Key Systems Issues Research Articles

Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment

BackgroundLittle information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD).MethodsData included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted.ResultsPsychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support.ConclusionQuebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

36.4 PHARMACOLOGIC STRATEGIES IN EMOTIONALLY DYSREGULATED AND MALTREATED YOUTH

Children and adolescents with a history of maltreatment experience significant emotional and behavioral dysregulation. They are frequently evaluated by child and adolescent psychiatrists and receive psychotropic medications to control dysregulation or treat underlying disorders. Many organizations, including AACAP and AAP, encourage trauma-informed approaches to care; however, the application of medications is quite variable. This presentation will review approaches to the use of medications in this population as well as key system issues that are critical to the delivery of evidence-based, trauma-informed care.

Rapid cycle system improvement for COVID-19 readiness: integrating deliberate practice, psychological safety and vicarious learning

IntroductionIn the face of a rapidly advancing pandemic with uncertain pathophysiology, pop-up healthcare units, ad hoc teams and unpredictable personal protective equipment supply, it is difficult for healthcare institutions and...

A systems approach to assessing complexity in health interventions: an effectiveness decay model for integrated community case management

ABSTRACT Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.

An exploration of the experiences of Australian Grey Nomads travelling with chronic conditions.

Internationally, the population is ageing and people are living well, longer. In Australia, extended travelling has gained popularity among older Grey Nomads due to time and opportunity post retirement. However, there is limited research available focusing on older Australians' health while travelling. This paper reports the qualitative phase of a larger mixed-method project that explores the experience of Australian Grey Nomads travelling with chronic conditions. Eight Grey Nomads participated in telephone interviews. Data were analysed using inductive thematic analysis. Two themes emerged, namely: continuity of care while travelling and experts on the road. Participants described encountering a fragmented health system, with challenges regarding finding health services; a lack of shared medical records; and difficulties accessing regular medications. Despite these challenges, participants demonstrated health preparedness, an ability to accommodate health on the road, and were all travelling for their health. This study highlights key systems issues that challenge health care while travelling, and identifies opportunities for both usual practices and rural health services to enhance the care provided to this group.

The Uncertain Character of Recent Educational Reform in Greece

This article outlines the main education reforms that have taken place in Greece from the 1960s until the present. The author discusses how the direction of these reforms has been influenced not only by ‘global’ pressures for ‘modernization’ but also by the distinctive socio-cultural Greek context. The conclusion stresses that despite the various attempts to reform the Greek education system key issues about the purposes of education provision remain unresolved.

Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects

This article describes a public health approach to the study of service systems for people with substance use disorders. Such an approach is broadly conceived to include the consideration not only of specialized services for alcohol and drug dependence, but also of medical care and social welfare services that interact with and complement specialized drug and alcohol services. After describing a conceptual model of the substance abuse service system, we discuss how systems of care may contribute to population health and social welfare by reducing the societal burden of substance use disorders. The article then summarizes key systems issues pertaining to mediators and moderators of effective treatment systems. The potential benefits of systems thinking in relation to the management of substance use disorders are described. It is suggested that systems concepts and research may help to improve access, efficiency, economy, continuity of care, and effectiveness, thereby improving the population impact of treatment services.

Adaptive Coding and Modulation for the DVB-S2 Standard Interactive Applications: Capacity Assessment and Key System Issues

Point-to-point multibeam satellite systems based on the DVB-S standard are currently designed for link closure in the worst-case propagation and location conditions. The DVB-S standard, conceived for broadcasting applications, considers a fixed coding rate and modulation format that are selected according to the assumed coverage and availability requirements. This approach implies the occurrence of high margins in the majority of the cases, when interference and propagation conditions allow for higher signal-to-noise-plus-interference ratio. The adaptive coding and modulation (ACM) introduction in the new DVB-S2 standard for the interactive service profile opens up a number of appealing opportunities for the design and development of satellite broadband networks. In this article we show how the ACM introduction in the satellite downlink enables greatly enhanced system performance but also has a profound impact on the way the system and some of the key system components are designed.

Analysis of how the health systems context shapes responses to the control of human immunodeficiency virus: case-studies from the Russian Federation.

To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.

A Novel On-Line Palmprint Identification System

Computer-aided personal identification is emerging as a top-notch technology in various automated security systems. Different biometric features, such as fingerprint pattern, speech quality, face feature, signature manner, hand geometry and iris characteristics, have been proposed as means for individual identification. In this paper, we developed a brand new method-a unique on-line palmprint identification system-to verify individuals by measuring the inner surface of a palm. We began the introduction of our approach by discussing the system's key issues. Next, we thoroughly explained the two crucial parts of the system: the on-line palmprint capture device and the feature extraction algorithm. Experiments and their results were shown to prove the effectiveness of the proposed method on our palmprint database.

