<p><b>Background</b><br></p> <p>More than 90% of individuals aged 65 years or older in the United States (US) are taking at least one prescription medication, and more than 40% are taking five or more prescription medications. The potential for non-adherence and risk of medication therapy problems (MTPs) increases with the use of multiple medications. To enhance patient understanding of appropriate medication use, improve medication adherence, and reduce MTPs, the Centers for Medicare & Medicaid Services (CMS) launched Medication Therapy Management (MTM) services as part of Medicare Prescription Drug (Part D) policy; however, “best practices” for achieving positive MTM outcomes are not well understood.</p><p><br></p> <p> </p> <p><b>Objectives</b></p> <p>This study had two objectives. The first objective was to identify and explain reasons for concordance and discordance between a) consistently high, moderate, and low performing pharmacies and b) pharmacies that improve or worsen in performance overtime. The second objective was to generate hypotheses for strategies that contribute to community pharmacies’ ability to achieve high performance on widely accepted MTM quality measures. </p><p><br></p> <p> </p> <p><b>Methods</b></p> <p>This comparative mixed-methods, case study design incorporated two complementary conceptual models. First, an adaptation of the Positive Deviance (PD) model explains reasons for deviations in MTM quality measure performance among community pharmacies and informs study design. Second, the Chronic Care Model (CCM) guided data collection and analysis. Data consisted of pharmacy/staff demographics and staff interviews. When appropriate, quantitative and qualitative data were analyzed within and across pharmacy MTM performance (i.e., high, moderate, low) or change-in-performance (i.e., consistent, improved, worsened) categories using descriptive statistics and cross-tabulation respectively. MTM performance component measures used to evaluate and rank pharmacy MTM performance mirrored measures under Domain 4 (Drug Safety and Accuracy of Drug Pricing) of the 2017 CMS Medicare Part D Plan’ Star Rating measures. This study was approved by the Institutional Review Board for the Purdue University Human Research Protection Program. </p><p><br></p> <p> </p> <p><b>Results </b></p> <p>Across the sample of eligible pharmacies (N = 56), MTM performance composite scores varied by 21.3%. Of the five component scores, the <i>Comprehensive Medication Review (CMR)</i> component score had the highest percent variation (88.3%). Pharmacy staff at 13 pharmacies of the 18 pharmacies selected as case study sites participated in interviews, yielding a 72.2% case pharmacy participation rate. Of the 13 pharmacies, five were categorized as high performers, four were moderate performers, and four were low performers. Of the 39 pharmacy staff approached across all pharmacies, 25 participated in interviews, yielding a 64.1% participation rate. Interviewees included 11 pharmacists, 11 technicians and three student interns. Eight strategies were hypothesized as positively (7) or negatively (1) contributing to pharmacies’ MTM performance. Hypotheses generated were organized by CCM elements and included: <i>Delivery System Design (DSD)</i> – Having a high degree of technician involvement with MTM activities; Inability to meet cultural, linguistic, and socioeconomic needs of patients (negative); Having sufficient capacity to provide CMRs to patients in person compared to telephone alone; Pharmacy staff placing high priority on addressing MTM activities<i>; Clinical Information Systems (CIS) </i>– Faxing adherence-related MTP recommendations and calling providers on indication-related MTP recommendations; Technicians’ use of CISs to collect/document information for pharmacists; Using maximum number of available CISs to identify eligible MTM patients; <i>Health System Organizations (HSO) </i>– Strong pharmacist-provider relationships and trust. No hypotheses were generated for the remaining three CCM elements.</p><p><br></p> <p> </p> <p><b>Conclusions </b></p> <p></p>A total of eight strategies were hypothesized as contributing to community pharmacies’ ability to achieve high performance on MTM quality measures. Notable strategies were related to three of the six chronic care model elements. Future research should engage stakeholders to assist with prioritizing hypotheses to be statistically tested in a larger representative sample of pharmacies.

