Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

EXISTENCE OF UNUSED MANAGED CAPACITY ON DEDICATED LANES AND AN ALTERNATIVE ON HOW TO SELL IT VIA AUCTIONS

This dissertation verifies whether the following two hypotheses are true: (1) High-occupancy/toll lanes (and therefore other dedicated lanes) have capacity that could still be used; (2) such unused capacity (or more precisely, “unused managed capacity”) can be sold successfully through a real-time auction. To show that the second statement is true, this dissertation proposes an auction-based metering (ABM) system, that is, a mechanism that regulates traffic that enters the dedicated lanes. Participation in the auction is voluntary and can be skipped by paying the toll or by not registering to the new system. This dissertation comprises the following four components: a measurement of unused managed capacity on an existing HOT facility, a game-theoretic model of an ABM system, an operational description of the ABM system, and a simulation-based evaluation of the system. Some other and more specific contributions of this dissertation include the following: (1) It provides a definition and a methodology for measuring unused managed capacity and another important variable referred as “potential volume increase”. (2) It proves that the game-theoretic model has a unique Bayesian Nash equilibrium. (3) And it provides a specific road design that can be applied or extended to other facilities. The results provide evidence that the hypotheses are true and suggest that the ABM system would benefit a public operator interested in reducing traffic congestion significantly, would benefit drivers when making low-reliability trips (such as work-to-home trips), and would potentially benefit a private operator interested in raising revenue.

Entre ecos e narcisos: estudo de caso sobre a prática teatral com adolescentes como atividade extracurricular numa escola de nível médio

This masters thesis discusses the studying and the teaching of drama and its implications among teenagers of the contemporary world. This paper also analyses an extracurricular project entitled Drama in the development of citizenship , which was carried out in the public state school Berilo Wanderley in Natal/RN, between 1999 and 2005 with high school students. It comprises a case study that aimed at understanding how and why they chose to take drama classes outside of the school curriculum and even after they graduated, some of them never left the school project and even started participating in the cultural and artistic context of the city of Natal quite actively, both as part of an audience as well as on artistic, political, social and pedagogical performance. The project was high significant for its participants, for the school and for the community, by creating a sense of recognition of the relevance of the pedagogical and artistic production in the public school, as it managed to yield knowledge that helped students to understand the values of group work, sharing information, collaborative assessment and, most of all, to engender actions of protagonism by the teenagers themselves within their social environments. The empirical process developed is placed in a contemporary historical context where educational paradigms shifts occur, and where categories of youth empowerment and protagonism are fundamental to the educational process in the 21st century. The objective of this study is to reflect upon the pedagogical dimension of drama classes for teenagers, aiming at providing further discussions on the role of acting classes in the construction of the personality among youngsters, thus hoping to contribute to other teaching practices, including drama and other subjects of general education

Population estimates and behavioral analyses of managed cat (Felis Catus) colonies located in Miami-Dade County, Florida, parks

The purpose of my study was to collect data on managed cat (Felis catus) colonies located in two Miami-Dade County, Florida, parks, in order to test the following assertions put forward by proponents of the colonies: 1) Managed cat colonies will decline in size over time and 2) The territorial behavior of cats living in established cat colonies will prevent additional cats from joining. I collected observational and photographic capture-recapture data in order to track colony population dynamics. Behavioral data were also collected in order to understand the role that cat behavior plays in influencing colony population dynamics. My results do not support the assertion that colonies will decline over time. Instead, my findings demonstrate that the establishment of colonies on public lands encourages dumping of cats and creates an attractive nuisance. Furthermore, my behavioral analysis suggests that territorial behavior does not play a role in excluding new cats.

