Background: Individuals with intellectual and/or developmental disabilities (IDD) are experiencing longer life expectancies with the majority requiring the ongoing support of family caregivers into adulthood. Medicaid is the primary funding source for supports and services for adults with IDD. Growing Medicaid expenditures and goals to improve quality of care are driving more states to move their Medicaid fee-for-service programs into a managed care model. The stated goals of Medicaid managed long-term services and supports (MLTSS) are to improve care coordination and access to care while controlling costs, but the evidence regarding these outcomes is limited and mixed. Given the level of uncertainty about MLTSS for adults with IDD and their family caregivers, best practices recommendations have been produced by the federal government and advocacy agencies to help guide future MLTSS implementation efforts. These best practice recommendations combined with the continued expansion of MLTSS in the states, provided an opportunity to further explore implementation of MLTSS to inform both policy and practice. One state which recently reformed their Medicaid program to MLTSS and which has been referred to as a bellwether state is Kansas. The MLTSS program in Kansas, titled “KanCare”, is the first for adults with IDD to integrate across health, behavioral health, and LTSS while also contracting through three private-for-profit managed care organizations (MCOs). Aims: The objective of this study was to describe the current implementation of MLTSS for adults with IDD and their family caregivers in one state, Kansas. Study aims were as follows: 1) To understand the rationale behind and what actually happened with MLTSS implementation for adults with IDD in Kansas; 2) To understand how service coordination providers and family caregivers perceived care coordination and access to services for adults with IDD in MLTSS; 3) To understand how family caregivers and their roles were recognized in MLTSS for adults with IDD. Methods: A single case embedded design case study approach was used with in-depth semi-structured interviews completed with state/regional level representatives (N=13), MLTSS service coordination providers (N=7), and family caregivers of adults with IDD (N=11). Data collection and analysis were guided by the unified theory of family quality of life (FQOL) and Bronfenbrenner’s ecological model. The framework method was used to structure the data analysis process. Member checking was completed to ensure accuracy of results. Findings: Regarding aim one, respondents identified reducing costs and improving care quality as the rationale behind MLTSS, but these were outcomes not yet realized given the early stages of implementation. At the time of this study, the Managed Care Organizations (MCOs) were continuing to work on expanding provider networks and to provide additional services to address health disparities amongst individuals with IDD. Study participants identified the importance of adequate planning and stakeholder engagement to reduce confusion and fear when transitioning into MLTSS. Addressing aim two, timely and accessible consumer education, clear care coordination processes, and provider network adequacy were identified as important to influence the challenges experienced to date in care coordination and access to services. Regarding aim three, participants acknowledged the important role of family caregivers. At the current stage of the KanCare implementation, participants reported lack of formal processes for family caregiver assessment and a need for more proactive family support services planning. Conclusion: Lessons learned from this implementation experience include the importance of having long planning timelines and including stakeholder feedback into the design of MLTSS programs. Care coordination holds promise to better integrate care, but more research is needed to understand best practices for the provision of care coordination in MLTSS. In order to address access to services, MLTSS programs will need to work and build provider capacity and provider networks. MLTSS programs will also need to formally recognize the role of family caregivers by incorporating the use of family caregiver assessments to proactively plan for support needs.