No Brasil, os Centros de Atenção Psicossocial (CAPS) têm sido considerados experiências inovadoras no cuidado às pessoas em sofrimento psíquico. Estes dispositivos territoriais organizam suas práticas em pressupostos da Reforma Psiquiátrica devendo transpor as práticas tradicionais da psiquiatria. Esta pesquisa visa analisar o Centro de Atenção Psicossocial - Espaço Vivo - localizado em um município do interior paulista, enquanto um dispositivo que apresenta-se como intermediário à internação psiquiátrica e cujo eixo institucional tem se baseado nos pressupostos da Reabilitação Psicossocial. Para a realização deste estudo, primeiramente, descrevi a estrutura e dinâmica do CAPS e, em um segundo momento, pretendi entender como o processo terapêutico oferecido pelo serviço é percebido pelos usuários atendidos. Para a apreensão do proposto trilhei o caminho da pesquisa qualitativa, realizando um estudo de caso, descritivo e analítico. Para a coleta dos dados foram realizadas observação participante e entrevistas semi-estruturadas com os usuários atendidos pelo serviço, totalizando onze pacientes. Os dados colhidos foram submetidos à análise temática. Os resultados apresentados na pesquisa foram estruturados por meio de três grandes temas emergidos dos depoimentos dos sujeitos da pesquisa. O primeiro deles foi A influência organicista no cuidado prestado pelo serviço. A partir deste recorte foi analisado e discutido como os usuários têm percebido as práticas terapêuticas no serviço. Sendo assim, surgiram outros subtemas vinculados a esta questão: a valorização do profissional médico, a ênfase na terapêutica medicamentosa e a importância da abordagem terapêutica sobre os sintomas apresentados pelos usuários. O segundo tema que emergiu durante a análise foi O CAPS enquanto cenário favorecedor da rede de relações sociais. Neste, discuti como o espaço do CAPS tem se conformado dentro das ações terapêuticas, nas relações usuário/serviço e usuário/profissional, a formação do vínculo, e, também, como os usuários têm percebido e utilizado do CAPS. O último tema apresentado é o que traz a emergência do Trabalho terapêutico voltado à vida cotidiana do usuário. Nele, foram abordadas as dificuldades e facilidades dos usuários em enfrentar os desafios da vida cotidiana e como as práticas terapêuticas do serviço têm se conformado nesta direção. Constatei que a ação cotidiana do serviço acontece em terreno contraditório, uma vez que foi possível apreender práticas ainda ligadas ao modelo tradicional da psiquiatria mas, também, ações inovadoras e que vão ao encontro da reforma psiquiátrica e reabilitação psicossocial. Ao final deste estudo pretendo colaborar nas reflexões sobre o trabalho em saúde e, também contribuir para a organização dos serviços de saúde mental, a fim de melhorar o cuidado oferecido aos usuários que passam por uma experiência de sofrimento psíquico. / In Brazil, the Psychosocial Care Centers (CAPS) have been considered to be innovative experiences in caring for people who have psychiatrical sufferings. These territorial facilities organize their practices in principles from the Psychiatric Reformation and must go beyond the traditional psychiatric practices. This research aim to analyze the Psychosocial Care Center - Espaço Vivo - located in a city in the countryside of São Paulo state, as an apparatus which is presented as an intermediate way to the psychiatric hospitalization and whose institutitional axis has been based in the Psychosocial Rehabilitation principles. For this study to be carried out, firstly, I described the structure and dynamics of CAPS and, in a second moment, I intended to understand how the therapeutic process offered by the service is experienced by the users served by it. For the aprehension of this purpose, I followed the path of qualitative research, performing a case study, descriptive and analytical.. For collecting the data, participating observation and semi-structured interviews with the users helped by the service were used, making a total of eleven patients. The collected data were submitted to theme analysis. The results presented in the research were structured by three large topics coming from the testimonials of the research subjects. The first topic was The organicist influence in the care provided by the service. From this idea, the way the users have been experiencing the therapeutic practices in the service could be analysed and discussed. This way, other subtopics came from this question: the medical professional value, the emphasis in the medicine-based therapeutics and the importance of the therapeutic approach on the symptons presented by the users. The second topic which came from the analysis was The CAPS as a helping scenario in the social relations network. On this topic, I discussed how the CAPS space has been conforming within the therapeutic actions, in the user/service and user/professional relations, the bonding formation, and also, how the users have experienced and used the CAPS. The last presented topic is the one which brings the Therapeutic work towards the users daily life. In this topici, the difficulty and readiness of the users in facing the daily life challenges and how the service therapeutic practices have been conforming in this direction were approached. I concluded that the daily action of the service happens in a contradictory area, once it was possible to aprehend practices which are still connected to the traditional psychiatric model but also innovative actions which go towards the psychiatric reformation and psychosocial rehabilitation. In the end of this study, I intend to be helpful in the reflexions on the health work and, also to be able to contribute in the mental health service organization, in order to improve the care offered to the users who pass through a psychiatric suffering experience.

