Integrated care approaches and skills mix policies in Europe

ABSTRACT - Background: Integration of health care services is emerging as a central challenge of health care delivery, particularly for patients with elderly and complex chronic conditions. In 2003, the World Health Organization (WHO) already began to identify it as one of the key pathways to improve primary care. In 2005, the European Commission declared integrated care as vital for the sustainability of social protection systems in Europe. Nowadays, it is recognized as a core component of health and social care reforms across European countries. Implementing integrated care requires coordination between settings, organizations, providers and professionals. In order to address the challenge of integration in such complex scenario, an effective workforce is required capable of working across interdependent settings. The World Health Report 2006 noted that governments should prepare their workforce and explore what tasks the different levels of health workers are trained to do and are capable of performing (skills mix). Comparatively to other European countries, Portugal is at an early stage in what integrated care is concerned facing a growing elderly population and the subsequent increase in the pressure on institutions and professionals to provide social and medical care in the most cost-effective way. In 2006 the Portuguese government created the Portuguese Network for Integrated Care Development (PNICD) to solve the existing long-term gap in social support and healthcare. On what concerns health workforce, the Portuguese government already recognized the importance of redefine careers keeping professional motivation and satisfaction. Aim of the study: This study aims to contribute new evidence to the debate surrounding integrated care and skills mix policies in Europe. It also seeks to provide the first evidence that incorporates both the current dynamics of implementing integrated care in Portugal and the developments of international literature. The first ambition of our study is to contribute to the growing interest in integrated care and to the ongoing research in this area by identifying its different approaches and retrieve a number of experiences in some European countries. Our second goal of this research is to produce an update on the knowledge developed on skills mix to the international healthcare management community and to policy makers involved in reforming healthcare systems and organizations. To better inform Portuguese health policies makers in a third stage we explore the current dynamics of implementing integrated care in Portugal and contextualize them with the developments reported in the international literature. Methodology: This is essentially an exploratory and descriptive study using qualitative methodology. In order to identify integrated care approaches in Europe, a systematic literature review was undertaken which resulted in a paper published in the Journal of Management and Marketing in Health care titled: Approaches to developing integrated care in Europe: a systematic literature review. This article was recommended and included into a list of references identified by The King's Fund Library. A second systematic literature review was undertaken which resulted in a paper published in the International Journal of Healthcare Management titled: Skills mix in healthcare: An international update for the management debate. Semi-structured interviews were performed on experts representing the regional coordination teams of the Portuguese Network for Integrated Care Development. In a last stage a questionnaire survey was developed based on the findings of both systematic literature reviews and semi-structured interviews. Conclusions: Even though integrated care is a worldwide trend in health care reforms, there is no unique definition. Definitions can be grouped according to their sectorial focus: community-based care, combined health and social care, combined acute and primary care, the integration of providers, and in a more comprehensive approach the whole health system. Indeed, models that seek to apply the principles of integrated care have a similar background and are continually evolving and depend on the different initiatives taken at national level. . Despite the fact that we cannot argue that there is one single set typology of models for integrated care, it is possible to identify and categorize some of the basic approaches that have been taken in attempts to implement integrated care according to: changes in organizational structure, workforce reconfiguring, and changes in the financing system. The systematic literature review on skills mix showed that despite the widely acknowledged interest on skills mix initiatives there is a lack of evidence on skills mix implications, constraints, outcomes, and quality impact that would allow policy makers to take sustained and evidence-based decisions. Within the Portuguese health system, the integrated care approach is rather organizational and financial, whereas little attention is given to workforce integration. On what concerns workforce planning Portugal it is still in the stage of analyzing the acceptability of health workforce skills mix. In line with the international approaches, integration of health and social services and bridging primary and acute care are the main goals of the national government strategy. The findings from our interviews clarify perceptions which show no discrepancy with the related literature but are rather scarce comparing to international experience. Informants hold a realistic but narrow view of integrated care related issues. They seem to be limited to the regional context, requiring a more comprehensive perspective. The questionnaire developed in this thesis is an instrument which, when applied, will allow policy makers to understand the basic set of concepts and managerial motivations behind national and regional integrated care programs. The instrument developed can foster evidence on the three essential components of integrated care policies: organizational, financial, and human resources development, and can give additional input on the context in which integrated care is being developed, the type of providers and organizations involved, barriers and constraints, and the workforce skills mix planning related strategies. The thesis was successful in recognizing differences between countries and interventions and the instrument developed will allow a better comprehension of the international options available and how to address the vital components of integrated care programs.