Ingeniero Civil Electricista / Las redes móviles de tercera generación (3G) brindan servicios de voz y datos en forma separada mediante conmutación de circuitos y conmutación de paquetes, en una misma tecnología. En cambio, una red Long Term Evolution (LTE) presenta un enfoque exclusivo al uso de datos de manera All IP (todo con Internet Protocol), de modo que las llamadas deben ser cursadas mediante Voz sobre IP (VoIP) en una red de conmutación de paquetes. Esto se logra haciendo uso de un núcleo de paquetes IP Multimedia Subsystem (IMS), a través de servidores Session Initiation Protocol (SIP). De esta manera, se heredan los problemas de un servicio ofrecido por mejor esfuerzo mediante IP, surgiendo la gran necesidad de establecer Calidad de Servicio (QoS), mecanismo que establece prioridad de tráfico según las aplicaciones a las cuales acceden los usuarios. Así, resulta obligatorio monitorear el correcto funcionamiento de este mecanismo para cumplir con los acuerdos de nivel de servicio establecidos con el usuario. En este escenario, las mediciones de Calidad de Experiencia (QoE), son clave. El presente trabajo de título tiene como objetivo general diseñar e implementar una metodología para medir indicadores de QoE y QoS en aplicaciones multimedia Over The Top (OTT), en una red de laboratorio LTE/IMS. Para esto, se implementa un IMS Open Source en una red de área local (LAN), lo que sirve como prototipo de verificación para el correcto desempeño de los servicios y herramientas de medición, así como también para tener un punto de comparación de los valores logrados por la metodología en el caso LTE/IMS. El resultado del trabajo es una metodología compuesta por 5 pruebas de concepto, las cuales miden un indicador específico de calidad de acuerdo al servicio y a la modalidad de acceso (Internet, o vía operador). Dichas pruebas son verificadas en dos escenarios de tráfico: (i) el óptimo, que consiste en no establecer más de una sesión multimedia en la red; y (ii) el congestionado, que emula el comportamiento de una red con tráfico. Se logra obtener indicadores de calidad en las redes LAN/IMS y LTE/IMS. De lo anterior, se obtienen herramientas docentes para realizar capacitaciones y cursos de LTE e IMS orientados al estudio de QoS y QoE en la Universidad de Chile. Este trabajo constituye, por un lado, un acercamiento práctico a la medición y monitoreo de QoE aplicable a una red móvil LTE; y, por otro, a nivel docente, entrega una plataforma de medición y de estudio para las nuevas arquitecturas móviles. Esto último permite proponer como trabajos futuros los siguientes temas: estudio del impacto de la movilidad y de las políticas de control de recursos en el QoE, en servicios sobre LTE; implementación de la interconexión de LTE a la telefonía fija a través de IMS y una Central Telefónica IP tipo Asterisk; y, por último, un estudio del sincronismo audio-video en un servicio de videostreaming montado sobre LTE haciendo uso de herramientas de medición de QoE.

There is a body of research on the effect of physical activity oncognition in the old adult population. Less research areconducted on adolescents. The aim for this study is to find out ifadolescents long-term memory is affected by physical activity.144 pupils were asked to rate their physical activity each week.Thereafter their long- term memory was tested through tests onepisodic- and semantic memory. The results showed that thosewho are physically active more than 4 hours had a better scoreon part of the semantic test but no effect was found in theepisodic test. This result indicates that physical activity not onlyaffects working memory, as was shown by previous research butalso has an effect in parts of the semantic long-term memory.

Magister Scientiae (Biodiversity and Conservation Biology) / Nearly 40 years ago McLachlan and Moll highlighted the need for a well-defined path system on the Western Table of Table Mountain in the immediate vicinity of the Upper Cable Station (UCS). At that time the numbers of people using the cableway was heavily impacting the vegetation on the Western Table, particularly in the vicinity of the UCS. This prompted a study by Coley (1977) to assess the long-term impacts of trampling in this area. In order to monitor changes in the vegetation through time Coley set up 12 permanently marked plots (each ~4x4 m), arranged at increasing distances from the UCS. Plot positions were carefully selected so that the effects of trampling on the vegetation could be measured at various points (distance being a surrogate for trampling intensity). Field observations in 1977 revealed that Mountain Fynbos vegetation was heavily impacted by cableway tourists. Furthermore the vegetation was most damaged closest to the UCS, with a sharp decrease in damage with increasing distance from the station. In order to monitor the vegetation change Coley used aerial photographs of permanently marked plots, so that visual comparisons of species cover, condition and composition could be made over time. The vegetation was then assessed in terms of percentage cover, and percentage damaged for each plot. My study marks the fifth time data were collected since Coley (1977) and the results show that there has been a marked improvement in vegetation quality since the construction of well-defined paths and a concerted effort by managers to ensure tourists do not leave the paths; which has greatly reduced trampling since the 1997 upgrade. The implications of this study provided evidence of the importance of restricting iv tourist traffic in areas that are regularly visited and, therefore, highly impacted. It also shows that denuded fynbos is resilient and does recover over time, provided that the substrate is not eroded too heavily by trampling. Finally, I present several management recommendations, of which the most controversial, albeit important, is for a rotational block burn programme on the Western Table; since fire is a keystone ecological process that has been absent of the Western Table for at least 80 to 90 years.

