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By N. Abe. William Paterson University.

Information was collected about the actions involved in practice guideline implementation for participating MTFs discount zithromax 100mg visa infection dictionary, the dynamics of the change process quality 250mg zithromax bacterial yeast infection, and responses of participants to their experi- ences with the process. Similarities and differences in the attitudes, motivations, and preferences of the stakeholders were considered as the process evaluation information was collected and results were synthesized. To capture changes in structures, processes, and issues as guideline implementation moved forward, site visits were con- 107 108 Evaluation of the Low Back Pain Practice Guideline Implementation ducted to collect information at baseline and at two follow-up times, as shown in Table A. A participant-observer approach was used throughout the imple- mentation process and evaluation. In addition to the site visits, we used routine progress reports and maintained an ongoing communi- cation process to provide a structure through which implementing MTFs could get assistance from each other, MEDCOM, or RAND. Both qualitative and quantitative data collection methods were used in the process evaluation to collect information on a set of questions that cover the dimensions shown in Table A. Focus groups were conducted with three groups: the im- plementation team, providers, and other clinic staff. Participants in each stakeholder group were asked questions regarding their atti- tudes toward guideline implementation, how they worked with the practice guideline, how they were affected by the implementation process, and issues or concerns they identified. Semi-structured in- terview methods were used for all interviews, group discussions, and focus groups, working from lists of questions to cover during each session. A brief survey regarding stakeholders’ attitudes toward practice guidelines and quality improvement processes was administered at baseline and the final site visit. The survey at the final site visit also included questions about education received on the guideline, ac- tions taken to implement the new practices, and how those actions affected providers and clinic staff. Documents and materials were also important sources of informa- tion for the process evaluation. These included written information about the MTF structure and management, MTF policies and proce- dures, MTF data collection and monitoring, and materials developed by the MTF implementation teams as they prepared and carried out 110 Evaluation of the Low Back Pain Practice Guideline Implementation Table A. The materials provided the primary documentation on the actions planned by the team, changes made to clinic processes, resulting events, and actions taken to monitor their progress. These measures were estimated based on episodes of treatment for acute low back pain that began with an initial clinic visit for low back pain and con- tinued through a subsequent six-week time period. According to the DoD/VA low back pain guideline, this six-week period represents acute low back pain, and pain continuing after that period is consid- ered to be chronic low back pain. For a specified quarter year (three-month period), we extracted all SADR encounter records that (a) were coded as active duty Army personnel, (b) had a code of 722 (intervertebral disc disor- ders) or 724 (other and unspecified disorders of back) in any di- agnostic code field, and (c) were treated at one of the MTFs in- cluded in the analysis. We deleted from the data set any record that was coded as no- show, canceled by facility, canceled by patient, left without being seen, or telephone consult (APPTMNT Status = 6). When two or more encounter records were found for an individ- ual during the quarter, we retained only the record with the ear- liest "start date" of service. We deleted any encounter record containing one of the following codes: • Clinic code of BCC (obstetrics), BEE (orthotics), BFD (psychiatry), or BLA (physical therapy). For records with missing specialty and provider class codes, we retained those with clinic codes of BAA, BIA, BGA, BHA, and BJA (all primary care clinics). For each candidate "initial visit" in the resulting data set, we searched for any SADR encounter records for that patient that occurred within 90 days before the date of service on the candi- date visit record and that had diagnostic codes of 722 or 724. Any candidate "initial visit" record for a patient with such an earlier encounter was deleted from the study. Building Analysis Files with Data on Low Back Pain Episodes and Patients Data on subsequent clinical encounters and pharmaceuticals for pa- tients’ low back pain episodes were extracted from the SADR, USPD, and SIDPERS source files. Data from these three sources can be merged using the patient Social Security number. The focus could be on conservative treatment during the acute care phase (first six weeks after initial low back pain visit) or the chronic care phase (up to six months after the initial visit). Although we extracted data for encounters up to six months after the initial visit, we focused on the acute care phase for this evaluation. The following records were ex- tracted for all initial patient visits: • All SADR encounter records for a six-month time period follow- ing the initial visit, regardless of the health care facility where the patient obtained care. We believe the missing data do not affect our results because all but a very small percentage of active duty personnel would obtain acute low back pain care at the MTFs where they are currently posted (this is less likely to be the case for chronic low back pain care). In addition, military rank, age, and gender were used to control for patient characteristics in modeling effects of the demonstration.

