By T. Tangach. Northwestern University. 2019.

The programme board then authorised the convening of shadow provider alliances discount 100mg januvia visa symptoms diabetes 9 month old, where provider clinicians took the opportunity offered of working on operational detail buy generic januvia 100 mg on-line diabete protocol program, in particular a reworking of interfaces between different mental health services cheap januvia online master card diabetes insipidus statistics. This was associated with the development of normative networks among provider staff, carrying and strengthening the moral ethos of working in alliances, with its central notion of a more integrated patient experience. This moral ethos can be seen as originating, along with the articulation of the alliance concept, from the GP chairperson of the mental health programme board and the programme director. This experience of a first phase of alliance working then fed back to further institutional work at the programme board, clarifying and strengthening the rationale for providers to work in alliances, leading to the vesting of resources in a further phase of the alliances. In case A2, the urgent care programme board was itself the origin of the concept of the innovative service. The GP clinical chairperson and the programme director used this forum to agree new service designs jointly with clinician representatives from provider organisations. This programme board then engaged providers to work on defining the operational detail on a pilot service and a subsequent evaluation of this clinically led shaping of practice led to a revised version of the service being shaped by the programme board. The defining of operational detail was accompanied by the development of a normative network of provider staff carrying the moral ethos of the initiative first developed within the programme board. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 75 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. CROSS-CASE FINDINGS AND COMPARISONS TABLE 5 Cases demonstrating higher levels of integration across arenas of clinical leadership Case study: clinical leadership activities Case C: redesigning Case A1: innovating Case B: redesigning early intervention in mental health Case A2: innovating general practice and services for mental Arena services in urgent care primary care health Strategic CCG board approves CCG board encourages GP triumvirate on CCG board approves commissioning funding for this urgent care programme governing body leads funding for this locally and budget initiative instigated at board to make use of formulation of new initiated service holding programme board level non-current funding standards of primary innovation opportunity from NHSE care combined with additional services Operational GP chairperson of GP chairperson of CCG establishes Activist GP with lead commissioning, mental health urgent care programme co-commissioning of responsibility for clinical monitoring and programme board board asks for ideas as primary care and area (mental health) evaluation works with managerial to how to reduce A&E performance makes case for funding a counterpart to attendances and management systems, pilot well-being hub challenge existing hospital admissions: including inspections, statutory and voluntary proposal for a joint GP/ opportunities for sector providers to form paramedic emergency practices to bid to deliver alliances and holds vehicle emerges from additional integrated them to achieving clinical debate on care services patient-focused programme board integration Operational Provider clinicians GPs from out-of-hours Locality GPs act as local GP advocate for delivery and develop interfaces service and paramedics commissioners and well-being services shaping of between existing from ambulance trust provider leads for drew on established practice services, reinterpreting define the service and additional services relationships with six established service develop it in practice as previously delivered by neighbouring practices definitions and build a pilot, building acute providers, drawing and voluntary sector normative networks normative commitment on GP practices and providers and built a committed to more among crews and other community health steering group, funded integrated working colleagues service organisations initially from CCG locality discretionary budget Case B offers a different pattern. Here, the idea and associated moral ethos of devising, and then implementing, a new set of primary care standards originated with a triumvirate of GPs in the most senior positions on the CCG governing body. These three GPs steered the governing body to establish a programme for co-commissioning primary care (with NHSE), which developed the standards for core and additional services and implemented them, leading to further engagement of locality GPs and community health services during implementation. So, in this case, the articulation of the service innovation and its ethos occurred at the level of the CCG governing body. However, the programme arena and locality delivery level were again characterised by the involvement of clinicians in both developing the operational detail and persuading colleagues about the value of engaging with the new standards and building a normative network carrying the underlying moral ethos of improving population health. Case C offers yet a further variation on how coherence and productive interplay can be achieved in clinical leadership across the three arenas in Figure 24. Here, the service innovation concept and moral ethos emerged from a history of collaborative relationships between a GP innovator, passionate about improving early intervention in mental health conditions, his six neighbouring practices and a number of voluntary sector organisations. This activist GP established his own role within the CCG as mental health lead and worked with the governing body to vest resources in an innovative pilot scheme. In effect, he persuaded the CCG to establish a new programme arena focused on mental health and well-being, which could then authorise the development of operational practices and further strengthen the associated normative network. Together these four cases illustrate how clinical leadership is involved in all three kinds of arenas – strategic commissioning, operational commissioning and operational delivery – in order to create innovative services. However, there appears to be no simple top-down or bottom-up flow that