Background: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC. / Dentistry, Faculty of / Graduate

Background: Persons with developmental disabilities (DDs) represent about 1-3% of the total population in Canada; however, very little statistical data exists regarding this population in the context of long-term care (LTC). As the life expectation of these individuals increases, the distinct needs they have that are associated with aging should be addressed in LTC to help improve the quality and relevancy of the care they receive. Methods: An exploratory qualitative study. Semi-structured interviews were conducted. Open coding of interview transcripts, and content analysis was completed. Descriptive statistics of the sample were calculated using Excel. Results: All participants had experienced earlier functional decline which resulted in changes in their care needs. Often this meant needing to change their assistive devices. Many participants feared losing their independence as they aged. Conclusion: There is insufficient understanding of the unique needs that face people aging with DDs or how they access LTC. The preference for these individuals is to age in place, their independence must be maintained in order for this to be successful. Three factors help to facilitate this: assistive devices, attendant care and accessibility of health care services. Contexte: Les personnes ayant un handicaps developmental représentent environ 1-3% de la population totale au Canada. Cependant, très peu de données statistiques concernant cette population existent dans le contexte de soins de longue durée. L’espérance de vie de ces personnes augmente, les besoins distincts associés au vieillissement devraient être examinés pour aider à améliorer la qualité et la pertinence des soins qu'ils reçoivent dans les soins de longue durée. Méthodes: Une étude qualitative exploratoire. Des entrevues semi-structurées ont été menées. Les transcriptions d'entrevues ont été codées en utilisant un style de codage ouvert et l'analyse de contenu a été accomplie. Les statistiques descriptives des participants ont été calculées. Résultats: Plusieurs thèmes sont devenus apparents. Tous les participants avaient connu un déclin fonctionnel à un jeune âge qui a entraîné des changements dans leurs besoins de soins. Souvent, cela signifit avoir à changer leurs appareils et accessoires fonctionnels. De nombreux participants craignaient de perdre leur indépendance en vieillissant. Conclusion: Il y a une méconnaissance des besoins uniques auxquels font face les personnes vieillissant avec un handicap developmental et la façon dont ils accident aux soins de longue durée. La préférence pour ces personnes est de viellir en place, leur indépendance devant être maintenue pour que ce soit un succès. Trois facteurs contribuent à faciliter ceci: les appareils et accessoires fonctionnels, les soins auxiliaires et l'accessibilité aux services santé.

Total produced energy in the world is mostly consumed as thermal energy which is used for space or water heating. Currently, more than 85% of total thermal energy consumption is supplied from fossil fuels. This high consumption rate increases the depletion risk of fossil fuels as well as causing a tremendous release of hazardous gases such as carbon dioxide, carbon monoxide, sulfur oxides, nitrogen oxides and particulate matter that effects both environment and human health. Those drawbacks force humankind to search for new technologies, like renewables, to reduce fossil fuel dependency on thermal energy production. Thermal energy storage in adsorbent beds is one of the resulting technologies. Adsorption is an exothermic process in which a fluid (adsorbate) diffuses into the pores of a porous solid material (adsorbent) and trapped into the crystal lattice. In this system, exothermic adsorption of water vapor from air is carried out by using hybrid adsorbent of activated alumina and zeolite. In previous studies, through literature review, this adsorbent was selected to be the most efficient adsorbent for this process due to its high water adsorption capacity, high heat of adsorption, and stability [Dicaire and Tezel, 2011]. In this study, previous studies started on this project was confirmed and pursued by trying to increase the efficiency of the process and confirm the feasibility and applicability of this system in larger scales. In this thesis, various zeolite and activated alumina hybrid adsorbents with varying zeolite compositions were screened to find the most efficient adsorbent for thermal energy storage process that gives the highest energy density. Then, existing small column was replaced with a new one, which is 16 times bigger in volume, in order to confirm the feasibility of this process at larger scales. Applicability of on-off heat release in adsorption process was also investigated by conducting several on-off experiments at different on-off time periods. Moreover, exothermic adsorption process was modeled by doing mass and energy balances in the column, water accumulation balance in the pellets, and energy balance in the column wall. Validity of this model was confirmed by comparing it with experimental results at different column volumes, and at different volumetric flow rates. Finally, an overall plant design, capital cost and thermal energy price estimations were done for adsorption thermal energy storage plants for different storage capacities and payback periods.

