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Most common are caregiving rewards or benefits capillaries around nose 80 mg propranolol amex, appreciation of life cardiovascular disease mortality rates propranolol 80 mg discount, personal growth cardiovascular system of a pig buy propranolol 80 mg on line, enhanced selfefficacy cardiovascular system nursing questions generic propranolol 80 mg mastercard, competence or mastery, self-esteem, and closer relationships (Haley et al. Prevalence rates for positive psychological effects are high across the caregiving population as a whole, with variation evident among demographic subgroups of caregivers. Percentages are substantially higher on this indicator for African American caregivers (68 percent), Hispanic caregivers (60 percent), caregivers with less than a high school education (67 percent), caregivers with income below $20, 000 (67 percent, ) and caregivers who help more often with self-care tasks (58 percent). Again, percentages are higher for African American caregivers (67 percent), caregivers with less than a high school education (64 percent), and caregivers who help more often with self-care tasks (66 percent). These findings are consistent with literature reviews showing that racial and ethnic minority caregivers experienced higher levels of subjective well-being and perceived uplifts than White, nonHispanic caregivers (Pinquart and Sorensen, 2005). Positive psychological effects may mitigate some of the negative effects of caregiving, as several studies find that positive effects are associated with lower levels of burden and depression and better overall mental health. In summary, a large body of literature, including population-based cross-sectional and longitudinal studies, provides strong evidence that a substantial proportion of the caregiving population experiences negative psychological effects, even though caregiving has some positive effects as well. Regardless of the mental health indicator used, levels of distress are high enough to constitute a public health concern. Evidence about predictors of negative psychological health effects suggests that prevalence rates vary across subgroups of caregivers, placing some caregivers at higher risk for negative effects than others. Further evidence suggests that risk factors are multifactorial and may be cumulative. Women providing many hours of care weekly to a recipient with challenging behavioral symptoms may be at particularly high risk. Thus, multidimensional assessment is needed to identify the specific array of risk factors present for any given caregiver. Likewise, interventions need to be tailored to specific subpopulations of caregivers. Physical Health Effects A variety of indicators have been used to assess the physical health of caregivers including global health status indicators, physiological measures, and health behaviors (see Table 3-4). Global health status indicators include standardized self-assessment tools such as healthrelated quality of life, chronic conditions, physical symptoms. For example, in a review of 176 studies of family caregivers of older adults assessing the physical health of caregivers, Pinquart and Sorenson (2007) found 66 percent of studies used a "single-item indicator" self-report measure, 21 percent incorporated measures related to physical impairment (Activities of Daily Living or Instrumental Activities of Daily Living scales), 19 percent included measures based on a symptom checklist. The diversity of methods and instruments used to measure caregiver health makes cross study comparisons and meta-analyses difficult (Grady and Rosenbaum, 2015). Thus, caution is advised in overattributing negative health outcomes to the effects of caregiving. The physical health status and outcomes for caregivers may be relatively independent of the caregiving role or related to individual characteristics that existed prior to assuming the caregiving role, such as socioeconomic status, health habits, and prior illness (Brown and Brown, 2014; Robison et al. Nevertheless, the data support the conclusion that at least some caregivers are at risk for adverse health outcomes (Capistrant, 2016). In the discussion below we identify a broad range of individual and contextual factors that contribute to adverse health outcomes in caregivers. Caregivers for older care recipients consistently report poorer subjective health status than non-caregivers (Berglund et al. Poorer caregiver physical health is closely associated with greater caregiver burden and depressive symptoms and is associated to a lesser degree with hours of care provided, the number of caregiving tasks, months in the caregiver role, as well as the physical, cognitive and behavioral impairments and problems of the care recipient (Pinquart and Sorenson, 2007). Family caregivers in England responding to a national survey of users of primary care services also reported poorer health and a worse primary care individual experience compared with non-caregiver individuals with similar demographics, including age, gender, ethnicity and level of social deprivation (Persson et al. These effects were more pronounced when the type of cancer had a high mortality rate, such as pancreatic and lung cancers. One of the consistent themes in the caregiver health effects literature concerns the role of caregiver strain in predicting negative health effects (Schulz et al. Schulz and Beach (1999) found increased risk of mortality (63 percent) among older spousal caregivers, but only if they reported emotional strain in the caregiving role. Living with a person with Parkinson disease 5 years after first Parkinson hospitalization was associated with higher risk of all-cause mortality for both husbands and wives in a study by Nielsen et al.