This thesis is a study of social divisions and an assessment of the impact of neoliberalism upon them. Its purpose is to investigate the nature of contemporary social divisions, and whether or not the ????underclass???? is a useful way of conceiving the social and economic marginalisation of some individuals. The underclass thesis crystallises in a powerful and contentious way some fundamental premises that underpin the neoliberal philosophy, namely that the welfare state is considered a threat to freedom, discourages work, and is socially and economically damaging. Thus there ought to be a reduced role for the state in the provision of welfare. There are two fundamental weaknesses in social democratic critics???? contributions to debates about welfare reform. The first relates to a focus on residual welfare and measurements of poverty, largely neglecting the systems of power that underlie welfare distribution. The second relates to the omission of agency. Critics???? responses have tended to ignore the behaviour of the welfare beneficiaries targeted by current reform. In order to address both of these issues, I have formulated a critical post-traditional paradigm of social divisions. The study comprises three stages. The first is an historical overview of neoliberal policy developments and a quantitative analysis of social divisions. The findings indicate that neoliberal nations have the lowest commitment to welfare, and the highest levels of poverty and widening inequality. In Australia, labour market changes and educational underachievement are likely to contribute to new and emerging divisions, and the cumulative nature of disadvantage is apparent within low socio-economic areas. The second stage of the study examines the policies of the Howard Coalition Government in Australia and focuses on the prevalence of the underclass phenomenon in current welfare reform. Records central to the Government????s welfare reform agenda are analysed to examine policy makers???? normative beliefs. The findings reveal that the underclass thesis is an ideological construct that legitimises a reduction of welfare provision and control of the unemployed. The third stage of the study focuses on the experiences of unemployment among young people, and the views and experiences of welfare providers who work with them. The data show that individuals make decisions about their lives from the range of options they perceive to be available to them at a particular point in time. These options are not limited to those made available by the provisions of the welfare state, nor are they solely the product of inter-generational welfare. The welfare providers enforce the Government????s position on welfare reform by endorsing a version of the underclass thesis in their work and directing their interventions at the individual. Considered together, the findings reveal that a conservative neoliberal social policy fails to capture the complex interaction that occurs between individuals and their social environment, and the impact this has on their labour market activities. By successfully converting the problem of welfare dependency into a private issue, a neoliberal social policy is legitimised and current social arrangements are maintained. / PhD Doctorate

This study set out to answer the question: In what ways do social work practitioners in Philippine municipalities manage competing mandates? The research question was informed by a number of theoretical propositions outlined in Chapter 1 and a particular construction of social work as described in Chapter 2. The approach taken was to ground the study in a particular practice setting, with the study participants being social workers serving as Municipal Social Welfare and Development (MSWD) Officers in Philippine municipalities.

