<p> Traditional patient care in the U.S. has been fragmented and redundant, resulting in high healthcare costs and poor patient outcomes. New team patient care models are being attempted to improve outcomes and lower the cost of care. Models of integrated and coordinated care, including the Patient-Centered Medical Home model, have demonstrated some improvements, especially for chronically ill patients. Membership in a Health Maintenance Organization (HMO) and presence of a diabetes diagnosis is tested and results for the chronically ill are discussed.</p>

<p> The goal of the project was to implement best-practice guidelines for adults with heart failure (HF) receiving home care. Heart failure is incurable, but can be managed when healthcare providers use evidence-based treatment guidelines and patients comply with routine follow-up and practice a healthy lifestyle. Providing access to care for the elderly in the form of a structured telephone call program to monitor self-care efficacy related to adherence to medication and other treatments and therapies is associated with reduced HF symptoms and improved quality of life. This project implemented a phone call follow-up program to evaluate and improve self-care efficacy in adults with heart failure by monitoring compliance, providing education, and focusing on key indicators of HF symptom exacerbation. The Self-Care of Heart Failure Index (SCHFI) was used in weekly phone calls for a total of 10 weeks. Using the SCHFI tool provided structure and included key best practice content areas with scripting to enhance consistency. The project participants were adults age > 65 year old patients receiving care through a home health care team in central Louisiana who had an established diagnosis of heart failure. </p>

<p> Med-Equip Solutions LLC is an accredited wheelchair distributor start-up company located in the City of Laguna Woods, California, that strives to be a leading provider of manual and electric wheelchairs in the Laguna Woods area. The company is focused on helping improve the quality of life for elderly patients with mobility related disabilities in neighboring regions by providing high-quality equipment and exceptional customer service. Med-Equip Solutions LLC has geographic as well as economic advantages due to the population demographics of Laguna Woods City, socio-economic status of the population and the company&rsquo;s strategy of providing imported high-quality equipment, which creates enormous opportunity for profit and successful business operation in the area.</p><p> Chapter 1 provides detailed information about the company, services, target population, market research, customer analysis, competitor analysis, and marketing strategy. Chapter 2 deals with the feasibility analysis and provides information on company&rsquo;s SWOT analysis. Chapter 3 discusses the legal and regulatory issues pertaining to the business operation in the US abiding by the Regional, State &amp; Federal laws. Chapter 4 gives a description of the pricing structure, expenditure, revenues and detailed financial analysis of the business. In conclusion, Med-Equip Solutions LLC has shown significant potential for success in the market.</p>

<p> Directors of nurses in long-term care are faced with significant changes in the healthcare industry. The responsibilities of the position have evolved and now require director of nurses to have additional skill sets that were not previously associated with the expectations of the position. The purpose of this qualitative descriptive case study was to explore the perception of 8 directors of nursing in long-term care facilities in the Downstate Area of New York State. This research was guided by the following questions: What are the perceptions of directors of nurses or nurse executives in long term care facilities? Who may or may not be educated in graduate level business, particularly in the area of business decision making and fiscal responsibilities? How can registered nurses in leadership and executive positions enhance their educational preparedness as they pursue the responsibilities associated with their roles? A case study is an in-depth examination of individuals, organizations, or processes that seek further theoretical understanding. Several pertinent and relevant themes were identified such as; a) the review of the nursing curriculum, b) the need for standardized requirement to practice as a director of nurses, c) self-direction in ongoing education, mentorship and, d) training in business and fiscal responsibilities. Additionally, sub themes emerged during this qualitative study which included; a) organizational responsibility, b) director of nursing demanding change, and c) accelerated nursing programs. </p>