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Also capillaries under the tongue 40 mg propranolol with amex, since the method is based on individual units of care or service coronary artery yahoo purchase propranolol 40mg online, it can be difficult to heart disease in women statistics propranolol 40mg low cost coordinate payment across the many members of a care team blood vessels length buy 40mg propranolol with amex. The main advantages of payment by some unit of care are that it reduces the incentive for risk selection. For per diem payment methods, there can also be an incentive to produce care efficiently to maximize profits per day (Aas, 1995; Barnum et al. Blended Methods Approaches for bundling payments to providers have received increasing attention in recent years as a mechanism to align more closely the incentives faced by different providers involved in the care of a single patient. The central characteristic of bundled payment is that it covers multiple providers. The advantage of bundled payment methods is the opportunity to use resources more efficiently if some services across the continuum of care are substitutes for each other. Even if there is no substitution, a payer can make one entity responsible for a bundle of services and provide that entity with an incentive to deliver an efficient combination of services (Welch, 1998). Any possible gains associated with shifting patients among services is diminished. Concerns with bundled payment approaches include questions about which entity should receive the payment and be held responsible for care (Welch, 1998). Possible responsible entities include health plans, hospitals, and physician groups. Another concern is feasibility in rural areas, where providers may face special difficulties in managing a continuum of services. Concerns have also been raised regarding the technical issues involved in building billing systems that can combine services offered by multiple providers (Schmitz, 1999). Additionally, legislative changes may be required to bundle payments for some combination of services, such as acute and postacute care (Welch, 1998). One evaluated program that illustrates the potential of bundled payment is found in the Medicare Participating Heart Bypass Center demonstration, begun in 1991 by the Health Care Financing Administration (Cromwell et al. Four hospitals were paid a single fee for all inpatient institutional and physician care for heart bypass patients. Hospitals and physicians could split the fee in whatever manner they chose; however, no additional inpatient billing was permitted. The average total costs fell in three of four hospitals, and length of stay for patients in the program declined in all four hospitals. The savings were achieved because of changes in physician practice patterns that occurred when hospital and physician Copyright National Academy of Sciences. Surgeons took a more active role in discharge planning, review of drug protocols, and elimination of unnecessary standard orders for routine testing. Payment methods could be combined along several dimensions (Aas, 1995; Barnum et al. For example, physicians could be paid using a combination of fee for service and a target rate of growth in overall spending for physician services. Medicare applied this approach when it combined a fee schedule with a sustainable growth rate system for updating physician payment rates (Medicare Payment Advisory Commission, 2000c). For example, a provider could be paid under capitation, with certain services designated for separate payment (Maguire et al. For example, in an integrated delivery system, physicians could be paid under capitation and hospitals paid on a per diem basis. For example, providers could be paid under a prospectively determined budget, with a retrospective adjustment for the mix of patients actually seen. Summary In general, payment methods based on budget for a range of care are better at controlling the total costs of that care, but can create concerns regarding underuse. They may also require greater institutional investment in information and management systems so the provider organization can monitor care and costs. Payment on a per unit basis has the opposite effect: it is often easier for providers to manage, but is usually less amenable to controlling total costs.

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Management needs to cardiovascular disease prevention guidelines buy generic propranolol 80 mg on line understand the flow of information coronary heart valve disease 40 mg propranolol otc, which should be documented arteries and nerves generic 40 mg propranolol otc. A strong system of internal controls and supporting technologies must be in place for the Program to heart disease guidelines purchase propranolol 40 mg on line maintain integrity and to help ensure completeness and accuracy of information. The program should contain controls and checks for completeness, limits and reasonableness. Automated enforcement detects and identifies moving violations without the dependency on police presence. A question to be answered is which model-in-house or outsourced-is more effective and efficient. There is one vendor staff person detailed to provide unspecified technical support to the Program and a half-time-equivalent project manager. As part of the red light component the Program, images and video are captured of vehicles entering intersections against red lights. Under the speed component, cameras enforce traffic laws through the use of sensors and photograph vehicles exceeding the posted speed limit by 11 miles per hour. Citations are mailed to the owner of the vehicle within 25 days of an event occurring, in accordance with the law. Mapped locations can also be found on unofficial websites maintained by internet users. A summary of the cameras that were active during the audit period are shown below. Not all were active continuously during the audit period, but we were unable to obtain the dates cameras were placed in service at each location. The red light camera system typically monitors two opposing approaches to an intersection, primarily for straight-through or right-turn traffic. For each monitored approach, the unit digitally records video and photographic evidence of red light violations. The radar calculation is a wavelength translated to the tone of the assigned tuning fork. An electronic record along with an entry into a log provides evidence of the test. Failure to maintain this rate or failure to keep units operational will result in monetary penalties. The license number, make and model of the vehicle are visible and match the data acquired. Location image and camera alignment are correct and the citation image matches the location image. In the case of speeding violations, location codes in the deployment log match the event data. If a processor is unable to determine if an event should be approved or rejected, they may transfer it to the Supervisor Review queue. All events, which have been rejected, are reviewed by the Supervisory Legal Instruments Examiner ("Processor Supervisor"). Both civilian and Officer Processors receive one week of on-the-job training, which is followed by one week of monitoring by a seasoned civilian or Officer processor, respectively. On an ongoing basis, processors are encouraged to seek a second opinion if uncertain about the proper disposition of an event. Once cameras are installed, preemptive maintenance is conducted to ensure minimal equipment downtime. Once the upload has been completed, the unit will be wiped clean and placed in storage waiting to be placed back in the field. The deployment log is closed and given to Processing to be uploaded into the system. This documentation includes an introduction, objective, process overview, process flowchart and operating instructions. Field Services Manager Step On a weekly basis, create schedule for deployment verification based on box location as well as date of deployment.