Whereas we cannot purge ourselves of outside concerns buy zithromax 100mg mastercard antibiotics for ear infections, such as earning a living order 500 mg zithromax amex infection kidney, getting home to our families, gaining a good reputation and taking care of our biological needs, we will not be good teachers (or nurses or doctors) if we do not feel called to do our special professional work. So some of the most important questions for a potential medical student or for a graduate nurse who is choosing a field are: "Do you feel a knack for doing this? When the answers are yes, then we can attend to our professional duties more single-mindedly. Responsibility This refers to rigorous projection of consequences and acceptance of one’s own role in producing them. Patients do not want us to throw up our hands and abjure responsibility by claiming that we are only cogs in a large industrial machine. We are, whether we accept it or not, either responsible as parts acquiescing in the workings of a system or as agents asserting our independence from that system. If a surgeon refuses to treat someone whose insurance will not pay for gastric stapling, she is not the puppet of policy, but an active enactor of it, whatever its merits and demerits. Nothing Dewey encourages prevents us from trying to arrange external conditions in such a way that our inner fires remain lit. Overscheduling, poor equipment, indifferent colleagues, impossible demands for paper work and lack of appreciation can and do wear caregivers down. And opportunities for education, consultation, sharing of experience, clinical investigation and interesting, engaging patients can nourish them. But it should be apparent that these things nurture the spirit of inquiry only when it is already there in force, whereas distracting goals and fearsome strictures tend to stifle it. Not every desirable consideration can be fully explored in advance of engagement in action, lest paralysis ensue. In no way does Dewey, despite all the above desiderata, advocate waiting to act until the final answers about the problem, the 104 CHAPTER 4 alternatives and the consequences are in. In fact, this is impossible because we learn through reflection and experimentation. Besides, as already noted, there are penalties for indecision, of which he is well aware. We cannot, in genuinely unsettled situations, have finished preconceptions of our aims because, in fact, we are just about to learn something. We honor our values most by leaving them permeable to modification in the course of experiences occurring as we attempt to actualize them. This capacity to learn while doing exemplifies the virtue of open-mindedness as Dewey describes it. Dewey seems confident that the ongoing modification of values and strategies during action will be enhancement and not vitiation, but he does not fully explain how. Be that as it may, congealed values truncate experience in addition to foreclosing possibilities for their own growth. Our psychic investment in experience is lessened when we make our values sacrosanct and keep them closed. To the degree that we protect our values from the influence of experience, we diminish its power to move us. Tiles draws attention to the dynamic, although not infinitely malleable quality of ends in his book Dewey. In contrast to the final cause of Aristotle, which has to do with completion of an entelechy involving the expression of a pre-determined essence, Dewey denies that the end, the fulfillment, can be so largely read out of the beginning. This is because he has a more plastic idea of the nature of organisms, particularly humans, than did Aristotle. As Tiles notes, the thoroughly reciprocal relation of ends and means for Dewey requires some interdeterminacy of ends. They are not, as current theories too often imply, things lying beyond activity at which the latter is directed. Here the intravascular volume contracts or the osmolarity increases, renin, anti-diuretic hormone and other hormones pour out, and water seeking behavior plus the qualitative subjective state of "thirst" is generated. These aims-in-view or "final causes" exert what might be analogous to a "pull" as opposed to the "push" of hypovolemia and a dry mouth. They act as cues which further reinforce both the subjective state of thirst in its dominance over consciousness, and its production of water seeking behavior. The "push" of the DEWEY’S VIEW OF SITUATIONS, PROBLEMS, MEANS AND ENDS105 drive, habit or trait is reinforced by the "pull" of the cue or aim-in-view which could either be present in the environment or produced in fantasy.