Advanced Methodologies in Dynamic Traffic Assignment Modeling of Managed Lanes

Managed lane strategies are innovative road operation schemes for addressing congestion problems. These strategies operate a lane (lanes) adjacent to a freeway that provides congestion-free trips to eligible users, such as transit or toll-payers. To ensure the successful implementation of managed lanes, the demand on these lanes need to be accurately estimated. Among different approaches for predicting this demand, the four-step demand forecasting process is most common. Managed lane demand is usually estimated at the assignment step. Therefore, the key to reliably estimating the demand is the utilization of effective assignment modeling processes. Managed lanes are particularly effective when the road is functioning at near-capacity. Therefore, capturing variations in demand and network attributes and performance is crucial for their modeling, monitoring and operation. As a result, traditional modeling approaches, such as those used in static traffic assignment of demand forecasting models, fail to correctly predict the managed lane demand and the associated system performance. The present study demonstrates the power of the more advanced modeling approach of dynamic traffic assignment (DTA), as well as the shortcomings of conventional approaches, when used to model managed lanes in congested environments. In addition, the study develops processes to support an effective utilization of DTA to model managed lane operations. Static and dynamic traffic assignments consist of demand, network, and route choice model components that need to be calibrated. These components interact with each other, and an iterative method for calibrating them is needed. In this study, an effective standalone framework that combines static demand estimation and dynamic traffic assignment has been developed to replicate real-world traffic conditions. With advances in traffic surveillance technologies collecting, archiving, and analyzing traffic data is becoming more accessible and affordable. The present study shows how data from multiple sources can be integrated, validated, and best used in different stages of modeling and calibration of managed lanes. Extensive and careful processing of demand, traffic, and toll data, as well as proper definition of performance measures, result in a calibrated and stable model, which closely replicates real-world congestion patterns, and can reasonably respond to perturbations in network and demand properties.

A DEA-based incentives system for centrally managed multi-unit organisations

In multi-unit organisations such as a bank and its branches or a national body delivering publicly funded health or education services through local operating units, the need arises to incentivize the units to operate efficiently. In such instances, it is generally accepted that units found to be inefficient can be encouraged to make efficiency savings. However, units which are found to be efficient need to be incentivized in a different manner. It has been suggested that efficient units could be incentivized by some reward compatible with the level to which their attainment exceeds that of the best of the rest, normally referred to as “super-efficiency”. A recent approach to this issue (Varmaz et. al. 2013) has used Data Envelopment Analysis (DEA) models to measure the super-efficiency of the whole system of operating units with and without the involvement of each unit in turn in order to provide incentives. We identify shortcomings in this approach and use it as a starting point to develop a new DEA-based system for incentivizing operating units to operate efficiently for the benefit of the aggregate system of units. Data from a small German retail bank is used to illustrate our method.

2016 Quarter 2 Managed Care Ombudsman Program Quarterly Report

This report provides an update on the following items for the first programmatic quarter (July, August and September 2016): • 2nd Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update

2016 Quarter 1 Managed Care Ombudsman Program Quarterly Report

he Managed Care Ombudsman Program provides various services including education and information regarding managed care plans, services, care and processes, advocacy and outreach on behalf of members, and appeals assistance and complaint resolution for members needing assistance with resolving issues with their managed care plan or navigating the managed care system. This report provides an update on the following items for the first programmatic quarter (April, May and June 2016): • 1st Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update

Review of Program Integrity Operations At Six Managed Care Organizations Delivering Medicaid Services under a Contract with the South Carolina Department of Health & Human Services

The State contracted with six managed care organizations to deliver Medicaid managed care at an annual cost of $2.7 billion, representing 10% of the State’s annual budget, to 750,000 Medicaid beneficiaries in South Carolina. This review’s scope and objectives were: Test the six MCOs’ compliance and effective execution of the SCDHHS’s managed care contract “Section 11 - Program Integrity” focusing on the operational components of pre-payment review and post-payment review. Identify opportunities to improve SCDHHS’s biennial managed care contract, contract monitoring, and MCO compliance and effective execution of the contract.

Stylosanthes guianensis cv. BRS Bela managed as organic fodder bank for supplementation of lactation crossbred cows in the Cerrado.

2016

Mitigation of clayey soil compaction managed under no-tillage.

2015

A methodological framework to assess the carbon balance of tropical managed forests.

