What Is the Gaokao

In China, applying to college is about one thing and one thing only: the gaokao. Gaokao (é «ËœÃ¨â‚¬Æ') is short for æ™ ®Ã©â‚¬Å¡Ã© «ËœÃ§ ­â€°Ã¥ ­ ¦Ã¦   ¡Ã¦â€¹â€ºÃ§â€Å¸Ã¥â€¦ ¨Ã¥â€º ½Ã§ »Å¸Ã¤ ¸â‚¬Ã¨â‚¬Æ'è ¯â€¢ (â€Å"The National Higher Education Entrance Examination†). A student’s score on this all-important standardized test is pretty much the only thing that matters when it comes to determining whether or not they can go to college—and if they can, which schools they can attend. When Do You Take The Gaokao? The gaokao is held once annually at the end of the school year. Third-year high school students (high school in China lasts three years) generally take the test, although anyone may register for it if they desire to. The test generally lasts for two or three days. What's On The Test? The subjects tested vary by region, but in many regions,  they will include  Chinese language and literature, mathematics, a foreign language (often English), and one or more subjects of the student’s choice. The latter subject depends on the students preferred major in college, for example, Social Studies, Politics, Physics, History, Biology, or Chemistry. The gaokao is especially famous for its sometimes inscrutable essay prompts. No matter how vague or confusing they are, students must respond well if they hope to achieve a good score.   Preparation As you might imagine, preparing for and taking the gaokao is a grueling ordeal. Students are under huge amounts of pressure from their parents and teachers to do well. The final year of high school, especially, is often focused intensely on preparation for the exam. It isn’t unheard of for parents to go so far as quitting their own jobs to help their children study during this year. This pressure has even been linked to some cases of depression and suicide amongst Chinese teens, especially those who perform poorly on the exam. Because the gaokao is so important, Chinese society goes to great lengths to make life easy for test-takers on testing days. Areas around testing sites are often marked as quiet zones. Nearby construction and even traffic  are  sometimes halted while students are taking the test to prevent distractions. Police officers, taxi drivers, and other car owners will often ferry students they see walking the streets to their exam locations for free, to ensure that they are not late for this all-important occasion. Aftermath After the exam is over, local essay questions are often published in the newspaper, and occasionally become hotly-debated topics. At some point (it varies by region), students are asked to list the colleges and universities they prefer in several tiers. Ultimately, whether they are accepted or rejected will be determined based on their gaokao score. Because of this, students who fail the test and thus cannot attend college will sometimes spend another year studying and  retake  the test the following year. Cheating Because the gaokao is so vitally important, there are always students willing to attempt cheating. With modern technology, cheating has become a veritable arms race between students, the authorities, and enterprising merchants who offer everything from false erasers and rulers to tiny headsets and cameras connected to off-site helpers using the internet to scan questions and feed you answers. Authorities now often outfit test sites with a variety of signal-blocking electronic devices, but cheating devices of various sorts are still readily available to those foolish or unprepared enough to attempt using them. Regional Bias The gaokao system has also been accused of regional bias. Schools often set quotas for the number of students they will take from each province, and students from their home province have more available spaces than students from remote provinces. Since the best schools, both high schools and colleges, are mostly in cities like Beijing and Shanghai, this effectively means that students lucky enough to live in those areas are better prepared to take the gaokao and are able to enter China’s top universities with a lower score than would be needed by students from other provinces. For example, a student from Beijing might be able to get into Tsinghua University (which is located in Beijing and is former president Hu Jintao’s alma mater) with a lower gaokao score than would be necessary for a student from Inner Mongolia. Another factor is that because each province administers its own version of the gaokao, the test is sometimes demonstrably harder in some areas than others.

Sympathetic or Antisympathetic Essay - 509 Words

In Henrik Ibsens A Dolls House, Nora starts out as sympathetic person, making decisions based upon the welfare of only others, and never herself. She is a caring, na#239;ve and loving person, making it easy to forgive her for her faults. As the story proceeds her motives are questioned, and so is the idea of whether or not she is still a sympathetic character. Previous to the opening of the play, Nora makes the decision to get a loan without Torvalds knowledge so that he can go to Italy and improve his health, showing compassion and love for her husband. Noras aquiring the loan with her father as a guarantor, shows that she cared enough not to worry her husband with money problems at a time that he needed to heal. Forging her†¦show more content†¦Linde, ...when I am no longer pretty...Torvald no longer loves me as he does now...amuse[s] him... play the fool for him(1497). We do not know when she came upon this realization, but it does not affect her until she acknowledges his reaction to the news of her forgery may be much different than previously expected. This realization creates a devastating blow to her mind, paralleled with her tarantella practice, Not so violently, Nora. (1523). Nora is literally dancing for her life as she is now unsure of Torvalds reaction to the news will be. Chaos overtakes her mind, as she bec omes aware that Torvald would not take the news of her forgery well, yet hangs on to her image of the ideal husband who like herself would do anything for her spouse. Torvalds comment, ...the beautiful apparition disappeared (1528) is the turning point of Noras beautiful character into that of a selfish one. In the end, Nora makes the decision to end her marriage, leave her children, and run away from her problems, showing only self-interest. She forfeits her family for that of her happiness believing what Torvald previously says, an atmosphere of lies contaminates and poisons...breath...children draw...contains the germs of evil (1509). Even though she is aware of his dishonesty, I must try to buy him off (1534), she still leaves her children with their father. Her decision is selfish, and her selfishness is backed up with the factShow MoreRelatedA Brief Note On Osteoporosis And Its Effects2126 Words   |  9 Pages 5-HT directly activates osteoblastic 5-HTRs to inhibit bone formation, whereas centrally it inhibits the sympathetic nervous system, thus alleviating the negative adrenergic tone on osteoblasts. It appears that the negative skeletal effects of peripheral SSRI-induced increase in 5-HT outweighs the skeletal benefits resulting from the enhanced central 5-HT antidepressa nt and antisympathetic activity. Warden et al. researched the impact of 5HTT inhibition on bone by studying an animal model with