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Understanding health services utilization buy zithromax 100 mg mastercard antibiotics for sinus infection and pneumonia, its deter- such as hospital geriatric assessment and management minates quality zithromax 250 mg bacteria mod minecraft 125, and ways to effectively manage it are major units, rehabilitation wards, day hospitals, nursing homes, priorities for health services research and policy analysis and home care service. In other countries with less-developed geri- product was spent on health care, or $3632 per capita. In a more detailed study using the behavioral model, which subdivided potential predictors of hospital use into the three traditional categories of predisposing, enabling, and need characteristics, signifi- cant predictors of hospital use included lower functional status, poorer perceived health, lack of social supports, and health concerns. The most common diagnoses responsible for hospi- talization among older persons in the United States in 1996 were, in decreasing order, heart disease, cancer, cerebrovascular disease, injuries, pneumonia, and eye diseases. United States per capita health care expenditures hospital length of stay in 1998 for persons age 65 and by older persons, by service type and age group. Among 1996 Medicare Current Beneficiary Survey, Older American the most common diagnoses, mean hospital length of 2000. Over the past two Hospital Use decades, diagnosis-specific length of stay has been dra- Hospital use is by far the largest single health expense matically falling, largely in response to economic in- category, and it dramatically increases with age, as indi- centives from the payors. This shortening of charges, total hospital days per year, or per capita expen- length of stay has been the major factor behind the ditures. Persons age 75 years and over use five times as declining proportion of the health care dollar spent on many annual per capita hospital days as persons 45 to 64 hospital care—from 42% in 1980 to 33% in 1998—and years of age (30. A number of studies have identified predictors of A number of studies have looked at factors predic- hospital use that largely explain this disproportionately tive of hospital outcomes. In one studies, the most commonly found predictors of adverse study, the most important predictors were hospital use in hospital outcomes (i. For instance, the lifetime probabil- ity of nursing home use in the United States is about 45% Nursing Home Use 9 for women versus 28% for men. It has been argued that approaches 46% for the population age 85 and over (see when the effects of such variables are controlled for, Fig. As discussed in Chapter 11, the nursing tions, most likely widowed and incontinent. This diversity presents itself in several areas, including the degree of physical or Use of Physician Services mental impairment, the type of care required, and the duration of stay. The important distinction has been made A physician contact can take place in the office setting or between short stayers (less than 6 months) and long clinic, in the hospital, in the nursing home, in the patient’s stayers (more than 6 months). Long stayers include three large sub- office, 10% in the hospital, 19% in the home or nursing groups: those with cognitive impairment; those with home, 9% on the phone, and 12% in other places such as physical impairment (largely musculoskeletal, neuro- clinics. Factors shown to correlate with physician utiliza- logic, cardiac, or pulmonary disease); and those with both tion include perceived health status, having an active cognitive and physical impairments. The proportion of health problem, having a functional impairment, and short stayers has increased in the past two decades in having a regular primary care physician. Use of Community Health Care Services Interrelationships of Service Use This category covers auxiliary and support health serv- Utilization of each service in the health care system is ices and is usually subdivided into the two subcategories inexorably linked to that of other services. These linkages of home care services (which include visiting nurses, hot are difficult to analyze because of the complexity of the meals, home health aides, or other special care delivered relationships as well as the lack of accurate information. Also some- Research, Denson attempted to construct a diagram- times considered are services offered by community matic movement pathway for the U. One can see that, in a given In the 1980 National Health Interview Survey, only 4% year, about 87% of the U. Also shown is the complexity of portion of the health care dollar paying for home care movement between many of the services. Age have dramatic effects on service utilization and on the is also a major predictor, largely related to increased 13 rates of transition. Although community care services are often system of hospital care introduced by Medicare in 1984 advocated as "alternatives" to more costly institutional led to dramatically shortened hospital lengths of stay and services, most studies have been unable to show a sub- increasing proportions of hospital patients discharged to stantial substitution effect. In fact, several studies suggest that use of com- References munity services may actually lead to increased use of other health care services, albeit often appropriately so. Thus, issues of unproven cost-effectiveness have often London: British Medical Journal Publications; 1995.

