Total Points = 55 for all plans
Component criteria targeted to type of plan (50 points of total 55)
Comments may be placed in appropriate cell.
Quality of writing
(used for all Plans)
5 points possible
APA correct: must follow 6th ed. APA.
Many mistakes in spelling, grammar, citation, referencing, page formatting, numbers, tables
Fewer than 2 mistakes per page for grammar & spelling & APA format
No mistakes in grammar, spelling, or sentence structure.
Correct in-text citation; correct reference page; correct page formatting; correct use of numbers and tables
3 points possible;
Plan Appropriate and Scaled to Master level work with Scholarly Tone
Population is not appropriate and the plan is not within the scope of a Master’s thesis.
Population is partially appropriate.
Adjust scope of plan to be appropriate for a Master’s thesis.
Appropriate for identified population.
Scope of plan is appropriate for a Master’s thesis.
2 points possible; points earned
(targeted to plan type)
For Education Program
50 points possible all components
Purpose: clear statement of importance and relevance for nursing
Purpose not clearly stated.
No sources cited.
Clearly states the importance and relevance for nursing education.
Appropriate sources cited.
Very clearly and concisely states the importance and relevance for nursing education. Appropriate sources cited.
2 points possible;
Statement of Problem with supporting evidence.
5 points possible;
Objectives: Includes a minimum of 5 behavioral, measurable objectives
Not written in behavioral & measurable terms.
3-4 objectives. Partially written in behavioral & measurable terms.
Minimum of 5 objectives written behaviorally & measurably.
8 points possible;
Population Action Plan: detailed plan which includes timeline, participants, location, materials developed for incorporation into delivery of plan, method & tools to assess plan outcomes, etc.
Weak plan. Many aspects and details of plan missing.
No sources cited.
Plan clearly & concisely states timeline, participants, location, materials developed for incorporation into delivery of plan, method & tools to assess plan outcomes.
Not all aspects of plan
Cites sources per APA.
Detailed plan very clearly & very concisely states timeline, participants, location, materials developed for incorporation into delivery of plan, method & tools to assess plan outcomes &/or other aspects specific to plan.
Cites sources per APA.
17 points possible;
Evaluation: includes collecting evaluation data and analysis of effectiveness of the plan; achievement of outcomes
Weak discussion of evaluation plan. Evaluation methods/tools not included.
No discussion of how data will be evaluated to effectiveness of plan.
No discussion of achievement of outcomes.
Discusses how the population plan will be evaluated. Specific evaluation methods/tools partially discussed. Evaluation tool/method may not be included.
Partial discussion of how data will be evaluated to determine effectiveness of plan.
Clearly states if outcomes were achieved.
Very clearly & specifically discusses how the population plan will be evaluated. Includes evaluation methods/tools to be used to evaluate plan. Thoroughly discusses how the data will be analyzed to determine effectiveness of plan.
Very clearly states if outcomes were achieved.
10 points possible;
Identifies possible limitations or areas of plan that may require modification and suggests possible alterations that can be made.
Few or no recommendations made for change in plan.
Recognizes changes that might be needed in plan.
Very clearly & succinctly discusses limitations and possible recommendations for change.
8 points possible;
Population Action Plan – Heart Failure
Cleveland State University
Population Action Plan
Summary of assessment data collected
The worksheets have been significant in making certain that there is clear understanding of major clinical challenges affecting patients in different ways. Categorizing the patient into different groups offers an opportunity to develop reliable action plans. The first worksheet provided an assessment on physical factors linked with aggression and agitation in patients. The study categorizes the physical factors into two distinct factions that consist of situation events and the phrase setting events. The physical factors have been categorized in these segments to assist in understanding how their nature has influence to the cause of agitation and aggression for some patients. Identified physiological aspects associated with increasing aggression and agitation comprise of mood, sensory performance along with cognitive impairment among others. However, it is clarified through the study that violent behaviors incline among patients due to physical distress or sensory impairments. Lifestyle is the leading cause of the diseases related with physical factors.