characterises the way that these arenas function effectively. They each appear to have a crucial function in producing service innovation and a particular associated role for clinical leadership, but the way these intertwine can vary. This is bound up with further extending the normative network of staff committed to working in the new way. A key element of the variety across the cases reflects the way in which the articulation of a new service concept can arise in any of the three arenas. Although institutional work always needs to be done at the strategic level in order to achieve the vesting of resources in new ways, clinically led ideas for service redesign can apparently arise in delivery or practice arenas, at programme board level, or at the level of the CCG governing body. The four cases in Table 5 also each illustrate the role of clinical leaders in engaging across the three arenas, making sure that each plays its role while engaging appropriately with the other two. The cases illustrating a disconnect between arenas Turning now to the four cases, each one illustrates a form of disconnect in the way that the three arenas of clinical leadership function as a system. In case D, the strategic work of the six CCGs attempting to reconfigure services across an entire county was, at the time of data gathering, decoupled from the initiatives arising from groups of GP practices. Although there was mutual awareness of an underlying ethos of improving and making use of primary care staffing and moving appropriate activity out of acute hospitals, there appears to have been something of a vacuum in terms of operational commissioning forums that could harness and encourage initiatives emerging at the level of primary care practice. The GP federation can be seen as attempting to fill this space, but without achieving solid cohesion with strategic plans which remained at an early and unclear stage. The GP federation further found CCGs reluctant to vest resources in its plans for integrated care and began to look to other national sources of authorisation and funding, which further undermined system coherence. This case can be characterised as one where a clear service concept and moral ethos emerged at the operational level, but failed to find backing in the strategic and operational commissioning arenas – the degree of turmoil in these arenas was too great. Cases E1, E2 and F can be seen as providing a mirror image to the pattern of case D. In each of these, clinical leaders played prominent roles in strategic arenas, articulating the concept and moral ethos of a new or improved service. This led to programme-level work in further articulating the new service and establishing a framework for bringing providers on board. However, in each case the transmission of the concept and moral ethos to operational provider staff was weaker. In case E1, provider clinicians appear not to have fully understood the new integrated care model. In case E2, provider clinicians continued to query the concept of the single point of entry for urgent and emergency care. In case F, provider staff had little contact with, or even knowledge of, the ACO concept that was being developed within an innovative and highly collaborative strategic arena. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 77 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. CROSS-CASE FINDINGS AND COMPARISONS Factors shaping clinical leadership Tables 6–8 summarise what was has been achieved through the exercise of clinical leadership across the three arenas in our eight cases, dividing them into the same two groups as above. The tables summarise the factors that were found to help or hinder forms of clinical leadership capable of bringing about service innovations. We have already seen that the coherence of implementation of service redesign was greater in the four cases in Table 5, and this is reflected in the specificity of the achievements documented. The achievements shown emphasise service outcomes, whereas those in Table 6 mostly emphasise service arrangements that have yet to deliver improved outcomes. However, Tables 5 and 6 emphasise that both groups of four cases involved clinicians grappling with both favourable and unfavourable conditions as they engaged with the challenges of service redesign. TABLE 6 Cases demonstrating less consistent relationships between arenas of clinical leadership Case study: clinical leadership activities Case F: towards an Case D: system and Case E1: redesigning Case E2: redesigning accountable managed Arena multilevel redesign integrated care urgent care care organisation Strategic Six CCGs working GPs in formal lead roles CCG establishes review Devolved locality plans commissioning together across a shape aspirations for of urgent-care services, for city-wide integration and budget county to address integrated care service given inconsistent of health and social care holding existing poor redesign across a formal facilities and services under development, performance and collaboration between across its area and with the LA and CCG financial shortfalls. In four CCGs and LAs increasing demand discussing the form of a parallel, finance-led health and social care CCG-level initiatives, ACO with strong influence from NHSE Operational GP federation supports GPs in formal lead roles Clinical leads of a GP Specific collaborative commissioning, establishment of a local shape nature and out-of-hours centre, an projects between CCG monitoring and pilot integrating primary objectives of integrated urgent-care centre, a and LA (e. BCF and evaluation care across practices care programme, and walk-in centre, A&E and Warm Homes scheme), with community communicate these to GP extended hours where health funds services, with support GP community explore models for contribute to improving from NHSE rather than consistent access to homes and advising the CCGs urgent care residents Operational GP practice-led GPs in practice Working party of GPs GPs and acute providers delivery and initiatives for sharing networks call for more and acute A&E clinicians involved in specific and shaping of capacity across a locality focus on operational agree on telephone relatively narrow scope practice and integrating with detail and education of access as first point of improvements to existing community services and different staff groups. As yet, little community hospitals Community services working party designs engagement or run by primary care struggle to understand protocols.

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Conse- moved to a more centralized locus of control buy line januvia diabetes prevention nhs, evaluation of quently generic januvia 100 mg otc diabetes prevention for kids, numerous studies have been directed at these issues purchase januvia 100mg online diabetes kurze definition. In a book For example, SSRIs have been compared to tricyclic antide- titled Who Shall Live, Victor Fuchs (2) discussed three fac- pressants (TCAs) for the treatment of depression (5–8). Over time the pendulum swings from pressant but also in which agent should be chosen as first- one to another of these dimensions. If costs containment or second-line therapy, the appropriate course (length) of goes too far, then quality or access may suffer. Likewise, it therapy, and whether initial therapy should be augmented with an additional agent (9–12). Given the wide variations in care and the possibility that alternative treatments could Ramin Mahmoud and Amy Grogg: Janssen Research Foundation, Titus- lead to similar outcomes, particularly under the less than ville, New Jersey. Kozma: Strategic Outcomes Service of Care Sciences, Inc. Reeder and Brian Meissner: College of Pharmacy, University of most efficient outcome. In a resource-constrained environ- South Carolina, Columbia, South Carolina. For example, it is esti- more efficient if devoted to another alternative? One useful mated that $44 billion is spent annually on the treatment way to address this question is with data on patient and of depression and $100 billion is spent annually on the cost outcomes. The cost to treat There is an inextricable but sometimes complex relation- schizophrenia has been estimated at $33 billion per year, ship between quality of care and outcomes. Outcomes data accounting for 22% of dollars spent to treat all categories are one way of evaluating quality. Increasing competition for scarce resources encour- ment. What is acceptable quality to one person may be ages decision makers to use outcomes data to evaluate the unacceptable to another at any given level of cost. On a macro level, an analysis using These issues are not new to health care providers, but the measures of quality and cost will not define the percentage development of drug formularies as mechanisms to control of gross domestic product (GDP) that a nation should spend costs has generated a need for outcomes studies to evaluate to achieve a certain level of quality in health care, but rather the benefits obtained from new pharmacologic agents. On a micro level, arose regarding whether health care outcomes were better there is no specific quality of life score on an instrument for patients treated with SSRIs than for patients treated with that indicates if or when a drug product should be reim- traditional TCA therapy (5–7). There is no single clinical measure that indicates ceuticals was more costly than prior standard therapy (the that a patient is in perfect health. All outcomes data require TCAs), prescribed for a wide variety of patients, and had the interpretation and evaluation of a medical decision (in clinical trials) fewer side effects. Outcomes data provide one more, albeit in many were shown to be superior in some domains in clinical trials, cases relevant, piece of information on which to base deci- there was a practical question regarding whether these bene- sions. Is the total cost per acute improve outcomes, for outcomes to be documented and depressive episode (successfully treated case) therefore lower improved, this terminology must be defined in more con- with the newer products despite higher drug acquisition crete terms. One conceptualization of health care outcomes costs? Does treatment with SSRIs cost more, but provide is the economic, clinical, humanistic outcomes model better humanistic outcomes such as quality of life or quality- (ECHO) (13). This conceptualization portrays health out- adjusted life years? These are the types of questions that comes along three dimensions. Clinical outcomes are out- outcomes research and pharmacoeconomic evaluations at- comes related to the effects of medical treatments or disease tempt to answer. This chapter does not specifically address on medical events such as hospitalization or death (i. Economic outcomes are usually expressed as costs issues in outcomes research. Humanistic out- from an evaluation of a body of literature. In addition to these outcomes, there are cal aspects of the treatment of mental health diseases. Given many intermediate variables that are important when mea- the substantial clinical information in the remainder of this suring the effects of a disease or treatment. These variables text, this chapter focuses on evaluation of the economic and are referred to in the published literature by many names humanistic outcomes related to pharmaceutical use. Specifi- including process variables, surrogate outcomes, or interme- cally, the techniques of pharmacoeconomics will be re- diate variables. In many cases making a clear distinction viewed as well as the instruments for evaluating humanistic between these consequences of pharmaceutical use is proba- outcomes in mental health care populations. For example, a score PHARMACOECONOMICS on a depression inventory is probably closer to an intermedi- ate variable, whereas events such as rehospitalization or sui- In the current health care environment, many decisions are cide reflect the 'end results' or outcomes one would like driven by costs. Although Chapter 39: The