This thesis explores the level of awareness women in Sunderland have of help-seeking intervention and what is known about the agencies that respond to domestic violence, regardless of personal experiences. It examines the extent of how understandings of domestic violence impact on potential help-seeking and the barriers that contribute to the difficulty of help-seeking. Previous research has largely focussed on survivors of domestic violence who have had contact with formal agencies. Feminist theory informed this thesis and standpoint epistemology was used as a framework for the procedures that were applied in the research. A mixed method approach was utilised in the form of an on-line survey, which recruited participants, and informed the interview schedule in the qualitative phase. The qualitative phase included 20 semi-structured interviews with women of varied ages, which was analysed using thematic analysis. Through reflexive practice of the fieldwork process there emerged, as a result of consciousness raising, what I have coined, an ‘ontological transition’. Significantly, ontological transitions vary between respondent pending upon their knowledge and/or personal experiences of domestic violence. However, crucially the analysis of the respondent interviews highlights that one characteristic is the impact of shame. It was found that the experience of shame is not confined to a particular social positioning or related to faith or ethnicity. Through talking about their experiences of shame respondents were able to consider a different relationship. Some respondents were able to reject shame as they recognised that their experience is not personal but a collective of experiences in some way. This realisation and their transformation through taking part in the interview is part of the ontological transition and will be discussed further in the body of the thesis. Importantly, this thesis illustrates the significant difference in knowledge of 3 identified respondent group types, which emerged during analysis of the qualitative data. Through reflection on the written documents and thematic maps it enabled the development and management of the key themes and new ideas (appendix 18). It was through this process that a relationship between experiences of domestic violence, and knowledge emerged as the data was refined. This was the recognition of 3 identified groups of knowledge about domestic violence, which, after further analysis, were named the experiential, institutional and notional groups (see appendix 18). The groups are informed through their social, personal or professional experiences, and this shapes their potential for future help-seeking (chapters four and five). This gives the opportunity to offer an understanding of how domestic violence and help-seeking are understood by women regardless of their experience of domestic violence. Current theoretical and policy explanations of domestic violence and help-seeking are predominantly based on the collective experiences of survivors. They do not take into account the understandings and experiences of other women regardless of their experiences of domestic violence and, how this shapes their potential for help-seeking. I argue help-seeking is complex and the decision to seek help is a consequence that starts with recognising that what is being experienced is domestic violence. Additionally, I argue that the help-seeking is hampered through non-recognition of behaviour as domestic violence and ideologies of gendered roles and expectations, male entitlement, ownership, love and acts of altruism by women that normalise and minimise abusive behaviours in the heterosexual relationship.

Hospital-based specialist palliative care services are designed to address the needs of critically ill patients by psychosocial and spiritual support, improving symptoms management, and offering discussions on goals of care. Integrating palliative care upstream in the care continuum for patients who eventually die in the hospital will help to address the many individualistic needs of the critically ill patient. The diffusion of specialist hospital-based palliative care services requires an understanding of patterns of utilization by patients. The purpose of this study was to examine the population characteristics of decedents who may or may not have utilized specialist palliative care services in a hospital setting in order to develop a model of predictors of access to specialist palliative care services. The basic constructs of this study are grounded in the Behavioral Model of Health Services Use. Potential access is measured in terms of population characteristics, which include predisposing characteristics, enabling resources, and evaluated need. Building on this theoretical model, the study sought to better understand equitable and inequitable access to specialized palliative care services and to define which predictors of realized access were dominant. The research question asked was: What are predictors of access to specialized palliative care within a large urban public teaching hospital? A model of access to a palliative consult and a predictor of access to a palliative care unit were explored. Findings from this study revealed that factors encouraging access to a palliative care consult include older age, White non-Hispanic ethnic membership, a diagnosis with solid cancer and insurance. Factors encouraging access to a palliative care unit include older age, gender (female), insurance, and either a solid cancer or hematologic malignancy diagnosis.

Although gangs have long been present, gangs exert an increasingly significant influence on the culture of students who attend schools, especially in urban environments. This case study investigation involved a purposeful sampling of four young men who were involved in gangs. By spending time with each young man in several interviews, I was able to gain insight into his perceptions of schooling, his teachers, and his view on caring in schools. The individual interviews focused on each student’s experiences in schooling through the lens of care. This research took in-depth look at these four gang members in their individual schooling environments. Although the literature gives a glance at gang members and their perspectives on education, the research has only touched the surface in understanding this complex youth. This study has added to the literature on gangs in schools and has explained in detail what these four gang members perceived in regards to their teachers and care. With these interviews, I have identified other themes related to gangs in schools that can be further researched. In this study, these four gang members have been given a voice.

This study explored the differences between the organisation of maternity care in Britain and the Netherlands. The debates within each national system between proponents of high-technology obstetric hospitals and those of low-technology maternity care were analysed. This specific comparison was approached through a qualitative analysis and a quantitative content analysis. In the Netherlands I analysed the debate between home and hospital-birth supporters in a medical journal in 1986-1987 and in Scotland I analysed the replies to Grampian Health Board's proposals to close peripheral maternity units in 1987-1988. At a theoretical level the distinction is made between 'medical' and 'social' model of childbirth. Three levels of approaching the differences between these two models were unravelled in order to come to a better understanding of reality. One of the central points is question of risk in childbirth, which is the dividing factor between models of childbirth. The concepts of 'patriarchy' and 'medicalisation' are rejected as possible explanations for the differences between the Dutch and British organisation of maternity care. I explore the possibility of Jamous and Peloille's I/T ratio as an explanatory tool, and suggest a minor adaptation to this theory. Furthermore, in order to incorporate the state intervention in the interprofessional competition between midwives and doctors I suggest that Abbott's theory of 'systems of professions' could bring some light on the question. Finally, I suggest as a policy conclusion that a risk selection list similarly to the one in existence in the Netherlands should be drawn up in Britain. However, such a list should not be drawn up by obstetricans only or even a committee wherein obstetricians form a majority. I argue that a committee for the drawing up of national selection criteria should include representatives from midwives, health visitors and consumers.

