Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Effect of A-site ionic size variation on TCR and electrical transport properties of (Nd0.7-xLax)0.7Sr0.3MnO3 with x = 0, 0.1 and 0.2

In this work, the structural and transport properties of (Nd0.7-xLax)0.7Sr0.3MnO3 manganites with x 0, 0.1 and 0.2 prepared by solid state reaction route are studied. These compounds are found to be crystallized in orthorhombic structural form. Experimental results showing a shift in the metal to semiconductor/insulator transition temperature (TMI) towards room temperature (289 K) with the substitution of Nd by La, as the value of x is varied in the sequence (0,0.1,0.2), have been provided. The shift in the TMI, from 239 K (for x=0) to near the room temperature 289 K (for x=0.2), is attributed to the fact that the average radius of site-A increases with the percentage of La. The maximum temperature coefficients of resistance (TCR) of (Nd0.7-xLax)0.7Sr0.3MnO3 (x= 0.1 and 0.2) are found to be higher compared to its parent compound Nd0.7Sr0.3MnO3. The electrical transport mechanisms for (Nd0.7-xLax)0.7Sr0.3MnO3 (x= 0 to 0.2) are explored by using different theoretical models, for temperatures below and above TMI. An appropriate enlightenment for the observed behavior is discussed in detail

Study of structural effect on Eu-substituted LSMO manganite for high temperature coefficient of resistance

n this work, Eu substituted La0.7Sr0.3MnO 3 (LSMO) is studied to achieve high temperature coefficient of resistance (TCR). The compounds La0.7-xEuxSr 0.3MnO3 with x=0, 0.1 0.2 and 0.3 are prepared by solid state reaction route and their structural and transport properties are examined by different characterization techniques. The metal-semiconductor/insulator transition temperature (TMI) decreases from 390 K (for x=0) to 240 K (for x=0.3) with decrease in average ionic radius 〈rA〉 of A-site. The maximum TCR percentage of La0.7-xEuxSr 0.3MnO3 compound is found to be increased for x=0.2 (1.9%) and for x=0.3 (3.36%) compared to its parent compound La0.7Sr 0.3MnO3 (1.1%). The substitution of Eu increases the lattice distortion, which enhances the TCR value from 1.1% to 3.36%. The robustness of distortion increases with decreasing 〈rA〉 which is well correlated with the high magneto-resistance, and high TCR findings

Case study: Systemic complications following absolute alcohol embolisation of scalp arteriovenous malformation

Alcohol ablation is an accepted technique for the management of arteriovenous malformations. It is preferred due to the unique property of absolute alcohol to cause complete ablation and prevention of revascularisation. However, this technique is associated with multiple complications which may lead to patient morbidity. Here the case is presented of a female patient with scalp arteriovenous malformation who underwent alcohol ablation and developed supraventricular arrhythmia accompanied with haemodynamic instability and intravascular haemolysis in the postoperative period

Vocal cord palsy in an infant with myelomeningocoele

In this article we describe the case of a four-month-old male infant with myelomeningocoele, who presented with inspiratory stridor and vocal cord palsy (VCP). Hindbrain dysfunction is a leading cause of mortality and morbidity in children with neural tube defects. It is important to consider the above in the differential diagnosis of infants with breathing difficulties. A discussion of myelodysplasia, Arnold-Chiari malformations, bilateral VCP and anaesthesia management is presented.South Afr J Anaesth Analg, 2011;17(6):394-39

Computational Fluid Dynamics Modelling to design and optimise Power Kites for Renewable Power Generation

Power kites provide the potential rewards of obtaining the disused energy supply from high altitude wind. This paper aims to provide a design of Power kite and optimise the potential for renewable power generation. The Power kite was modelled using Computational Fluid Dynamics (CFD) to study its characteristics. The numerical modelling results were compared against the wind tunnel experimental study and two 3D printed Power kites. The design was optimised using several variables, including aerofoil choice, surface roughness, wind speed and operating parameters. Attempts at optimising the kite design were implemented. The results suggest that operating the kites at minimum 15 m horizontal separation is favourable, with the trailing kite operating below the leading, removing the potential for this kite to operate in the wake turbulence of the first. As the wind speed is generally very low at low altitudes, it is recommended to use a symmetrical aerofoil for the kite design, as these tend to produce greater lift with low Reynolds airflow. This paper presents relevant, applicable data which can be used for predicting the performance, and potentially optimising further Power kite designs