Role of Pharmaceuticals in Mental Health Care Outcomes 527 the fraction of the health care dollar spent on pharmaceuti- tion, then the decision is based entirely on the costs of the cals is low, it is clear that as both the pressure to reduce inputs. The classic example of a cost minimization analysis costs and the percentage of health care dollars spent on is the use of generic versus branded products. If the chemical pharmaceuticals grow, so does interest in the costs of medi- entities and formulations are identical, then there is no rea- cations. Economists, however, are quick to point out that son to suspect that the outcomes associated with the use of the acquisition cost of the pharmaceutical is not the most either product would be different. In this case, the decision appropriate unit of analysis. It is possible that the acquisition is based solely on the costs of the inputs. The difficulty with cost of many pharmaceuticals may be offset by reductions cost-minimization analysis is establishing that outcomes are in other more expensive forms of care. Even in the case of generic pharmaceuticals there are expensive atypical antipsychotic leads to reductions in hos- examples where alternative formulations have been ques- pitalizations, then the 'value' of the pharmaceutical from tioned. Additionally, products may be equivalent on some a total cost perspective is greater than the acquisition cost outcomes such as clinically significant improvement in of the pharmaceutical. This is a key idea behind pharmaco- depression, but not with regard to others such as side-effect economics. These natural units may include outcomes such as Studies are typically categorized by whether they consider years of life saved, hospitalizations avoided, or scores on a costs, outcomes, or both cost and outcomes. For example, traditional clinical trials vere disease state. This information was incorporated into focus on comparing the consequences of alternatives when a Markov state transition model to compare the cost-effec- one of the alternatives is typically a placebo. In many cases it is possible a regulatory agency striving to meet its special mandate, to develop several cost-effectiveness ratios for a comparison from the perspective of many health care decision makers a of relevant treatment alternatives.

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We start by presenting the views of policy-makers involved with development and roll-out of PRISM purchase 100mg januvia with visa diabetes type 2 hypoglycemia, and staff from Welsh health boards who were invited to pilot PRISM within their chronic conditions management programmes purchase januvia now diabetes gestacional dieta. We then explore local aspects of the context for the PRISMATIC study buy januvia with a mastercard diabete 2 alimentazione, by reporting on the expectations of and views on PRISM from community health staff and health board staff in the ABM UHB areas at baseline of the study. We then examine the process of adoption of PRISM in general practice within the PRISMATIC trial, through reporting the views and experiences of staff from the 32 general practices at three time points: baseline, mid-trial and end of trial. This analysis is informed by the NPT described in Chapter 3. The four components or tasks associated with implementing innovation in normal health-care practice are summarised in Box 2. We conclude the presentation of qualitative data with reflections from an AMB UHB manager at the end point of the PRISMATIC trial intervention on the potential and use of the PRISM tool in their area. This chapter also contains information on the implementation and use of PRISM from the surveys administered to participating practices, to complement the interviews and focus groups. Normalisation process theory suggests that each of these tasks is shaped by factors that promote or inhibit the extent to which participants look on a new practice as meaningful. Respondents Table 37 summarises the stages in which each of the three main staff groups participated in the qualitative data collection, as well as the number of staff involved. Health services policy-makers, managers and community health staff During 2013 we conducted face-to-face interviews with policy and health board managers (n = 12) to explore the story of developing the PRISM tool. Six respondents had responsibility for supporting and implementing chronic conditions management policy (including developing the PRISM tool) at an all-Wales level and worked for the Welsh Government or an agency which advised the Welsh Government on this BOX 2 Normalisation process theory: components of implementing innovation in health care l How people understand the innovation and its purpose (coherence). This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 71 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. STAKEHOLDER VIEWS: THE PREDICTIVE RISK STRATIFICATION MODEL IMPLEMENTATION AND USE TABLE 37 Summary of qualitative data collection stages Time point Baseline: pre PRISM Mid-trial: 3–6 months End of trial: 18 months Staff group activation post PRISM activation post PRISM activation All-Wales policy-makers and health 12 interviews Not interviewed Not interviewed board staff Local health board and community 1 focus group (n = 7) Not interviewed 1 interview staff General practice staff 4 focus groups (GPs, 22 interviews (GPs, 19 interviews (GPs, n = 21; PMs, n = 10; n = 18; PMs, n = 4) n = 17; PMs, n = 2) nurses, n = 2) 9 questionnaires (GPs, 15 