This thesis is a study of social divisions and an assessment of the impact of neoliberalism upon them. Its purpose is to investigate the nature of contemporary social divisions, and whether or not the ????underclass???? is a useful way of conceiving the social and economic marginalisation of some individuals. The underclass thesis crystallises in a powerful and contentious way some fundamental premises that underpin the neoliberal philosophy, namely that the welfare state is considered a threat to freedom, discourages work, and is socially and economically damaging. Thus there ought to be a reduced role for the state in the provision of welfare. There are two fundamental weaknesses in social democratic critics???? contributions to debates about welfare reform. The first relates to a focus on residual welfare and measurements of poverty, largely neglecting the systems of power that underlie welfare distribution. The second relates to the omission of agency. Critics???? responses have tended to ignore the behaviour of the welfare beneficiaries targeted by current reform. In order to address both of these issues, I have formulated a critical post-traditional paradigm of social divisions. The study comprises three stages. The first is an historical overview of neoliberal policy developments and a quantitative analysis of social divisions. The findings indicate that neoliberal nations have the lowest commitment to welfare, and the highest levels of poverty and widening inequality. In Australia, labour market changes and educational underachievement are likely to contribute to new and emerging divisions, and the cumulative nature of disadvantage is apparent within low socio-economic areas. The second stage of the study examines the policies of the Howard Coalition Government in Australia and focuses on the prevalence of the underclass phenomenon in current welfare reform. Records central to the Government????s welfare reform agenda are analysed to examine policy makers???? normative beliefs. The findings reveal that the underclass thesis is an ideological construct that legitimises a reduction of welfare provision and control of the unemployed. The third stage of the study focuses on the experiences of unemployment among young people, and the views and experiences of welfare providers who work with them. The data show that individuals make decisions about their lives from the range of options they perceive to be available to them at a particular point in time. These options are not limited to those made available by the provisions of the welfare state, nor are they solely the product of inter-generational welfare. The welfare providers enforce the Government????s position on welfare reform by endorsing a version of the underclass thesis in their work and directing their interventions at the individual. Considered together, the findings reveal that a conservative neoliberal social policy fails to capture the complex interaction that occurs between individuals and their social environment, and the impact this has on their labour market activities. By successfully converting the problem of welfare dependency into a private issue, a neoliberal social policy is legitimised and current social arrangements are maintained. / PhD Doctorate

Since the profession of social work began, there has been debate about whether it should be involved in helping individuals make change, or in encouraging societal change. Towards gaining an understanding of how this debate has played out in Aotearoa New Zealand, this research explores the question “What are the past present and future perspectives on the role of counselling in social work in Aotearoa New Zealand?” A mixed methodology format was used in this research. Qualitative interviews with individuals who had helped create the professions of social work, counselling and psychology were conducted to help understand the historical development of counselling within social work, and the factors which had impacted upon it. Questionnaires were then sent out to 985 members of the Aotearoa New Zealand Association of Social Workers that asked about members’ current views on, and practice of, counselling within social work. The research shows that social work developed late in New Zealand within a welfare state where governments questioned the need for it. With social work education not widely available until the 1970s there was limited training in counselling type approaches. The drive for professionalism (often aligned with those doing counselling) was tempered by those mindful of community and bicultural commitments due to differing ideologies and lack of access to education. Tangata whenua have had a major impact on the development of social work, and counselling within it. Respondents in this research were clear that aspects of counselling fell within their definitions of social work and that counselling in Aotearoa New Zealand should hold a strengths-based, collaborative stance that recognised the importance of a bicultural perspective. Most respondents indicated that they did some amount of counselling within their practice, but only 34% of respondents felt that their basic social work qualification had prepared them adequately or really well for their counselling role. The majority of questionnaire respondents had undertaken additional training to help them with their counselling role and over two-thirds indicated a strong desire to engage in further study in counselling. Registration of the helping professions presents challenges that include the potential for unhelpful competition between them. The thesis concludes that there is a need for more counselling education options for social workers and that there is a need for the profession of social work to formally define its scopes of practice.

No description available.

This thesis presents an ecological exploration of the experiences of mental health workers faced with critical incidents and traumatic events in the course of their work. A qualitative study, it takes the experiences of twenty workers from a range of disciplines and environments, and examines their preparation for exposure to extreme stress, their passage through the incidents that they chose to relate, and the organisational response to the events. The central research question explores the knowledge bases currently utilised within trauma and critical incident response, and the degree to which these provide adequate explanatory, practice and evaluation models for responses to workplace incidents. It is examined through the narratives of the mental health workers, who self-define and explore the nature of their preparation for, and experience of, critical incidents and traumatic events in their workplace. The question is contextualised through a review of the knowledge bases of trauma and extreme stress, and of the mental health environment in which the workers practice. A case study of the workplace support known as debriefing illustrates the tensions between current knowledge bases in the area. Informed by this, the key issues of what did or did not work for the participants are explored. The thesis argues that the paradigm shift signalled by the latest developments within conceptualisations of trauma is not yet complete, and that the ensuing tensions have created debate and confusion in the creation of adequate responses to workplace incidents. Whilst conceptualisations that attempt to address issues of complexity and context are evolving, it is argued that an ecological framework has the potential to both explain and respond to incidents that occur within the mental health environment. The findings of the research raise issues of complexity in the design and implementation of appropriate support systems, and lend a perspective to the critique of debriefing that has been missing from existing debates. Key principles for the development of safe and sound support systems, and their evaluation, are developed.

