The First Contact in Apocalypse Now

The First Contact in Apocalypse Now and Heart of DarknessIn Apocalypse Now, Francis Ford Coppola obviously modifies and embellishes the characters, scenes and dialogue of Joseph Conrad’s Heart of Darkness. However, with only minor modification Coppola powerfully represents Charlie Marlow’s first contact with Kurtz’ camp. Marlow is greeted by a completely unexpected young Russian adventurer who had become a part of Kurtz’s family. Although Coppola has changed the Russian adventurer into an American photojournalist he has kept the characterizations and dialogue very close to Conrad’s original. In doing so, the impact, theme and message of the cinematic and textual versions of the same scene are virtually parallel. Nonetheless several elements missing from the screen version causes it to be less than helpful in understanding the text version.The young Russian was Charlie Marlow’s first sight when he reached Kurtz’ camp and he looked at hi m â€Å"in astonishment. There he was before me, in motley, as though he had absconded from a troupe of mimes, enthusiastic, fabulous. His very existence was improbable, inexplicable, and altogether bewildering† (p. 119). Although not English like Marlow, he made immediate note of his commonality as a â€Å"brother sailor† (p. 116). Rather impetuously he requests some of Marlow’s â€Å"excellent English tobacco† while pointing out â€Å"your pilot-house wants a clean up!† (p. 115). Aware of Marlow’s potential peril at the hands of the natives, he advises him to keep the boat’s whistle ready; â€Å"one good screech will do more for you than all your rifles† (p. 115).The Russian took it upon himself, and appeared literally compelled to tell Marlow as much as possible of Kurtz and his relationship with him. He was clearly in awe of Kurtz and yet casually mentioned Kurtz had threatened to kill him. He described the great intellectu al and emotional conversations they shared. He made no apologies for the obvious atrocities carried out under Kurtz’ command—human heads mounted on stakes. As an explanation he pleaded to Marlow â€Å"you don’t know how such a life tries a man like Kurtz† (p. 124).He denied Kurtz was mad; he protested â€Å"you can’t judge Mr. Kurtz as you would an ordinary man† (p. 121). In spite of it all—or perhaps because of it all—the Russian had nursed Kurtz through illnesses and tried to convince Kurtz to leave the jungle. But Kurtz remained: according to the Russian â€Å"this man suffered too much. He hated all this, and somehow he couldn’t get away† (p. 121). The Russian knew it was time to leave and perhaps time for Kurtz to leave as well, and Marlow gave him cartridges, tobacco and even shoes as he was leaving the camp. Upon leaving he exclaimed â€Å"you ought to have heard him recite poetry—his own, too†¦oh, he enlarged my mind!† (131).Coppola is very faithful to the original in his characterization of the American photojournalist who greets Willard on his arrival. The American, nameless as Conrad’s Russian, quickly establishes his commonality with Willard and the crew, crying out â€Å"American! I’m an American civilian!† Similarly he quickly boards the boat, stating happily â€Å"you got the cigarettes!† and exclaiming â€Å"This boat is a mess, man!† Willard is flabbergasted at his appearance, but just as grateful as Marlow when the American advises â€Å"just zap ‘em with your siren!† in reference to the hostile natives surrounding the boat.The American, like the Russian, is a â€Å"disciple† of Kurtz and takes it upon himself to tell Willard all he can about Kurtz and his relationship with him. He’s concerned Willard has â€Å"come to take him away† this â€Å"great man† who is â€Å"a poet warr ior in the classic sense.† Like the Russian, the American has also been threatened with death by Kurtz but is loyal nonetheless. Willard, like Marlow, sees the grotesque heads on pikes and the American responds â€Å"you’re looking at the heads—sometimes he goes too far† and fears â€Å"you’re gonna call him crazy.†The two scenes are virtually parallel in theme and message. The appearance of both characters is completely unexpected and adds the suspense of â€Å"what else can be expected in this other-worldly place?† The unexpectedness is combined with the theme of being caught off-guard by the appearance of someone â€Å"familiar† in an unfamiliar environment. Is it safe or dangerous to trust this person?Additionally the characters provide Marlow/Willard with â€Å"interpretations† and defense of Kurtz, which is equally frightening when the profound effect of Kurtz upon the characters is revealed. It is a very effective way of giving substance to a man who has yet to be seen. The characters are very appropriate gatekeepers to the â€Å"Heart of Darkness† Marlow/Willard are about to enter. The message is the power Kurtz can exert on a fellow European/American and both reader and viewer are left to wonder what effect Kurtz will have on Marlow/Willard.Unfortunately Coppola’s scene does little to assist in understanding the scene as written by Conrad for a very simple reason: despite the dramatic jolt the American gives, he is an â€Å"incomplete† if not â€Å"throwaway† character. Conrad’s Russian is a man of his own adventure who had nursed Kurtz and urged him to leave; he clearly recognizes the time to move on, which helps put Kurtz and his influence on the Russian in perspective.Coppola’s American, by contrast, has not been of any assistance to Kurtz nor urged him to leave, and is not heard from after bringing Willard into the camp. The Russian has survived and thrown off the influence of Kurtz; whether the American survives is left to the imagination. Despite this, Coppola has provided the viewer a powerful visual representation of the entry into the Heart of Darkness.ReferencesConrad, Joseph. (2003). Heart of Darkness. New York: Barnes & Noble.Coppola, Francis F. Apocalypse Now. 1979. Zoetrope Studios.