Gas tungsten arc welding of NiTi shape memory alloy

Shape memory alloys are characterized by the ability of recovering their initial shape after being deformed and by superelasticity. Since the discovery of these alloys, a new field of interest emerged not only for the scientific community but also to many industries. However, these alloys present poor machinability which constitute a constrain in the design of complex components for new applications. Thus, the demand for joining techniques able to join these alloys without compromising their properties became of great importance to enlarge the complexity of existing applications. Literature shows that these alloys are joined mainly using laser welding. In the present study, similar NiTi butt joints, were produced using TIG welding. The welds were performed in 1.5 mm thick plates across the rolling direction. A special fixture and gas assist device was designed and manufactured. Also a robot arm was adapted to accommodate the welding torch to assure the repeatability of the welding parameters. Welds were successfully achieved without macroscopic defects, such as pores and distortions. Very superficial oxidation was seen on the top surface due to insufficient shielding gas flow on the weld face. The welded joints were mechanically tested and structurally characterized. Testing methods were used to evaluate macro and microstructure, as well as the phase transformation temperatures, the mechanical single and cyclic behaviour and the shape recovery ability. Differential Scanning Calorimetry (DSC), Scanning Electron Microscopy (SEM), Energy Dispersive Spectroscopy (EDS), microhardness measurements were techniques also used to evaluate the welded joints. A depletion in Ni in the fusion zone was seen, as well as a shift in Ms temperature. For strain values of 4% the accumulated irrecoverable strain was of about 30% and increased with the strain imposed during cycling. Nevertheless, a complete recovery of initial shape was observed when testing the shape memory effect on a dedicated device that introduces a deformation of 6.7%. That is, the welding procedure does not remove the ability of the specimens to recover their initial shape.

Toxicity of carcinogenic and non-carcinogenic Polycyclic Aromatic Hydrocarbons and their mixtures to aquatic organisms under ecologically-relevant scenarios

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous priority pollutants that tend to be trapped in aquatic sediments due to their high hydrophobicity. Nonetheless, the differential toxicological effects and mechanisms between the various classes of PAHs and their mixtures, as they invariably occur in the environment, are scarcely known, especially under ecologically-relevant scenarios. This thesis aimed at establishing a bridge between the study of mechanistic pathways and environmental monitoring of carcinogenic and non-carcinogenic PAHs, by introducing ecological-relevance in the research with model PAHs. A first bioassay conducted in situ with the mussel Mytilus edulis demonstrated that, dredging operations in harbours increase PAH bioavailability, eliciting genotoxicity, and showed that established environmental guidelines underestimate risk. Subsequent ex situ bioassays were performed with the carcinogenic benzo[b]fluoranthene (B[b]F) and non-carcinogenic phenantrene (Phe), selected following preceding results, and revealed that low-moderate concentrations of these PAHs in spiked sediments induce genotoxic effects to the clam Ruditapes decussatus, therefore contradicting the general notion that bivalves are less sensitive to PAHs than vertebrates due to inefficient bioactivation. Also, it was demonstrated that passive samplers permit inferring on PAH bioavailability but not on bioaccumulation or toxic effects. On the other hand, sea basses (Dicentrarchus labrax), yielded a complex pattern of effects and responses, relatively to genotoxicity, oxidative stress and production of specific metabolites, especially when exposed to mixtures of the PAHs which led to additive, if not synergistic, effects. It was shown that Phe may elicit significant genotoxicity especially in presence of B[b]F, even though the low, albeit realistic, exposure concentrations diluted dose- and time-independent relationships. The present work demonstrated that environmental quality guidelines underestimate the effects of PAHs in realistic scenarios and showed that the significant genotoxic and histopathological effects caused by mixed PAHs may not be reflected by oxidative stress- or CYP-related biomarkers. Besides important findings on the metabolism of PAH mixtures, the work calls for the need to re-evaluate the criteria for assessing risk and for the disclosure of more efficient indicators of toxicological hazard.