Metallised Fuel rich Propellants for Solid Rocket Ramjet: A Review

This paper reviews the research work carried out in the field of metallised fuel-rich propellants (FRP). Limitations and merits of various potential metals (Al, Mg, B, Be, or Zr) as a component of FRP are discussed. The paper also includes a discussion on the combustion mechanism of metallised propellants, including problem areas and probable remedial measures. Zirconium and Ti appear to have potential to offer FRP with efficient combustion. Ideal performance is not achieved with current systems based on Al and B and further work is needed to develop FRP having all three desirable attributes, viz., ease of ignition, stable combustion and high specific impulse (I/sub sp/) in a single composition

Strength Degradation of Sapphire Fibers During Pressure Casting of a Sapphire-Reinforced Ni-Base Superalloy

Transient-liquid-phase (TLP) bonding was used to fabricate a Haynes 230 Ni-base superalloy/sapphire fiber composite for high-temperature applications. Boron was used as a melting-point depressant for the Ni, to aid superalloy infiltration of the fibers. Preliminary study of the composite indicated an incomplete TLP bonding cycle. Therefore, microstructural and microchemical analyses were carried out to determine the TLP bonding mechanism. It was found that the TLP process did not occur under local thermodynamic equilibrium conditions at the solid/liquid interfaces, contrary to the primary assumption of conventional models, so a modified model for TLP bonding is proposed. The main differences between the proposed and the conventional models are: (a) the concentration of the melting-point depressant increases with time during isothermal solidification, (b) extensive boride segregation at grain boundaries and boride precipitation occurs within grains adjacent to the interlayer in the initial composite assembly, (c) because of the relatively high boron concentration in the interlayer, the TLP bonding cycle was incomplete, resulting in residual-liquid borides. To achieve ideal TLP bonding, four modifications are recommended: (i) use less boron, (ii) use finer sapphire fibers, (iii) create smaller initial grain sizes in the matrix and (iv) increase the homogenization time

Integrating the voluntary sector in personalised care: mixed methods study of the outcomes from wellbeing co-ordination for adults with complex needs

PurposeThis integrated care study seeks to highlight how voluntary sector “wellbeing co-ordinators” co-located in a horizontally and vertically integrated, multidisciplinary community hub within one locality of an Integrated Care Organisation contribute to complex, person-centred, co-ordinated care.Design/methodology/approachThis is a naturalistic, mixed method and mixed data study. It is complementing a before-and-after study with a sub-group analysis of people receiving input from the wider hub (including Wellbeing Co-ordination and Enhanced Intermediate Care), qualitative case studies, interviews, and observations co-produced with embedded researchers-in-residence.FindingsThe cross-case analysis uses trajectories and outcome patterns across six client groups to illustrate the bio-psycho-social complexity of each group across the life course, corresponding with the range of inputs offered by the hub.Research limitations/implicationsTo consider the effectiveness and mechanisms of complex system-wide interventions operating at horizontal and vertical interfaces and researching this applying co-produced, embedded, naturalistic and mixed methods approaches.Practical implicationsHow a bio-psycho-social approach by a wellbeing co-ordinator can contribute to improved person reported outcomes from a range of preventive, rehabilitation, palliative care and bereavement services in the community.Social implicationsTo combine knowledge about individuals held in the community to align the respective inputs, and expectations about outcomes while considering networked pathways based on functional status, above diagnostic pathways, and along a life-continuum.Originality/valueThe hub as a whole seems to (1) Enhance engagement through relationship, trust and activation, (2) Exchanging knowledge to co-create a shared bio-psycho-social understanding of each individual’s situation and goals, (3) Personalising care planning by utilising the range of available resources to ensure needs are met, and (4) Enhancing co-ordination and ongoing care through multi-disciplinary working between practitioners, across teams and sectors.</jats:sec