Culture and Social Structure Essay

Culture is a difficult thing to strictly define. Such a large variety of societal aspects fall under its realm, that it’s sometimes complicated to draw a line between what is part of a culture and what is not. To put it in extremely vague terms, culture is a way of life. All the traits that make up a particular society, from religious beliefs to modes of dress to art to methods of farming, build up a culture. Culture includes the good and the bad, the old and the new, the strong and the weak – essentially it includes â€Å"everything†. Many varieties of cultures exist. There are the obvious ethnic cultures – African-American culture, Latino culture, Greek culture, etc., each with their own foods, art, religion, familial roles, and values. American culture, for example, is generally considered to be relaxed – apple pie, blue jeans, baseball and the like. Family roles are not set in stone, there is freedom to choose a religion based on one’s own comfort (or choose no religion at all), and while a certain level of morality is maintained, values are generally loose. Compare this to the culture of the remote parts of India. There, a woman is required to serve her husband and his family, even after his death. They are very devout, and there is only one religion to â€Å"choose† from. They are held to a strict moral code, and anyone who violates this code is considered an outcast. There are many other ways to consider culture. There is the culture of a particular age group. A septuagenarian has a way of life very different than that of a teenager. His music, dress, beliefs, and goals are generally dissimilar to those of his younger counterpart. Or there is the culture of a particular time period. Pre-historic culture is, through modern inventions and human development, very different than the culture of today. A very important part of any culture is the social structure within. The social structure is essentially the roles or positions that particular individuals or groups in a culture fall into. For example, in the American culture, the President takes on a leadership role, those in the armed forces take on a protective role, and everyday citizens take on the responsibility of keeping the economy alive. On a much smaller scale, the social structure exists within a family as well. In your â€Å"typical† family, the mother takes on a nurturing position, while the father takes on the responsibility of earning money and providing for the others. Similarly, on a sports team, the coach is the leader, charged with guiding and motivating his players. The players themselves are responsible for putting forth their best effort and taking the team as far as it can go. While culture can be hard to define using words, one need only look around to experience everything that culture contains. One’s everyday life is culture, from the worldwide culture that everyone lives in, down to the personal culture of one’s own house. Each person has a role in many different social structures, and each role is genuinely important. It is these roles, in these social structures that make up every part of every culture.

The Mezquita Mosque Research Paper Example | Topics and Well Written Essays - 2750 words

The Mezquita Mosque - Research Paper Example It is the third largest mosque in the world and also one of the oddest, because it contains a Christian cathedral that was built inside it after the Moors got expelled in 1236. The graceful Moorish architecture combined with the triumphant Baroque cathedral memorializes in stone the conflict between Christianity and Islam that wracked Spain for 700 years. The Mezquita mosque was built in 785 and enlarged four times during the following 200 years; the cathedral was added in the 16th century. (Brockman, 2011, pg. 330) The Mezquita Mosque was founded by Abd ar-Rahman I in 785. Rahman I was the sole survivor of a tribe known as the Umayyards who fled Syria. Before Rahman I, the first Muslims who arrived to Cordoba shared la Mezquita with Christians. Rahman I bought the Christians out and started what would become a seven century dynasty of Muslim rule over Spain. After Rahman I died, he was followed by Abd ar-Rahmann II (822-52), who vastly extended the Mosque in the ninth century and un der Abd ar-Rahman III (912-61), Cordoba rose to become the largest and most prosperous city in Europe. Improvements on the Mosque continued under his son Al-Hakim II (961-76) who doubled its size and hired Greek contractors to build the new Mihrab (huge doorway used as the entrance to the Mezquita), which stands to this day. The final improvement in size, on the mosque, came under Al-Mansour (977-1002). (Ward, pg. 151) The Mezquita Mosque is a patchwork combination of all civilizations that occupied Cordoba. None, however, could bring themselves to destroy the Mosque, so each culture added their own personal touches. (Ward, pg. 151) Cordoba was probably a sophisticated center of the arts from the time of ‘Abd al-Rahman I. Chronicles suggest his keen interest in Syrian culture, which is apparently confirmed by aspects of the Mezquita. (Bloom, J.M., and Blair, S., 2009, pg. 506) The mosque began as the Christian Visigothic church of St. Vincent around 600, which was in turn buil t on the ruins of a Roman temple. In 784, the local emir bought it and began replacing it with the mosque. It got enlarged and embellished over the next two hundred years. (Brockman, 2011, pg. 331) The architectural uniqueness of the Mezquita lies in the fact that it was a revolutionary building for its time, structurally speaking. It defied precedents. Both Jerusalem’s Dome of the Rock and the Great Mosque in Damascus had vertical, navelike designs, but the aim of the Mezquita mosque was to create an infinitely spacious, democratically horizontal and classic space, where the spirit could roam freely and communicate easily with God. The original space of Islamic prayer (normally the open yard of a desert home) was transformed into a 14,400 square meter metaphor for the desert itself. Men prayed side by side on the argamasa, a floor made of compact, reddish slaked lime and sand. A flat roof, decorated with gold and multicolored motifs, shaded them from the sun. The orange pati o, where the ablution fountains gurgled with water, was the oasis. The terracotta and white striped arches indicated a hallucinogenic forest of date palms, and upheld the roof with over one thousand columns, 1293 to be precise, (856 of which remain). (Ham, 2010, pg 204) Construction of the Mezquita It is almost certain that the building that

Portrayal of vampires in cult tv Dissertation Example | Topics and Well Written Essays - 1250 words