The second assessment is based on health effect occurring from common drugs administered to patients. In the study, it is clear that heart failure is a problem that reacts differently to various drugs taken by patients. Notable heart problems identified in the process comprise of drugs boosting heart functionality and some drugs causing dilation of blood vessels. Focusing on Cleveland, it is evident that health care practitioners administered different kinds of drugs with the objective of managing diverse patient conditions. However, the research proves that heart failure conditions have been on the rise since 2015. Other elementary causes of the heart diseases comprise of poor diets in addition to substance abuse (Bloss, 2016). Unfortunately, the conditions have forced the nursing sector within the region to consider administering different kinds of drugs for increasing patient safety in the wake of the increased alarming heart conditions. The proper selection of drugs to deal with the increasing issue of heart failure within Cleveland is a significant plan.
Environmental factors have been assessed in the third assessment to help establish some of the negative factors that affect patients in different settings. As the study continues to focus on the people suffering from heart failure in Cleveland, it is notable that certain environmental factors have contributed to their poor conditions. Physical environmental factors cause tremendous effects on the general health of the people living within the region. For instance, the fact that the people living within the region are highly affected by the large volumes of polluted air is a questionable factor (Pourmadadkar, Beheshtinia, and Ghods, 2019). The problem persists because Cleveland falls under the category of the highest polluted cities across the United States. Therefore, these environmental factors have an impending impact on the modes of treatment being implemented, rendering some of them less effective.
On the fourth assessment, the main study objective has incorporated understanding the heart failure condition. Through conducting an assessment on heart failure conditions, it becomes easy to establish some of the common ways in which the phenomena can be resolved. In the assessment task, common factors causing the occurrence of heart failure among certain people have been established. The study is effective since it ensures all elements related with heart failure have been incorporated to derive some of the root causes of the condition. Heart failure patients in Cleveland, Ohio represent the population of interest in the study. According to the information provided within the study, it is notable that the population comprises of people from different racial backgrounds. With approximately 20% of the city’s population being above 65 years, it is certain that a great faction of its population is vulnerable to the heart failure conditions (Joffe et al., 2013). Influenced by the poor environmental factors, Cleveland is under great risk of losing its population to heart failure diseases, which makes the population action plan necessary in saving the lives of these residents.
The Convening Partners are pleased to be involved in a planning process to develop this action plan for Cleveland to identify interventions that promote healthy eating and active living. A healthy diet reduces heart disease cases by preventing obesity and overweight, the major risk factors. The convening partners are comprised of a collaboration of philanthropic organizations and state agencies. They joined hands to respond to the rising public health epidemic of obesity and overweight in Cleveland. We as partners are concerned about the impact of obesity on life quality and the exploding healthcare costs for heart illnesses. We, therefore, support a process of planning to create this countywide action plan from the start. To identify suggested interventions to address the problem, we have looked to experts in Ohio. We will connect together a wide based expert’s panel. The experts represent food and recreation industries, worksites and businesses, municipalities and communities, healthcare industry and schools. With their help and contribution, it becomes easier to investigate proven interventions for promotion of active living and healthy eating.
Identification of Nursing Problems
The ability to resolve the health care predicament brought by the increasing cases of heart failure is limited by the reduced number of the region’s population undertaking nursing causes. The rate of registered nurses within the region is at risk because the general population comprises of over 79% high school graduates. Finding ways to recruit a higher number of professional clinical officers would influence the ability of providing required health care services to attempt and resolve the condition. Poverty is another major concern linked with the challenges of resolving the heart failure in Cleveland. More people are unable to access reliable health care services for proper and timely treatment of the heart conditions (Bloss, 2016). In some cases, it becomes difficult for health care facilities to procure additional equipment for the treatment of patients with heart conditions in regions where the rate of poverty is rather low. The government is unable to provide all the required resources needed to deal with the heart conditions, which explains the importance of seeking other alternatives to lessen poverty.
The heart failure conditions identified need appealing goals of issuing proper treatment of the disease. Improving the quality of life is an important approach towards gaining the most satisfying outcomes of the resolution process. Lessening the symptoms through educating the public about some of the physical changes they need to observe is an advisable strategy of dealing with the condition. More centers need to be established to ensure the sector is in a better position of offering diagnosis, patient evaluation, and monitoring services (Bloss, 2016). The region needs to be educated on approaches to take in order to ensure that they reduce the rates of air pollution identified to be causing them great health risks.