Thus discount zithromax 100mg free shipping virus killer, activation of more satisfying behaviors appeared to be contingent upon cognitive intervention 500mg zithromax with mastercard virus protection program, and both areas were emphasized in the treatment plan presented to the couple. INTERVENTION Contracting During the fourth session, I proposed the following to Indira and José in the form of a written contract based on my assessment: 1. Weekly conjoint sessions of 75 minutes, initially for six more weeks followed by a mutual evaluation of progress and an option for renewal 2. The partners’ perceptions of their early relationship and style of re- lating and their expectations for dealing with children, home, work, and family b. Discussion and rehearsal of clear communication concepts and methods 132 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES c. Discussion and evaluation of the importance of both partners having the sense that they are receiving and giving equitably in the relationship e. Determination of each partner’s ability to accept differences in the other and maintain a consistent sense of commitment f. In-session and at-home exercises, including some reading and videos on the concepts and skills they were working on g. Sessions at home where they would discuss their concerns about their children individually with each child and together as a family Discussion of this treatment plan continued during the fourth session, and the couple and therapist signed it and began to implement it. Progress The first treatment session (end of number 4) and the subsequent one (number 5) focused on the cognitive aspects of initial perceptions and expectations about the relationship. The couple was animated in dis- cussing how they met and were so excited about each other, and believed that the glow they felt would carry them through everything. They ac- knowledged that they assumed incorrectly that they did not need to plan their time more carefully; work on clear, direct communication; or develop negotiating skills. Their refrain was (commonly heard among clinical cou- ples) "Why should we have to work so hard on our relationship? The concepts of empathy and listening skills, the difference between feeling and thinking, and assertiveness were also discussed (cf. This was followed by behavioral rehearsal and role reversal, and as the couple took well to these ideas and techniques, they were urged to prac- tice them during the week, including a 30- to 45-minute session consisting of only "feeling talk" and active listening. During the eighth session, the feeling tone between Indira and José was notably more vital and positive. When I mentioned this, they responded that they realized that by facing their difficulties and working on them, they could move ahead and have more realistic expectations of each other. They identified and prioritized key problem areas and agreed to work on them one at a time. In the ninth session, they acknowledged their different perceptions regarding Elena and Roberto, but concluded that each of their perceptions were valid, and the couple could work with each other in addressing them. Because José felt strongly about Roberto’s choice of friends and Indira was most con- cerned about Elena’s "precociousness," they both agreed to have individual Cognitive Behavioral Couple Therapy 133 discussions with the child each was most concerned about and then to discuss the results as a couple. As it turned out, Indira was satisfied with Elena’s comments and assurance that she was not in danger and knew her limits. José was less confident about Roberto’s descriptions of his activities with his friends, and Indira agreed that the three of them would speak to- gether. Essentially, a mutually supportive process for problem solving was created, and they proceeded to work on their sexual relationship and divi- sion of home responsibilities for six additional sessions following the end of the contract, bringing the total to 15. As the treatment reached conclusion, the issue of behavior exchange, or quid pro quo, was highlighted as a means of integrating the cognitive, com- munication, and problem-solving dimensions. By progressing sequentially through these areas, Indira and José each came to feel that their partner was truly as invested in the relationship as they were. I pointed out that this sense of equity is essential to maintaining goodwill in the relationship, and for accepting differences and strengthening commitment. Further, I ex- plained that at any moment, the balance of responsibility may be 80%/20% when one partner shoulders most of the responsibilities while the other is ill, has extra work commitments, or may be caring for an aging parent. Such an imbalance requires open discussion and negotiation, with a clear sense that the balance of responsibility will be more nearly equal when the stresses of the 20% partner decrease. With this sense of equal behavior ex- change, clear communication, and good problem-solving skills, all aspects of a relationship can remain functional and satisfactory over time.

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