This thesis is about the causal relationship between interest rates. In chapter 1, with the help of time-series econometrics and by applying linear Granger causality tests based on the Toda-Yamamoto approach, the linear causality directions between the federal funds rate and five different interest rates during the last seven business cycles in the U.S. are investigated. We also examine the linear Granger causality directions between the overnight rate and five other interest rates during the last three business cycles in Canada. In chapter 2, the Diks and Panchenko Granger causality test is applied to explore the nonlinear causality effects between the short-term and long-term interest rates. By combining nonlinear causality effects with the linear ones which are found in the first chapter, it is seen that during the related periods in the U.S. and Canada, the most common Granger causality direction between short-term and long-term interest rates is a bidirectional one. Moreover, our findings show that during recent periods, the federal funds rate and overnight rate Granger cause other interest rates significantly. In chapter 3, the rolling window strategy is employed to detect the linear and nonlinear Granger causality relationship between the federal funds rate and the 10-year government bond rate, during different time horizons, investigating whether these causalities change with the passing of time. Our findings show that during different time horizons, there is a significant two-way Granger causality relationship between these interest rates. Although we have a different interpretation of the existence of bidirectional causation between short-term and long-term interest rates, this conclusion provides some support to some post-Keynesian structuralists viewpoints like Pollin (2008). However, Pollin's claim indicating that with the passing of time the significant causality effects of the federal funds rate to the market rates becomes insignificant is not supported by the current thesis findings because our results demonstrate that these causality effects have not been diminishing over the most recent business cycles.

Class of 2006 Abstract / Objectives: To determine the economic impact of controlled substance destruction in multiple long term care facilities in Southern Arizona and to identify related demographic characteristics of the patients and facilities. Methods: Subjects had controlled substance prescriptions destroyed at nursing homes serviced by a pharmacy nursing home provider in Tucson, Arizona. Controlled substances destruction records and existing prescription records were reviewed and data was collected on the name, strength, number of units destroyed, date of destruction and schedule of each controlled medication that was destroyed for a particular patient over the course of a year. Demographic data was collected on patient gender, age, type of insurance coverage and the size of the nursing home facilities. Results: A total of 1095 controlled substance prescriptions were destroyed during the time period of the study and the total cost of destroyed medication was $26,886.37. The average cost of destroyed medication per prescription was $24.55 ± 60.38 (mean ± SD). Schedule II controlled substances accounted for the highest total cost per prescription destroyed and destruction of unused controlled substances cost indigent insurance programs more than any of the other payers studied. There was no difference in mean cost per prescription destroyed by facility, therapeutic class or between women and men. Conclusions: The value of controlled substance destruction in long term care facilities is sizeable. To reduce waste, prescribers and pharmacy providers should initially dispense moderate quantities of controlled substances until it is apparent that the medication is tolerable and efficacious for the patient.

The purpose of the study was to design a reliable and valid assessment instrument that would provide a multidimensional profile of the elderly resident of a long term care facility. Use of this instrument would be a method of collecting and corrmunicating information concerning the full range of problems experienced by this group, in a form that is suitable for use at different levels of decisionmaking. The instrument consists of 31 unweighted items measuring functioning in 5 essential areas - cognitive, physical, emotional, social, and instrumental. Ratings were based on the observations of long term care staff who were in close contact with the individual over extended periods. Reliability and validity were tested using a non random sample of 76 elderly residents of one extended care unit. Both test-retest and interjudge reliability proved to be high and item analysis indicated that, with the exception of 2 items, the instrument provides levels of functioning appropriate to the sample population. The instrument also showed a high degree of internal consistency with the 3 major components identified as - cognitive behaviour, independence in daily living, and physical functioning. The validity of the instrument and its subsections was demonstrated through significant relationships with external criteria, namely - the number of problems listed on the multidisciplinary problem-oriented record, a health index measure, and a mental status rating. Further evidence of the instrument's validity was its ability to predict, retrospectively, 72 percent of the sample deaths in the first year following admission. Although only a preliminary form of analysis, this showed that a high level of mental functioning, combined with a low level of independence in daily living, was predictive of death within 3 to 9 months in the sample population. The implications of these results are discussed along with suggestions for further research in the area. Finally, potential uses for the assessment instrument in the field of long term care are provided. / Applied Science, Faculty of / Nursing, School of / Graduate