Portrayal of vampires in cult tv - Dissertation Example End Notes Introduction Vampires have haunted the pages of history since times immemorial; in most cultures around the world, there has been a confluence of these creatures and people have created a sense of fear and associated these mythical wonders with a sense of peril. But what are they? Vampires have been described as â€Å"blood sucking ghosts or souls of dead people superstitiously believed to come from the grave and wander about by night, sucking the blood of those that sleep and thus, causing their untimely death.† (Easton, 2009). Many people correlate vampires with bats; they say that during the day bats hang asleep and at night time, they come alive in the form of these blood sucking creatures. People have instilled in themselves a sense of dread and terror because of the idea of a vampire. They have believed that these creatures should not be allowed to live. Most legends suggest killings of vampires to eradicate them from the face of the planet, because they Ã¢â‚¬Ë œdo not belong’. However, in the 21st century, today, people have come to terms with the fact that vampires do not exist (Sklar, Rachel). Most people do not believe in the supernatural and idea of immortality in this day and age of fast communication, information and technology. Even then, the idea of maybe having such creatures around and existing excites a vast amount of the population of the world. As seen with time, the most popular form of entertainment has usually been in the form of fiction or letting people think about what ‘might’ exist. Thus, much the same way, vampires have been popularised today through television, books and movies. People crave an understanding of things that have not yet been explained by scientists or do not have reason. Staying alive eternally, having super powers to carry out tasks etc are things that human beings get thrilled with because they are not able to do so. It is because of an endless thirst of curiosity that people wan t to know more and more and try and delve into the unknown. It is because of the same reason that today, people are eager to know about vampires and whether or not they do exist in real life. People often wonder, ‘what if there is a vampire amongst me and all the people I interact with?’ Scary and exciting as it may be, all this has led to the creation of very popular vampire cult television; series that depict forms of vampires, interacting with normal human beings on a daily basis, doing everything they do - and a little more. From Bram Stoker’s Dracula to Stephenie Meyer’s Twilight, these immortal beings have been reflected over the years with dramatic changes in their characteristics and surroundings. In television most of the current â€Å"Vampire Series† have achieved a â€Å"cult† status. As Roberta Pearson (2010) explains â€Å"As a quick google will show, the term â€Å"cult television† flourishes beyond the confines of acade mia in the virtual world and, by implication, in the â€Å"real† world.† The word â€Å"cult† depicts a religious group that is devoted to, or even obsessive about what they believe in. The term â€Å"Cult Television† is somewhat close to this. It is a term gained for a show that has an obsessive or even extreme following; a show that might not have been appreciated when it was first broadcast and is a step away from the mainstream. â€Å"There is no single quality that characterizes a cult text; rather, cult texts are defined through a process in which shows are positioned

THE PRE-SOLICITATION NOTICE Essay Example | Topics and Well Written Essays - 250 words

THE PRE-SOLICITATION NOTICE - Essay Example Contracting processes normally are slower and require spending a lot of time and resources on checking and verification of the offices or other property and this can be sped up through pre solicitation process. Since notices of buying attract many people, pre solicitation notices assist in sorting out the potential buyers from the rest of the group and this also saves a lot of lost hours in trying to determine the serious buyers from the whole lot. The process should have oral presentation where the contract bidders are offered enough information about the process especially its importance and even allowed to ask question. This will enable them make an elite choice or decision in regards to the contract. The language in the pre solicitation notices should be simple and to the point. These notices have technical language which confuses many people and especially the first time contract bidders that they fail to understand what they are getting into. Lastly is the shortening of the notice and the notice process. Many contract bidders are busy and have little patience for long processes not to mention a lengthy notice which they are required to read through before agreeing to it. Reducing the wording and the process altogether will really help the first time contract

Wilson War Message Essay Example | Topics and Well Written Essays - 500 words

Wilson War Message - Essay Example These vessels were comprised not only their enemies, but of peaceful ships on innocent business. Germany became responsible for the destruction of many innocent men, women, and children. Their activities were deemed inhumane and in need of correction. Wilson thoroughly described Germany’s awful behavior as he presented the case against them before Congress. In expression of his feelings regarding the situation Wilson stated, â€Å"I was for a little while unable to believe that such things would in fact be done by any government that had hitherto subscribed to the humane practices of civilized nations† (Wilson). In describing the actions of Germany, he told how the vessels were destroyed without any warning to the passengers. They were not given the chance to escape. They were not afforded the opportunity to change their course and save their lives but were immediately struck down. However, Germany had previously promised that they would not sink any passenger boats and that all other vessels would be given fair warning; a promise that they clearly did not keep. In framing the US’s involvement in the conflict, Wilson informed Congress that some of the vessels that had been sunk were American. He explained that the vessels of both neutral and friendly nations were being attacked insomuch that the conflict had become an issue of every nation. Basically, by sinking American ships Germany was responsible for causing America to get involved. Although Wilson had not wanted to make a declaration of war, the actions of Germany had brought America to the point where they had no choice but to do so. America would now have to fight, not only for the protection of their vessels, but, as Wilson put it, â€Å"the vindication of human rights† (Wilson). Germany’s actions could not be ignored. If they had been, then the destruction of innocent lives would continue, Germany might have advanced in their shameful actions by