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The most common way that speakers discover topics is by simply observing what is happening around them-at their school cardiovascular system regulation cheap propranolol 80mg without prescription, in their local government 3 blood vessels in the body buy generic propranolol 80 mg on-line, or around the world arteries in the leg 40 mg propranolol visa. This is because all speeches are brought into existence as a result of circumstances blood vessels dilate trusted propranolol 40 mg, the multiplicity of activities going on at any one given moment in a particular place. For instance, presidential candidates craft short policy speeches that can be employed during debates, interviews, or town hall meetings during campaign seasons. When one of the candidates realizes he or she will not be successful, the particular circumstances change and the person must craft different kinds of speeches-a concession speech, for example. In other words, their campaign for presidency, and its many related events, necessitates the creation of various speeches. Rhetorical theorist Lloyd Bitzer (1968) describes this as the rhetorical situation. Put simply, the rhetorical situation is the combination of factors that make speeches and other discourse meaningful and a useful way to change the way something is. Student government leaders, for example, speak or write to other students when their campus is facing tuition or fee increases, or when students have achieved something spectacular, like lobbying campus administrators for lower student fees and succeeding. In either case, it is the situation that makes their speeches appropriate and useful for their audience of students and university employees. More importantly, they speak when there is an opportunity to change a university policy or to alter the way students think or behave in relation to a particular event on campus. But you need not run for president or student government in order to give a meaningful speech. On the contrary, opportunities abound for those interested in engaging speech as a tool for change. See the textbox entitled "Questions for Selecting a Topic" for a few questions that will help you choose a topic. There are other questions you might ask yourself, too, but these should lead you to at least a few topical choices. The most important work that these questions do is to locate topics within your pre-existing sphere of knowledge and interest. David Zarefsky (2010) also identifies brainstorming as a way to develop speech topics, a strategy that can be helpful if the questions listed in the textbox did not yield an appropriate or interesting topic. Starting with a topic you are already interested in will likely make writing and presenting your speech a more enjoyable and meaningful experience. It means that your entire speechwriting process will focus on something you find important and that you can present 8-2 Chapter 8 Outlining and Organizing Once you have answered these questions and narrowed your responses, you are still not done selecting your topic. For instance, you might have decided that you really care about conserving habitat for bog turtles. To resolve this problem, speakers must also consider the audience to whom they will speak, the scope of their presentation, and the outcome they wish to achieve. If the bog turtle enthusiast knows that she will be talking to a local zoning board and that she hopes to stop them from allowing businesses to locate on important bog turtle habitat, her topic can easily morph into something more specific. For instance, the bog turtle habitat activist might write the following specific purpose statement: At the end of my speech, the Clarke County Zoning Commission will understand that locating businesses in bog turtle habitat is a poor choice with a range of negative consequences. In short, the general purpose statement lays out the broader goal of the speech while the specific purpose statement describes precisely what the speech is intended to do. In this example, the thesis statement outlines the main points and implies that the speaker will be arguing for certain zoning practices. In short, a purpose statement clearly states what it is you would like to achieve. Purpose statements are especially helpful for guiding you as you prepare your speech. When deciding which main points, facts, and examples to include, you should simply ask yourself whether they are relevant not only to the topic you have selected, but also whether they support the goal you outlined in your purpose statement. The general purpose statement of a speech may be to inform, to persuade, to inspire, to celebrate, to mourn, or to entertain. Thus, it is common to frame a specific purpose statement around formulating the purpose statements the specific purpose statement is a tool that you will use as you write your talk, but it is unlikely that it will appear verbatim in your speech. Instead, you will want to convert the specific purpose statement into a thesis statement that you will share with your audience. A thesis statement encapsulates the main points of a speech in just a sentence or two, and it is designed to give audiences a quick preview of what the entire speech will be about.

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