questionnaires (GPs, 11 interviews (GPs, n = 7; PMs, n = 2) n = 14; PMs, n = 1) n = 10; PMs, n = 1) matter. The other six respondents had regional responsibility for planning and delivering chronic conditions management services in Welsh health boards. At baseline (before PRISM was introduced to GP practices), we conducted a focus group with seven ABM UHB staff with a responsibility for the management, redesign and/or delivery of primary and/or community care services. Two of them were practising nurses involved in delivering community care, and one was a GP working in a management role at the time of the focus group. One respondent had a role which spanned the whole of ABM UHB, whereas the remaining six respondents worked in a particular locality or network. Part-way through the focus group, we presented a handout explaining PRISM and giving examples of screenshots. At the end of the trial, we interviewed one ABM UHB manager. Two other ABM UHB locality managers declined to participate, saying they had changed roles and had no knowledge of the PRISM implementation. We also circulated a short questionnaire about the PRISM implementation to members of the baseline ABM UHB focus group, but none was returned completed. Staff from general practitioner practices trialling the Predictive RIsk Stratification Model tool At baseline, we invited each GP who had been nominated as lead for PRISM in a participating practice to attend one of four focus groups, along with other staff members (such as PM or nurse), if desired. Thirty-three respondents attended focus groups: group A (GPs, n = 5; PMs, n = 4; nurses, n = 1), group B (GPs, n = 4; PMs, n = 3; nurses, n = 1), group C (GPs, n = 7; PMs, n = 1), group D (GPs, n = 5; PMs, n = 2). We also interviewed 10 GPs who were unable to attend a focus group, by telephone (n = 7) or in person (n = 3); in one of the face-to-face interviews, the GP was joined by their PM. This gave a total of 44 participants from across all 32 practices. Part-way through the focus group or interview, we presented a handout explaining PRISM and giving examples of screenshots. At two time points after PRISM was introduced (at the mid-point and at the end of the trial), we carried out follow-up data collection with respondents from the practices. For half of the participating practices (n = 16), we interviewed the PRISM lead GP in order to understand how the tool was introduced and used over the study period. The PM or practice nurse also contributed to a small number of these interviews. The mid-trial interviews took place at the time when practices were preparing reports required for QOF: interviews with practices who gained access to the tool early in the PRISMATIC trial occurred up to 6 months before the QOF deadline, whereas later implementing practices were interviewed during the few months or weeks before they submitted their reports. By the time of the interviews at the end of the trial, the QOF payment for focusing on patients at high risk of emergency admissions had ended. Characteristics of practices and respondents are described in Appendix 10. Figure 6 illustrates the timing of mid-trial interviews with participating GPs in relation to the QOF reporting deadline. Where a respondent emphasised a word or phrase, that emphasis is indicated by bold type. Quotations are identified by respondent role (GP, PM, practice nurse), practice-unique identifier, time point (baseline, mid-trial, end of trial). Quotations for policy and health board managers are identified by PHB and the unique number (e. Views of health service managers at strategic level: pre implementation How the Predictive RIsk Stratification Model risk tool was planned and developed across Wales This section presents results of interviews with policy-makers and health services managers (n = 12) responsible for chronic condition management in Hywel Dda, Betsi Cadwaladr, Powys, Cardiff and Vale, Cwm Taf, and Aneurin Bevan Health Boards. Interview respondents reported broad support for the introduction of a risk prediction tool in Wales. PHB01 We knew that we had to look at these patients who were multiple admissions to hospital, and that there was a keenness to stop people going into hospital, and to keep them in the community, and keep them at home. You should be able to plan, as far as you can, and try and understand where your demands for health care are going to come from. PHB07 Several respondents recalled that PRISM had been anticipated for some time. They indicated that there were high levels of awareness and enthusiasm across different staff groups with a strategic interest in chronic conditions management:. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 73 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. P ra ct ice P ra ct ice P ra ct ice Q O a r ra ct ice ra ct ice ra ct ice ra ct ice 1 ril ra ct ice P ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice Q O en d 5 w eeks 3 a rch P ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice P ra ct ice ra ct ice ra ct ice ra ct ice ra ct ice P ra ct ice P ra ct ice P ra ct ice F U R T he tim in g o fm id- tia lin ter view s w ith a r tic i a tin g a c tic es in ela tio n to the Q ep o tin g dea dlin e. PHB10 Most respondents were aware that PRISM had initially been proposed as a tool to support the planning of services. A minority of respondents expressed the opinion that this original vision was preferable to the subsequent emphasis on use within GP practices:.

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