Background: Managed forests are a major component of tropical landscapes. Production forests as designated by national forest services cover up to 400 million ha, i.e. half of the forested area in the humid tropics. Forest management thus plays a major role in the global carbon budget, but with a lack of unified method to estimate carbon fluxes from tropical managed forests. In this study we propose a new time- and spatially-explicit methodology to estimate the above-ground carbon budget of selective logging at regional scale. Results: The yearly balance of a logging unit, i.e. the elementary management unit of a forest estate, is modelled by aggregating three sub-models encompassing (i) emissions from extracted wood, (ii) emissions from logging damage and deforested areas and (iii) carbon storage from post-logging recovery. Models are parametrised and uncertainties are propagated through a MCMC algorithm. As a case study, we used 38 years of National Forest Inventories in French Guiana, northeastern Amazonia, to estimate the above-ground carbon balance (i.e. the net carbon exchange with the atmosphere) of selectively logged forests. Over this period, the net carbon balance of selective logging in the French Guianan Permanent Forest Estate is estimated to be comprised between 0.12 and 1.33 Tg C, with a median value of 0.64 Tg C. Uncertainties over the model could be diminished by improving the accuracy of both logging damage and large woody necromass decay submodels. Conclusions: We propose an innovating carbon accounting framework relying upon basic logging statistics. This flexible tool allows carbon budget of tropical managed forests to be estimated in a wide range of tropical regions

Reproductive seasonality in Saanen goats managed in southeast Brazil.

The aim of this study was to characterize the reproductive seasonality during the period of one year in Saanen goats managed in southeastern Brazil These results endorse hormonal methods (estrus synchronization and induction of synchronized estrus) or natural (male effect, flushing or light treatment) more appropriate according to the time of year in the region. Saanen goats, managed under tropical climate in southeastern Brazil, have a breeding season set from March until mid-August with the transitional phase to the anestrus in September. It is extends to mid-December at the new one transition phase for the reproductive season in March.

Is Thyroid Stunning Clinically Relevant? A Retrospective Analysis Of 208 Patients.

Current guidelines have advised against the performance of (131)I-iodide diagnostic whole body scintigraphy (dxWBS) to minimize the occurrence of stunning, and to guarantee the efficiency of radioiodine therapy (RIT). The aim of the study was to evaluate the impact of stunning on the efficacy of RIT and disease outcome. This retrospective analysis included 208 patients with differentiated thyroid cancer managed according to a same protocol and followed up for 12-159 months (mean 30 ± 69 months). Patients received RIT in doses ranging from 3,700 to 11,100 MBq (100 mCi to 300 mCi). Post-RIT-whole body scintigraphy images were performed 10 days after RIT in all patients. In addition, images were also performed 24-48 hours after therapy in 22 patients. Outcome was classified as no evidence of disease (NED), stable disease (SD) and progressive disease (PD). Thyroid stunning occurred in 40 patients (19.2%), including 26 patients with NED and 14 patients with SD. A multivariate analysis showed no association between disease outcome and the occurrence of stunning (p = 0.3476). The efficacy of RIT and disease outcome do not seem to be related to thyroid stunning.

[strategies For Integration Of Health Care Practices And Sanitary Surveillance In The Context Of The Implementation Of Rede Cegonha - A Brazilian Mother And Infant Health Care Network].

Mother and infant mortality has been the scope of analysis throughout the history of public health in Brazil and various strategies to tackle the issue have been proposed to date. The Ministry of Health has been working on this and the Rede Cegonha strategy is the most recent policy in this context. Given the principle of comprehensive health care and the structure of the Unified Health System in care networks, it is necessary to ensure the integration of health care practices, among which are the sanitary surveillance actions (SSA). Considering that the integration of health care practices and SSA can contribute to reduce mother and infant mortality rates, this article is a result of qualitative research that analyzed the integration of these actions in four cities in the State of São Paulo/Brazil: Campinas, Indaiatuba, Jaguariúna and Santa Bárbara D'Oeste. The research was conducted through interviews with SSA and maternal health managers, and the data were evaluated using thematic analysis. The results converge with other studies, identifying the isolation of health care practices and SSA. The insertion of SSA in collectively-managed areas appears to be a potential strategy for health planning and implementation of actions in the context under scrutiny.