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.

Creation of a web application for smart park system and parking prediction study for system integration

In the last few years, we have observed an exponential increasing of the information systems, and parking information is one more example of them. The needs of obtaining reliable and updated information of parking slots availability are very important in the goal of traffic reduction. Also parking slot prediction is a new topic that has already started to be applied. San Francisco in America and Santander in Spain are examples of such projects carried out to obtain this kind of information. The aim of this thesis is the study and evaluation of methodologies for parking slot prediction and the integration in a web application, where all kind of users will be able to know the current parking status and also future status according to parking model predictions. The source of the data is ancillary in this work but it needs to be understood anyway to understand the parking behaviour. Actually, there are many modelling techniques used for this purpose such as time series analysis, decision trees, neural networks and clustering. In this work, the author explains the best techniques at this work, analyzes the result and points out the advantages and disadvantages of each one. The model will learn the periodic and seasonal patterns of the parking status behaviour, and with this knowledge it can predict future status values given a date. The data used comes from the Smart Park Ontinyent and it is about parking occupancy status together with timestamps and it is stored in a database. After data acquisition, data analysis and pre-processing was needed for model implementations. The first test done was with the boosting ensemble classifier, employed over a set of decision trees, created with C5.0 algorithm from a set of training samples, to assign a prediction value to each object. In addition to the predictions, this work has got measurements error that indicates the reliability of the outcome predictions being correct. The second test was done using the function fitting seasonal exponential smoothing tbats model. Finally as the last test, it has been tried a model that is actually a combination of the previous two models, just to see the result of this combination. The results were quite good for all of them, having error averages of 6.2, 6.6 and 5.4 in vacancies predictions for the three models respectively. This means from a parking of 47 places a 10% average error in parking slot predictions. This result could be even better with longer data available. In order to make this kind of information visible and reachable from everyone having a device with internet connection, a web application was made for this purpose. Beside the data displaying, this application also offers different functions to improve the task of searching for parking. The new functions, apart from parking prediction, were: - Park distances from user location. It provides all the distances to user current location to the different parks in the city. - Geocoding. The service for matching a literal description or an address to a concrete location. - Geolocation. The service for positioning the user. - Parking list panel. This is not a service neither a function, is just a better visualization and better handling of the information.

Managing innovation complexity: About the co-existence of innovation types

The purpose of this study is to contribute to the changing innovation management literature by providing an overview of different innovation types and organizational complexity factors. Aiming at a better understanding of effective innovation management, innovation and complexity are related to the formulation of an innovation strategy and interaction between different innovation types is further explored. The chosen approach in this study is to review the existing literature on different innovation types and organizational complexity factors in order to design a survey which allows for statistical measurement of their interactions and relationships to innovation strategy formulation. The findings demonstrate interaction between individual innovation types. Additionally, organizational complexity factors and different innovation types are significantly related to innovation strategy formulation. In particular, more closed innovation and incremental innovation positively influence the likelihood of innovation strategy formulation. Organizational complexity factors have an overall negative influence on innovation strategy formulation. In order to define best practices for innovation management and to guide managerial decision making, organizations need to be aware of the co-existence of different innovation types and formulate an innovation strategy to more closely align their innovation objectives.

Pedestrian Priority Zones in the Context of Urban Mobility and Valorization of Public Space

The second half of the XX century was marked by a great increase in the number of people living in cities. Urban agglomerations became poles of attraction for migration flows and these phenomena, coupled with growing car-ownership rates, resulted in the fact that modern transport systems are characterized by large number of users and traffic modes. The necessity to organize these complex systems and to provide space for different traffic modes changed the way cities look. Urban areas had to cope with traffic flows, and as a result nowadays typical street pattern consists of a road for motorized vehicles, a cycle lane (in some cases), pavement for pedestrians, parking and a range of crucial signage to facilitate navigation and make mobility more secure. However, this type of street organization may not be desirable in certain areas, more specifically, in the city centers. Downtown areas have always been places where economic, leisure, social and other types of facilities are concentrated, not surprisingly, they often attract large number of people and this frequently results in traffic jams, air and noise pollution, thus creating unpleasant environment. Besides, excessive traffic signage in central locations can harm the image and perception of a place, this relates in particular to historical centers with architectural heritage.

PV systems linked to the grid: parameter identification with a heuristic procedure

This paper focuses on a PV system linked to the electric grid by power electronic converters, identification of the five parameters modeling for photovoltaic systems and the assessment of the shading effect. Normally, the technical information for photovoltaic panels is too restricted to identify the five parameters. An undemanding heuristic method is used to find the five parameters for photovoltaic systems, requiring only the open circuit, maximum power, and short circuit data. The I–V and the P–V curves for a monocrystalline, polycrystalline and amorphous photovoltaic systems are computed from the parameters identification and validated by comparison with experimental ones. Also, the I–V and the P–V curves under the effect of partial shading are obtained from those parameters. The modeling for the converters emulates the association of a DC–DC boost with a two-level power inverter in order to follow the performance of a testing commercial inverter employed on an experimental system.