Implementation of a European infrastructure for satellite navigation: from system design to advanced technology evaluation

Europe is initiating the Galileo programme, targeting the implementation of a navigation system independent and interoperable with GPS and GLONASS. Galileo will bring Europe a wide range of political, economical and industrial benefits. The architecture of Galileo is based on an MEO constellation, possibly completed with Geostationary satellites. Possible constellations are 24 MEO+3–9 GEO depending on the area to be covered, or 30 MEO only. The integrity concept is regional, like in EGNOS. One of the major issues is to define adequate frequency bandwidth to be used for broadcasting the navigation signal to the users. Several scenarios are being considered, depending on the possible level of co-operation with US and/or Russia. System key issues are integrity data generation, orbit-determination/synchronization, and constellation design. The major challenges to face are to propose an innovative concept offering advantages to the users compared to GPS, while keeping costs low and using well-proven technologies not to endanger the programme implementation. In order to do so, it is proposed to take advantage of several space programmes implemented by Alcatel, at ground and space segment levels. EGNOS heritage is, of course a major heritage for the development of the Galileo ground segment. Payload design is based on a direct heritage from the MTSAT products, and satellite design is taking advantage of the Alcatel product line including Proteus, Skybridge, Spacebus and Globalstar. Galileo will take full benefit of the expertise gained through all these programmes. This expertise and the resulting Galileo design is described in this paper. Copyright © 2000 John Wiley & Sons, Ltd.

Improving diabetes care in the primary health setting. The Indian Health Service experience.

To identify key systems issues from the Indian Health Service (IHS) experience that must be addressed to improve metabolic control among patients with non-insulin-dependent diabetes mellitus (NIDDM) who were followed in primary care settings. Records of diabetic patients seen in IHS facilities in specific geographic regions from 1987 to 1994. A representative sample of charts from each facility was reviewed yearly to measure key variables. The sampling frame was the number of diabetic patients currently active on the registry and the sample size calculated to measure a 10% change in selected practices at each facility. Regional diabetes coordinators reviewed charts or trained local providers to sample and extract data in a standard format. Regional data were examined to show trends in the performance of immunizations and foot examinations and in other variables such as hypertension and metabolic control. The percentage of diabetic patients who received a single dose of pneumococcal vaccine improved from 24% in 1987 to 1988 to 57% in 1994 (P < 0.01 for trend) among diabetic patients in Minnesota, Wisconsin, and Michigan. Rates of yearly comprehensive foot examination increased from 36% to 58% (P < 0.01 for trend) over the same period. In Montana and Wyoming, the percentage of diabetic patients with uncontrolled hypertension (defined as the mean of three systolic blood pressure measurements of > or = 140 mm Hg or diastolic pressure measurements > or = 90 mm Hg, or both, during the previous year) decreased from 36% in 1992 to 25% in 1993 after the regional diabetes coordinator emphasized hypertension control. In 1994, when less emphasis was placed on hypertension, 33% of the diabetic patients had uncontrolled hypertension. Estimates of metabolic control from records of diabetic patients in Washington, Oregon, and Idaho in 1994 showed that 29% of patients had excellent metabolic control (a hemoglobin A1c [HbA1c] level < or = 7.5% or mean blood glucose level < or = 9.2 mmol/L) within the past year; only 9% experienced poor control (a HbA1c level > 12% or mean blood glucose level > 18.9 mmol/L). The IHS experience shows that standard, ongoing monitoring of key variables allows facilities to improve diabetes care. Simple, reliable methods of defining metabolic control combined with a feedback system in the primary care setting are needed to improve metabolic control in patients with NIDDM.

Analog lightwave links for detector front-ends at the LHC

Lightwave links are being developed for volume application in the transfer of analog signals from the tracking detector front-ends to the readout electronics. The links are based on electro-optic intensity modulators which are mounted on detectors and connected by optical fibers to remotely located transceivers (lasers and photoreceivers). The modulators are III-V semiconductor reflective devices based on multi-quantum well structures. The transceivers will be integrated devices of a novel design. Modulator prototypes have been fabricated and tested. Neutron and /spl gamma/-ray irradiation studies have been performed on modulators and fibers. The main results achieved so far are reported and key system issues are reviewed. This work is part of the CERN DRDC project RD23.< <ETX xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">&gt;</ETX>

Analogue optical links for detector front ends at the LHC

Analogue lightwave links are being developed for the readout of tracking detectors at the CERN Large Hadron Collider (LHC). The links are based on arrays of reflective electro-optic intensity modulators, mounted on detectors and connected by optical fibres to remotely located transceivers (CW lasers and photoreceivers). The modulators are essentially passive devices with negligible power requirements. The transceivers are integrated optics devices of a novel design. Modulator prototypes have been fabricated and tested. The results achieved so far and the key system issues are reviewed.