Development of the Andalusian Registry of Patients Receiving Community Case Management, for the follow-up of people with complex chronic diseases.

Background: Complex chronic diseases are a challenge for the current configuration of Health services. Case management is a service frequently provided for people with chronic conditions and despite its effectiveness in many outcomes, such as mortality or readmissions, uncertainty remains about the most effective form of team organization, structures, and the nature of the interventions. Many processes and outcomes of case management for people with complex chronic conditions cannot be addressed with the information provided by electronic clinical records. Registries are frequently used to deal with this weakness. The aim of this study was to generate a registry-based information system of patients receiving case management to identify their clinical characteristics, their context of care, events identified during their follow-up, interventions developed by case managers, and services used. Methods and design: The study was divided into three phases, covering the detection of information needs, the design and its implementation in the healthcare system, using literature review and expert consensus methods to select variables that would be included in the registry. Objective: To describe the essential characteristics of the provision of ca re lo people who receive case management (structure, process and outcomes), with special emphasis on those with complex chronic diseases. Study population: Patients from any District of Primary Care, who initiate the utilization of case management services, to avoid information bias that may occur when including subjects who have already been received the service, and whose outcomes and characteristics could not be properly collected. Results: A total of 102 variables representing structure, processes and outcomes of case management were selected for their inclusion in the registry after the consensus phase. Total sample was composed of 427 patients, of which 211 (49.4%) were women and 216 (50.6%) were men. The average functional level (Barthel lndex) was 36.18 (SD 29.02), cognitive function (Pfeiffer) showed an average of 4.37 {SD 6.57), Chat1son Comorbidity lndex, obtained a mean of 3.03 (SD 2.7) and Social Support (Duke lndex) was 34.2 % (SD 17.57). More than half of patients include in the Registry, correspond lo immobilized or transitional care for patients discharged from hospital (66.5 %). The patient's educational level was low or very low (50.4%). Caregivers overstrain (Caregiver stress index), obtained an average value of 6.09% (SD 3.53). Only 1.2 % of patients had declared their advanced directives, 58.6 had not defined the tutelage and the vast majority lived at home 98.8 %. Regarding the major events recorded at RANGE Registry, 25.8 % of the selected patients died in the first three months, 8.2 % suffered a hospital admission at least once time, 2.3%, two times, and 1.2% three times, 7.5% suffered a fall, 8.7% had pressure ulcer, 4.7% had problems with medication, and 3.3 % were institutionalized. Stroke is the more prevalent health problem recorded (25.1%), followed by hypertension (11.1%) and COPD (11.1%). Patients registered by NCMs had as main processes diabetes (16.8%) and dementia (11.3 %). The most frequent nursing diagnoses referred to the self-care deficit in various activities of daily living. Regarding to nursing interventions, described by the Nursing Intervention Classification (NIC), dementia management is the most used intervention, followed by mutual goal setting, caregiver and emotional support. Conclusions: The patient profile who receive case management services is a chronic complex patient with severe dependence, cognitive impairment, normal social support, low educational level, health problems such as stroke, hypertension or COPD, diabetes or dementia, and has an informal caregiver. At the first follow up, mortality was 19.2%, and a discrete rate of readmissions and falls.

Work, Professional Development And Teaching Commitment: Deconstructing Meanings

The paper we present is part of the research project "The professional identity of teacher studies", that we are development for last 3 years. The third phase of this research put the focus on the experience of job placement of novel teachers, graduated no more than 5 years. We work with focal groups and professional experience and teacher education accounts of teachers implied in this research. Also, for any teachers, we do biographical interviews to deepen on processes of construction of professional identity. In this paper we present the Ana Belen History, a female teacher of pre-school education with an experience of 4 years in school, working in a urban school with students in risk of exclusion. This school have a educative project, commitment with the neighbourhood, joint with the community and other social groups. Ana Belen story, from professional perspective, is linked with the social politic and educational commitment of this school. Our interest is focused in the comprehension of professional identity that Ana Belen has gone forging along her personal story and how her education and job placement has contributed for it. Also we are interested in knowing how early professional experiences have influenced in her professional development as teacher. Specifically we ask ourselves about what influence have for her professional identity, that her career starts in this particular school. In consequence, this paper leads us to question the current teacher education model. In particular we are interested on the kind of professional experience that have place and, so, the kinds of commitments that enables. We understand that frameworks in which professional education and experience have place are relevant to enable more or less transformer understandings about teaching. From conceptual perspective this paper adopts a socio-critical point of view (Gergen, 1985; Kincheloe, 2001; Wenger, 1988, etc.). We understand that teaching has to be analysing according work contexts and personal stories of teachers, because we face processes historical and collective building. Teaching is the result of action of their actors, over time, and in specific stage. So, with this research we intend to break with the old gap between pre and in-service education. We think that both of them are part of the same process and are formed according similar logical; although scenes change. We understand that they are part of a continuous process in which is giving sense to different and complex settings where teaching profession is built, but they are not differenced and independent stages. The teacher work, so, is subject to particular conditions, generated from such different fields as institutional, corporative, cultural, social, political, moral, etc. It displays a kaleidoscopic view on space, time, context, ... These are the axis in which the teaching is formed, from the complexity and heterogeneity. How this complexity is articulated results in different ways to face the teacher work, according different personal and professional stories. The teacher acts with subjects in instituted contexts from relationships he has with them, which gives a situated and contingent character. But, these contexts are strongly structured and ruled according centralized and generalized positions; which is, at the very least, paradoxical. Possibly, from our point of view, same of the crisis of teaching have to explain from this paradoxical perspective and the conflict, which characterize this job (Rivas, Leite y Cortés, 2011)