Diversity and dynamics of airborne fungi in São Luis, State of Maranhão, Brazil

Introduction: This study aimed to identify airborne fungi in São Luis, Maranhão, Brazil, to determine the prevalent genera and to correlate these genera with the area and season. Methods: In total, 1,510 colony-forming units (CFUs) of airborne fungi were isolated from the north, south, east and west sides and from the center of the city from January to December 2007. The samples were collected on Petri dishes that were exposed to the fungi by the gravitational method. Results: Twenty genera of fungi were isolated; the most common were Aspergillus (33.5%), Penicillium (18.8%), Cladosporium (14.2%), Curvularia (10.6%) and Fusarium (7.6%). The CFUs of the fungi were statistically significant (p < 0.0001). Fungal biological diversity was present all year, without any large seasonal variations but with slight increases in May, August and September. Conclusions: The fungal genera identified in this study were correlated with natural systems and could be useful when evaluating the impact of environmental changes on the region.

Development and application of NMR techniques to study water-in-CO2 microemulsions

Self-assembly is a phenomenon that occurs frequently throughout the universe. In this work, two self-assembling systems were studied: the formation of reverse micelles in isooctane and in supercritical CO2 (scCO2), and the formation of gels in organic solvents. The goal was the physicochemical study of these systems and the development of an NMR methodology to study them. In this work, AOT was used as a model molecule both to comprehensively study a widely researched system water/AOT/isooctane at different water concentrations and to assess its aggregation in supercritical carbon dioxide at different pressures. In order to do so an NMR methodology was devised, in which it was possible to accurately determine hydrodynamic radius of the micelle (in agreement with DLS measurements) using diffusion ordered spectroscopy (DOSY), the micellar stability and its dynamics. This was mostly assessed by 1H NMR relaxation studies, which allowed to determine correlation times and size of correlating water molecules, which are in agreement with the size of the shell that interacts with the micellar layer. The encapsulation of differently-sized carbohydrates was also studied and allowed to understand the dynamics and stability of the aggregates in such conditions. A W/CO2 microemulsion was prepared using AOT and water in scCO2, with ethanol as cosurfactant. The behaviour of the components of the system at different pressures was assessed and it is likely that above 130 bar reverse microemulsions were achieved. The homogeneity of the system was also determined by NMR. The formation of the gel network by two small molecular organogelators in toluene-d8 was studied by DOSY. A methodology using One-shot DOSY to perform the spectra was designed and applied with success. This yielded an understanding about the role of the solvent and gelator in the aggregation process, as an estimation of the time of gelation.

Cultural journalism in a digital environment : new models, practices and possibilities

Both culture coverage and digital journalism are contemporary phenomena that have undergone several transformations within a short period of time. Whenever the media enters a period of uncertainty such as the present one, there is an attempt to innovate in order to seek sustainability, skip the crisis or find a new public. This indicates that there are new trends to be understood and explored, i.e., how are media innovating in a digital environment? Not only does the professional debate about the future of journalism justify the need to explore the issue, but so do the academic approaches to cultural journalism. However, none of the studies so far have considered innovation as a motto or driver and tried to explain how the media are covering culture, achieving sustainability and engaging with the readers in a digital environment. This research examines how European media which specialize in culture or have an important cultural section are innovating in a digital environment. Specifically, we see how these innovation strategies are being taken in relation to the approach to culture and dominant cultural areas, editorial models, the use of digital tools for telling stories, overall brand positioning and extensions, engagement with the public and business models. We conducted a mixed methods study combining case studies of four media projects, which integrates qualitative web features and content analysis, with quantitative web content analysis. Two major general-interest journalistic brands which started as physical newspapers – The Guardian (London, UK) and Público (Lisbon, Portugal) – a magazine specialized in international affairs, culture and design – Monocle (London, UK) – and a native digital media project that was launched by a cultural organization – Notodo, by La Fábrica – were the four case studies chosen. Findings suggest, on one hand, that we are witnessing a paradigm shift in culture coverage in a digital environment, challenging traditional boundaries related to cultural themes and scope, angles, genres, content format and delivery, engagement and business models. Innovation in the four case studies lies especially along the product dimensions (format and content), brand positioning and process (business model and ways to engage with users). On the other hand, there are still perennial values that are crucial to innovation and sustainability, such as commitment to journalism, consistency (to the reader, to brand extensions and to the advertiser), intelligent differentiation and the capability of knowing what innovation means and how it can be applied, since this thesis also confirms that one formula doesn´t suit all. Changing minds, exceeding cultural inertia and optimizing the memory of the websites, looking at them as living, organic bodies, which continuously interact with the readers in many different ways, and not as a closed collection of articles, are still the main challenges for some media.