Property Law Practice 2013-14 Report on Legal Liability Free Essays

A. Issues: There are a number of issues that arise in the construction project posed, especially if there are not sufficient measures in place to limit legal liability. These issues are: The state of the current site, because it is known to be in an extremely dangerous condition, and this may result in harm to any person that enters the site. We will write a custom essay sample on Property Law Practice 2013-14 Report on Legal Liability or any similar topic only for you Order Now The design of the building has been undertaken by in-house architects. Thus, the potential liability for defective design has to be considered, in relation to the construction. Potential liability for professional negligence may arise, because of the direct contract between ABC and the purchasers and the business leaseholders. There are obligations under the Party Wall etc Act 1996 (PWA 1996), because of the shared party walls between the building and adjoining neighbours. Finally, jib poses a problem, because it may amount to trespass of airspace and there is a potential breach of adjoining neighbours’ right to light. The purpose of this report is to highlight when exclusion clauses and notices cannot be used to limit liability. This will be identified through the obligations that are owed and the potential liability if there has been failure to meet them. In a development this size there are a wide range of potential claimants, as such the report needs to undertake a broad approach to determine potential classes that could result in legal liability for ABC and/or XYZ. The structure of this report is to examine the six different areas of potential advice, in which a summary of advice will be given at the end of each section. Thus, the report will include six standalone mini reports. B. Law of Negligence Vicarious Liability: B.1 Law of Negligence, Latent Damage and Obligation of ABC for its Vicarious Liability for Its Architect: The hiring of an in-house architect may give rise to a future claim of latent damage under the Latent Damage Act 1986 (LDA 1986), breach of contract and if there is harm caused by negligence (Adriaanse, 2010, p. 21). The act of tort will arise if the property causes physical harm, such as falling debris. The liability under tort will begin from the time that the damage is discovered (Pirelli General Cable Works Ltd v Oscar Faber and Partners [1983] 2 AC 1; Dugdale, 2006, p. 197). The same argument applies, if a latent defect is identified with respect to breach of contract. The rationale is if the design and/or the construction are defective then there should not be a limitation of liability, because it was not identifiable until years later (Abbott v Will Gannon Smith [2005] PNLR 30 CA). The case of Invercargill City Council v Hamlin [1996] 1 NZLR 513 identified that the time runs from the point of â€Å"reasonable discoverability†, which means that ABC cannot place a clause in the contract with respect to when potential liability for defect runs. B.2 Negligence and Vicarious Liability – Application to the Leaseholder and Purchaser: The main factor that is highlighted is whether there is actual or reasonable knowledge of the defect for when the purchaser and/or leaseholder can launch a claim for defective property (Murphy v Brentwood DC [1991] 1 AC 398). It is also not possible for ABC and XYZ to exclude liability for latent defect, which is the purpose of the LDA 1986. In addition, defective property may give rise to a breach of warranty, which highlights that there is liability if there is a contract in place. If the negligent harm is purely economic then there needs to be a direct contractual relationship for liability (D F Estates v Church Commissioners for England and Wales [1989] AC 177; Murphy v Brentwood DC). For example, if the negligence is due to the defect of design then this is a pure economic claim. The claim will be allowed when there is a direct relationship between the designer and the person negatively affected by the defect of design (Lowe, 2005, p. 4). The rationale is that the direct relationship creates the duty of care and proximity (McGee, 2000, p. 42). In the case of the purchasers and leaseholders, the direct relationship is created through the sale and lease deeds with ABC. The link between ABC and the architect is that he/she is an in house employee, thus there is vicarious liability. B.3 Delegation of Duty to XYZ by ABC: It may be that ABC excludes their liability to XYZ as the main contractor. There is a duty owed by XYZ to ABC to supervise, in order to prevent latent defects (East Ham v Bernard Sunley [1966] AC 406). The delegation of liability from ABC to XYZ may be furthered through a clear contractual clause, which highlights that the contractor should ensure that any design defects are corrected to maintain the obligation of quality assurance (East Ham v Bernard Sunley). Nevertheless, the contractor owes the duty of care of the average professional in the industry (Tharsis Sulphur Copper Co v M’ Elro7 (1878) 2 App Cas 1040). This means the expectation of rectification of design will only be to the extent that it is obvious to the reasonable contractor. This means that the contractor must adapt obviously defective designs into a workable solution (Turiff Ltd v Welsh National Water Development Authority [1994] Const LY 122). If he/she fails to do this then the contractor (XYZ) will be held liable. If it is not an obvious defect then the architect will be held liable. IRC v Maxse (1919) 12 TC 41 held that a profession â€Å"in the present use of language involves the idea of occupation requiring purely intellectual skill, or if any manual skills†¦ controlled by the intellectual skill of the operator† will be held liable for breaches of professional knowledge. The duty of care that is owed is of a â€Å"reasonable degree of skill and care† for the given professional (Lanphier v Phipos (1838) 8 CP 475; Midland Bank Trust Co Ltd V Hett, Stubbs and Kemp [1978] 2 WLR 167; Hedley Byrne v Heller Partners [1964] AC 465 HL). This means that if there is a defect of architectural design or supervision that the design is followed then there will case of professional negligence (Saif Ali v Sydney Mitchell [1980] AC 198; Nye Saunders and Partners (a firm) v Alan E Bristow (1987) BLR 92). This breach must be below the standard of the reasonable architect (Michael Hyde and Associates Ltd v JD Williams and Co Ltd [2000] EWCA Civ 211). Thus, if it can be shown that the defect was of design (and not construction) then the architect will be in breach. This breach will then hold ABC liable. Finally, the contracts directly with the purchasers and leaseholders will enable an economic claim under negligence for breach of professional negligence. B.4 Recommendation: Thus, the potential liability of ABC for being in control of the design has to be ascertained, in relation to the liability for XYZ continuing to carry out a defective design. This will be important for the purchasers to identify, because liability may or not be with the seller ABC. It may be worth delegating the duty of supervision and monitoring the design to XYZ. Nevertheless, it is unlikely that this will prevent a claim brought by the purchasers and leaseholders if treated as consumers, due to enhanced obligations through the direct contractual link. An exclusion clause for latent defect may be considered, but it will have no effect due to the LDA 1986 and the fact that such a defect is breach of warranty. C. Landlord Obligations: It is important to note, that ABC when acting as a landlord, owes an obligation to provide a safe and fit property. This means that all residential properties must be fit for human habitation (s. 8 Landlord and Tenant Act 1985 (LTA 1985)), which includes an implied repairing covenant under ss. 13-14 LTA 1985 (Duke of Westminster v Guild [1985] QB 688). This includes repair of the common parts (Liverpool City Council v Irwin [1977] AC 239), even if there are commercial leases that contain a leasee repairing covenant. These obligations cannot be excluded. Regardless of whether it is a commercial or residential lease, there is an obligation to ensure that the premises are not defective (s. 4 Defective Premises Act 1972). Failure to so will give rise to liability in tort, which means that the landlord must repair the premises in a reasonable manner (Ratcliffe v Sandwell MBC [2002] EWCA Civ 6 (2002) 1 WLR 1488). These obligations cannot be excluded. Recommendation: If there is a defective property ABC, as a landlord and freeholder of the property, will have to ensure that common defects are repaired. In addition, any defects specific to its commercial and residential leases will have to be repaired. Finally, in the case of residential properties there is an obligation to ensure the properties are fit for human occupation. Nevertheless, it is advisable that the general repairing option lies with the leaseholder in the commercial leases (but this will not extend to defective property (s. 4 DPA 1972). D. Trespass to Land – Trespass to Airspace: Two next issue concerns the jib is swinging over the land occupied by several neighbouring properties. This will amount to a breach of airspace (Kelsen v Imperial Tobacco Co [1957] 2 QB 334; Bernstein of Leigh (Baron) v. Skyviews General Ltd. [1978] Q.B. 479). The liability will be that of XYZ, unless ABC retains control of the site. Thus, it is advisable that there is a delegation of control to XYZ and limitation of liability, in respect to failures by XYZ to gain permission from the neighbours to swing the jib. In addition, such a clause should give special consideration of any negligence that may ensue to the swinging jib (i.e. all supervision is the obligation, which means that there is effective limitation of liability for ABC). E. Right to Light and Nuisance: There is a potential nuisance and breach of land law, in respect to the number of the adjoining buildings that have windows over the site. The private nuisance arises, because the building blocks their light (Westminster City Council v Ocean Leisure [2004] BLR 393). This is a breach of their right to light and can be a public nuisance. There needs to be special consideration that the building does not block the light, which means that the 45-degree rule should be followed (Law Commission, 2013, 4.7). Limitation of liability cannot occur, because the action will be in nuisance and under the land law. Thus, there needs to be proper designing of the building, which means that ABC will be ultimately liable as it is using an in house architect. Another potential nuisance that may arise is if ABC and XYZ do not minimise the dust and debris from the site (Andreae v Selfridge [1938] Ch1). ABC may delegate these obligations to XYZ and limit liability; however, as the owner occupier there is still a duty to supervise. This means that to limit liability ABC will need to have a supervisory plan in place. F. Occupier’s Liability: Homeless Persons Vacant Site: The frequenting of homeless people may give rise to legal liability if the site is not appropriately secure to prevent access. Section 1(1) of the Occupiers Liability Act 1957 (OLA 1957) provides a duty of care to visitors on the site (Adriaanse, 2010, p. 126). A homeless person will not be identified as a visitor; rather he/she will be a trespasser. However, the Occupiers Liability Act 1984 (OLA 1984) requires that visitors on a construction site without invitation also have to be protected. It is arguable that the property is not a construction site yet, but this does not mean that there should be no protection for trespassers at all. Rather, there is still an obligation to prevent harm to trespassers. Under s. 1(2) OLA 1957 it provides that there is an obligation to protect licensees. A licensee can be a trespasser who enters the land where the occupier is aware of the trespass and the danger (Lowery v Walker [1911] AC 10). Without knowledge of the trespass, there will not be a direct obligation (Edwards v Railway Executive [1952] AC 737). Taylor v Glasgow City Council [1922] 1 AC 44 indicates that if there is an allurement on the land, such as a vacant property then a license may be implied. This has been limited with OLA 1984, as such there is a reluctance to impute an implied license based on allurement alone (i.e. the imputed knowledge that individuals will enter the land) (Tomlinson v Congleton [2003] 3 WLR 705). The implication is that the accessibility of the site is not enough to impute occupier’s liability. The failure to prevent the homeless persons would give rise to liability under s. 1(2) OLA 1957. To discharge liability under s. 1(2) OLA 1957, ABC has to take all reasonable acts to make the property safe (s. 2(2) OLA 1957). It is possible for him to discharge liability through a notice, which identifies that no trespassers are allowed (Roles v Nathan [1963] 1 WLR 1117) and the danger of the site is identified (White v Blackmore [1972] 3 WLR 296). It may be argued that if no sign is put up, and the danger is obvious then there will not be liability against ABC because the individual has assumed the risk (Darby v National Trust (2001) 3 LGLR 29). Nevertheless, as the property is boarded up it may not be obvious how dangerous the site is to others. Recommendation: Therefore, a sign that clearly should be posted, which states that: No trespassers are allowed; and The dangers of the site The posting of the sign should be at all possible access points, in order to exclude liability. Liability for Active Construction Site: When the site becomes active, there may be dual liability under OLA 1957 and OLA 1984 for ABC and XYZ. This will depend on the nature of control by ABC and XYZ (Adriaanse, 2010, p. 126). For XYZ to be held as an occupier, it should have a degree of control and supervision (Wheat v Lacon [1966] AC 552). As XYZ is the controlling contractor then it will owe an obligation to prevent visitors, employees and sub-contractors from dangers caused by physical defects on the site (Bunker v Charles Brand [1969] 2 QB 480). It is important to stress that there is an obligation on ABC and XYZ to secure the site, which includes all moveable; otherwise liability may arise from harm that emanates from the site (Jolley v London Borough Council [2000] 1 WLR 1083). Securing of the site is also important, because if children access it and are harmed then there will be liability, even with signage, due to the frivolity of youth doctrine (confirmed in OLA 1984) (Keown v Coventry Trust Healthcare NHS [2006] EWCA Civ 39). If the harm is caused by an adult entering the site when there is clear signage of danger then there is assumption of risk and no obligation is owed (Tomlinson v Congelton). Recommendation: ABC and XYZ will need to ensure that there are special measures in place to secure the property when it is an active construction site. This is because any harm that emanates from the site needs to be reasonably mitigated (s. 2(2) OLA 1957) to protect third parties on the site or passing by the site. Securing the site, in order to prevent children entering is paramount, because signage is not enough. Nevertheless, such signage is important to prevent liability for adult trespassers, such as the homeless persons. G.Obligations under the PWA 1996: There is an obligation under s. 1(1) PWA 1996 that there must be notification of any work on a party wall, or that may affect a party wall (Jessop, 2000, p. 8). In fact, Excavations below the level of the foundations of nearby buildings also require that there are notifications under s. 6 PWA 1996. Finally, ss. 2 to 5 PWA 1996 provides that works directly on the party walls, which pose harm to the neighbour’s wall must be notified (Bickford Smith and Lamont, 2007, p. 2). The failure for ABC to notify those neighbours under the PWA 1996 will result in a civil breach of the act. In addition, any damage that is caused must be rectified (Geoffrey Kaye v Matthew Lawrence [2010] EWHC 2678). The obligations of notification are as follows: There must be at least one month’s notice before the construction starts (ss. 2-3 PWA 1996); The neighbours then have the right to consent, consent with provisos or reject the proposed building (s. 4 PWA 1996); and If the neighbour fails to reply and/or no agreement is made then s. 10 PWA 1996 must be engaged (i.e. the dispute resolution procedure) (RICS, 2011; s. 4.1 PWA 1996). A security may be requested by the affected neighbours in case there is harm to the party walls ( 12(1) PWA 1996), in order to meet the obligation of rectification. The failure to engage the notice procedure is too big a risk, because if notice is not served, and harm occurs then there is a presumption of negligence that cannot be discharged (Roadrunner Properties Limited v (1) John Dean (2) Suffolk and Essex Joinery Limited [2003] EWCA Civ 1816). Recommendation: It is essential that ABC serves notices of all neighbours that fall under the PWA 1996; otherwise, it will be in breach of the act, and if harm occurs, there is a presumption of negligence that cannot be waived. Rather, it is the obligation of ABC to prove they were not liable for the harm, which is difficult due to the nature of the harm. ABC may argue that they are not liable, because such an act is delegated to XYZ and liability limited. However, the PWA 1996 holds the property owner liable, which cannot be delegated. H. Conclusion: To summarise the following recommendations identified in each of the sections highlight that there are obligations that ABC and XYZ will owe. Many of the obligations cannot be excluded through limitation of liability clauses and notices. Those that do allow limitation of liability requires reasonable steps to be taken, in order to notify persons of the potential harm (e.g. proper and sufficient signposting of the danger of the site, prohibition of trespassers and limitation of liability). Thus, the overall advice that is given is that ABC and XYZ do not cut corners and fully comply with the law, especially the PWA 1996 due to the nature of the construction project. References: Adriaanse, J (2010) Construction Contract Law 3rd Edition, Palgrave MacMillan Bickford Smith, S and Lamont, C (2007) â€Å"Party Walls etc Act 1996: Ten Years On† Property Bar Association Mini-Conference 13th November 2007 Dugdale, T (2006) â€Å"The Date of Damage in Defective Property Cases† PN 22(3) 196-199 Jessop, D. (2002) ‘Party Wall Practice Procedure in Brief’, The Journal of the RICS Building Surveying Faculty 4, 8-10 Law Commission (2013) Rights to Light Consultation Paper 210 Lowe, D (2005) Duty of Care Deeds and Commercial Property RICS McGee, A (2000) â€Å"Economic Loss and the problem of the running of time† (2000) CJQ 19, 39-55 Cases: Abbott v Will Gannon Smith [2005] PNLR 30 CA Andreae v Selfridge [1938] Ch1 Bernstein of Leigh (Baron) v. Skyviews General Ltd. [1978] Q.B. 479 Bunker v Charles Brand [1969] 2 QB 480 D F Estates v Church Commissioners for England and Wales [1989] AC 177 D F Estates v Church Commissioners for England and Wales [1989] AC 177 Darby v National Trust (2001) 3 LGLR 29 Duke of Westminster v Guild [1985] QB 688 East Ham v Bernard Sunley [1966] AC 406 Edwards v Railway Executive [1952] AC 737 Geoffrey Kaye v Matthew Lawrence [2010] EWHC 2678 Hedley Byrne v Heller Partners [1964] AC 465 HL Invercargill City Council v Hamlin [1996] 1 NZLR 513 IRC v Maxse (1919) 12 TC 41 Jolley v London Borough Council [2000] 1 WLR 1083 Kelsen v Imperial Tobacco Co [1957] 2 QB 334 Keown v Coventry Trust Healthcare NHS [2006] EWCA Civ 39 Lanphier v Phipos (1838) 8 CP 47 Liverpool City Council v Irwin [1977] AC 239 Lowery v Walker [1911] AC 10 Michael Hyde and Associates Ltd v JD Williams and Co Ltd [2000] EWCA Civ 211 Midland Bank Trust Co Ltd V Hett, Stubbs and Kemp [1978] 2 WLR 167 Murphy v Brentwood DC [1991] 1 AC 398 Murphy v Brentwood DC [1991] 1 AC 398 Nye Saunders and Partners (a firm) v Alan E Bristow (1987) BLR 92 Pirelli General Cable Works Ltd v Oscar Faber and Partners [1983] 2 AC 1 Ratcliffe v Sandwell MBC [2002] EWCA Civ 6 (2002) 1 WLR 1488 Roles v Nathan [1963] 1 WLR 1117 Saif Ali v Sydney Mitchell [1980] AC 198; Taylor v Glasgow City Council [1922] 1 AC 44 Tomlinson v Congleton [2003] 3 WLR 705 Turiff Ltd v Welsh National Water Development Authority [1994] Const LY 122 Westminster City Council v Ocean Leisure [2004] BLR 393). Wheat v Lacon [1966] AC 552 White v Blackmore [1972] 3 WLR 296 How to cite Property Law Practice 2013-14 Report on Legal Liability, Essay examples