It is important to review the varying trends in the epidemiology of heart failure as indicated by heart failure management advances, comprising diagnostic treatments and procedures. Furthermore, the elderly population is increasing, thus necessitating the assessment. Fonarow et al. (2018) examined the trend in the annual prevalence and rate, as well as heart failure related mortality in Cleveland. For HF patients in Ohio, diagnostic work-up was also examined. The regional electronic medical records and national health registers were the source of the used data. There was a decline of the annual HF incidence rate between 2010 and 2014, as shown by the results. The prevalence of HF however increased. This implied that there was improved management of risk factors, although the aging pollution living with heart failure was on the rise.
Obesity Trend in the US
Since the mid-seventies, there has been a sharp increase in obesity ad overweight prevalence for both children and adults. To assess the health and nutritional status of Americans, a survey combining physical examinations and interviews was conducted in the CDC’s National Health and Nutrition Examination Survey (NHANES). For adults aged between 20 and 70 years, the obesity prevalence increased from 15 percent to 32.9 percent as indicated in the respective NHANES. In nearly 30 years, cases of obese children (under 11 years) in America have tripled. It was revealed that almost 6% of under-elevens were obese during 1976-80. The presented has increased to 19% in the 2003-2004 NHANES. Cases of obesity had risen from 5.0 percent to 17.4 percent among youth aged 12-19 years.
Figure 1; Obesity Trends Between American Adults
Source: Centers for Disease Control (CDC), BRFSS 1990, 1998, 2006
The overall decreased contribution from ischemic heart disease and myocardial infarction as causes of death further reinforce the improvement in underlying risk factors. Nevertheless, we showed that patients experienced relatively high all-cause and cardiovascular-related mortality. Most patients (almost two thirds) had not received an echocardiogram in the 6 months before and after their HF diagnosis, a trend that was improving over time but still did not exceed half of newly diagnosed patients. These results suggest that there is a growing population of elderly patients with HF in Sweden and that appropriate diagnostic work-up in these patients is not ideal while slowly improving.
Goals and Objectives
The main goal of the population action plan for heart failure is that all the occupants of Cleveland, Ohio, lead healthier lives, devoid of heart failure problems, through effective treatment, control, and prevention.
The action plan has three main objectives;
- Focusing on prevention be detecting and bettering the management of patients at risk of heart failure.
- Encouraging all citizens to live healthier lives through addressing the risk factors for heart failure.
- Increasing understanding and awareness on heart failure within the community in Cleveland.
The main priority of this plan will focus on the prevention and early detection of heart failure. For prevention and treatment, a comprehensive and holistic approach will be underpinned by the key priority. To ensure delivery of the main goal and the action plan’s main objectives, the priority are will be supported by actions.
Actions for objective one
The guidelines on the absolute cardiovascular risk assessment shall be updated. The second one involves increasing awareness for health checkups and screening promotion activities at legal ages. The action plan shall seek to improve the management of those at risk heart failure through primary care. Another focus will be the provision of appropriate tools to health professionals to promote screening and care.
Actions for objective two
The plan shall embark on reducing smoking in the community by building on and strengthening the existing efforts to address risk factors for heart failure. Another focus will be to ensure support to all community members to remain physically active. The plan advocates on healthy eating to curb the rising number of people with obesity. Health data collection for the population will be conducted.
Actions for objective three
To increase the population understanding of heart failure, an extensive awareness campaign shall be targeted.
Through early detection and prevention of heart failure, Cleveland and the US at large have a golden chance to reduce avoidable hospitalizations, and save lives. To properly address the burden of heart failure in Cleveland, two areas are likely to deliver important benefits; primary and secondary preventions. The former involves the use of population health measures in the promotion of better health and individualized treatment and control for the likely patients. Secondary prevention involves improved management for those with heart conditions, or have ever had a heart attack. Such people are at more risk for hospitalizations and other events.
Heart failure is highly preventable. Preventable actions help to decrease the impact of heart failure because it involves many risk factors. The provision of better health and economic outcome is an assurance if chronic conditions are well managed through the continuous focus on prevention.
Currently in Ohio, prevention is not a major focus area. If today we invest in prevention, we shall reap health dividends tomorrow. Research proves that there is a return of $15 on every invested dollar (Driscoll et al. 2019).
