform approach to training and delivering these services is available. Several resources and recommendations from nationally recognized organizations exist, however these resources cannot provide specific guidelines on managements and processes to deliver services. Florida Statute 381.0056 has been in place for 44 years. In that time, screening services has remained one of the largest services that school health programs must deliver. The program outlined is new to the field in that it seeks to push a service delivery method to its physical and logistical limitation given community resources that are locally considered the best possible methods available. More importantly, the current practice was designed with the idea of being replicable state wide. If the current practice were to be replicated (methods of screenings, equipment, scheduling, and availability of services for referred children), the current practice can achieve improved metrics in all categories that would be considered important to the delivery of vision screening services. These metrics include:

  • Standard protocols and processes that are disseminated and used throughout the district. 
  • A standard, accurate, reliable and equitable protocol of screening and for identifying students for possible health barriers to learning. 
  • A standard process of referral follow-up that focuses on obtaining a medical evaluation and education/ understanding of what the results of the evaluation mean for the child by all vested interests. 
  • Data Management- collection, processing, analysis, retrieval, and sharing.

Is it a creative use of existing tool or practice? What tool or practice did you use in an original way to create your practice?

The Welch Allyn VS100 SPOT Photoscreener is a tool for vision screening services. The device was incorporated into the vision screening protocol in 2013-2014 within Collier County. Its current use within the overall paradigm of the screening process was unique. The DOH-Collier screening program utilizes a three-step process to provide screening services. These steps bring together a data management system, an objective screening device (SPOT), and a gold standard acuity screening tool (SLOAN charts) to achieve and a quick, accurate and reliable protocol. This protocol allows screenings to be conducted in a timely manner. When paired with appropriate planning and scheduling, the program can screen nearly 400-600 students per day at one site, doubling these number when multiple teams are stationed at multiple schools.

The creation of the protocol, the use of the tools available, and the design of the overall program delivery systems was implemented using the Plan, Do, Check, Act (PDCA) process and continuation of quality improvement based on data and experience.

  • Is the current practice evidence-based?

The US preventative services task force gives a B” recommendation for screening children aged 3-5 years of age for amblyopia risk factors. The National Association of School Nurses as well as the National Center for Children Vision & Eye Health agree that screenings for children in grade school is an important practice, especially for vulnerable and underserved populations that may not have access to vision services (screenings or examinations). Although inconsistent evidence can be found regarding vision screening and methods, there is no argument that screenings are worthwhile and that identifying and treating a child with vision issues improves that child's quality of life. With the current vision screening protocol being used in the county, which incorporates advanced photoscreening technology with the Welch Allyn VS100 SPOT Photoscreener, the screening system refers around 10-15% of the population it screens annually. In the school year 2017-2018, this accounted for 1,828 students referred for follow up. Children who have failed a vision screening should be referred for examination. The incorporation of this equipment into the screening protocols was based on evidence based research and comparing outcome data over time to research regarding vision screening services. The data collected and studied by the program supports that the program is providing a adequate, reliable, equitable and efficient screening students.

Goal(s) and objectives of practice:
Provide mandated services to children under our responsibility in the most efficient and effective manner possible. This evolved into the idea of providing services for the entire district quicker than ever before, and then focusing on providing access to care to ensure more children who were referred by screenings received an examination prior to first compliance check on December 31st.???????

What did you do to achieve the goals and objectives?

Planned for the screening year during the prior school year. This entailed stating our objectives to partners to approve the proposed schedule, meeting with service providers to ensure accuracy of processes to obtain examination services. It also included refining processes and protocols for vision screening and referral, appropriately staffing each screening based on previous data regarding schedules and timing to screen students at school. Planning timelines for achieving paperwork compliance, and reviewing possible threats and weaknesses that were within and outside our control to effectively manage them.

Steps taken to implement the program  

The most important step taken was to outline our objective within the LHD program and presenting it to upper management for approval. The initial step to schedule and achieve the proposed plan of quickly screening students required participation from more than just the screening program within the Department. Without departmental approval to request partners to help us meet the objective, the project could not have been undertaken. After approval, additional steps involved normal program processes. With the added emphasis and knowledge, the goal was not just to deliver the required service, but planned on delivering them in a proposed timeline focused on achieving a specific goal.

  • Any criteria for who was selected to receive the practice (if applicable)?

The NCEF/FVQ partnership provided vision screenings to nearly half of the required population and was accomplished within the month of September. This aspect of the screening system in the county achieved this because the only focus was vision screenings. DOH-Collier was responsible for all screening services throughout the county and reporting on all services provided. It was necessary for the program to specifically plan a schedule that ensures all its required schools would receive vision screenings within the month of September and other mandated screening would be provided at a later date and time.