Antigone (454 words) Essay Example For Students

Antigone (454 words) Essay AntigoneAntigone Sophocles trilogy of Oedipus the King, Oedipus at Colonus, andAntigone is a powerful, tragic tale that examines the nature of human guilt,fate and punishment. Creon, Oedipus uncle and brother-in-law, is the storysmost dynamic character. His character experiences a drastic metamorphosisthrough the span of the three dramas. Creons vision of a monarchs proper role,his concept of and respect for justice, as well as his respect for the designevolve considerably by the trilogys tragic conclusion. In Oedipus the King (OK), the audience is introduced to a Creon who seems to put loyalty to the kingabove all. He sympathizes with the tragic plight of King Oedipus and asserts noapparent ambition himself. His attitude toward the king is one of yielding andfulfilling reverence. Creons notion of justice in OK stems directly from thedivine. That which the gods have decreed must become law. It pains Creon to haveOedipus exiled, but he must do so as the gods have willed it. Creons respectfor divinity and prophecy seems to be his defining trait in OK. His attitude isone of unquestioning reverence. In Oedipus at Colonus (OC), one sees thebeginning of Creons decline. Creon has now come to occupy the throne that oncebelonged to Oedipus. It soon becomes apparent that his vision of the proper roleof a king has changed to accommodate his new-found position. The emphasis shiftsfrom that of a king who must rule wisely to one who must rule unyieldingly. Thekingship becomes a selfserving instrument for Creon in his attempt to secure thereturn of Oedipus and the good fortune prophesied to accompany him. Creonsnotion of justice is severely distorted in OC. He becomes monomaniacal conducting his affairs with tyranny and belligerence. For example, he threatensto harm Oedipus daughters if the blind beggar does not return to Thebes. Hisview of rightness and fairness is no longer in line with that of his subjects. In OC, Creon still retains some respect for divine prophecies. These have afterall motivated his desire to return Oedipus to Thebes. Antigone reveals theultimate extent to which Creons character deteriorates. His transformationcompletes itself; he has become an unreasonable tyrant. Creon can no longer becalled a king. He has become a despot. There is absolutely no justice to befound. Violence and threats of violence are the tools by which he rules. Forexample, his senseless threats to an innocent sentry reveal the true extent ofhis loss of reason. Creon has distorted the proclamation against Polyneicesburial, which was originally intended to foster Theban unity, into a display ofrashness and incompetence. There is no mention of the gods and their intentionson Creons behalf in Antigone. He has been so far destroyed by his own power asto dismiss the divine will that he originally thrived on.

Rousseau And The Ideal Society Essays (202 words) - Deists

Rousseau And The Ideal Society Rousseaue and the Ideal Society Has the progress of the arts and sciences contributed more to the corruption or purification of morals? Rousseau criticized social institutions for having corrupted the essential goodness of nature and the human heart. Rousseaue believed that by becoming civilized, society has actually become worse because good people are made unhappy and are corrupted by their experiences in society.. He viewed society as articficial and corrupt and that the furthering of society results in the continuing unhappiness of man. He also argued that the advancement of art and science had not been beneficial to mankind. He proposed that the progress of knowledge had made governments more powerful, and crushed individual liberty. He concluded that material progress had actually undermined the possibility of sincere friendship, replacing it with jealousy, fear and suspicion. In his Discourse on the Origin of Inequality he elaborated on the process of how social institutions must have developed into the extreme unequal rights of aristocratic France where the nobility and the church lived in luxury while the poor peasants had to pay most of the taxes. And in his Discourse on Political Economy he suggested remedies for these injustices. Political Issues

Root and Butt Rot Tree Disease Management

Root and Butt Rot Tree Disease Management Root and butt rot is one of the most common forms of tree disease affecting hardwoods. Many fungi are capable of causing root rots and some cause considerable decay of the butts of trees as well. Root rots are more common on older trees or trees which have sustained root or basal injury. Root rots thrive on poor soil conditions. Trees with extensive root rot are less able to tolerate extreme weather conditions like extended droughts, long periods of heavy rain, or unusually high temperatures. Recognition Trees with root and butt rots (the one of most concern is Armillaria root disease) typically have combinations of crown dieback, loss and/or discoloration of foliage, and a generally unhealthy appearance. Internally, diseased roots exhibit patterns of discoloration and decay. Diseased trees can live for years without symptoms but, more commonly, trees with extensive root rot decline and eventually die in several years. Conks (fruiting bodies) at or near the base of declining trees are indicators of root rot. Prevention You can only control root diseases in trees by prevention. Prevent root diseases by avoiding root damage and wounds to the lower trunks of trees. When planting trees in areas where trees have previously died of root disease, remove old stumps and roots to reduce local fungus spread. Consider soil sterilization with an appropriate pesticide such as methyl bromide or vapam according to local conditions and state and federal regulations. Contact you county extension agent for specific information. Control Effective treatments for curing established root diseases in trees are unknown. Sometimes careful crown reduction by pruning and fertilization can prolong the life of diseased trees by reducing the transpirational demand on ailing root systems and promoting overall tree vigor.