Risk factors (modifiable and non-modifiable)
The risk factors that we can comfortably change are known as modifiable. They include alcohol intake, smoking, weight, physical activity, diet, cholesterol, and blood pressure. Socioeconomic status, ethnicity, gender, race, age, and family history are the non-modifiable risk factors that we as individuals cannot control.
The risk of heart failure is greatly reduced by not smoking, remaining physically active, and maintain a healthy weight. Medical intervention alone is not enough for those at risk. For general health improvement and risk management, it is essential to focus on behavioral and lifestyle changes. Particularly, this might imply reducing body weight, increasing physical activity, reducing harmful alcohol consumption, and quitting smoking. For a range of chronic illnesses, a major modifiable risk factor is being obese or overweight. Across the Cleveland community, these issues are becoming more prevalent day by day. Combined with an ageing population, these factors are likely to make more Americans live with chronic heart conditions (Driscoll et al. 2019).
Increasing the availability of therapies for patients diagnosed with heart failure conditions, several other approaches need to be taken. Being a highly prevalent sickness and a leading cause of hospitalization within the United States, it is certain that more people need to ensure they understand the risks associated with the condition (Joffe et al., 2013). Additionally, spreading knowledge about the symptoms of heart failure throughout the public is an important objective. Changing the prescribing of medication for patients suffering from heart failure is an appropriate objective since it helps in eradicating the issue through poor administering of drugs that has resulted in escalation of the heart failure condition in the Cleveland.
Lifestyle modification is an important objective to incorporate in the plan since it focuses on resolving one of the areas where a large population faces exposure to the causes of heart condition. The main aim of the life style modification objective is to assist with relieving the symptoms as well as signs of heart failure (Pourmadadkar, Beheshtinia, and Ghods, 2019). Other practices to include in the modification consist of influencing alcohol limitation and maintaining an ideal body weight as an imperative heart failure treatment procedure.
Outline of the Plan
The steering committee will be concerned with active living and healthy eating. It boosts of offering the first heal action plan in Cleveland. Over 200 people from over 45 organizations have shown commitment to their collaborative efforts to produce better results from this plan. A wide range of stakeholders and experts agree on the goals and recommendations explained in this plan. We have to succeed in implementing these recommendations. The success relies on the partners’ unity towards a common vision.
The Ohio action plan comprises on communication interventions, practices and policies based on established best practices. Elected officials and other volunteers should work together with communities and individuals. Efforts are ongoing to come up with a heal partner program and community grant program as a way of developing a nationwide system overseeing priority interventions at local levels.
The plan focuses on prevention and early detection of heart failure. To promote the detection and better management of community members at risk of heart failure, the first action will involve updating the absolute cardiovascular risk assessment guidelines. The team behind this action plan shall endure to identify the people at risk of a major heart event accurately. This helps to optimize treatment, reduce expenditure, and improve health outcomes. The National Vascular Disease Prevention Alliance designed the existing guidelines that outline how to best diagnose and control cardiovascular disease risk. To promote accuracy in identifying and managing Americans at risk of heart failure, the guidelines for managing absolute cardiovascular disease risk shall be recommended for update. Other updates will include the related risk stratification algorithm and website calculator.
Another action will be comprised of targeted approach to absolute cardiovascular risk assessment screening as well as uptake of integrated health checks (IHC). For people at risk of heart failure and other chronic heart conditions, the uptake of integrated health checks shall be boosted. This implies that the absolute cardiovascular risk assessment for heart failure will be combined by kidney disease test, and a type 2 diabetes check. The IHCs will be included in the quality improvement incentive programs (Dickson & Riegel, 2009). The team will ensure that a devoted Medicare Benefits Schedule (MBS) item is created. An expert advisory panel will be convened. It will be responsible of making recommendations to the Ohio State authorities on how to increase and monitor IHC as well as cardiovascular risk assessments uptake.
Through primary care for Atrial Fibrillation, a comprehensive screening will be developed. The most frequent heart arrhythmia is AF. Its prevalence rises with age. The affected people are likely to experience heart failure up to 7 times more (Baker et al. 2011). Almost a third of the Cleveland population is yet to be diagnosed. AF comprehensive screening will be implemented. For people above 65 years of age, it will involve opportunistic point of care screening in primary care context.