Monstrous Discourse & the Cultural Moment Research Paper

Monstrous Discourse & the Cultural Moment - Research Paper Example The paper will appoint the good works of Francisco De Goya artistic work – Sleep of Reason, which in this case is a prophetic outlook of how human nature will create monsters, and monsters rule the world. Another close appointment is the literal works by Scott Poole Monster in America, in which the author attempts to examine how America has created its own, social, economic and political problems. The paper is structured into four main parts. Firstly, Goya presentation of Sleep of Reason; secondly, Poole discuss on Monsters in America. Thirdly, the paper will appoint the application of artifacts, which in this case, the research will elaborate how artifacts initiate monsters into action. Fourthly, the document will present an argument on the freedom monster and how it has been applied to continuously cause belligerence against humans. Table of Contents Part I 5 Cultural moment to in the understanding the context 5 PART II 6 Poole’s Monsters in America 6 PART III 8 Appoi ntment of Artifacts in the interpretation of the two parts 8 PART IV 9 The Monsters of Freedom and development 9 The Metaphor of Monsters 10 Ambiguity and the Gates of difference 11 How Man create Monsters 12 The Presence of Monsters 13 The act of Self Consumption 14 Death and Mutation 15 Summary 16 Conclusion 17 PART I Cultural moment to in the understanding the context Scholarly, dreams present a vivid description, in which the writer focuses on social, economic and political issues. A dream may fail on the account of realism; however, descriptions presented in the dream may be applied to provide a coherent reflection of real life situations. In this case, the dream is consciously developing vivid description by applying logics and fact verification in the general concept of how practices, beliefs, and institutions are based. To present description, the combined application of art and science is so much influential in a dream, and in this case, the dream is analyzed on a rationali ty scale (Snow, 23). This exegesis will attempt to explore how a cultural moment – in this case influenced by dreams- creates substantive effects on the scope of social anxiety. The dream is largely applied by Goya to reflect on a given global revolution of Monsters, and how on several presentations social anxiety of the people is based on the economic and political account (Snow, 44). This reflection attempts to present how citizens consider and analyze themselves based on â€Å"self-fear, rejection, embarrassments, and criticism. Based on the setting period of the context, it is cognitive to understand, that the society was attacked diverse challenges, which by use of imagery they are presented by bats. The American cultural moment presented by sleep of reason has deep relation with scholarly aspect of thinking, intellect and cognition. Man attempts to comprehend the prevailing challenges, and analyzes them with cause, truth, effect and falsehood. However, it coherent to u nderstand that Sleep of Reason present a personal evaluation mechanism, at which the dreamer (read a citizen) will attempt to review his inner personal feeling, for the general good of the society. As this document will endeavor, self- conscious will attempt to alter attitudes, beliefs, institutions and beliefs of the society. The individual will evaluate personal self beliefs based on the prevailing cultural moment, and in this case, establish whether he meets the required humanism threshold of that

Technology and Education Essay Example | Topics and Well Written Essays - 4500 words

Technology and Education - Essay Example This study is vital as it can help in gaining a deeper understanding of the connection between technology and education. The paper will be divided into five sections. The first section is the introduction wherein the background of the study, the focus of research, and it significance and the structure of the paper are given. It guides the reader as to what may be expected from the entire study. The second section deals with the various learning theories. Discussion of constructivism, behaviourism, and audio-visual theories will be undertaken. These theories of learning provide a solid framework in which to understand the connection between use of technology and student-learning improvement. The third section will centre in laying down the advantages, limitations, and impact of the theories of learning to the integration of technology to education. This section highlights the presupposition that as each theory explains the reality of technology in education, its influence on the actual integration of technology in education varies. The fourth section will deal with the analysis. In this part of the pape r, BF Skinner’s behaviourism will be given more focus. Finally, the last segment of the paper will be the conclusion wherein the summary of the discussion as well as the position of the paper pertinent to the issue raise in this study will be given. In the end, theories of learning, especially behaviourism establishes a framework where technology becomes the tool, not just in learning but also in developing and re-enforcing positive behaviours towards learning. The Theories Three fundamental theories of learning will be discussed in this paper, namely, constructivism, audio-visual theories, and behaviourism. The selected theories provide an opportunity to see the theories of learning within a spectrum with constructivism on one side and behaviourism on the other end. Meanwhile, audio-visual theories present developments in technology have effect learning as it is

Wall Street Journal Hospitality Trend-Impact Report Research Paper

Wall Street Journal Hospitality Trend-Impact Report - Research Paper Example intelligence and reliable network to enable them make concrete decisions within the shortest time possible that can aid in solving problems arising at work place and websites. E-business not only increases customer base but also makes the products and services available to global customers in different parts of the world. In the article, Landmark Buildings Make Hotel Comebacks by Lana Bortolot, hotels within New York City transformed from one star to five stars. AKA building was an abandoned building and was renovated by Larry Korman to accommodate high number of visitors touring New York City. Hospitality is groomed in socio-economic and political facets of New York City where skills were injected into individuals to make them appreciate the roles played by tourism in economic stability. Customer Benefit Package is AKA Times culture that is geared towards achievement of consumer satisfaction. Consumer behaviour is given priority and considered in decision making in order to attract new and retain potential customers. In AKA Times, the restaurant and check-in services are maintained by well trained staff who give customer first priority. Customer Benefit Package can therefore, be measured by customer response after the stay. Complains and compliments helps in improvement of nature of service delivery because it aids in identifying weak and sturdy areas. The land mark building in AKA Times Square depicts the modern building that promotes tourism in the society. The building has many businesses within one premise that make accessibility and efficiency easy for instance, Artisanal coffee shop, five star restaurants and a boutique. Hospitality and tourism need modern buildings that can accommodate visitors who stay for long. The building was made city landmark in 2007 and this gives it advantage over other hotels for instance the nearby Texas hotel company FelCor Lodging Trust Inc. which is undergoing renovation. On the other hand, technology and information