Robbery Essay Example | Topics and Well Written Essays - 2500 words

Robbery - Essay Example This is even though both theories profess to be ones that posit their assumptions based on the criminal event - human ecology. The study ends with advice on how the inclusion of all people from all walks of life can enable a successful precautionary as well as preventive approach to crime as a whole and robbery in particular. Though some very elaborate theories are often proposed to explain robberies in the negative contexts of mental health and social problems the main and very down-to-earth explanations come from the perpetrators themselves - money, thrills, drugs and peer influences. These reasons, some of them quite trifling, are the principal propellants that induce persons to attempt to take by force things of some value from other persons. As representative of overall international demographical trends Canadian statistics reveal that robbery is almost the exclusive preserve of the young male. In Canada just 5 % of those accused of robbery are female, about two-thirds of those accused are below 25 and almost no accused is above 50. Also, approximately 16 % of those accused are young offenders (Research Division, Correctional Service of Canada, 1995). Though the derived statistics is slightly dated study of recent literature reveals that the trends persist to the present day for most countries, incl uding the USA. Another alarming trend revealed by statistics for robbery is that it is the crime most feared by victims. This is even though is constitutes about 10 % of all violent crimes committed in Canada (Research Division, Correctional Service of Canada, 1995). This is because robbery involves a high probability of suffering physical harm from a total stranger and it can happen to anyone anywhere, at any time. Robbery offenders are also more likely to use weapons than other offenders. About one quarter of robberies involve usage of fire-arms, one quarter involves usage of other weapons like clubs and knives and one half involves usage or threat of some sort of physical force. Also, what is alarmingly important, from the victims' point of view, is that almost one quarter of robbery victims in Canada sustained some sort of minor physical injury with about 4 % being treated medically either at the scene of the crime or at a medical facility after transportation there from the scene of crime (Res earch Division, Correctional Service of Canada, 1995). Another good indicator of the seriousness of the crime is that almost 80 % of offenders accused of robberies are incarcerated while, for offenders of other crimes convicted at Canadian federal courts during the same period, the figure is only 23 %. Statistics for those sentenced for two years or more in prison reveal that 20 % are there for robbery offenses. A December 31, 1994, survey revealed that almost one third of all federal offenders were identified as robbery ones (Research Division, Correctional Service of Canada, 1995). As mentioned earlier the statistic is slightly old but not much has

Finding and Expert and Interviewing Expert Effectively Essay

Finding and Expert and Interviewing Expert Effectively - Essay Example Reviewing the phone book and yellow pages directory can be a good option while searching for experts. Going through the faculty directory can allow the researcher to know about the different expert research studies conducted and therefore can easily find the one most suitable for his or her research. Internet is a vast database of getting out all the available and accessible contacts of the experts. The encyclopedia is another good database for knowing about the relevant organizations and the experts present in them (Ballenger 2009). Once an expert has been found, the researcher or interviewer needs to carefully devise the interview mode so that maximum amount of useful information can be gathered from the experts accordingly and conveniently. The interview mode needs to be decided to find out the best mode of interviewing the expert candidate, the interview modes can be personal interviews, telephonic interviews or email interviews. After deciding upon the interview mode, the interviewer needs to carefully design the questions that will be posed towards the expert for gaining the information. Questions need to be designed systematically and should be made sure that all important aspects are covered for the research. Open ended questions tend to provide more in-depth information and clarification about any certain area. Close ended questions do not provide much detail. Personal experiences of the expert and their reflection are highly important to be incorporated in the research as it gives the study more weight and authenticity. Interview sessions should be regarded as conversations rather than surveys and during these interview conversations the researcher can get maximum detail about his questions. At times informal behavior may be required so as to get maximum details. The researcher needs to make a note of all the information being gathered during the interview session and this can be done

The Case of BBC and TV Licensing Fee Essay Example | Topics and Well Written Essays - 3500 words

The Case of BBC and TV Licensing Fee - Essay Example People when faced with various alternatives have to decide based on various choices or options. The same thing happened in the case of BBC. In modern times, the existence of other independent televisions and live cable and satellites for free made it to a point that TV licensing became a controversial issue in the UK. There was fragmentation of political communications and even the rise of globalisation aggravates the said situation (Curran and Gurevitch, 2000, p.1; Curran, 2002, p.6). Before, in the absence of these alternatives a license fee should not come to be a controversial issue, but in the case of modern time and highly globalised world when people have various options to enjoy the media even for free, TV licensing seems to be an issue that needs amendment and critical assessment. There are two opposing sides regarding TV licensing as the prevailing system for funding the BBC. Those who stand against licensing fee point out that it is an iniquitous tax. This means it does no t quite have a logical approach that would make somebody realise that it is a fair thing to do. While other nations are enjoying media broadcast without fee, the UK according to TV licensing fee critics does not need to experience paying something or contents that at some point are not consumed. TV licensing fee according to its critics is just a way of forcing somebody to pay a hundred pounds to contents shown by a broadcaster that at some point could not be substantially consumed. At this point, the opponents of TV licensing fee advocates have a remarkable point. However, on the part of the advocates, they believe that BBC is the only broadcaster in Great Britain that is way beyond the control of vested interest. This particularly... In this essay, the proponent tries to elaborately discuss the advantages and disadvantages of the current system of funding the BBC and the reason why it is such a controversy today. The British Broadcasting Corporation (BBC) is one of the potential areas of concern in the United Kingdom because it includes the issue about significant funding that has to be shouldered by every household prior to sustaining its operation. A television license fee has to be charged to every British household, companies, or organizations prior to using equipment to record or receive live television broadcasts. This license allows somebody to have potential access to the BBC and its programs and to the current affairs that at some point may vary from those offered by commercial television and independent cable or satellites. The license fee is set by the British government and agreed by the parliament, which make everything about it controlled by the government, which could be determined as a form of cen sorship or capitalistic move. Today, the issue whether TV license that is associated with BBC’s funding is tenable or not is one of the potential concerns that require critical understanding. It is also concluded that the main reason why BBC remains a controversy nowadays is because of the presence of these highly commercialised pressures brought by independent and commercial broadcasting companies. This is actually the general essence of the whole point of the various advantages offered by TV licensing fee in funding BBC.

Developing Education in Latin American Countries

Developing Education in Latin American Countries Increasing the quality of Education in Latin American Countries Josà © Luis Llumiquinga Molina Abstract: The purpose of this study is to analyze the ways in which Latin American countries can improve their education. Latin American countries have always been classified as underdeveloped and poor, and one of the causes for which they have been classified as poor and underdeveloped is because of the low level of education that these countries have. There are some things that can be done to improve the education of growing nations. This study shows with practical things, the actions that the Latin Americans governments can do like investing in teachers training, buying technology equipment or focusing on students innovation and creativity. The expected results in this work should show that with these changes education must improve significantly. In conclusion to improve education in Latin countries the different states must invest in key areas for education. Key Words: Education, Latin American Countries, teacher training, technology, innovation and creativity Nations in other parts of the world have always classified Latin American countries as developing countries and this is due to low levels of education and poverty present in Latin America. Each year, international exams such as the PISA show that Latin American countries are below the international average in education. (Pisa results in focus, 2012). For a country, it depending on others and become a productive power and leader in knowledge, it is necessary that education be taken more into account by Latin American governments, who should invest more in this field. In addition to the investments in infrastructure that governments can make must they invested in the greatest productive force of all that is the strength of people. Governments must invest in the education of people so that they can overcome themselves and not depend on the charity of others. Latin American education quality can be improved by investing in the following three key points of education: teacher training, th e use of new technology and the promotion of student ´s interest in innovation and creativity Live as if you were to die tomorrow. Learn as if you were to live forever. (Quotes about Education, n.d.). The teachers of any educational institution in the world are fundamental for the process of teaching young learners to be effective, teachers are the guides of their students because they are the ones who bring new knowledge to their students and arouse interest of their students in some future profession, teachers are forming the future of society; That is why it is necessary for teachers to be able to teach correctly, that is to say that their students take ownership of the knowledge with the help of the teacher, then good education would be achieved with educational training of teachers with periodic tests and agreements with international universities that improve the education of teachers. In order for a teacher to teach his students correctly, the teacher must have all his knowledge updated and this is achieved thanks to continuous training as has been done in Ecuador since 2008. Another way to keep trained teachers is through periodic tests that require teachers to study regularly to ensure that their knowledge is updated. An example of periodic test is the evaluations made in Malaysia to teachers, A total of 1,022 English teachers are now undergoing the Cambridge Placement Test (CPT) in their respective districts in Sabah. Education Director Datuk Jame Alip (pic) said on Wednesday the course is aimed to improve their English skills and teaching pedagogy methods (Malaysia, n.d.). Another way to train teachers is to give them the opportunity to get fourth-level titles like in Finland. Teachers in Latin American countries must have opportunities to progress and increase their knowledge to improve their educational capacities and thus improve the overall education of a nation since the education of a country does not improve only by investing in the infrastructure of educational institutions But that investment in one of the most important parts of education prevails, this part is the teachers who, by giving them the opportunity to become learned in their subject matter, is contributing to the teachers being able to explain very easily one Theme and thus contribute to quality education. Quality education is something that can be achieved by giving greater importance to the education and training of teachers, a training that must be continuous and with the opportunity to study in international universities that give teachers more experience and knowledge to the Teachers therefore a real education is given when all members of this process, especially teachers, have adequate levels of training to provide an education that is beneficial to young people who in the future will be contributing with great knowledge to society . Technology is nothing. The important thing is that you have faith in people, that they are basically good and intelligent, and if you give them tools, they will do wonderful things with them (Jobs, n.d.). The second key pint, technology in classrooms is an important resource to improve education in any part of the world because with technology, access to information is very easy, it also promotes research because with technological equipment, the speed with which it is Access to information is the best, so one way to get a better education is through investments by the state in computers and the Internet in addition should use free software programs focused on education. With the provision of computers and internet in different educational institutions can significantly improve the education of students, students who may have never seen a computer in the past can now have the opportunity to learn to use them by breaking many digital gaps, improving Thus substantially the knowledge; The students besides improving their general knowledge could improve their technical knowledge by the simple use of these computational equipment. Students who already have computers and also access to the Internet will have at their disposal an unimaginable amount of information that they can use to improve their knowledge; This has a risk and is that students believe true everything they find on the internet but with the help of a teacher who guides their students this will not be a problem. Also with internet students can be communicated and thus could work together in an online way Free software can be a great educational tool because the costs of acquiring these programs do not exist and this means a great saving for educational institutions, who want to acquire didactic teaching programs at a low cost. An example of free software is the program Scratch is a free programming language and online community developed by the MIT Media Labs Lifelong Kindergarten group (Segal, 2016). This program is an environment in which children can learn to program in a playful and very easy way, in this Program can be programmed games for leisure or games for learning; The Scratch program can be an indispensable learning tool because students have fun while learning and in the end this can be a great way to improve knowledge (Segal, 2016). There are many other programs that can be of help to students, there are free programs such as google docs that can be used to perform group work regardless of distance, this type of program can be used to improve cooperatives among students. Another very useful program is Duolingo, this is a multiplatform program, that is to say that it can work in computers or any type of Smartphone, this program is free and also is a program that is used to learn other languages à ¢Ã¢â€š ¬Ã¢â‚¬ ¹Ãƒ ¢Ã¢â€š ¬Ã¢â‚¬ ¹through games; This program can be used in classrooms as a complement to normal classes (Segal, 2016). A very successful way to improve education is the use of technology, states can improve the education of their students through successful investments in computers, internet and over-the-counter programs, this set can become very useful because it improves The knowledge of its students by the new information that they can acquire and by the new skills that can get by the simple use of technological equipment that is why the technology is indispensable for an improvement in educational quality. Creativity involves breaking with established patterns to look at things differently (Las 75 Mejores Frases de Creatividad, n.d.). The last point, Research and creativity are two things that are very closely linked, scientists investigate to solve problems, understand phenomena of nature or to discover something new but this is achieved with creativity because creativity is the basis for the invention of some A new device that helps research creativity helps us to break the rules of the known to look for new things never seen before or even though (Ossola, 2016). So for a person to improve is necessary to create new things, to investigate what he does not understand. Education is the basis for a society to change and improve, but for real education to be a reality students should be encouraged to research and promote creativity. One way students improve their interest in research is by integrating them into extra-class clubs, these types of clubs must accept students who are curious about the subject even if they have not the slightest idea of what the Club Student creativity can be greatly enhanced by classroom activities where you have to expose something or demonstrate unprepared skills because students learn to think faster, learn to be resourceful, learn to solve problems faster Definitive are more creative. An example to improve the creativity of the students is to organize groups, give them different topics and organize debates in which each one has to think quickly what he is going to say. Quality in education is achieved with many factors but one of the most important are those that involve the students interest in research and the students ability to be creative, and this is achieved with the students motivation to discover new things as Is given in the case of extracurricular clubs and with the creativity of the student that is given when he learns to think and to develop quickly; Thats why students who are happier doing what they like are the ones with the most knowledge. Conclusion To finish education is an issue that should be of paramount importance for all governments in the world because education is able to overcome poverty and grow not only economically but culturally so that the Latin American people leave behind all that History of poverty and ignorance should improve the education of their youth and to achieve this requires that teachers constantly update their knowledge so that they can teach the right to their students and adequately; It is necessary to invest in technological equipment that will help in the classes and the students must be inculcated the interest in the investigation and the capacity to be creative so that they themselves are the ones that generate their own knowledge and in the future they become people Critical In order to improve education in Latin American countries, a comprehensive work by governments involving both teachers and students and technological infrastructure is needed. References Actualizacià ³n Docente i. (n.d.). Retrieved November 18, 2016, from https://educacion.gob.ec/oferta-de-cursos-de-actualizacion-docente/ Childress, S. (2016). A Young Tinkerer Builds a Windmill, Electrifying a Nation. WSJ. Retrieved 21 November 2016, from http://www.wsj.com/articles/SB119742696302722641 Compton, R.(2011). The Finland Phenomenon à ¢Ã¢â€š ¬Ã‚ ¢Compton, R.(2011). The Finland Phenomenon Docentes ecuatorianos obtienen su master gracias a un programa del gobierno. (n.d.). Retrieved November 18, 2016, from http://www.andes.info.ec/es/noticias/docentes-ecuatorianos-obtienen-master-gracias-programa-gobierno.html-0 Formacià ³n Docente. (n.d.). Retrieved November 18, 2016, from http://mecapacito.educacion.gob.ec/ H. (2016). 51 Frases de Tecnologà ­a de Grandes Hombres. Retrieved November 18, 2016, from http://www.lifeder.com/frases-de-tecnologia/ H. (2016). Las 75 Mejores Frases de Creatividad. Retrieved November 18, 2016, from http://www.lifeder.com/frases-de-creatividad/ Malaysia: 1,022 teachers take Cambridge Placement Test. (n.d.). Retrieved December 01, 2016, from http://www.eltnews.com/news/archives/2014/01/malaysia_1022_teachers_take_cambridge_placement_test.html Ossola, A. (2016). Scientists Are More Creative Than You Might Imagine. The Atlantic. Retrieved 21 November 2016. PISA 2012 Results. (n.d.). Retrieved December 01, 2016, from http://www.oecd.org/pisa/keyfindings/pisa-2012-results.htm Segal, S. (2016). The case for disruption in Latin Americas classrooms. World Economic Forum. Retrieved 21 November 2016. .. (n.d.). Citas, Pensamientos, Frases de EDUCACION. Retrieved November 116, 2016, from http://www.pensamientos.org/pensamientoseducacion.htm Quotes about Education (7687 quotes). (n.d.). Retrieved December 01, 2016, from http://www.goodreads.com/quotes/tag/education

Weltys Characterization in A Curtain of Green Essay -- A Curtain of Gr

Welty's Characterization in A Curtain of Green      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Myth, symbol, and allusion are not an uncommon characteristic in Eudora Welty's works. By using characters such as Odysseus and leaving hints of symbolism in works such as The Optimist's Daughter Welty places many questions in the minds of her readers. After a reader has pondered these questions a categorization of the story takes place in the readers mind. Although different readers have different interpretations of literature one collection of Welty's short stories can be classified into two categories. Katherine Anne Porter's introduction to Eudora Welty's A Curtain of Green explains the two categories:    as painters of the grotesque make only detailed reports of actual living types observed more keenly than the average eye is capable of observing, so Miss Welty's little human monsters are not really caricatures at all, but individuals exactly and clearly presented: which is perhaps a case against realism, if we cared to go into it. She does better on another level-for the important reason that the themes are richer-in such beautiful storiesLet me admit a deeply personal preference for this particular kind of story, where external act and the internal voiceless life of the human imagination almost meet and mingle on the mysterious threshold between dream and waking, on reality refusing to admit or confirm the existence of the other, yet both conspiring toward the same end. (xxi)    According to Porter the two categories found in A Curtain of Green are that of grotesque or monstrous and that of beauty or standing on the gateway between consciousness and unconsciousness. Acknowledging that there are two categories for Welty's stories Porter also address'... ...989): 59-70.    Boyce, Charles. Shakespeare A to Z . New York: Dell, 1990.    Brown, Alan. "Welty's A Curtain of Green." The Explicator 51.4 (1993) 242-44. Encarta Learning Zone. 1997-2000. Dionysus. 24 April 2000 <http://encarta.msn.com/find/Concise.asp?ti=057f8000>    Hauser, Marianne. "A Curtain of Green" The New York Times. 17 April 2000. http://channel.nytimes.com/books/98/11/22/specials/welty-curtain.html    Mythology The Myth of the Phoenix. 17 April 2000. http://www.geocities.com/Tokyo/Towers/1132/phoenixlhtm    Porter, Katherine Anne. Introduction. A Curtain of Green. By Eudora Welty. New York: Harvest, 1979.    Sykes, Dennis J. "Welty's 'The Worn Path.'" The Explicator 56.3 (1998): 151-53.    Welty, Eudora. The Collected Stories of Eudora Welty New York: Harvest, 1994.

Medical Home Practice-Based Care Coordination

Medical Home Practice-Based Care Coordination: A Workbook By: Jeanne W. McAllister Elizabeth Presler W. Carl Cooley Center for Medical Home Improvement (CMHI) Crotched Mountain Foundation & Rehabilitation Center; Greenfield, New Hampshire Beyond the Medical Home: Cultivating Communities of Support for Children/Youth with Special Health Care Needs Funded by: H02MC02613-01-00 United States Maternal and Child Health Bureau, Integrated Services for CSHCN, HRSA June 2007Workbook Contents This workbook includes the tools and supports needed for a primary care practice to develop their capacity to offer a pediatric care coordination service; particularly for children with special health care needs. The health care team, determined to develop such an explicit service, makes an assessment of current care coordination practice and frames their improvement efforts to achieve proactive comprehensive practice-based care coordination.Tools included in this resource are: a definition of care coordi nation in the medical home, a care coordination position description, a framework for care coordination services including structures and processes, strategies for the protection of devoted staff time, and a logical sequence of care coordination improvement ideas offered in the context of the Model for Improvement (Langley, 1996). Each tool can be used as is or it can be customized in a manner which best fits your practice environment and the strategic plans your organization holds for medical home improvement activities.Table of Contents Medical Home Practice Based Care Coordination Medical Home Care Coordination A Definition & A Vision Is It Medical Home Care Coordination? A Checklist Medical Home (Practice Based) Care Coordination – Position Description – A Worksheet A Medical Home (MH) Care Coordination Framework – Framework – Worksheet Time Protection Tips & Strategies †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 3 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦5 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦7 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦9 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 10 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 11Care Coordination Development: The Model for Improvement †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦12 Care Coordination Aim Statement †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦13 Care Coordination Outcomes †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦14 Plan Do Stud y Act (PDSA) Worksheet & Examples †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦15 1) Care Coordination Role/System †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦16 2) Care Coordination – Needs Assessment †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦18 3) Comprehensive Care Planning †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦20 Medical Summary, Action & Emergency Plans 4) Transition to Adult Care & Services †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦22 5) Community Outreach & Resources †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦24 Appendices A.Websites and References †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦.. 26 2 Medical Home – Practice-Based Care Coordination This workbook is designed to suppor t practice-based quality improvement teams in their efforts to build comprehensive primary care â€Å"medical homes†. The focus is specifically upon the professional role development for the provision of practice-based care coordination. The ideal care scenario is one where the staff within the medical home is proactively prepared to support the central care giving role of families.The role of care coordination discussed within this workbook is one designed in the service of children/youth with special health care needs (CYSHCN). It is acknowledged that care coordinators in different environments will apply their skills and efforts toward the care of all children as well as adults with special needs or chronic health conditions; you should find the structures and processes offered within suitably applicable.Workbook Goals and Objectives: Goal: To put forth a practice-based medical home care coordination framework from which practices can select and suitably customize. Content s include a medical home care coordination checklist, definition, position description, model framework with structures and processes, and strategies for effective and successful care coordination development and implementation. Objectives: 1) Define practice-based care coordination for children with special health care needs in a medical home ) Select and appropriately modify a position description that fits each unique medical home improvement team environment 3) Use a care coordination model framework to fit the role well within each practice environment 4) Draw from a list of time protection and resource allocation strategies those with the best fit for the practice environment and related improvements 5) Develop tests of change (PDSA – plan, do, study, act) for the incremental development of a comprehensive care coordination service model to include: care services, assessment of needs, care planning, transition support, and community outreach with resource linkages.It is established in the literature that the medical home is meant to be a centralizing resource for children and families, particularly for CYSHCN (AAP Medical Home Advisory Committee, 2002) Evidence is building that care coordination is essential to a medical home (Antonelli, 2004). It has been suggested that you cannot be a strong medical home without the capacity to link families with a designated care coordinator; this is the ideal.The policy statement issued by the American Academy of Pediatrics on Care Coordination (CC) describes CC as complex, time consuming, even frustrating but as key to effective management of complex issues in a medical home; and states that a designated care coordinator is necessary to facilitate optimal outcomes and prevent confusion. Care coordination takes resources and time. Practices need to be reimbursed for this labor intensive role (AAP Committee on Children with Disabilities, 1999).Horst, Werner, and Werner (2000) state that in all types of systems, care coordination is an essential element to ensure quality and continuity of care for CSHCN and their families. In a 10 point strategy to 3 achieve transformational change within health care for all, issued by the Commonwealth Fund, care coordination is cited as one of ten key components to organize care and information around the patient (Davis, K. 2005). Ideal care coordination provides timely access to services, continuity of care, family support, strengths-based rather than deficit-based thinking and advocacy.This is very time consuming, whether accomplished by parents or by parent professional partnerships (Presler, 1998). At the front lines of care, in the medical home Antonelli (2004) states that without the ability to support care coordination at the level of the medical home, barriers to achieve the Healthy People 2010 objectives remain. In the Future of Children (2005) the author claims that care coordination requires (at the very least) adequate personnel and time and i s often limited in primary care by lack of the very time and resources necessary.This is substantiated by the AAP Periodic Survey of Fellows #44, (2000), by a national Family Voices Survey (2000) with parents reporting their physicians have the skill for coordination but are difficult to access and have minimal time available for care coordination activity/implementation. Similarly a survey of state Title V Directors and their perception of barriers to care coordination in the medical home includes: time, reimbursement, lack of physicians, lack of skill/training, and limited cultural effectiveness.Successful medical homes result when partnerships with families offer fully implemented practice-based care coordination. Proactive care coordination and care planning are fundamentally essential for improved care quality, access to services and resources, health and function of children and youth, and quality of life as well as improved systems of care. No medical home will achieve optima l comprehensive, coordinated and compassionate care without dedicated time and resources to develop, implement, and evaluate a complement of care coordination activities.Such an investment is favorable in terms of cost and benefit for children/youth and families, primary care practices and their broader health care systems. In summary, care coordination: Is accomplished everyday by families with and for their children and youth, but Support is desirable, feasible and beneficial coming from the medical home Requires critical funding and protected time Requires tested tools and strategies (some are included in this workbook, others have been developed and continue to evolve) Is a defining characteristic (element) of a fully implemented and comprehensive medical home Medical Home Care Coordination – A Definition The literature offers several definitions of care coordination but most have been written for application across varied health care environments such as hospitals, speci alty based centers, community & home health agencies. Few definitions focus exclusively on the distinctions found within the primary care medical home for the role of practice-based care coordinator.The focus of the Center for Medical Home Improvement is on the primary care practice with the provision of team-based care coordination, delivered from the centralizing resource of a primary care medical home with physician leadership and by experienced nurses, social workers, and/or comparable professionals. Care CoordinationPractice-based care coordination within the medical home is a direct, family/youth-centered, team oriented, outcomes focused process designed to: Facilitate the provision of comprehensive health promotion and chronic condition care; Ensure a locus of ongoing, proactive, planned care activities; Build and use effective communication strategies among family, the medical home, schools, specialists, and community professionals and community connections; and Help improve , measure, monitor and sustain quality outcomes (clinical, functional, satisfaction and cost (McAllister, et al, 2007)A Vision for Practice Based Care Coordination Children, youth, and families have seamless access to their team, enhanced by they availability of a designated care coordinator who facilitates a team approach to family-centered care coordination services. (McAllister, et al, 2007) 5 CC CHECKLIST Is It Medical Home Care Coordination? Checklist – how are you doing? What elements are in place, which require some additional attention? NO / PARTIALLY/ YES 1) Families know who their care coordinator is and how to access him or her (or their backup)? ) Values of family-centeredness are known to the medical home team and drive the development and provision of care coordination? 3) A medical home care coordination position description is established; roles/activities are clearly articulated and care coordination training and education is available? 4) Administrative lead ership helps to develop/support a care coordination service system; protected time allows for CC role development? 5) CYSHCN identification and assessment of child/family needs/unmet needs are completed; care planning is a core CC/medical home response? ) Education and counseling are offered as an essential part of medical home care coordination? 7) Care coordination includes comprehensive resource information, referrals, and cross agency/organization communication? 8) Child/family advocacy is a part of care coordination 9) Families are asked for feedback about their experiences with health services/care coordination? 10) Medical home system improvements are implemented simultaneously with the development of care coordination (care coordinator contributes to this quality improvement process)? 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 1 2 2 3 3 1 2 3 1 2 3 Total score: _________/ out of 30. Notes: 6 Medical Home (Practice Based) Care Coordination – Position Description The care coor dinator works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well being.Care Coordination Qualifications: The care coordinator shall have: Bachelor’s preparation as a nurse, social worker, or the equivalent with appropriate past experience in health care Three years relevant experience, or the equivalent, in community based pediatrics or primary care, particularly in the care and service of vulnerable populations such as children/youth with special health care needs (CYSHCN) Essential leadership, advocacy, communication, education and counseling, and resource research skills Core philosophy or values consistent with a family-centered approach to care Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and belie fs Medical Home Care Coordination Responsibilities The care coordinator will: 1) Demonstrate and apply knowledge of the philosophy/ principles of comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordination services 2) Facilitate family access to medical home providers, staff and resources 3) Assist with or promote the identification of patients in the practice with special health care needs (such as CYSHCN); add to registry and use to plan and monitor care 4) Assess child/patient and family needs and unmet needs, strengths and assets 5) Initiate family contacts; create ongoing processes for families to determine and request the level of care coordination support they desire for their child/youth or family member at any given point in time 6) Build care relationships among family and team; support the primary care-giving role of the family 7) Develop care plan with family/youth/team (emergency plan, medical summary and action p lan as appropriate) 8) Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans 9) Serve as the contact point, advocate and informational resource for family and community partners / payers 10) Research, find, and link resources, services and supports with/for the family 11) Educate, ounsel, and support; provide developmentally appropriate anticipatory guidance; in a crisis, intervene or facilitate referrals appropriately 12) Cultivate and support primary care & subspecialty co-management with timely communication, inquiry, follow up and integration of information into the care plan 13) Coordinate inter-organizationally among family, medical home, and involved agencies; facilitate â€Å"wrap around† meetings or team conferences and attend community/school meetings with family as needed and prudent; offer outreach to the community related to the population o f CYSHCN 14) Serve as a medical home quality improvement team member; help to measure quality and to identify, test, refine and implement practice improvements 15) Coordinate efforts to gain family/youth feedback regarding their experiences of health care (focus groups, surveys, other means); participate in interventions which address family/youth articulated needs 7 Position Description WorksheetMedical Home (Practice Based) Care Coordination Position Description Responsibilities Worksheet – Customize for Your Practice Care Coordination in a Medical Home – The Care Coordinator will: 1) Demonstrate and apply knowledge of the philosophy/ principles of 2) 3) comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordination services Facilitate family access to medical home providers, staff and resources Assist with or promote the identification of those with special health care needs (such as CYSHCN); add them to the regi stry and use it to plan and monitor care Assess child/patient and family needs/unmet needs, strengths and assets Initiate family contacts; create ongoing processes for families to determine and request the level of care coordination support they desire for their child, youth or family member at any given point in time Build care relationships among family and team; support the primary care giving role of the family Develop care plan with family/youth/team (emergency plan, medical summary and action plan as appropriate) Carry out care plans, evaluate effectiveness, monitor in a timely way and make changes as needed; use age appropriate transition imetables for interventions within care plans Serve as contact point, advocate and informational resource for family and community partners/payers Research find, and link resources, services and supports with/for the family Educate, counsel, and support; provide developmentally appropriate anticipatory guidance; in a crisis, intervene or fac ilitate referrals appropriately Cultivate and support primary care & subspecialty co-management with timely communication, inquiry, follow-up and integration of information into the care plan Coordinate interorganizationally among family, the medical home, and involved agencies; facilitate â€Å"wrap around† meetings or team conferences and attend community/school meetings with family as needed and prudent; offer outreach to the community related to the population of CYSHCN Serve as a medical home quality improvement team member; help to measure quality and to identify, test, refine and implement practice improvements Coordinate efforts to gain family feedback regarding their experience with health care(focus groups, surveys, other means); participate in interventions that address family/youth articulated needs Accept Reject 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) *** Add additional key responsibilities here (use additional paper): 8 A Medical Home (MH), Team Based, Care Co ordination (CC) Framework Fundamental Tools Structures Medical Home Interventions Access to Medical Home, Health Care and Other Resources Identify and register the CYSHCN opulation Establish with families effective means for medical home/office access Provide accessible office contract for family and community agencies Catalog resources to link families to appropriate educational, information and referral sources Promote and â€Å"market† practice-based care coordination to families and others (e. g. brochures, posters, outreach efforts) Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care &agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate to improve systems of care for CYSHCN (families, payers, provides, and agencies) Community Connections Fundamental Processes Proactive Care Plannin g Medical Home Interventions Help to maintain health and wellness & prevent secondary disease complications Maximize outcomes (e. g. lleviation of the burden of illness, effective communication across organizations, enrollment in needed services, and school attendance/success) Listen, counsel, educate, & foster family skill building Screen for unmet family needs Develop written care plans; implement, monitor and update regularly Plan for future transition needs; incorporate into plan of care Facilitate subspecialty referrals, communication & help family integrate recommendations of specialists Link family, staff to educational/financial resources †¢ †¢ †¢ †¢ Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care & agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate with famil ies, payers, providers and community agencies to improve systems of care for CYSHCN Improving and Sustaining Quality 9 Framework Worksheet A Medical Home (MH) Care Coordination Framework – WORKSHEET Fundamental Structures Access to Medical Home, Health Care and Other Resources Who? How? Medical Home InterventionsIdentify and register the CYSHCN population Establish with families effective means for medical home/office access Provide accessible office contract for family and community agencies Catalog resources to link families to appropriate educational, information and referral sources Promote and â€Å"market† practice-based care coordination to families and others (e. g. brochures, posters, outreach efforts) Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care &agencies offering respite, housing, & transportation) Align transition support activities wit h schools & other groups Collaborate to improve systems of care for CYSHCN (families, payers, provides, and agencies) Community Connections Fundamental Processes Proactive Care Planning Medical Home InterventionsHelp to maintain health and wellness & prevent secondary disease complications Maximize outcomes (e. g. alleviation of the burden of illness, effective communication across organizations, enrollment in needed services, and school attendance/success) Listen, counsel, educate, & foster family skill building Screen for unmet family needs Develop written care plans; implement, monitor and update regularly Plan for future transition needs; incorporate into plan of care Facilitate subspecialty referrals, communication & help family integrate recommendations of specialists Link family, staff to educational/financial resources †¢ †¢ †¢ †¢ Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. amily support, schools, early intervention, home care, day care & agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate with families, payers, providers and community agencies to improve systems of care for CYSHCN Who? How? Improving and Sustaining Quality 10 Time Protection Tips & Strategies The statement (on page 4) that no medical home will achieve optimal comprehensive, coordinated and compassionate care without dedicated time and resources to develop, implement, and evaluate a complement of care coordination activities warrants a few tips about how to achieve such dedicated time.Ideas for the successful implementation of practice based care coordination include administratively supported techniques and the resulting implemented care coordination (systematic) processes. Consider the following suggestions for time protection and use them to craft your own strategic approaches. Administrative Strategies for Achieving Some  "Think† and Implementation Time Personnel – proactively allocate a block of dedicated time. This includes the number of hours, days and time blocks or hours and how those hours will be prepared for, spent and accounted for. (This can be done as a trial or test of change) You may need a private place, an office, or even a â€Å"my care coordination development hat is on today† sign!Clear activities – Use the position description and the CC framework on page 9 to select the focus and logical progression of this role development and how time will be spent Determine how you will document and/or account for this time Team based care coordination – determine how you will allow for the development of care coordinator – family partnership. Could there be a designated clinic time for specific group of CYSHCN, or a special condition focused approach with a care coordination protocol? Some practices have held what is referred to as a DIGMA (drop in grou p medical appointments) for a group of families with children with similar conditions. A DIGMA can take on many forms such as family education, community resource connections, or even time for care coordination introduction and development with the opportunity to meet, greet and complete care plans.Approaches Helpful to Building Time into Your System Use your population identification system to determine who needs care coordination Use the development of your CC role to establish systematized screening assessments and resulting care planning and monitoring Hold medical home related staff meetings; offer education regarding CYSHCN and gain buy-in and staff understanding for the value of providing care coordination Engage families who can educate staff about the complexity of their child’s needs Create a reporting line to senior leaders from the Care Coordinator so that CC development is built into their role expectation Develop the capacity for care coordination â€Å"roundsà ¢â‚¬  by discussing direct CC efforts around individual children and youth with staff; gaining the input of colleagues will help you with staff education and their buy in to the medical home and practice-based care coordination approach; all will then learn about complex health and community based needs and resources Maximizing Reimbursement for Care Coordination: Ensuring affordability and sustainability by: Developing smart legitimate up-coding; Tracking CC data (service/outcome) to negotiate new payment opportunities Prepare for the use of new codes (care plan oversight) Become aware of and access Title V supports 11 Care Coordination Development: 1) The Model for Improvement 2) Care Coordination Aim Statement 3) Plan Do Study Act (PDSA) cycles or â€Å"tests of change†Model for Improvement Questions 1) What are we trying to accomplish? Medical Home Improvement Responses Medical Home – Care Coordination 2) How will we know that a change is an improvement? Measures – Medical Home Index, Medical Home Family Index & Survey, Other 3) What changes can we make that will result in an improvement? Good ideas – ready for use (e. g. CC definition, job description, framework & activities, PDSA examples 12 2) Care Coordination Aim Statement A good aim statement includes the following elements: Population – CYSHCN Timeframe – by when Intent – what/why Stretch goals – e. g. identify 100% CSHCN Example: Overarching Aim – Care CoordinationBetween Learning Session 2 and spring of 2006 we will customize and use a model of medical home care coordination for children/youth with special health care needs so that a position description and framework of activities are explicit, with time protected and accounted for and ~ 75% (goal) of children, youth and families report that they: Know who their care coordinator is Know they are receiving care coordination Participate in decisions about the level of care coordination needed Are satisfied with their access to care, care coordination, and resources (most of the time) For Veterans – Advanced Care Coordination Aim Goals Youth and families report that: A transition timetable is shared among family, practice and community professionals They have coordinated support getting their child’s needs met within the community and from sub-specialists 13 Thinking Through Some Measurement Ideas – For Practice-Based Care Coordination – PDSA Cycles Care Coordination Outcomes Family satisfaction decrease in worry and frustration (CMHI survey tools) increased sense of partnership with professionals (CMHI survey tools) improved satisfaction with team communication (CMHI survey tools)Staff satisfaction improved communication and coordination of care improved efficiency of care elevated challenge and professional role Improved child/youth outcomes Decrease in ER visits, hospitalizations, & school absences (family, plan report) Increase in a ccess to needed resources (CMHI survey tools) Enhanced self-management skills (CMHI survey tools) Improved systems outcomes decreased duplication decreased fragmentation improved communication and coordination (CMHI Medical Home Index) 14 PDSA Worksheet PDSA Team: Aim: CMHI Plan-Do-Study-Act Worksheet PLAN: Objective: (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen?How will you know your change is an improvement? DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 15 CMHI Plan-Do-Study-Act (PDSA) Worksheet PDSA Example Team: #1 Care Coordination Role/System Aim: Use from page 13 or create own PLAN: Objective: (Including details (who, what, where, when) We will develop and test a clearly defined system of care coordination (CC) services using strategies that fit our practice environment.This will include the use of a: 1) clear CC definition, 2) CC position description and 3) CC framework with an outline of activities. CC role, contact and access information will be explicit for families. {Our test of change will include dedicated time for the CC to share plans with staff and implement CC PDSA cycles (see examples in following pages). We will feed back lessons learned to our Medical Home Improvement team for guidance and direction. What additional information will you need to take action? Knowledge of and securing the availability of senior leader support with designation of one (or more) staff members to provide CC leadership What do you predict will happen?There will be false starts with â€Å"tyranny of the urgent† keeping us from our task; our will, ideas and execution will overcome this in the end. How will you know your ch ange is an improvement? Staff/families begin to ask for care coordination / CC activities (e. g. care plan); selected outcome measures improve (see page 14) DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 16 PDSA Worksheet PDSA Team: Aim:CMHI Plan-Do-Study-Act Worksheet PLAN: Objective: (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen? How will you know your change is an improvement? DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 17 CMHI Plan-Do-Study-Act Worksheet PDSA Example Team: #2 Care Coordination Needs Assessment Aim: Use from page 13 or create own PLAN:Objective: (Including details (who, what, where, when) With MH lead physician review pending CYSHCN visits; select 3 CYSHCN who will benefit from an assessment for care coordination. By â€Å"a week from next Tuesday† complete an assessment (e. g. parent/youth screening tool in appendices behind page 26) either before the office visit or by pre-visit phone call. Begin care planning process with child/youth and family What additional information will you need to take action? Listing of pending CYSHCN visits from the CYSHCN list or â€Å"registry† What do you predict will happen? Some false starts finding the right CYSHCN and with timing; we will succeed if persistent over slightly longer time span How will you know your change is an improvement?Follow up with 3 families in 2 weeks to determine if pre-visit assessm ent and follow-up planning are helpful and what needs to be added/improved; review value with lead physician as well. DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 18 PDSA Worksheet PDSA Team: Aim: CMHI Plan-Do-Study-Act Worksheet PLAN: Objective: (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen?How will you know your change is an improvement? DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 19 CMHI Plan-D o-Study-Act Worksheet PDSA Example #3 Comprehensive Care Planning Team: Aim: Use from page 13 or create own PLAN: Objective: (Including details (who, what, where, when) 1) Develop/choose care plan medical summary and use with 5 identified CYSHCN/week. 2) Add an emergency plan if warranted. ) Study provider and family feedback and integrate to improve the plan and the process for plan use. Create immediate action plan for how to meet resource, educational and other needs of CYSHCN/patient and family 4) Use lessons learned to share, engage, educate and spread medical home to staff. What additional information will you need to take action? Sample care plans to choose from using team priorities; identified CYSHCN with pending visit to initiate plan with. Also identify educational needs of staff /families. What do you predict will happen? Will start slow, 1-2 per week and pick up speed to reach 5. Value will result in better preservation of care coordinator time to complete plans, thus i ncreased use of CC and team process.Ultimately, we may schedule comprehensive care planning â€Å"rounds† with team/staff; review 3-5 CYSHCN/patients who are receiving this care coordination. Use rounds to review successes, challenges, needs of child/family with staff and address questions. How will you know your change is an improvement? Review with families for benefit, follow up in 4-6 weeks; review also with staff DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 20 PDSA Worksheet PDSA Team: Aim: CMHI Plan-Do-Study-Act Worksheet PLAN:Objective: (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen? How will you know your change is an improvement? DO : Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 21 CMHI Plan-Do-Study-Act Worksheet PDSA Example #4 Transition to Adult Care & Services; Up-coding to maximize reimbursement Team: Aim: Use from page 13 or create own PLAN:Objective: Have MD & Care Coordinator jointly see (2) YSHCN & family for transition visit; use a transition assessment (timetable) checklist to guide the visit and align activities with community partners. Bill for visit – document nature of complexity Details (who, what, where, when) CC Schedules 2 YSHCN for transition care plan visit next week, with family permission informs/communicates with key community partners about assets & needs. Codes for â€Å"99214† for 60 minute visit with established patient and document extent and complexity of the visit What additional information will we need to take action? – Extract from list of CYSHCN youth over 14 due for visit; communicate with family and learn community partners – Clarify with senior leaders ability to track reimbursement results for these visits What do we predict will happen? (E. g.May take time to match YSHCN with open slots; will need to follow up with payers for denials and use documentation to justify activities). How will you know your change is an improvement? Review with family staff; community partners. Select other ongoing measures (p14) DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 22 PDSA Worksheet PDSA Team: Aim: CMHI Plan-Do-Study-Act Worksheet PLAN: Obj ective: (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen?How will you know your change is an improvement? DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 23 CMHI Plan-Do-Study-Act Worksheet PDSA Example #5 Community Outreach / Resources Team: Aim: Use from page 13 or create own PLAN: Objective: (Including details (who, what, where, when) Plan for care continuity across the: medical home, school, and community agencies with 4 families and children/youth over the next four weeks.Use a selected communication strategy (fax back, email, NCR paper, electronic forum, other) to centralize key information with strengths, goals, care plans, access information, an d releases fostering cross organizational communication; the CC performs as a â€Å"hub of the wheel function† in these activities. What additional information will you need to take action? Identification of children/youth and families in need of transition and/or community-based coordination; identification of key community partners; consensus on communication strategy What do you predict will happen? Territorial barriers will crop up and family will need to be front and central to the process.How will you know your change is an improvement? Review with family and agencies whether there has been improved care communication, also consider other systematized outcome measures (see page 14). DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of c hange: 24 PDSA Worksheet PDSA Team: Aim: CMHI Plan-Do-Study-Act Worksheet PLAN: Objective: (Including details (who, what, where, when) What additional information will you need to take action?What do you predict will happen? How will you know your change is an improvement? DO: Was the plan carried out? What was observed that was not part of the plan? STUDY: What happened? Is this what you predicted? What new knowledge was gained? ACT: As a result, list next actions: Are there organizational forces that will help or hinder efforts? Objectives for next test of change: 25 Appendices A. Key Websites for Care Coordination Tools 1) Center for Medical Home Improvement (CMHI): www. medicalhomeimprovement. org 2) National Center for Medical Home Initiatives (AAP) www. medicalhomeinfo. org 3) Utah Medical Home Portal www. medhomeportal. orgReferences 1) McAllister, J. W. , Cooley, W. C, Presler, E. Practice-Based Care Coordination: A Medical Home Essential. Pediatrics, Volume 120, Number 3, S eptember 2007, e1e11. 2) American Academy of Pediatrics, Medical Home Initiatives for Children with Special Health Care Needs Project Advisory Committee. The medical home. Pediatrics, 2002; 110:184-186. 3) American Academy of Pediatrics, Committee on Children with Disabilities. Care Coordination: Integrating Health and Related Systems of Care for Children with Special Health Care Needs, Pediatrics, 1999, Vol. 104:978-981. 4) American Academy of Pediatrics, Division of Health Policy Research.Periodic Survey of Fellows #44. Health Services for Children with and without Special Needs: The Medical Home Concept Executive Summary. Elk Grove Village, Illinois: American Academy of Pediatrics; 2000. Available at: www. aap. org/research/ps44aexs. htm. Accessed April, 2005. 5) Antonelli, R. , Antonelli, D. , Providing a Medical Home: The Cost of Care Coordination: Services in a Community-Based, General Pediatric Practice. Pediatrics (Supplement) 2004; Vol. 113: 1522-1528 6) Cooley, W. C. and M cAllister, J. W. Building Medical Homes: Improvement Strategies in Primary Care for Children with Special Health Care Needs. Pediatrics (Supplement) 2004; 113: 1499-1506. ) Davis, K. , Transformation Change: A Ten Point Strategy to Achieve Better Health Care for All. The Commonwealth Fund. Accessed at www. cmwf. org April 13, 2005. 8) Family Voices. What Do Families Say About Health Care for Children with Special Health Care Needs in California: Your Voice Counts. Boston, MA: Family Voices at the Federation for Children with Special Health Care Needs; 2000. 9) Future of Children, Health Insurance for Children; Care of children with Special Health Care Needs. Key Indicators of Program Quality. Available at www. futureofchildren. org/information2827/Accessed April 13, 2005. 10) Horst, , Werner, R. , & Werner, C. 2000) Case management for children and families Journal of Child and Family Nursing, 3, 5-14. 11) Langley, G. J. , et al. The Improvement Guide: A Practical Approach to Enhanc ing Organizational Performance. Jossey-Bass, San Francisco, 1996. 12) Lindeke, L. L. , Leonard, B. J. , Presler, B, Garwick, A, Family-centered Care Coordination for Children with Special Health Care Needs across Settings. Journal of Pediatric Health Care, Vol. 16, No. 6, November/December, 2002, 290-297 ** 13) Presler, B. (1998, March/April) Care Coordination for Children with Special Health Care Needs. Orthopedic Nursing, (Supplement), 45-51. 26 CMHI Center for Medical Home Improvement (CMHI) Crotched Mountain Foundation Greenfield, New Hampshire 2007 27