No description available.

This thesis examines residential relocation process within the Seoul Metropolitan Region (SMR) in the Republic of Korea at both a macro and micro level. The thesis makes theoretical and methodological contributions to residential mobility, housing vacancy chains and location choice behaviour in urban geography. The empirical study specifically focused on the relationship between housing opportunity and residential relocation process in the SMR during the 1990s. In developing countries, large scale suburban land and housing development on the fringe of metropolitan areas is seen as an important issue in the process of rapid urbanization and capital accumulation. This is particularly true of Korea where the population of the capital city, Seoul (SCC) has declined since the introduction of massive scale of new suburban housing developments in the 1990s. This is the first time the SCC’s population has decreased in Korean modern history. However there is still debate about the impact of government proposed suburban new housing construction initiatives on residential relocation within the SMR. In addition there remain uncertainties concerning the impact of large suburban housing development on residential relocation behaviour. To date little evaluation of outcomes of the policies has been undertaken, a deficiency which this research seeks to address. Like other capital cities in the developing world, Seoul (SCC) has undergone significant urban expansion throughout its contemporary history, fuelled by the movement of refugees from North Korea in the period immediately following the end of the Korean War (1953) and by significant rural-to-urban, and later by intra urban movement. The SCC, in particular grew significantly, with the metropolitan area of Seoul soon expanding beyond its borders in a process akin to suburbanisation. The rapid urban growth in the Seoul Metropolitan Region (SMR) was accompanied by a series of urban problems including housing shortages, a decline in housing and urban quality, and the concentration of population in large cities, especially in the SCC. To counter these problems the national government in the Republic of Korea initiated a series of policies. Most prominently among these was a massive scale new housing development program initiated in 1988, aimed at developing large scale new satellite cites in Kyonggi, with the objective of decentralising the SCC’s population and thus alleviating an urban housing shortage. This research focuses on two main issues charactering contemporary housing and land development policies in the SMR. The first relates to government efforts to redirect migration from the capital city, Seoul, to the outlying jurisdictions of Kyonggi and Inchon in an attempt to diffuse the concentration of population in the SCC and to alleviate housing shortages. The second issue concerns the determinants of residential mobility and residential location choice behaviour in the SMR. Mirroring the two issues, two approaches have been used to address these issues: a macro level study of residential relocation and a micro behavioural analysis. At macro level the research attempts to measure the impact of new housing developments on easing urban housing markets in the SMR during the 1990s, notwithstanding the continuous population movement from other regions in the Republic of Korea. The macro investigation addresses the questions: • What are the changes in spatial mobility patterns occurring in the SMR since the introduction of government’s suburban residential developments? • Are the size of housing vacancy chains different by spatial mobility patterns among the three regional housing markets in the SMR? Multi-regional vacancy chain models are used to examine whether vacant housing opportunity spills over into neighbouring regions in the SMR, particularly the city of Seoul. The models focus mainly on the structural determinants of household mobility, such as local new housing construction, household formation, household mobility rate and demolition rate, and their role in creating and absorbing vacant housing opportunities in the three jurisdictions comprising the SMR: Seoul (SCC), Kyonggi and Inchon. The vacancy chain analysis uses a Markov chain model and Leontief input-output model to assess the impact of these structural differentials on household mobility in the multiregional system of the SMR. This macro study provides a structural framework for the subsequent micro behavioural approach to residential mobility occurring in the SMR. The micro behavioural approach investigates the following questions: • What are the socio demographic profiles of people who relocate within the SMR?’ • What are the housing transitions that occur after moving to regions of the SCC in the SMR? • What are the reasons households give for moving within the SMR? This micro approach focuses on the behavioural aspects of residential mobility decision process as influenced by age, marital status, employment status, education level, duration of residence, dwelling size and tenure status. Apart from the mover’s socio demographic profile, the study further investigates longitudinal housing transitions before and after a move by their origin and destination within the SMR, particularly those movers who relocated to suburban rings (Kyonggi/Inchon). However the reasons for movers to choose a particular location vary and they are socio demographically diverse. The research also discusses these behavioural reasons for moving within the SMR.