Patient monitoring is a complex task, particularly during childbirth, where assessment of the baby's condition is inferred from the continuous electronic recording of the baby's heart rate pattern and maternal uterine contractions (CTG). Computerised decision support has long been advocated, as difficulties in the interpretation of the CTG have led to failure to intervene and unnecessary intervention. The problem is large, for obstetric litigation now accounts for 80% of the UK National Health Service litigation bill. The Plymouth Perinatal Research Group has developed a computerised decision support system for patient monitoring during childbirth and the UK Medical Research Council has agreed to fund a multicentre randomised trial. The work of this thesis was an investigation of the labour ward care system to inform the human-centred design of the decision support system for patient monitoring in childbirth, prior to the clinical trial. It was recognised that many decision support systems have failed to gain clinical acceptance, as conventional design models were inadequate. Lack of attention to the organisational context of the care system and the process of the direct patient care led to the design of inflexible 'expert' systems, which constrained working practices. A pilot ethnographic study of an existing decision support system, used for the analysis of umbilical cord blood samples, was undertaken to clarify the research approach required for the main study. It was found that barriers to effective use within the wider work system included inadequate implementation and lack of organisational support. A case study approach produced a more comprehensive account of the context and process of the use of the computer system. The main study combined qualitative with quantitative techniques to investigate the system of care in childbirth, both outside and within the delivery room, to provide a unique, holistic perspective. The organisational context of the labour ward was investigated by direct observation of clinicians over the course of their work for 220 hours. Observations were documented and transcribed to computer text files. Patterns of actions and events were coded using ATLAS(ti) data analysis software. The codes were counted and tabulated to model the main features of this labour ward care system, which was expressed in the form of a rich picture diagram. These findings were confirmed by a limited study of five other UK labour wards. The core qualitative categories, derived from the observation data, found a complex and problematic relationship between communication, decision making and accountability. Decisions were often made outside the delivery room and were subject to misinterpretation and bias. The organisational hierarchy made it difficult for junior staff to question clinical management decisions. A system of tacit practice, external demands upon clinicians and transient allocation of junior midwives to labour ward militated against teamwork. This increased the vulnerability of the care of mothers to error. The process of direct patient care, within the individual delivery room, of 20 mothers in labour was captured in a novel audio-video observation study. The 111 hours of first stage labour and 12 hours of second stage labour were recorded and digitised to computer files. Recurrent actions and patterns of behaviour were coded both quantitatively and qualitatively using ATLAS(ti) data analysis software. Midwives left the room on average every 15 minutes to be absent for 27% of the first stage of labour. Record keeping occurred on average every 10 minutes and accounted for 19% of midwives' time. Midwives had little time to talk with mothers and only sat down at the bedside for 15% of the time. Psychosocial support was not given priority. Parents were generally excluded from communication between clinicians yet 108 clinicians took part in the care of the 20 women. Pressures from medicolegal directives and task-orientated imperatives overshadowed meaningful interaction with parents and caused spurious care priorities. This work has revealed the need for a critical reassessment of the type of support that is required for monitoring situations in all areas of medicine. A range of functions, such as shared information displays and models, have been suggested to augment roles and relationships between clinicians and parents to support patient-centred care. The present work has revealed that a combination of computer-based technology and changes to working practice can support the parents, their individual carers and their various roles. In this way the system of care can be more aligned to the objective of a safe and emotionally satisfying birth experience for parents and staff. A further programme of research is required to follow-up the existing studies, develop these new forms of interaction between technology and clinicians, and evaluate their effectiveness. The research methods employed in the present work will provide a more comprehensive evaluation of the decision support system in the forthcoming multicentre trial. The methods of investigation have also been shown to be of relevance to patient safety research, service delivery and training.

<p> Sightseers Ophthalmology Services is a mobile medical business that provides concierge vision and ophthalmic services to individuals in Newport Beach and Huntington Beach. The implementation of the Affordable Care Act (ACA) has provided millions of previously uninsured patients with medical coverage, which is causing increased demand for primary and specialty care services, in addition to higher premiums for those who have historically maintained an insured status. A result of the ACA is overcrowding; patients are having more difficulty getting access to care, and are experiencing long wait times in clinic when they actually <i>do</i> get an appointment. Concierge medicine is becoming more popular as many patients are finding that increased costs and inconvenient access to care are not worth their time and money. Newport Beach and Huntington Beach are home to a population who may prefer concierge eye services, and be able to meet the expense of them, if needed. Sightseers is an affordable way to have access to same-day or next-day appointments; and, moreover, we come directly to the patient. Whether the patient has difficulty with transportation, a conflicting work schedule, or if he or she simply does not want to travel to and wait in a busy ophthalmology clinic, Sightseers&rsquo; business plan proves that convenient and high quality services can benefit both the patient and the provider.</p>