Novel ready-to-eat mango product using gellan gum as gelling agent: physico-chemical, microbial and sensory characteristics

Este trabalho foi efectuado com o apoio da Universidade de Lisboa, Instituto Superior de Agronomia com o Centro de Engenharia dos Biossistemas (CEER

Al-doped ZnO ceramic sputtering targets based on nanocrystalline powders produced by emulsion detonation synthesis – deposition and application as a transparent conductive oxide material

Transparent conducting oxides (TCOs) have been largely used in the optoelectronic industry due to their singular combination of low electrical resistivity and high optical transmittance. They are usually deposited by magnetron sputtering systems being applied in several devices, specifically thin film solar cells (TFSCs). Sputtering targets are crucial components of the sputtering process, with many of the sputtered films properties dependent on the targets characteristics. The present thesis focuses on the development of high quality conductive Al-doped ZnO (AZO) ceramic sputtering targets based on nanostructured powders produced by emulsion detonation synthesis method (EDSM), and their application as a TCO. In this sense, the influence of several processing parameters was investigated from the targets raw-materials synthesis to the application of sputtered films in optoelectronic devices. The optimized manufactured AZO targets present a final density above 99 % with controlled grain size, an homogeneous microstructure with a well dispersed ZnAl2O4 spinel phase, and electrical resistivities of ~4 × 10-4 Ωcm independently on the Al-doping level among 0.5 and 2.0 wt. % Al2O3. Sintering conditions proved to have a great influence on the properties of the targets and their performance as a sputtering target. It was demonstrated that both deposition process and final properties of the films are related with the targets characteristics, which in turn depends on the initial powder properties. In parallel, the influence of several deposition parameters in the film´s properties sputtered from these targets was investigated. The sputtered AZO TCOs showed electrical properties at room temperature that are superior to simple oxides and comparable to a reference TCO – indium tin oxide (ITO), namely low electrical resistivity of 5.45 × 10-4 Ωcm, high carrier mobility (29.4 cm2V-1s-1), and high charge carrier concentration (3.97 × 1020 cm-3), and also average transmittance in the visible region > 80 %. These superior properties allowed their successful application in different optoelectronic devices.

Microstructural changes befor macroeconomic announcements: Predictability of economic surprises in the U.S. market

Flow of new information is what produces price changes, understanding if the market is unbalanced is fundamental to know how much inventory market makers should keep during an important economic release. After identifying which economic indicators impact the S&P and 10 year Treasuries. The Volume Synchronized Probability of Information-Based Trading (VPIN) will be used as a predictability measure. The results point to some predictability power over economic surprises of the VPIN metric, mainly when calculated using the S&P. This finding appears to be supported when analysing depth imbalance before economic releases. Inferior results were achieved when using treasuries. The final aim of this study is to fill the gap between microstructural changes and macroeconomic events.

The names of things: terminology and the practice of art history

This paper aims to explore the ways in which standard art history terminology shapes the practice of art history by conditioning the interpretation of specific works of art and, in certain cases, the definition of a research subject (especially where questions of genre and periodization are concerned). Taking as a case study a painting by Georges de La Tour, the Peasant Couple Eating, I will argue that terms such as realism, realistic, naturalistic etc. used for its description and/or interpretation, far from constituting objective stylistic characterizations, shape our perception of the work in question. Bringing the question of social class to the center of the discourse on realism, I propose to show how the social divide between the painter and his subject matter (in this case, the peasants) is internalized in the painting’s style and meaning, and how it is fundamental for the understanding of its intentionality and function.

Eggs and eggshells of Crocodylomorpha from the Upper Jurassic of Portugal

Crocodylomorph eggs are relatively poorly known in the fossil record when compared with skeletal remains, which are found all over the world, or when compared with dinosaur eggs. Herein are described crocodiloid eggshells from the Upper Jurassic Lourinhã Formation of Portugal, recovered from five sites: Cambelas (clutch), Casal da Rola, Peralta (eggshell fragments), and Paimogo North and South (three partial crushed eggs and eggshell fragments). The clutch of Cambelas, composed of 13 eggs, is the only sample not found in association with dinosaur eggshells. Morphological characters of the eggshells described herein, such as shell units and microstructure, are consistent with the crocodiloid morphotype. As such, this material is assigned to the oofamily Krokolithidae, making them the oldest known crocodylomorph eggs so far and the best record for eggs of non-crocodylian crocodylomorphs. Two new ootaxa are erected, Suchoolithus portucalensis oogen. et oosp. nov, for the clutch of Cambelas, and Krokolithes dinophilus, oosp. nov., for the remaining eggshells. The basic structure of crocodilian eggshells has remained stable since at least the Late Jurassic. Additionally, the findings suggest previously unknown biological associations with contemporary archosaurs, shedding light on the poorly understood egg morphology, reproduction strategies and paleobiology of crocodylomorphs during the Late Jurassic.