Physiological Impacts of World War Two Essay Example for Free

Physiological Impacts of World War Two Essay When a soldier enlists into the military forces they know they are going in to fight for their country and freedom for everyone. They spend months training and preparing for the war and what to come. They learn to fight, shoot, and kill enemies, but what they do not learn is how to cope with the after math of the war. Soldiers in war every year come home with many post traumatic effects from what they had witnessed. During world war two this was known as shell shock; however what can be concluded is that world war two impacted the soldiers emotionally and physiologically from the time they entered to post war. World War Two was one of the biggest struggles nations everywhere have ever seen. â€Å"It killed more people, costs more money, damaged more property, and affected more people†¦than any other war in history† (The History on the Net Group). People everywhere were in panic when the War started. With all the damage done during the war it can be imagined how the soldiers were traumatized by losing their fellow soldiers. â€Å"The number of people killed, wounded, or missing between September 1939 and September 1945 can never be calculated, but it is estimated that more than 55 million people perished† (The History on the Net Group). Soldiers were devastated by the tragedies that occurred at the time of war. However, before the war started there were a lot of causes that went into why everything ended up in war. World War Two began in September 1939 when Britain and France declared war on Germany following Germany’s invasion of Poland. The war was triggered by Germany’s invasion of Poland but the causes of the war are far beyond this fact. After World War One had occurred Woodrow Wilson, the president of the United States of America wanted to make a treaty on his four point plan to bring peace to Europe. Other countries involved in this treaty did not have the same idea as President Wilson. George Clemenceau wanted revenged. He wanted to make sure Germany would never be able to start a war again. When Germany received this treaty they were very surprised with the terms. The terms included, war guilt clause, which meant Germany accepted all the blame for  World War One. Reparations, Germany had to pay millions in damage from the war. Disarmament, Germany could not have tanks or air force and land was taken away from them and given to other countries. The Germans were not happy with this treaty and thought of it as very harsh. However the Germans took responsibility and continued on in hope to get revenge later. In 1919, to help keep the world safe for democracy the League of Nations was set up. League of Nations would intend that if there were disagreements between countries they would negotiate rather than fight. The failure of the League of Nation can be summarized by points such as, not all countries joining in such as Germany as a punishment and Russia because of the spread of communism. The League of Nations had no power or any army. Countries were hesitant to get involved with an aggressive country and taking direct action against them. These things led to the fall of the League of Nations. People were angry because they did not want to cut off resources with other countries, even if they were aggressive because during the late 1920’s depression hit most of them. â€Å"The depression destroyed the market for imported silk from Japan, which had provided the country with two fifths of its export income’’ (The History on the Net Group). Economic problems played a fundamental part in the cause of World War 2. Germany, one of the poor countries became crippled in power and vulnerable. When Adolf Hitler came into power he immediately began placing blame on other countries and making Germany at the top of resources again. All these aspects lead to the start of World War two in Europe. As the war in Europe continued President Franklin D. Roosevelt told America he did not want to get involved. He thought it was better to stay neutral in this matter and let them handle their own battle. The United States decided to eventually join the war after the bombing of Pearl Harbor, however the issues had started years before Pearl Harbor was attacked. It starts with the Japanese invasion of Manchuria, China. The Japanese invade Manchuria on September 18th, 1931. China was in the middle of a depression, so the Japanese had the upper hand. When Russia found this out they were enraged meaning America was as well, being alliances with Russia. Also, â€Å"the Japanese invading China violated the Kellogg-Briand Pact of 1928 which renounced war as national policy† (Ketchum). The United states told Japan  if they dont get out of China, they would stop trading oil with them. Japan stayed in China so the U.S stopped trading oil. Japan disliked this and held a grudge on America for years. Besides this, The US was already trading with other countries through the Lend-Lease Act, a document allowing the US to lend countries like Britain war materials in exchange for money. Germany was also angry that America was helping their enemies. As a result the Nazi’s decide to sink the U.S supply ships to help keep them from sending resources to other countries. However, President Roosevelt did not want to enter war until the attack of Pearl Harbor, Hawaii occurred. This pushed the United States into the war officially on December 8, 1941. Right after we entered the war Hitler declared war on the United States. Followed by a United States declaration of war against Germany, and then the United States was fully involved in the war. America did not want to go to war but when America was targeted they decided to counter attack, however they did not plan on going to war with Germany but once they did it lead to one of the biggest and bloodiest wars of all time in history. My grandfather, Edward Weil was lucky and un lucky enough to be able to experience World War 2. As a veteran of war he tells me all his stories about what the war was like. â€Å"The war was a very hard time.† He tells me, â€Å"it was rough but it also brought the nation closer together and America’s pride shined.† When I asked my grandfather why he joined the war he has told me about the attack of pearl harbor and how everyone had to stand for the pledge of allegiance out of respect and when he put his hand to his heart a navy officer came up to him and told him, â€Å"You would look very good in a uniform.† It really made my grandfather look at what he wanted to do and how he wanted to protect his nation. At the same time joining the war also impacted him in a negative way. During the war my grandfather was nervous but knew this was what he wanted to do. He saw the Japanese bomb his mother ship and his sailors being killed and put on the edge of the deck to take back and bury. These experiences get scarred into soldiers minds forever. They cannot escape what they saw and those horrific actions done to one another. My grandfather was only 17 years old when he entered war. He wanted freedom and security for the American people. However, as a young teenage boy still the war affected his emotions and to this day it is still  a very sentimental and emotional topic to him. During my interview with my grandfather as I talked about what he wished he could change about the war, he started to tear up and told me about all the people lost to the war and his friends. His ship pulled next to another ship while it was burning and the people were asking for help and they tried to save as many people as they could. My grandfather even lost his left hearing due to the war. He is very proud to show his metals from the war and how he helped our nation. My grandfather is very proud to be a world war to veteran.