Semantic adaptability for the systems interoperability

In the current global and competitive business context, it is essential that enterprises adapt their knowledge resources in order to smoothly interact and collaborate with others. However, due to the existent multiculturalism of people and enterprises, there are different representation views of business processes or products, even inside a same domain. Consequently, one of the main problems found in the interoperability between enterprise systems and applications is related to semantics. The integration and sharing of enterprises knowledge to build a common lexicon, plays an important role to the semantic adaptability of the information systems. The author proposes a framework to support the development of systems to manage dynamic semantic adaptability resolution. It allows different organisations to participate in a common knowledge base building, letting at the same time maintain their own views of the domain, without compromising the integration between them. Thus, systems are able to be aware of new knowledge, and have the capacity to learn from it and to manage its semantic interoperability in a dynamic and adaptable way. The author endorses the vision that in the near future, the semantic adaptability skills of the enterprise systems will be the booster to enterprises collaboration and the appearance of new business opportunities.

The emergence of product certification systems as trade barriers

This paper addresses the growing difficulties automobile manufacturers face within their after sales business: an increasing number of trade obstacles set up by import countries discriminates against the foreign suppliers and impedes the international sales of genuine parts. The purpose of the study is to explore the emergence of trade restrictive product certification systems, which affect spare parts exports of automobile manufacturers. The methodology used includes review of the literature and an empirical study based on qualitative interviews with representatives of major stakeholders of the automotive after sales business. Relevant key drivers, which initiate the introduction of technical regulations in importing countries, are identified and analysed to evaluate their effect on the emerging trade policy. The analysis of the key drivers outlines that several interacting components, such as the global competitiveness of the country, macroeconomic and microeconomic factors, and certain country-specific variables induce trade restrictive product certification systems. The findings allow for an early detection of the emergence of product certification systems and provide a means to early recognise the risks and opportunities for the sales of automotive spare parts in the automakers’ target markets. This allows the manufacturers to react immediately and adapt in time to the upcoming changes.

Assessment of overlay masonry strengthening system under in-plane monotonic and cyclic loading using the diagonal tensile test

The development of novel strengthening techniques to address the seismic vulnerability of masonry elements is gradually leading to simpler, faster and more effective strengthening strategies. In particular, the use of fabric reinforced cementitious matrix systems is considered of great potential, given the increase of ductility achieved with simple and economic strengthening procedures. To assess the effectiveness of these strengthening systems, and considering that the seismic action is involved, one important component of the structural behaviour is the in-plane cyclic response. In this work is discussed the applicability of the diagonal tensile test for the assessment of the cyclic response of strengthened masonry. The results obtained allowed to assess the contribution of the strengthening system to the increase of the load carrying capacity of masonry elements, as well as to evaluate the damage evolution and the stiffness degradation mechanisms developing under cyclic loading.

Information systems assessment in pathologic anatomy service

Information technologies changed the way of how the health organizations work, contributing to their effectiveness, efficiency and sustainability. Hospital Information Systems (HIS) are emerging on all of health institutions, helping health professionals and patients. However, HIS are not always implemented and used in the best way, leading to low levels of benefits and acceptance by users of these systems. In order to mitigate this problem, it is essential to take measures able to ensure if the HIS and their interfaces are designed in a simple and interactive way. With this in mind, a study to measure the user satisfaction and their opinion was made. It was applied the Technology Acceptance Model (TAM) on a HIS implemented on various hospital centers (AIDA), being used the Pathologic Anatomy Service. The study identified weakness and strengths features of AIDA and it pointed some solutions to improve the medical record.

Pervasive business intelligence platform to improve the quality of decision process in primary and secondary education – A Portuguese case study

Business Intelligence (BI) can be seen as a method that gathers information and data from information systems in order to help companies to be more accurate in their decision-making process. Traditionally BI systems were associated with the use of Data Warehouses (DW). The prime purpose of DW is to serve as a repository that stores all the relevant information required for making the correct decision. The necessity to integrate streaming data became crucial with the need to improve the efficiency and effectiveness of the decision process. In primary and secondary education, there is a lack of BI solutions. Due to the schools reality the main purpose of this study is to provide a Pervasive BI solution able to monitoring the schools and student data anywhere and anytime in real-time as well as disseminating the information through ubiquitous devices. The first task consisted in gathering data regarding the different choices made by the student since his enrolment in a certain school year until the end of it. Thereafter a dimensional model was developed in order to be possible building a BI platform. This paper presents the dimensional model, a set of pre-defined indicators, the Pervasive Business Intelligence characteristics and the prototype designed. The main contribution of this study was to offer to the schools a tool that could help them to make accurate decisions in real-time. Data dissemination was achieved through a localized application that can be accessed anywhere and anytime.