The action will involve raising awareness for health checkups and screening promotion activities at necessary ages. People must be informed if they are at higher risk of heart failure. They also need the steps they can follow to minimize the risk. A system of notification and recall shall be used to increase awareness of the needed health checks for all Ohio residents (Dickson & Riegel, 2009). The targeted population includes linguistically and culturally diverse and other identified vulnerable groups. A pilot study of an immunization style record for adults will be funded. The aim is to set up a system of notifying and recalling every Cleveland resident. All the approved checks they require at certain ages will also be listed.
Primary care will be used to improve management of people at high risk. A primary care chronic disease management will enhance encourage people to live healthier lives. Blended payments will be introduced. This will better the support of continuous care for patients living with heart conditions, including those at high risk of heart failure. Measures for introducing specific payments for general practice will be suggested implementation by relevant authorities. The referral pathways will be improved to appropriate and lifestyle modification programs based on evidence. A dedicated portal linking healthcare settings and simplifying referrals for practitioners and patients will be instituted.
To support screening and care, health professionals will be granted appropriate tools and resources. Primary healthcare professionals will be supported to provide improved evidence-based care through programs on quality improvement. To enable the use of evidenced-based decision support tools, appropriate education and training shall be provided and promoted, including software. We shall campaign in partnership with appropriate industry bodies and services to educate general practitioners about absolute cardiovascular risk assessment, building on work previously undertaken under the primary care collaborative program. The campaign shall involve promoting a promotional and educational tool, embedding educational materials or commonly branded resources in systems and programs, and establishing a targeted communication campaign as advised by Baker et al. 2011.
Another last action will involve building on and strengthening current efforts to reduce smoking in the community. In terms of tobacco control, the US is a world leader. Smoking prevalence is however very high, with the current smokers being over 30 million adults. Tobacco use highly contributed to the disease burden in Cleveland in 2018. We can reduce the rate of smoking by 5% or lower with targeted investment (Driscoll et al. 2019). For the life of the next tobacco strategy, we can further reduce smoking prevalence if we invest in a mass media education campaign. For populations with high smoking rates, complementary targeted approaches and a population level approach will be employed. The existing funding provided to tackle indigenous smoking program will be complemented by investment.
The plan involves developing a research and development strategy offering guidance about some of the measures to undertake in relation to solving the heart failure condition affecting Cleveland. A significant threat of mortality along with hospitalization needs to be addressed through reducing the factors influencing its occurrence (Joffe et al., 2013). Discovering multiple ways of dealing with heart failure conditions is an important approach that needs to be taken to ascertain better health standards for the people living in Cleveland, Ohio.
The study demonstrates that heart failure conditions have been on the ascent since 2015. Other basic reasons for the heart illnesses include less than stellar eating routines notwithstanding substance misuse. Lamentably, the conditions have constrained the nursing part inside the locale to consider regulating various types of medications for expanding quiet wellbeing in the wake of the expanded disturbing heart conditions (Joffe et al., 2013). The best possible choice of medications to manage the expanding issue of heart failure inside Cleveland is a noteworthy arrangement.
The issue endures in light of the fact that Cleveland falls under the classification of the most noteworthy dirtied urban areas over the United States. Subsequently, these natural variables impedingly affect the methods of treatment being actualized, rendering some of them less viable. Destitution is another significant concern connected with the difficulties of settling the heart failure in Cleveland. More individuals cannot get to solid human services administrations for appropriate and convenient treatment of the heart conditions. At times, it gets hard for social insurance offices to obtain extra gear for the treatment of patients with heart conditions in areas where the pace of destitution is somewhat low (Bhatnagar, 2017). The administration cannot give all the necessary assets expected to manage the heart conditions, which clarifies the significance of looking for different choices to decrease destitution. Finding various methods for managing heart failure conditions is a significant methodology that should be taken to discover better wellbeing gauges for the individuals living in Cleveland, Ohio.
Decreasing the side effects through teaching general society about a portion of the physical changes they have to watch is a fitting technique of managing the condition. More focuses should be built up to guarantee the part is in a superior situation of offering conclusion, quiet assessment, and checking administrations (Pourmadadkar, Beheshtinia, and Ghods, 2019). The area requires policies and guidelines on ways to deal with take to guarantee that they diminish the paces of air contamination distinguished to cause them incredible wellbeing dangers.