Effect Of Temperature On The Digestive Enzyme Pepsin Biology Essay

Effect Of Temperature On The Digestive Enzyme Pepsin Biology Essay In this study an experiment was carried out to determine if varied temperatures affect the rate at which enzymes function. Enzymes are biological catalysts; catalysts are substances that increase the rate of chemical reactions without being used up (BBC, 2010), without these catalysts it would take an extremely long time for these reactions to take place. The enzyme used in this particular experiment was pepsin; pepsin is a zymogen of pepsinogen. Pepsinogen is activated by hydrochloric acid, which is released from parietal cells in the stomach lining. The hormone gastrin and the vagus nerve trigger the release of both pepsinogen and hydrochloric acid from the stomach lining when food is ingested. Hydrochloric acid creates an acidic environment, which allows pepsinogen to unfold and cleave itself in an autocatalytic fashion, generating pepsin. (Life Science Network, 2010) A lot can be learnt about enzymes by studying the rate of enzyme catalyzed reactions, these rates of reaction can be studied in various ways. In this experiment, using a range of different temperatures, the enzyme pepsin will be mixed with egg albumen. This is high in protein and bound to the dye Coomassie blue to gain a light absorbance reading using a spectrophotometer and in effect see how much protein has been digested by the pepsin. Egg albumen was used as the protein source in this study as although it is composed mainly of around 80% water it has about 15% of its total mass made up from approximately 40 different types of proteins, mainly Ovalbumin (54%) (Edin Formatics, 1999). A spectrophotometer is a device used for measuring light intensity and will be used to determine the amount of protein in each mixture, it works by measuring the light intensity as a function of the colour or more specifically the wavelength of light (Global Water Instrumentation Inc, 2007) (Appendix 2). Therefore the lower the reading means less light has been absorbed by the solution being tested indicating in this case that more protein (egg albumen) has been digested by the enzyme (pepsin) and the lower the reading the faster the enzyme reaction rate. If enzyme reactions are affected by temperature, then changes in temperature may bring about different absorbances of light readings related to how much protein has been broken down by the enzyme. As pepsin is found in the stomach it would seem only logical to assume the optimum temperature for this particular enzyme would be around 37Â °c, human body temperature. Method A cuvette was filled with 0.5ml of distilled water and placed in a spectrophotometer, then the machine was calibrated by pressing the zero button with the spectrophotometer set to a wavelength of 595nm. After calibration 0.5ml of egg albumen (2mg.cm-Â ³) was added to a test tube using a glass pipette and incubated in a pre heated water bath at a temperature of 10Â °c (then 20Â °c, 30Â °c, 40Â °c, 50Â °c, 60Â °c, 70Â °c) for five minutes. 0.5ml of pepsin (0.1%) was then added to the test tube and incubated at the same temperature for a further ten minutes. After this incubation period 2.0ml of Coomassie blue reagent was added to the test tube and immediately mixed by capping the test tube with parafilm and inverting several times. After the test tubes contents had been mixed they were carefully poured into a cuvette and placed into the spectrophotometer with the light absorbance levels being recorded at a wavelength of 595nm. The experiment was carried out three times at each temperature to achieve reliable data. Results The results documented in Table 1 are the light absorbance reading averages of three separate experiments carried out at each temperature. A full set of results can be seen in Appendix 1. Figure 1 shows the averaged results plotted on a scatter graph. Table 1 Temperature (Degrees Celsius) Average light absorbance at 595nm 10 2.501 20 2.550 30 2.516 40 2.403 50 2.543 60 2.740 70 2.806 Fig 1 Change absorbance Discussion The results in Table 1 as well as the bell curve graph (Fig 1) show that the optimum temperature as predicted in the hypothesis seems to be 40Â °c, close to human body temperature. These results also show that temperature has a definite effect on the rate the enzyme reacts to breakdown the protein in the egg albumen. Table 1 shows that at 10Â °c, 20Â °c and 30Â °c the light absorbed by the solution is more than at 40Â °c, this is because the pepsin has not broken down as much of the egg albumen at lower temperatures as it has at 40Â °c so the spectrophotometer is picking up more undigested protein particles in these readouts. The same applies to the temperatures above 40Â °c and indicates 40Â °c is the best temperature range for pepsin to be active. Enzymes are made up of amino acids; amino acids are the basic building blocks of proteins consisting of a basic amino group, a carboxyl group, a hydrogen atom and an organic side group attached to the carbon atom (Biology Online, 2010). When an enzyme is formed it is made by stringing together between 100 to 1,000 amino acids in a specific and unique order defining the three dimensional shape of the enzyme and its particular chemical reactivity (Brain, M. 2000). The lock and key theory explains how an enzyme may work, it utilizes the concept of an active site on the enzyme. The theory is that a particular part of the enzymes surface has a strong affinity to the substrate (protein). The substrate is held in such a way that its conversion to the reaction products is more favorable. If you consider the enzyme is the lock and the substrate is the key, the key is inserted in the lock and turns it to open the door letting the reaction proceed (Worthington Biochemical Corporation, 2010) (Appendix 3). However, the induced fit theory expands on the rigid lock and key theory. This updated view of enzymology proposes that the substrate causes a conformational change in the enzyme so the active site achieves the exact configuration for a reaction to occur, the overall effect being a tighter binding between the enzyme and substrate (Allaby, M. 1999) (Appendix 4). The benefit of this tighter binding would be a faster reaction rate as more surface area of the enzyme would be in contact with the substrate. The kinetic collision theory describes temperature affects on a system as the amount of kinetic energy it has, a lower temperature will provide less kinetic energy than a higher temperature. When molecules collide the kinetic energy can be converted into chemical potential energy, if the chemical potential is great enough the activation energy or energy required for an enzyme to work can be reached. The more chemical potential energy molecules have when they collide, a greater number of molecules per unit time will reach the activation energy needed to bind the enzymes active site to the protein resulting in a quicker rate of reaction. If the temperature gets too high some of the weak bonds that determine the shape of a protein and its active site could be broken resulting in the enzyme becoming denatured and decreasing the rate of reaction sometimes rendering the enzyme inactive (Brooklyn College, 2010). Figure 1 shows that after 50Â °c the enzyme reaction rate slows down considera bly, the enzyme is denaturising at a faster rate than it is below 30Â °c. This change in enzyme reaction rate may be due to the fact that pepsins are stored at low temperatures to prevent the enzyme destroying itself, therefore pepsin is less active at lower temperatures until it reaches its activation energy around 30Â °c and anything beyond around 50Â °c 55Â °c will rapidly denature the pepsin so the molecules in the active site can no longer bind to the protein and produce a reaction, rendering the enzyme inactive permanently. Once the pepsin has digested the egg albumen it would still be difficult to analyse the amount of protein left at each temperature, this is why Coomassie was added before taking a reading. In an acidic environment the protein will bind to Coomassie causing a spectral shift from a reddish/brown colour with a low absorbance maximum of 465nm to a light blue colour with a higher maximum absorbance of 610nm with the difference of the two colours greatest at 595nm, an optimal wavelength (Thermo Fisher Scientific, 2010). The binding of the Coomassie takes place when the red form donates its free electron to the ionisable groups on the protein causing a disruption of the proteins normal state and revealing its hydrophobic pockets. These pockets, via Van der Waals forces (attractive and repulsive forces between molecules) bind to the non polar region of the dye, putting the positive amine groups close to the negative charge of the dye, creating a strong bond. Binding of the protein stabilizes the blue form of Coomassie dye, thus the amount of complex present in solution is a measure for the protein concentration by use of an absorbance reading. (Bradford M, 1976, P248-254) Although this experiment has produced reliable accurate data that has proven the hypothesis right, many things could affect the results and readings obtained. When using such an accurate way of recording the data such as a spectrophotometer a number of things could affect the reliability of the results. Things like minor differences in volumes of substances added to the test tubes or inattentive timing methods could be damaging to the results obtained. Simple human error could possibly influence any results with any fingerprints or water on the cuvette affecting the absorbance readings. Conclusion In conclusion, the study carried out was adequate for the data required and indicated that temperature definitely affects the rate at which an enzyme reacts. As long as the method is executed well this is a great experiment to look at temperature and its effect on enzyme activity however as with any scientific study human input is a crucial factor and could affect the quality of results. Another experiment may need to be carried out to determine what the optimum temperature is on a more specific scale, something closer to body temperature would help to discover a more precise optimum temperature, 35Â °c 40Â °c for example. As well as finding out an exact optimum temperature a further study to find out the optimum pH of pepsin could be done to further enhance the enzymes rate of reaction, focused around the acidic pH in the human stomach. Appendices Appendix 1 Temperature (Â °c) Absorbance at 595nm (Reading 1) Absorbance at 595nm (Reading 2) Absorbance at 595nm (Reading 3) 10 2.430 2.550 2.520 20 2.480 2.530 2.640 30 2.500 2.510 2.540 40 2.360 2.400 2.450 50 2.520 2.560 2.550 60 2.660 2.780 2.780 70 2.800 2.820 2.800 Appendix 2 http://commons.wikimedia.org/wiki/File:Spetrophotometer-en.svg Appendix 3 http://www.chemistry.wustl.edu/~edudev/LabTutorials/Carboxypeptidase/images/lockkey.jpg Appendix 4 http://wpcontent.answers.com/wikipedia/commons/thumb/2/24/Induced_fit_diagram.svg/450px-Induced_fit_diagram.svg.png

Senior Citizens Essay -- essays research papers

Activity: Chapter 9 After spending an afternoon interviewing my elderly neighbours I gained insight into how they perceive the aging process and its impact on the quality if their lives. First, and foremost they viewed aging in a very positive and healthy manner. The believed that a positive attitude assists in accepting physical and psychosocial changes. They enjoyed the fact that they were both physically fit and cognitively alert. They both felt confident that with the advances made in health care that the quality of their lives would continue to empowering. They enjoyed the benefits of being Senior Citizens, discounted travel, free education, and other incentives marketed towards the aged. The expressed a sense of well-being with respect to the numerous housing options geared towards the graying population, such as Retirement Villages, and assisted living. However, the subject of Long Term Care or Nursing Home placement was something that they both regarded with very negative emotions. There was als o a sense of sadness and longing for more contact with their offspring and grandchildren. In countries like China where grandparents are an integral part of the family, the United States has seen a major shift away from the nuclear family. It is my personal belief that America is a nation that suffers from ageism. It is the fear of growing old and the stereotypes that aging brings that causes ageism. Daily we are faced with advertisements that focus on youth, on looking, fe...

Drinking And Driving Essay -- Alcohol, Drunk Driving, DUI

What possesses a person to get behind the drivers’ seat of a car and drive intoxicated? This question is always asked whenever a drunk driver is involved in a drinking and driving incident. Many people drink and drive without thinking about the consequences. The majority of fatal car crashes are caused by alcohol related incidents. Of all traffic fatalities in the United States in 2005, 39% of traffic related accidents were alcohol related (Alcohol Alert, 2006). Driving while intoxicated puts drivers and others lives at risk. Drinking and driving do not mix and the consequences can be prevented. A simple solution can be by simply having designated drivers to help keep drunk drivers off the road. All 50 states have a designated blood alcohol concentration level. This blood alcohol concentration level is determined when a person is legally drunk. A person is not permitted to operate a vehicle when this limit is reached. The limit for all 50 states for the blood alcohol concentration level is .08. 43 states and the District of Columbia have strict laws that prohibit the driver and the passengers from possessing an open container of alcohol in the passenger compartment of a vehicle (DUI and DWI Laws, 2007). Drinking alcohol can have many side effects on a person. Every person’s body will react differently to alcohol absorption. Alcohol begins to be absorbed into a person’s bloodstream within one to two minutes after an alcoholic beverage is consumed. After consuming alcohol it accumulates in the bloodstream. Intoxication usually occurs when an individual drinks alcohol faster than the liver can oxidize it. While the percentage of alcohol in the blood increases, the more a person becomes intoxicated (Hanson, 2007). Remember th... ...or his or her actions, there would be fewer accidents in the world. The next time someone gets behind the wheel of a car he or she should reevaluate their actions and think of the consequences. References Alcohol Alert. (2006). Alcohol alert. Retrieved June 8, 2007, from http://www.alcoholalert.com/drunk-driving-statistics.html Drinking and Driving Data. (2007). Nhtsa. Retrieved June 8, 2007, from http://www.nhtsa.dot.gov/kids/research/drinking/index.cfm DUI and DWI Laws. (2007). Iihs. Retrieved June 8, 2007, from http://www.iihs.org/laws/state_laws/dui.html Hanson J.D., (2007). Alcohol Problems and Solutions. Potsdam. Retrieved June 8, 2007, from http://www2.potsdam.edu./hansondj/DrinkingAndDriving.html Jourard, R. (2007). Drinking and Driving. Retrieved June 13, 2007, from defencelaw Web site: from http://www.defencelaw.com/drinking-driving-1.html

Taiwan Must Eliminate the Dependence on Nuclear Power Essay -- Nuclear

The public awareness of nuclear power in Taiwan has increased markedly especially after the Fukushima nuclear accidents made nuclear power a contentious front-page issue. Nowadays, Taiwan produces 22% (i.e. 5028 megawatts ) of her energy from nuclear power produced by three power plants with 6 reactors. In addition to these three power plants, the under-construction nuclear power plant four has never been far away from the center of public opinion in the past 20 years. The rising environmental and anti-nuclear movements in Taiwan have created no shortage of policy disputes and public concern on the use of nuclear power for electricity generation (Hsiao.Liu et al, 1999).It seems to be an irresistible trend to make Taiwan a â€Å"nuke-free home†. But it must be a long-term process rather than an immediate action. Before we completely enable to get rid of nuclear power, there are a lot we can do to accelerate the process such as starting an energy saving revolution, developing th e technology of renewable energy and even properly making use of the existing nuclear power plants. 1. The condition of Taiwan After the Fukushima nuclear disaster, an international review of nuclear safety indicated that two of the three nuclear power plants operating in Taiwan were listed as the most dangerous in the world (Jung-Chun Ho et al, 2013). According to a survey conducted by Jung-Chun Ho et al in August 2011, 66% of the 2819 responders perceived that Taiwan's safety management of nuclear power plants was inferior to Japan's, while 40% perceived a higher possibility of nuclear accidents like that in Japan. Actually, the condition of Taiwan decides that it should create a â€Å"nuke-free home† First of all, Taiwan is a small and geological unstable ar... ... 21. 2013. Pages 674–683. 14. Fleiter. T, Fehrenbach. D.Worrell, E. Eichhammer.†Energy efficiency in the German pulp and paper industry—a model-based assessment of saving potentials†. Energy, 40 (2012), pp. 84–99. 15. Chen Falin, Lu Shyi-Min, Tsenga Kuo-Tung, Leeb Si-Chen, Wanga Eric. â€Å"Assessment of renewable energy reserves in Taiwan.†Renewable and Sustainable Energy Reviews,Volume 14, Issue 9, 2010, Pages 2511–2528. 16. Cheng-Dar Yuea,Chung-Ming Liua, Eric M.L. Lioub. â€Å"A transition toward a sustainable energy future: feasibility assessment and development strategies of wind power in Taiwan†. Energy Policy, Volume 29, Issue 12, October 2001, Pages 951–963. 17. â€Å"Taiwan's renewable energy sector grows 19 pct. in Q3.† The China Post, November 26, 2013. 18. Carmen Paun, Jens Kastner. â€Å"European review of Taiwanese safety.† World Nuclear News, 20 November 2013.

Effective communication within my time at BP Essay

While on my internship I wanted to show effective communication. This involved me communicating with my team, working well within my team and giving many presentations to them. At the end of my internship I got feedback from my manager who explained how I was able to show effective communication within my time at BP. Goal – To improve my communication. 1. Introduce and talk to people who I don’t know. 2. Share ideas with colleagues. 3. Ask for help when needed. Feedback – Being able to communicate effectively was an important part of her’ role, as she was dealing with numerous personnel for whom English was not their first language. In her first week she was tasked with composing an email to send to all the regionally based team members. She proved straight away that her written communications skills were good, although she was naturally looking for reassurance of her emails were as required. By the end of the internship, both her written and verbal communication could only be described as â€Å"excellent†. Goal – To improve my ability to ask questions 1. List down any questions that come to mind during work or home. 2. Do some research on the questions before hand and find an answer. 3. If I cannot find an answer I will ask a college or supervisor. Feedback – When she did have any questions she was happy to ask, and did so in a polite and concise manner. If she needed help on tasks or wanted extra elaboration on certain topics she was able to do so. Goal – To improve team working with new people 1. Introduce myself to the new people in my team. 2. Think of questions and ideas to contribute to the team. 3. Contribute my ideas to them and ask questions. 4. Use the information gained and adapt it to my work. Feedback – She fitted into the team from day one, she is reliable, punctual and always polite and courteous. Her attitude to work was excellent, she was always willing to give something ago, with minimal instruction. Goal – To improve my presentation skills 1. Plan a presentation and practice it. 2. Ask for feedback from colleagues. 3. Take the feedback into consideration and improve the presentation. 4. Invite colleagues, managers to listen to the presentation. The first time I met her, she highlighted that she wanted to improve her presentation skills during her time with us. So, on her first day I asked her to help me present the safety moment in our team meeting; and she did a great job! Over the next few weeks she had other opportunities to both help compile presentation material, and also present to others on her own. By the end on the internship when it was time to present to a room full of peers, parents and work colleagues, she was a professional! In conclusion, it’s always very important to show effective communication skills in the workplace as they are vital for teamwork and overall success. These skills were skills that I wanted to improve greatly as I know they will be beneficial in the future. The majority of the feedback from my line manager was very positive and I will take into account the comments for improvement.

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