What was the timeframe for the practice were other stakeholders involved?

The timeframe was to complete all mandated vision screenings for the district using community resources and partnership within a 6-week period from the beginning of the school year. This resulted in a goal of completing all vision screening by the end of the month of September. The second part of the goal was to achieve 50% of referrals having received medical examination for the possible vision conditions. This would be achieved by:  1. Relying on NCEF/FVQ partnership to meet their stated objectives of providing mobile vision examinations at schools for the students they were responsible for 2. Utilizing the Florida Heiken Vision Program to bring mobile care units to schools covered by DOH-Collier to ensure those students also received examinations on school grounds, prior to the December 31st deadline.

What was their role in the planning and implementation process?

NCEF/FVQ planned to deliver their services as they do annually. Their schedule for 2018-2019 was planned so they would be able to complete their initial screenings by the end of September. DOH-Collier followed accordingly and planned screenings so that all schools in the district would have initial vision screenings performed by this date.

DOH-Collier also met with Florida Heiken in May and evaluated each step of the process for applying for Heiken services. Heiken was made aware of the goal to utilize their services at higher rate than previous years. Items discussed included how DOH-Collier would be sending data to make the processes as efficient as possible. In addition, DOH-Collier coordinated with school during the month of October to obtain necessary permission from children's families and schedule the Heiken mobile care unit to come to the school grounds and service the clients.

What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)

Florida statute requires the DOH and DOE to partner and share responsibility for ensuring school health services are delivered. The DOH screening team has tried to standardize processes and protocols over the years so that that the school in the district have received a consistent and seamless service. This consistency helped when outlining the goal of performing vision screenings quicker than any previous years. School partners understood the importance of ensuring the screenings were performed quickly because it was explained that their main objective (examinations for referrals) could be achieved earlier if the screening requirement was met. The confidence in the program's ability to deliver a consistent and reliable services helped garner support for the innovative schedule and adjustments that would need to be made to achieve the intended goal (some schools were asked to have 2 screening dates when before they only had one).

Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.

Implementing the model practice has been developed over several years. Equipment costs and personnel costs are the main factors that have led to the program's success.

The program has acquired 10 SPOTs photoscreeners which was needed to screen at multiple schools in a quick and efficient manner. These SPOTS were purchased at different times and at different prices point due to multiple purchases at one time and sales. Since 2013 until today, estimated costs have been $50,000, or around $5000 per machine.

Annual cost for program staff are $251,763 annually. This funding includes the applicable fringe benefits for full-time staff. The program has tried various staffing models over the years, but currently funds 4 full-time positions and 6 part-time positions, which when paired with volunteer community resources helped achieve the staffing requirement necessary to meet scheduling requirement for the outlined goal. Other expenses that should be included to help achieved program goals have been the purchase of licenses for a data management system utilized by the local school district for documentation purposes. This system costs $5,250 annually so that all team members can access the system. Having a data management system that is shared between the two main partners, DOE and DOH, has been an extremely helpful and beneficial tool for sharing data and helping achieve program synergy.

Other recurring operating costs for supplies necessary to achieve the outlined goal, including travel costs, office supplies, printing, equipment rentals etc.  are estimated to be $6,500 to $10,000 annually.

Total estimated reoccurring costs to achieve the outlined goal of this practice would be under $300,000. However, all cost and estimates delivered are associated with the costs of delivering all mandated services (not just vision). These costs would not change if services needed to be increased due to community resources changing (the NCEF/FVQ program no longer performed screenings).  The program itself has been designed to operate under these costs and has used process planning and partnerships to improve service delivery and maintain a standard of care.

Enter the LHD and Community Collaboration related to your practice *

  • DOH-Collier
  • Collier County Public Schools
  • Naples Children's Education Foundation/ Florida Vision Quest (Local Partnership)
  • Florida Heiken Children's Vision Program
  • Naples Community Hospital, School Nurse Program
  • Lorenzo Walker Technical College (LWTC) and Immokalee Technical College (ITECH) health professional programs (provided volunteer resources to DOH screening teams)

What did you find out? To what extent were your objectives achieved? Please re-state your objectives.

The program faced limitations in achieving its goals from sources outside the direct control of the program staff. Meeting the screening requirements was not the most difficult part. The protocols in place and methods/processes used to screen at schools, along with appropriate scheduling, allowed for the program staff to achieve the goal of screening all mandated grades at all schools by the end of the month of September. However, the second important part of the goal was achieving examinations at the school using state contracted providers. This required the program to obtain permission from families and/or encourage families to apply to the program.

Previous year experience led the DOE and DOH to design an emergency contact card that included language allowing program staff to apply for families of children that fail screenings. This had been implemented for some time, however, obtaining this signed consent became problematic.

Although schools require the signed form, many referrals cases did not have the forms on file. For the 388 students that were initially identified for processing to Florida Heiken, documentation and approval was only obtained for 253 within the timeframe necessary to have them serviced when the provider was scheduled to come to the various schools around the district. More so, 62 of these 253 still did not receive services because they were either not present for the bus or the school they attended did not receive enough applicant to warrant the mobile unit visit. Thus, these students were instead issued vouchers that allow them to access a medical evaluation, but parents must still schedule time to do this. This results in more time necessary by program staff to call the parents, educate and encourage them to seek evaluation, and then confirm if the child was examined.

Did you evaluate your practice?

Using comparison data from state mandated reports, and focusing on similar size counties and populations, the program could evaluate (based on reported data) how our program was compared to others delivering services.

As of a 12/3/2018 report based on data submitted between 7/1/2018 and 11/30/2018, the following information was used to evaluate the program:

Counties with similar size populations that required vision screenings (12,000-15,000).

The total population screened was

Comparison A1 (N-12,742): 21.95% reported screened, 3.08% of referrals with outcomes

Comparison A2 (N-13,194) : 67.58% reported screened, Not applicable (obvious data reporting error of 1150% of referral with outcomes)

Comparison A3 (N-15,103): 56.99% reported screened, 3.55% referrals with outcomes

Comparison A4 (N-12,973) 63.66% reported screened, 0.48% referral with outcomes

Comparison A5 (N-12,734) 57.89% reported screened, 18.73% referrals with outcomes

Other data used for comparison was based on the DOH-Collier program's overall screening responsibility. Separating our partner data from the DOH requirement, we focused on the 5,980 reported students that were screened by the program. This number represents the total number of students screened by the program in one month, and represents 100% of schools screened by the DOH program without partner involvement. Similar sized counties with a mandated requirement ranging from 5000 to 7000 were looked at for comparison.

Comparison B1 (N-6,702): 74.89% reported screened, 1.82% referrals with outcomes

Comparison B2 (N-5,336): 88.08% reported screened, 0% referrals with outcomes

Comparison B3 (N-5,595): 32.75% reported screened, 0% referrals with outcomes

List any primary data sources, who collected the data, and how? (if applicable)

Data source is aggregated data provided by the DOH school health central office. It is based on reported data from each county. Data is reported with set deadlines for entry. Deadlines are as follows:

December 31st, 45% of mandated population screened

April 1st, 95% of population screened.

There is no deadline for reporting outcome data (referral follow-up), except for end of year reporting. There is also no set percentage of referrals that are required to have outcome data reported. However, it is best practice that outcome data be reported for all referred cases.

List any secondary data sources used. (if applicable)

Internal data sources are used to monitor and measure program efficiency and effectiveness. This data comes from the school's data management system that the DOH screening program uses. It is based on data entered by program staff, and subject to time delays depending on when data is entered and when reports are run.  The main use of this data is to monitor the number of mandated students that were screened in school.

Often the number of students that require screenings in the district is larger than the parameter set by the state offices. This is because the metrics set by state office are set at the beginning of the year and enrollment continues throughout the year. As students come into the district, which has a large migrant population, the screening target changes and fluctuates. We use these data sets to help monitor our own internal process and be more accountable to our screening population. 

List performance measures used. Include process and outcome measures as appropriate.

The most important performance measure was meeting the outlined schedules for vision screenings and data reporting. Any delay or change in the vision screening schedule would have resulted in the program not meeting the 100% screening requirement it set out to achieve.

There were no delays or adverse events that affected the schedule, resulting in 100% of screening delivered to mandated populations by 6-week deadline.

Describe how results were analyzed.

By achieving the outlined schedule, the program was confident it had screened a majority of the mandated requirement set by central office. Knowing that partner organizations achieved the same goal, the program was confident, but unable to confirm immediately, that the target was either met or would far exceed comparison groups. By December 19th, final internal reports could show that between the program and community partners, 92% of the total mandated population was screened in the month of September.

Based on this information, the program did not achieve its intended goal of 100% of screening completed, but did exceed all comparison groups.

In addition, this goal exceeded 61 out of 66 counties on the December 3, 2018 report. Those 5 excluded counties completed above 92% of their mandatory screening requirements and had a combined total of 7,160 students mandated to be screened. Of those 5, the largest county had 2,186 students that required screenings.

Given the size of Collier County's mandatory screening population, the partnerships involved, and the overall outcomes of the metric used for comparison, the program found that it met its intended goal and can be considered one of the quickest vision screening systems in the state.

Were any modifications made to the practice because of the data findings?

No modifications were made at this time. Future changes will include data reporting and obtaining partner organization data for reporting.

Lessons learned in relation to practice.

Vision screenings are mandated services. The underlying vested interest of the mandated service is the idea that visual systems are essential to learning, and that visual barriers to learning should be identified and corrected as early as possible. These factors alone ensure that vision screening services will continue to be provided and remain a focus of school health programs.

What was learned is that there is also a desire by several vested interests to deliver these services to a wider array of students in the population and in a timely and efficient manner. During the process planning and initial outset of achieving this goal, support was garnered from all parties. Everyone involved wanted to screen fast and obtain help for the children as quickly as possible. This made it easy to gain support and work through planning steps, which were essential steps to of achieving the goal.

We also learned that despite best efforts, processes in place within partner organizational and vested interest, delayed the speed at which the Collier screening program could implement its strategies and objectives to meet its goal. Referrals could be made, but the process of notifying parents and obtaining consent still relayed heavily on school participation. Sending applications to Heiken to obtain services still required a large amount of demographic data for each child that needed to be pulled from data bases and cleaned by program staff. These steps were achieved in the time allotted, but required significant time invested, thus, hampering other program activities.

The singular focus on achieving the goal, although it did not change service delivery, did reduce the overall time spent on other areas of the program. One example occurred during processing of the data necessary for Heiken services. In this instance, program leadership was unable to perform in-person site visits for some schools to coordinate the secondary screening services scheduled on later dates in October and November. Some of the schools encountered logistical problems that were correctable the day of, but in previous years would have been identified and corrected prior to the screening date at the site visit (i.e. class schedules and times, suitable accommodations for equipment, necessary staffing changes based on school's needs).

Did you do a cost/benefit analysis? If so, describe.

No cost/benefit analysis was performed.

Is there sufficient stakeholder commitment to sustain the practice?

There is sufficient stakeholder commitment to sustain the practice. All schools that received services, whether from DOH-Collier or NCEF/FVQ were satisfied with delivering vision screenings early in the year and attempting to obtain glasses” when needed as early as possible. This is reinforced by the schools' willingness to accommodate the needs of the FVQ and Heiken service providers' schedules for bringing mobile care units and coordinating students' schedules so they can receive services.

The NCEF/FVQ partnership at this time will remain in place. By leveraging their screening capabilities, the DOH-Collier program is confident that it can continue to schedule vision screenings in order to achieve 100% of mandated screening services, exceeding all other county vision screening systems when using speed of completion” as a metric.  

Describe sustainability plans.

Despite the willingness and ability to logistically plan and coordinate these efforts, sustainability of being the quickest screening system in the state is limited.

This model practice, that provides mass vision screenings in a coordinated effort, quicker than any other site, is partly achieved with the current available resources in the community and the investment and experience within the screening programs.

Changes to staff resources or partnerships would necessitate reevaluation and restructure planning coordination. In addition, the current referral service provided by Heiken this year for students was based on available private funding. This ensured they could see any student appropriately referred to their program. This is equivalent to the NCEF/FVQ model currently available in the county which to is subject to funding availability.

The standard contract for Heiken and FVQ as vision providers restircts certain students from utilizing these services (children with Medicaid are not accepted by these providers). If no private funding was available, this would require changes to the current model.

The program set out to achieve what a model vision screening services system can attain by utilizing partnership, all available resources, and coordinated efforts. In doing so, it pushed the logistical capabilities of its internal program and outside stakeholders to accomplish the goal.

Current metrics used showed that equivalent sized counties did not meet our current output. Larger counties, whose total number of students screened by 12/3/2018, matched our county's program in service output ( at or above 13,000 services provided); however the data showed they were still below 92% of total requirement for their county.  This means several programs could possibly benefit from replicating aspects the DOH-Collier program.  The DOH-Collier program is a dedicated screening program, focused solely on screening protocol processes. With focused effort, we reached a goal that is desirable as a model practice. It can be replicated, but may very well have reached an upper limit of service delivery, efficiency, and effectiveness given the current paradigm. 

The program has limited options for improving its metric further without improved data sets for comparison and more standard uniform approaches to screenings statewide. Based on what has been learned, we theorize the upper limits have been achieved for the speed and accuracy of screening services delivered with the model we are presenting; therefore, future developers must look at the system of vision screening services from higher system perspectives to improve performance at the county level.

Performing vision screenings and ensuring access to care as quickly as possible must be the goal of programs that provide vision screening services. Failing to do so leaves the opportunity for vulnerable and underserved children to suffer unnoticed with visual impairments that can affect their overall education and life satisfaction. The Collier County School Health Screening program has presented a team based, collaborative partnership model that utilizes all available resources and current technology to execute a desirable metric of success. Although this model requires more data for improvement, it is worthy of being replicated.

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