Lexicultura na Língua Chinesa e na Lexicografia Bilingue de Chinês-Português

No contexto de internacionalização de hoje, acompanhando os contactos cada vez mais intensos entre o mundo chinês e o mundo lusófono, é exigida a maior atenção à questão da lexicultura na comunicação interlingual e intercultural, pois o que preocupa as partes envolvidas não é apenas descodificar os signos meramente linguísticos, mas também perceber a cultura que a língua, nomeadamente as unidades lexicais transportam, visando um comportamento culturalmente correto e adequado nessa comunicação. Partindo desta preocupação, este trabalho tenta, através da abordagem e análise da língua, da escrita e do léxico chineses, comprovar que o chinês, devido às suas peculiaridades inexistentes em outras línguas do mundo, constitui o vivo exemplo que exemplifica e alarga o conceito de lexicultura, pois a própria língua, sobretudo a sua escrita e as suas unidades lexicais, além de refletirem a cultura popular e partilhada, também contam verdadeiras histórias da Humanidade e da China. Baseando-se nesta abordagem e análise, a tese apresenta um novo modelo de dicionário cultural chinês-português, com propostas concretas de seleção de vedetas para a sua macroestrutura e de definição de vedetas na sua microestrutura, ao serviço da comunicação entre os dois mundos em questão.

Professores realistas: mais eficazes e otimistas

A indisciplina na sala de aula prejudica o ensino e a aprendizagem sendo uma das principais causas do mal-estar dos professores, roubando-lhes energia e tempo conduzindo, muitos deles, à exaustão física e emocional e apresenta-se como um sério problema quer para professores principiantes, quer para professores experientes. A análise do ensino na perspetiva interpessoal possibilita uma nova visão sobre o ambiente de aprendizagem, nomeadamente no que se refere à relação professor-aluno. Nesta perspetiva, o enfoque dirige-se para a análise das perceções dos alunos sobre o comportamento do professor e o impacto que o mesmo tem sobre os alunos. Além de que, ao considerar-se a turma como um sistema deve ter-se em conta que o comportamento não pode ser visto como uma característica da pessoa mas, sim, como uma característica do sistema formado por aqueles que estão envolvidos na interação comunicacional. Analisar as interações comunicacionais à luz da pragmática da comunicação e dos seus cinco axiomas apresenta-se como um poderoso quadro clarificador de muitos dos comportamentos ditos disruptivos, possibilitando aos professores um “novo olhar” sobre o seu papel enquanto gestores da sala de aula. A formação realista de professores apresenta-se como uma estratégia com efeitos muito positivos uma vez que possibilita e ajuda-os a compreenderem o processo de circularidade característico da turma vista como um sistema. Por outro lado, permite evidenciar a impossibilidade dos professores de solucionarem os problemas disciplinares culpabilizando os alunos. Dito de outro modo, a formação realista conduz os professores a um (re) equacionar das suas práticas encorajando-os a selecionarem um comportamento interpessoal mais adequado. No 1º e 3º período letivo, os professores participantes (N= 15) responderam ao Questionário de Interação do Professor (Q.I.P.) e ao Questionário do Otimismo Académico (Q.O.A.) composto por três subescalas: Autoeficácia, Confiança nos alunos e famílias e Ênfase académica. Paralelamente, foram gravadas em suporte vídeo quatro aulas de cada professor, referentes a duas turmas selecionadas previamente pelos mesmos. Após a observação das suas aulas refletiram por escrito aquilo que observaram. No 2º período, participaram numa ação de formação intitulada “Ecologia da sala de aula: relacionamento interpessoal professor-aluno e a criação de ambientes de aprendizagem positivos” baseada no modelo realista de formação de professores. Desta formação resultou um conjunto de relatórios reflexivos que tiveram por objetivo desenvolver nos participantes a sua competência reflexiva, questionarem crenças tidas como inquestionáveis e otimizar a relação professor-aluno. A partir dos resultados obtidos pode afirmar-se que: 1) verificou-se um aumento no otimismo académico e no sentimento de autoeficácia; 2) observou-se um impacto nas conceções prévias, bem como no contexto organizacional.

Sustainable mortars with incorporation of microencapsulated phase change materials

The construction industry is responsible for high energy and raw materials consumption. Thus, it is important to minimize the high energy consumption by taking advantage of renewable energy sources and reusing industrial waste, decreasing the extraction of natural materials. The mortars with incorporation of phase change materials (PCM) have the ability to regulate the temperature inside buildings, contributing to the thermal comfort and reduction of the use of heating and cooling equipment, using only the energy supplied by the sun. The simultaneous incorporation of PCM and fly ash (FA) can reduce the energy consumption and the amount of materials landfilled. However, the addition of these materials in mortars modifies its characteristics. The main purpose of this study was the production and characterization in the fresh and hardened state of mortars with incorporation of different contents of PCM and FA. The binders studied were aerial lime, hydraulic lime, gypsum and cement. The proportion of PCM studied was 0%, 20%, 40% and 60% of the mass of the sand. The content of fly ash added to the mortars was 0%, 20%, 40% and 60% of the mass of the binder. It was possible to observe that the incorporation of PCM and fly ash in mortars caused differences in properties such as workability, microstructure, water absorption, compressive strength, flexural strength and adhesion.

Analysis and strengthening of carpentry joints

Joints play a major role in the structural behaviour of old timber frames [1]. Current standards mainly focus on modern dowel-type joints and usually provide little guidance (with the exception of German and Swiss NAs) to designers regarding traditional joints. With few exceptions, see e.g. [2], [3], [4], most of the research undertaken today is mainly focused on the reinforcement of dowel-type connections. When considering old carpentry joints, it is neither realistic nor useful to try to describe the behaviour of each and every type of joint. The discussion here is not an extra attempt to classify or compare joint configurations [5], [6], [7]. Despite the existence of some classification rules which define different types of carpentry joints, their applicability becomes difficult. This is due to the differences in the way joints are fashioned depending, on the geographical location and their age. In view of this, it is mandatory to check the relevance of the calculations as a first step. This first step, to, is mandatory. A limited number of carpentry joints, along with some calculation rules and possible strengthening techniques are presented here.

A model to simulate the moment-rotation and crack width of FRC members reinforced with longitudinal bars

The present work describes a model for the determination of the moment–rotation relationship of a cross section of fiber reinforced concrete (FRC) elements that also include longitudinal bars for the flexural reinforcement (R/FRC). Since a stress–crack width relationship (σ–w)(σ–w) is used to model the post-cracking behavior of a FRC, the σ–w directly obtained from tensile tests, or derived from inverse analysis applied to the results obtained in three-point notched beam bending tests, can be adopted in this approach. For a more realistic assessment of the crack opening, a bond stress versus slip relationship is assumed to simulate the bond between longitudinal bars and surrounding FRC. To simulate the compression behavior of the FRC, a shear friction model is adopted based on the physical interpretation of the post-peak compression softening behavior registered in experimental tests. By allowing the formation of a compressive FRC wedge delimited by shear band zones, the concept of concrete crushing failure mode in beams failing in bending is reinterpreted. By using the moment–rotation relationship, an algorithm was developed to determine the force–deflection response of statically determinate R/FRC elements. The model is described in detail and its good predictive performance is demonstrated by using available experimental data. Parametric studies were executed to evidence the influence of relevant parameters of the model on the serviceability and ultimate design conditions of R/FRC elements failing in bending.

Durability indicators comparison for SCC and CC in tropical coastal environments

Self-compacting concrete (SCC) demands more studies of durability at higher temperatures when subjected to more aggressive environments in comparison to the conventional vibrated concrete (CC). This work aims at presenting results of durability indicators of SCC and CC, having the same water/binder relations and constituents. The applied methodologies were electrical resistivity, diffusion of chloride ions and accelerated carbonation experiments, among others, such as microstructure study, scanning electron microscope and microtomography experiments. The tests were performed in a research laboratory and at a construction site of the Pernambuco Arena. The obtained results shows that the SCC presents an average electrical resistivity 11.4% higher than CC; the average chloride ions diffusion was 63.3% of the CC; the average accelerated carbonation penetration was 45.8% of the CC; and the average open porosity was 55.6% of the CC. As the results demonstrated, the SCC can be more durable than CC, which contributes to elucidate the aspects related to its durability and consequent prolonged life cycle.

Using customer lifetime value to improve the prediction of bank deposit subscription in telemarketing campaigns

Customer lifetime value (LTV) enables using client characteristics, such as recency, frequency and monetary (RFM) value, to describe the value of a client through time in terms of profitability. We present the concept of LTV applied to telemarketing for improving the return-on-investment, using a recent (from 2008 to 2013) and real case study of bank campaigns to sell long- term deposits. The goal was to benefit from past contacts history to extract additional knowledge. A total of twelve LTV input variables were tested, un- der a forward selection method and using a realistic rolling windows scheme, highlighting the validity of five new LTV features. The results achieved by our LTV data-driven approach using neural networks allowed an improvement up to 4 pp in the Lift cumulative curve for targeting the deposit subscribers when compared with a baseline model (with no history data). Explanatory knowledge was also extracted from the proposed model, revealing two highly relevant LTV features, the last result of the previous campaign to sell the same product and the frequency of past client successes. The obtained results are particularly valuable for contact center companies, which can improve pre- dictive performance without even having to ask for more information to the companies they serve.