Justification and Budget
A collaboration of partners will provide support and funding for this action planning process. They include Ohio Charitable Foundation which has pledged 50,000 dollars, Ohio departments of transport, health and human services fish and game, education, and agriculture, and Ohio Citizens Health Initiative, both contributing a staggering $233, 0000.
The action plan for tobacco cessation and increases awareness program is helpful in many ways. The rate of tobacco use in Ohio is among the highest compared to other states. The state is also leading in the US heart failure mortality. These numbers can be reduced if an effective plan and educational system are created to enhance tobacco cessation. This project will have a minimal budget. It will involve the costs of printing and producing educational materials. It will also consist of room rental costs. Other personnel will be paid for their services and time sacrificed during the educational program.
Assessment of Resources
Segmenting the patient into various gatherings offers a chance to create solid activity plans. The assessments gave legitimate evaluation on physical elements connected with hostility and tumult in patients. The examination arranges the physical components into two particular groups that comprise of circumstance occasions and the expression setting occasions (Bhatnagar, 2017). Being an exceptionally pervasive infection and a main source of hospitalization inside the United States, it is sure that more individuals need to guarantee they comprehend the dangers related with the condition. Also, spreading information about the indications of heart failure all through people in general is a significant target.
Changing the recommendation of medicine for patients experiencing heart failure is a proper target since it helps in killing the issue through poor regulating of medications that has brought about heightening of the heart failure condition in the Cleveland. The heart failure conditions distinguished need engaging objectives of giving appropriate treatment of the illness. Improving the personal satisfaction is a significant methodology towards picking up the most fulfilling results of the goals procedure (Bhatnagar, 2017). The subsequent appraisal depends on wellbeing impact happening from regular medications controlled to patients.
In the investigations, palpable heart failure is an issue that responds distinctively to different medications taken by patients. Outstanding heart issues distinguished in the process involve drugs boosting heart usefulness and a few medications causing enlargement of veins. The fundamental point of the way of life alteration objective is to help with soothing the side effects just as indications of heart failure. Different practices to remember for the adjustment comprise of influencing liquor confinement and keeping up a perfect body weight as a basic heart failure treatment methodology.
Baker, D. W., DeWalt, D. A., Schillinger, D., Hawk, V., Ruo, B., Bibbins-Domingo, K., … & Pignone, M. (2011). “Teach to goal”: theory and design principles of an intervention to improve heart failure self-management skills of patients with low health literacy. Journal of health communication, 16(sup3), 73-88.
Bhatnagar, A. (2017). Environment determinants of cardiovascular disease. Circulation Research, 121(2), 162-180. doi:10.1161/CIRCRESAHA.117.306458
Bloss, R. (2016). “Embedded medical sensors, an emerging technology to monitor hearts, brains, nerves and addressing other medical applications for improved patient care.” Sensor Review, Vol. 36 No. 2, pp. 115-119.
Dickson, V. V., & Riegel, B. (2009). Are we teaching what patients need to know? Building skills in heart failure self-care. Heart & Lung: The Journal of Acute and Critical Care, 38(3), 253-261.
Driscoll, A., Davidson, P., Clark, R., Huang, N., & Aho, Z. (2019). Tailoring consumer resources to enhance self-care in chronic heart failure. Australian Critical Care, 22(3), 133-140.
Fonarow, G. C., Abraham, W. T., Albert, N. M., Gattis Stough, W., Gheorghiade, M., Greenberg, B. H., … & Young, J. B. (2018). Day of admission and clinical outcomes for patients hospitalized for heart failure: findings from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Circulation: Heart Failure, 1(1), 50-57.
Joffe, S. W., Dewolf, M., Shih, J., McManus, D. D., Spencer, F. A., Lessard, D., … Goldberg, R. J. (2013). Trends in the medical management of patients with heart failure. Journal of clinical medicine research, 5(3), 194–204. doi:10.4021/jocmr1376w
Pourmadadkar, M., Beheshtinia, M. and Ghods, K. (2019). “An integrated approach for healthcare services risk assessment and quality enhancement.” International Journal of Quality & Reliability Management, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/IJQRM-11-2018-0314
The Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey (NHANES). 2. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm