IRVING Surname Meaning and Family History

The Irving surname generally  originated as a geographical surname, indicating someone who was from Irving, the name of a historic parish in Dumfriesshire, Scotland, or from Irvine in Strathclyde, Scotland.   It may also be a variant of Irvine, a habitational surname for someone from Irvine in Ayrshire, which is named for the  river Irvine that originates in Ayrshire and flows through Dumfriesshire, from the Welsh ir, yr,  meaning green or fresh, and afon, meaning water.   Surname Origin: Scottish, English Alternate Surname Spellings: IRVINE, IRVIN, IRWIN, IRWINE, URVINE, ERWIN, ERWINE, ERVING Where in the World is the IRVING Surname Found? While it originated in Scotland, the Irving surname is now most prevalent in the United States, according to surname distribution data from Forebears. However, it is more common, based on percentage of population, in Jamaica, followed by Micronesia, Isle of Man, Scotland, New Zealand, Taiwan and England. Within Scotland, Irving is still most common in Dumfriesshire, where it originated, ranking as the 3rd most popular surname in that area at the time of the 1881 census. The Irving surname is also popular in the Cumbria and Northumberland counties of England, according to  WorldNames PublicProfiler, followed by the Dumfries and Galloway council district in Scotland. It is also more common in Canada than in the United States, especially in Nova Scotia.   Famous People with the Last Name IRVING Sir Henry Irving -  British stage actor during the Victorian eraT. B. (Thomas Ballantyne) Irving  - publisher of the first American English translation of the QuranThomas Irving - Union navy sailor during the U.S. Civil War; recipient of the Medal of Honor for helping to rescue his grounded shipEdward Irving - Scottish clergymanWashington Irving - American author  best known for his short stories Rip Van Winkle (1819) and The Legend of Sleepy Hollow (1820). Genealogy Resources for the Surname IRVING Clan IrwinLearn about the history of this ancient Scottish border clan, plus upcoming events and tours. Clan Irwin Surname DNA StudyTradition recorded in the 17th century claims that the Irvines or Irvings of Eskdale and Bonshaw (in Dumfriesshire, in the Scottish Borders),  Castle Irvine (in Co.  Fermanagh,  in Ulster), Drum and Marr (in Aberdeenshire), Mearns (Kincardineshire), Orkney and Perthshire were all descended from a single ancestor, who was also the progenitor of the kings of Scotland from 1034 to 1286.  This study, with over 400 members, aims to use Y-DNA testing to sort out the various family branches. Most Common Scottish Surnames and their MeaningsCampbell, Stewart, Wilson, Reid, MacDonald... Are you one of the millions of  individuals of  Scottish ancestry sporting one of these top common last names from Scotland?   Irving Family Crest - Its Not What You ThinkContrary to what you may hear, there is no such thing as an Irving  family crest or coat of arms for the Irving surname.  Coats of arms are granted to individuals, not families, and may rightfully be used only by the uninterrupted male line descendants of the person to whom the coat of arms was originally granted. FamilySearch - IRVING GenealogyExplore over 400,000 historical records and lineage-linked family trees posted for the Irving surname and its variations on the free FamilySearch website, hosted by the Church of Jesus Christ of Latter-day Saints. IRVING Surname Family Mailing ListsRootsWeb hosts several free mailing lists for researchers of the Vanderbilt surname. DistantCousin.com - IRVING Genealogy Family HistoryExplore free databases and genealogy links for the last name Irving. The Irving Genealogy and Family Tree PageBrowse genealogy records and links to genealogical and historical records for individuals with the popular last name Irving from the website of Genealogy Today. ----------------------- References: Surname Meanings Origins Cottle, Basil.  Penguin Dictionary of Surnames. Baltimore, MD: Penguin Books, 1967. Dorward, David.  Scottish Surnames. Collins Celtic (Pocket edition), 1998. Fucilla, Joseph.  Our Italian Surnames. Genealogical Publishing Company, 2003. Hanks, Patrick and Flavia Hodges.  A Dictionary of Surnames. Oxford University Press, 1989. Hanks, Patrick.  Dictionary of American Family Names. Oxford University Press, 2003. Reaney, P.H.  A Dictionary of English Surnames. Oxford University Press, 1997. Smith, Elsdon C.  American Surnames. Genealogical Publishing Company, 1997. Back toGlossary of Surname Meanings Origins

Analysis Of Laura Palmer By Bastille / Running Away...

â€Å"Laura Palmer† by Bastille// Running Away From Pencey Prep The song â€Å"Laura Palmer† by Bastille reminds me of the scene in Catcher in the Rye where Holden ran away from Pencey Prep, thoroughly finished with the â€Å"morons† there. Pencey, the last school Holden attended, was full of phonies according to Holden. Although he did not like the people at Pencey, the school provided a generally stable environment for Holden. After Holden ran away from Pencey, he had three days to kill before the start of the Christmas break when he would have to face his parents. His parents would know â€Å"something was up† if Holden returned home early instead of at the start of the holiday. In these few days, Holden was denied the relative level of stability and comfort he enjoyed at Pencey Prep and was forced to face the hard reality of the outside world. As I picture Holden in this situation, I can visualize the song â€Å"Laura Palmer† through the lyric s â€Å"You ran into the night from all you had.† Thus, as in the song, Holden unknowingly left a good situation for one that was worse. This scene was significant to the story line launched Holden into a particularly self-destructive journey. The lyrics â€Å"Walking out into the dark† directly apply to Holden. If Pencey was the known and where Holden was going was the unknown, Holden was walking out from the light into the dark, as in the song. 2. â€Å"I Wanna Dance With Somebody† by Whitney Houston// Lavender Room â€Å"I Wanna Dance With Somebody† by

Looking at Othello as a Tragic Hero Essay example

Looking at Othello as a Tragic Hero Killing myself, to die upon a kiss. Othellos death brings a sense of justice to the play, one of the main forms and conventions of a tragedy. But if Othello is a tragedy then Othello must be a tragic hero. Traditionally a tragedy follows the downfall of an individual who is usually high up in society (such as a king). This downfall is triggered by a fatal flaw in the tragic heros character. During the play the audience must have many different feelings towards the hero, from respect to anger and maybe even pity. These may also turn to terror, as people close to the hero are hurt. Fate is seen to be predetermined and ensures that justice is seen to†¦show more content†¦Their use of racial comments such as Thick-lips and Old black ram imply that a black man is not a common sight especially of such a high rank. These racist images of Othello do not provide very good pictures for the readers and almost turn us against him. However in the next scene a very different version of Othello is shown. Othello is seen to be Hotly called for by the duke leading us to believe that he is a very important person. He commands respect from noble men like Montano and the Duke, suggesting that Othello is a noble man. Shakespeare then continues to build Othello up. We are shown how many people care for and respect the moor, for example when Othello is sailing to Cyprus Montano, Cassio and Desdemona are all concerned for his safety during the storm. When Cassio reaches the shore he begs the heavens to Give him defence against the elements implying his wish for Othello to arrive safely. This shows that many people look up to him and respect him. From this we can see that Othello is an honourable and respected man. He can sort out problems quickly and efficiently and he is confident that his services to Venice shall out-tongue his complaints. He believes that the Duke will be on his side because of his rank, so it does not matter what Brabantio has to say. If Othello is a tragic heroShow MoreRelatedOthello : An Aristotelian Tragedy And Tragic Hero1604 Words   |  7 PagesOthello, an Aristotelian Tragedy and Tragic Hero When reading a story, specifically a tragedy, what stands out? Tragedy often enables its audience to reflect on personal values that might be in conflict with civil ideas, on the claims of minorities that it neglected or excluded from public life, on its on irrational prejudices toward the foreign of the unknown (Kennedy Gioia, 2103, p. 857). Readers feel sympathy for the characters, especially the tragic hero. Othello, the Moor of Venice isRead MoreOthello is Not a Tragic Hero Essay1481 Words   |  6 PagesOthello has been described as one of William Shakespeare’s most popular plays because the play focuses on its themes of good and evil, military, politics, love and marriage, religion, racial prejudice, gender conflict, and sexuality; but the controversy and debate surrounding Othello is â€Å"Why is Othello a qualification for a tragedy?† Most readers are aware of the many famous deaths or acts of death within the Shakespearean plays. And when the main characters die in Shakespeare’s plays, indeedRead MoreOthello, By William Shakespeare Essay1203 Words   |  5 PagesDramatic play entitled Othello is an unusual story full of jealousy, dark misunderstandings, lies, and regrets. Following Aristotle s definition of a true tragedy, where does the tale of Othello fall? Is Othello too dramatic too be considered a tragedy or does it barely fall along the lines of tragic? Shakespeare s innovation with poetry and dramatic plays have been recognized by critics and playgoers throughout the centuries (Lee,1899). The Bard s play entitled Othello, is among some of the mostRead MoreThe Tragedy Of Othello By William Shakespeare1141 Words   |  5 Pages2 Hr 16 December 2014 Othello Essay The Tragedy of Othello The renowned play of Othello was written by William Shakespeare in the 17th century. The drama follows the life of Othello, a well-respected and admired Venetian general, and the lie he gets tangled up in. Othello is deceived by his â€Å"trustworthy† friend, Iago, who confidently convinces Othello that his honest wife, Desdemona, committed infidelity upon him with his honorable lieutenant, Cassio. At the start, Othello doesn’t quite believe IagoRead MoreTragic Hero in Othello by William Shakespeare1306 Words   |  6 Pagesprojecting. The entire play of Othello conveys a motion that of a Shakespearean Tragedy. Firstly, the plot of a Shakespearean tragedy dictates that there will be multi-action and the culminating of one tragic hero. In Othello, the multi-action takes place between Othello, Desdemona, Iago, Cassio, and Roderigo and how their stories intertwine. The plot structure usually leads to or starts with the hero making a great error in judgment, which leads to his downfall. Othello makes the misjudgment in trustingRead MoreThe True Nature Of Shakespeares Characters In Othello1546 Words   |  7 PagesThe True Nature of William Shakespeare’s Characters in â€Å"Othello† Ever since it’s creation over four centuries ago, William Shakespeare’s classic tragedy â€Å"Othello†, has reigned as one of the greatest play’s of all time. Being widely studied and analyzed, there should be no question as to why this piece has remained so relevant, even within the twisting and turbulent times of the 20th century and beyond. With copious amounts of today’s youth becoming caught and obsessed with the virtual life of socialRead MoreHeroes and Villains: Iago and the Extent of Human Potential in Shakespeare’s Othello1646 Words   |  7 PagesThe character of Iago has traditionally been viewed as the most infamous villain in all of Shakespeare. The conniving ringmaster of the tragedy of Othello, Iago serves as a necessary catalyst for the action of the play. He takes such a principal role in the drama that the play has commonly been described as Othello’s tragedy, but Iago’s play. Scholars have disagreed, however , as to whether or not Iago can simply be described as an ingenious villain lacking all regard for morality. Many have seenRead MoreOthello Is Essentially an Noble Character, Flawed by Insecurity and a Nature That Is Naive and Unsophisticated1070 Words   |  5 PagesOthello is essentially an noble character, flawed by insecurity and a nature that is naive and unsophisticated. Looking at William Shakespeares Othello The Moor Of Venice, the central character, Othello is revered as the tragic hero. He is a character of high stature that is destroyed by his surroundings, his own actions, and his fate. His destruction is essentially precipitated by his own actions, as well as by the actions of the characters surrounding him. The tragedy of Othello is not aRead MoreReputation and Image in William Shakespeare ´s Othello862 Words   |  4 Pages Othello Explication In William Shakespeare’s Othello, unspoken fears of being an outsider and concerns about his public image contribute to the downfall of a tragic hero named Othello. Othello, a general in the Venetian army’s, final monologue reflects the importance of reputation and the conformity needed to fit his surroundings. He is seen as an outsider of the Venetian culture; he is frequently referred to as â€Å"the Moor† and is called an abundance of racial slurs by the Venice born natives.Read MoreTo What Extent Is Iago Responsible for Othellos Downfall1326 Words   |  6 PagesAS English Literature Othello Coursework: How far do you agree with Bradley’s view that Iago is wholly responsible for Othello’s downfall? A.C Bradley, a known literature critic, argues that it is in fact the machinations of the character Iago that is wholly responsible for the downfall of Othello. â€Å"..that these worthy people, who are so successful and popular and stupid, are mere puppets in his hands, but living puppets, who at the motion of his finger must contort themselves in agony, while

Comparison of the Matrix and the Allegory of the Cave Essay

Composition I 3 October 2012 The Matrix and the Allegory of the Cave What if one were living through life completely bound and facing a reality that doesnt even exist? The prisoners in Platos Allegory of the Cave are blind from true reality as well as the people in the movie The Matrix. They are given false images and they accept what their senses are telling them. They believe what they are experiencing is not all that really exists. Plato, the ancient Greek philosopher wrote The Allegory of the Cave, to explain the process of enlightenment and what true reality may be. In the movie The Matrix, Neo (the main character) was born into a world of illusions called the Matrix. Neo’s true reality is being controlled by the†¦show more content†¦In The Matrix the puppet-handlers and the machines spawned from a singular consciousness called A.I. (artificial intelligence). In both The Matrix and Allegory of the Cave, the puppeteers have created artificial surroundings as a way to control and operate the information the prisoners receive. Plato also stated that eventually one of the more intellectual prisoners would break free from the cave and into the outside world. The one prisoner that Plato refers to reflects Neo in The Matrix when he is being released from his pod that the machines have created. Once the prisoner of the cave has broken free he can now look all around him and see the objects as they really are. While in the movie The Matrix, Neo is using is own eyes for the first time and sees that he is actually living in a human factory. In Platos Allegory of the Cave, he states that the freed prisoner would be shocked and not used to the outside world. The prisoner would try to think that what he saw and experienced before was truer than what is he sees now. When Neo is revived from being detached from the pod, Morpheus tells him what state the world is in now. Neo turns into a state of disarray and denial. This new knowledge of the truth overwhelmed Neo so much that he vomited and passed out. The released prisone r in The Allegory of the Cave might feel that what he is seeing was the illusion and shadows on theShow MoreRelated A Comparison of The Matrix and Platos The Allegory of the Cave1838 Words   |  8 PagesA Comparison of The Matrix and Platos The Allegory of the Cave In the movie The Matrix we find a character by the name of Neo and his struggle adapting to the truth...to reality. This story is closely similar to an ancient Greek text written by Plato called The Allegory of the Cave. Now both stories are different but the ideas are basically the same. Both Stories have key points that can be analyzed and related to one another almost exactly. There is no doubt that The Matrix was based offRead MoreThe Matrix, Descartes First Meditation, And Plato s The Allegory Of The Cave909 Words   |  4 Pagesis in life. Humans have a natural instinct to raise questions to material that we are uncertain of. The movie The Matrix, Descartes First Meditation, and Plato’s The Allegory of the Cave all raise different aspects to questions such as do I exist, what is reality, and how do I know? In The Allegory of the Cave, Socrates and Glaucon are conversing. Socrates asks Glaucon to image a cave, where prisoners are kept and have been kept since their childhood. 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The basic tenet that fuels Socrates Allegory of the Cave and the other two previously mentioned works is that reality through the human senses cannot be trusted, may not be true, and cannot necessarily be validated through the human senses. Based on this central premise, there are a number of specific points of comparison existent between this literature and film, particularly between Meditations and The Matrix. The essential element in doubting theRead MoreAllegory Of The Cave And The Matrix Essay860 Words   |  4 PagesThe Allegory of the Cave, by Plato and The Matrix have similarities and differences when compared. These two story lines are completely different scenarios, but they both paint the same picture leading you to the question what is real? The allegory of The Cave revolves around prisoners who have been bound to chains their entire lives. They face a blank wall, and only a blank wall. They know nothing of what is outside of the cave. 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Medical Home Practice-Based Care Coordination Free Essays

string(176) " perception of barriers to care coordination in the medical home includes: time, reimbursement, lack of physicians, lack of skill/training, and limited cultural effectiveness\." 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 2007 Workbook 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. We will write a custom essay sample on Medical Home Practice-Based Care Coordination or any similar topic only for you Order Now 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 coordination 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¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 11 Care 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 Study 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 support 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. Contents 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 comprehens ive 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 is 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. You read "Medical Home Practice-Based Care Coordination" in category "Papers" 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 optimal 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, specialty based centers, community home health agencies. Few definitions focus exclusively on the distinctions found within the primary care medical home for the role of pract ice-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 Coordination Practice-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 leadership helps to develop/support a care coordination service system; protected time allows for CC role development? 5) C YSHCN 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 coordinator works within the context of a primary care medical home, from a team approach, and in continuous partnership wi th 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 beliefs 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) Fac ilitate 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 plan 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 of 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 Worksheet Medical 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 registry 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 r ole 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 facilitate 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 need ed 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 Coordination (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 re ferral 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 Planning 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, moni tor 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 families, 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 Interventions Identify 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 with 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 Interventions Help 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 â€Å"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 group 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"rounds† 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 n eeds 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 Coordination Between 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 access 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 change 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 assessment 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-Do-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 increased 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: 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: 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, and 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 change: 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. org References 1) McAllister, J. W. , Cooley, W. C, Presler, E. Practice-Based Care Coordination: A Medical Home Essential. Pediatrics, Volume 120, Number 3, September 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 McAllister, 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 Enhancing 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 How to cite Medical Home Practice-Based Care Coordination, Papers

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Speed and responsiveness to Market, Zara has changed the way clothing industry works where deigning, production and delivery to the retailers requires period of six months. The design and distribution cycle of the company takes just 10-15days in the whole process. Zara’s speed to market in product development exceeds the capabilities of its competitors. This in itself provides additional value to stakeholders, customers, and stores in producing quality clothing at affordable prices. The proximity of their manufacturing and operational processes allows Zara to maintain the flexibility necessary to design and produce over 12000 new items annually. This capability allows Zara to achieve their strategy of expedited response to consumer demand. The process of obtaining market information and relaying it to design and production teams expedites product development by shortening the throughput time of their products from design to store. Dependability Due to Zara’s ownership and control of production, they ensure timely delivery and service. We will write a custom essay sample on What are the key issues deciding to purchase for zara internally and externally or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Although most of their stores run out of stock, signifying that they have low dependability in terms of product availability, another perspective of dependability in terms of keeping to date with fashion is achieved. Quality Zara brand has been said to be ‘synonymous with the cutting edge of fashion at affordable prices. ’ (123helpme. com, 2008) Another Quality advantage is the added sense of quality to the product as the tags would be labelled with â€Å"made in Europe† rather than â€Å"made in China† due to Zara’s trade-off between Low labour costs in Asia and operational efficiency. Flexibility: Designers (of average age 26) draw the design sketches then discuss it with market specials and planning procurement staff illustrating a flexibility of ideas generation and on the other hand the huge number of designs reflects the ability to meet almost all the fashion requirements by customers of all ages (up to 55). This adaptive model rather than traditional merchandising is very different from its competitors. Many competitors rely on a small elite design team that plans both design and production needs well in advance. Stores have little autonomy in deciding which products to display or put on sale because Headquarters plans accordingly and ships quantities as forecasted. Zara owned many of the fabric dying, processing and cutting equipment that provided Zara added control and flexibility to adopt new trends on demand. The added flexibility helped Zara on two fronts: shorter lead times and fewer inventories. (OPPapers. com, 2009) Cost: Zara produces most of its products in Europe. Compared to their competitors, they outsource very little to Asia [6] . Though the cost of production in Spain is 17-20% more expensive than Asia, Zara does have a competitive advantage over its competitors in regards to operations. Though there is a cost advantage in their approach in regards to labour, the lack of flexibility in changing orders based on current trends hinders their operational efficiencies. Inventory costs are higher for competitors because orders are placed for a whole season well in advance and then held in distribution facilities until periodic shipment to stores. Lower inventory cost is a key sustainable advantage as it enables Zara to manufacture and sell its products at cheaper prices. A case study analysis of Zaras Operations Strategy Zara is the largest division and flagship brand of the Spanish retail group Inditex [1] . It sells up-to-the-minute ‘fashionability’ at low prices, in stores that are clearly focused on one particular market. (Slack, Chambers, Betts, Johnson, 2006) The first store opened by accident in 1975 due to a large pyjamas order cancellation. This typically can be said to be an emergent strategy as the Zara store today was not an intended strategy. [2] As described in a case study of Zara’s supply chain, the company is vertically integrated, controlling most of the processes in its supply chain. On the average, 50% of its products are manufactured in Spain, 26% in the rest of Europe and 24% in Asian countries. Zara outsources products of high labour intensive processes but maintains in-house capital intensive processes, protecting knowledge and know-how. It takes less than two weeks for a skirt to get from Zaras design team in Spain to a Zara stores in any part of the globe, as much as 12 times faster than the competition. And with shorter lead times, Zara can ship fewer pieces, in a greater variety of styles, more often and they can more easily cancel lines that dont sell as well, avoiding inventory backlogs. (Upadhyay, 2009) Zara’s quick response capacity is made possible by the fact that it controls the 3 main stages of its operations that define the competitive edge of the company: design, manufacturing and distribution. This strategy is embraced to focus on the operations which can enhance cost efficiency while boosting service delivery and value proposition. As a fashion imitator, Zara ‘s priority was to focus its attention on understanding the dynamic fashion trends, aligning these changes to meet its customers’ wants rather than on promoting predicted seasons trends via fashion shows and similar channels of influence, which the fashion industry traditionally used. Other production activities are completed via a network of about 500 subcontractors in close proximity to Zara’s operations at La Coruna. Mr. Ortega the CEO of the Inditex, the parent company of Zara, once said that the secret to retail success is to have five fingers touching the factory and five touching the customer. (Slack Lewis, Operations Strategy, 2008) This paper uses the models and frameworks of the Operations Strategy module to describe analyze how Zara’s operations strategy led to a sustainable competitive advantage in the global apparel industry. 2 Introduction Zara is the flagship brand of the Spanish retail group, Inditex SA, one of the super-heated performers in a soft retail market in recent years. The first Zara shop opened its doors in 1975 in La Coruna, GaliciaSpain, the city that saw the Groups early beginnings and which is now home of its central offices. Its stores can now be found in the most important shopping districts of more than 400 cities in Europe, the Americas, Asia and Africa. With year-on-year sales increasing at around 25% over the last 5 years, it has become one of the world’s fastest growing retailers. As of late last year, Zara had 350 shops in Europe, 18 in the Middle East, 52 in the Americas and five in Asia. With roughly 40% of Inditex shops, Zara brings in about 80% of the groups revenue.(Zara founder makes a mint, 2001) As retailers like Marks Spencer and Gap join retailers in reporting falling profits, what makes a Spanish retailer to announce profit and Growth and assume this post as forthcoming leader in the fashion retail industry? What Ortega, the founder of Inditex, saw that others didn’t see? What is Zara Business Model? What is Z ara strategy? What are the factors behind the success of Zara? How scalable its model is? What are the challenges? How Zara would cope with the challenging environment of fashion retail business faced nowadays by the leaders in this industry? Amancio Oretga thought that customer would regard clothes as perishable commodity – no different from yogurt or bread- to be consumed rather than stored in closets, and has gone about building a retail business that provides â€Å"freshly baked clothes â€Å". By Focusing on apparel as product for consumption Zara compete on speed. This business is all about reducing response time. In fashion stock is like food it goes bad quickly. So, Zara concentrates on three winning formulas: Offering fashionable variety with limited supply at affordable price (cost) with a quick response to market.(Devangshu Dutta 2002) 3- Zara Vertical integrated Supply Chain An efficient supply chain is becoming more and more key success factor for companies. Henry Ford assembly line was the event of mass industrial production. Is supply chain management the new differentiation for companies? According to McMillan and Mullen (Operations Management Vol-2, 2002), â€Å"the purpose of SCM is to integrat e all tasks associated with the bi-directional flow of materials, information and finance into organized, coherent, managed processes in order to provide end-to-end management and control. †

Relationship between Income Inequality & Crime-Samples for Students

Question: Write a Reflective essay over relationship between income inequality and crime. Answer: This reflective essay is based on the topic income inequality and crime. It is based over two previous assessments which are also based on the same topic. There are various reasons which are responsible for occurrence of crime and income inequality is one of those aspects which lead to occurrence in crime. In order to control crime rate, it is necessary to develop strict rules and regulations. Penalties associated with the crime are majorly responsible for the crime rate. Apart from the income, there are various sociological factors which affect the crime rate and some of those sociological factors are unfair treatment, discrimination practices, etc. The major focus of this reflection essay will be based over the relationship between income inequality and crime. I have learnt that income inequality plays crucial role in occurrence of crime and income distribution is one of those factors which lead to occurrence of crime in developed countries. Globalisation is also one of those factors which lead to occurrence of crime as it has filches employment opportunities from the local residents (Pickett Wilkinson, 2015). I have also realised that multinational and other large companies are moving towards the cheap markets of Asian countries in order to reduce cost of production and this has generated unemployment in the developed countries. People have lost their jobs due to globalisation and due to aggressive competition. In these scenarios, people have moved towards the negative aspects such as crime and other related activities for their livelihoods. I have learnt that information technology has acquired a large part of the market and with this, requirement of skilled and educated labours have been increased. Due to this, unskilled labours do not get relevant chance to justify themselves. Therefore they choose alternative ways for their survival and for improving their financial conditions (Cooper, Kennelly, Durazo-Arvizu, Oh, Kaplan Lynch, 2016). According to my experience, for living a healthy and basic life, it is necessary to get educated, skilled and gain specialization in any field as per the individuals interest. This helps an individual to find the most appropriate manner in order to get a job or find a way to satisfy his or her needs. But people who could not able to get all these facilities due to low financial conditions or due to other factors such as low cast, discriminatory practices followed by the rich and high class people, etc. This decreases the morale of the people and fills an immense level frustration to prove themselves in front of the society irrespective of the way chosen and sometimes, this let them towards anti-social activities to bring out frustration as well as to prove themselves. I have researched on this topic and found that majorly it is seen in under developed countries (Enamorado, Lpez-Calva, Rodrguez-Casteln Winkler, 2016). This is because those countries have various issues such as high u nemployment rate, huge population, practices of unfair treatment, discrimination, etc. Due to these factors, competition amongst the individuals increases and people who are skilled enough get the opportunity and uneducated and unskilled people chose the anti-social way to survive as well as to fulfil their basic needs. Though, anti-social activities are risky but people with less education and with fewer capabilities adopt these ways to snatch the money from rich people along with ignoring the risk involved in those activities (Buttrick Oishi, 2017). Distribution of income is based over the individuals effectiveness and efficiency but sometimes, people found this distribution system of income as unfair treatment which leads to generation of disputes. As per the discussion in previous tasks that before 1965, US were suffering from huge crime rate and the major reason behind was lack of education. Most of the criminals arrested were found college dropouts and they take support of anti-social activities for their livelihoods as well as to attain the higher position in the life. Crime is associated with acquiring short term benefits and these cannot be obtained from the legal activities. I have also learnt that therefore, poor people are generally found engaged in executing illegal activities for acquiring short term benefits. Rich people need to put comparatively less efforts to attain success because they receive luxury and comfort from their birth. On the other hand, poor people need to fight with circumstances to uplift their lif e standards. This is the major reason that I had learnt from studying the relationship between income inequality and crime. Poor people found illegal way ore easier in compared to legal activities for gaining success and growth in their life (Eckenrode, Smith, McCarthy Dineen, 2014). Crime has several types such as theft, robbery, kidnapping, murder, extortion, etc. All these are performed for different objectives but the major objective is earning or snatching money in short period of time. I have also learnt that there are various other objectives which lead to occurrence of crime and dissatisfaction is one of those perspectives. Dissatisfaction towards life, towards work and other parts may force the individual to opt the negative manner or anti-social activity for reducing the gap between dissatisfaction and satisfaction as this seems to be the shortest way to overcome with the issues. This can be understood with the research that daily more than 200,000 rape cases are being reported across the globe. Apart from recorded cases, there are various other which are not reported due to societys pressure, or due to other sorts of pressure (Thompson Gartner, 2014). Rape is also a part of crime but this is not because income inequality, infect this is due to dissati sfaction. To stop these types of illegal practices, according to my point of view, government authorities should impose heavy penalties on such criminal practices. Penalties and crimes both have unique and direct connection, the more will be penalty, crime rate will be less but in the countries where penalties for such incidents are not heavy or strict, and occurrence rate of crime is quite high (Pare Felson, 2014). In relevance with the relationship amongst the crime rate and thee income inequality, it has been observed that there are various countries in the globe which have controlled this rate. In order to remove this to the fullest, it is necessary to adopt certain crucial and advanced measures. As per my opinion, the only way to stop these crimes are imposing penalties and providing all those facilities and the services to the poor people who could easily be consumed and attained by rich people easily and effectively. This will generate equal opportunities for both rich and poor people and on the basis of capabilities and efficiency; they will get their roles accordingly. Government bodies should also introduce certain awareness programs through which people should be informed regarding the penalties for performing any type of illegal activities. Apart from this, I have also experienced that fear is not the only measure to stop crime; there are several others also such as reducing the gap of income inequality (Schneider, 2016). Apart from these factors, disposable income of an individual is also a great source of increasing the unequal distribution of income. Rich people are majorly found doing this and this is known as showing less total earned income in order to reduce the tax payable to the government (Rueda Stegmueller, 2016). This ultimately reduces the purchasing power of the consumers and hence, it leads to black money. Corruption is the biggest limitation of inequality in income distribution system (Cheung Lucas, 2016). Thus, I suggest the government to develop strong rules, regulations and the policies for collection of tax and revenues so that rich people could not be able to show less income compared to the actual earned income. This will increase the earning of government and thus, they will easily be able to adopt certain effective measures to provide better facilities and services to poor people in order to reduce unequal distribution of income. Ultimately it will help the country to increas e its GDP as well as provide opportunities for being a developed country (Wang, Pan Luo, 2015). According to my opinion, in order to reduce the crime rate, country and its authorities are responsible for taking certain crucial steps in order to generate and provide employment opportunities, opportunity to learn as well as sundry other opportunities to prove their capabilities. This will help the poor people to get a satisfactory as well as effective chance to grow along with their families. This will also leads to increase in the GDP of the country which will ultimately result in growth and development of the whole country (Kawachi Subramanian, 2014). Thus, it could be said that income inequality is the strong evidence of increasing criminal activities. These activities are also known as anti-social and illegal activities. This reflective essay is based over my personal experience, learning and opinions over relationship between income inequality and crime. There are various reasons which are discussed in this essay which are responsible for the generation of crime. Various strategies have also been discussed in relevance with reducing the crime rate. References Buttrick, N. R., Oishi, S. (2017). The psychological consequences of income inequality.Social and Personality Psychology Compass,11(3). Cheung, F., Lucas, R. E. (2016). Income inequality is associated with stronger social comparison effects: The effect of relative income on life satisfaction.Journal of personality and social psychology,110(2), 332. Cooper, R. S., Kennelly, J. F., Durazo-Arvizu, R., Oh, H. J., Kaplan, G., Lynch, J. (2016). Relationship between premature mortality and socioeconomic factors in black and white populations of US metropolitan areas.Public health reports. Cushing, L., Morello-Frosch, R., Wander, M., Pastor, M. (2015). The haves, the have-nots, and the health of everyone: the relationship between social inequality and environmental quality.Annual Review of Public Health,36. Eckenrode, J., Smith, E. G., McCarthy, M. E., Dineen, M. (2014). Income inequality and child maltreatment in the United States.Pediatrics,133(3), 454-461. Enamorado, T., Lpez-Calva, L. F., Rodrguez-Casteln, C., Winkler, H. (2016). Income inequality and violent crime: Evidence from Mexico's drug war.Journal of Development Economics,120, 128-143. Kawachi, I., Subramanian, S. V. (2014). Income inequality.Social epidemiology,126. Pare, P. P., Felson, R. (2014). Income inequality, poverty and crime across nations.The British journal of sociology,65(3), 434-458. Pickett, K. E., Wilkinson, R. G. (2015). Income inequality and health: a causal review.Social science medicine,128, 316-326. Rueda, D., Stegmueller, D. (2016). The externalities of inequality: Fear of crime and preferences for redistribution in Western Europe.American Journal of Political Science,60(2), 472-489. Schneider, S. M. (2016). Income inequality and subjective wellbeing: Trends, challenges, and research directions.Journal of Happiness Studies,17(4), 1719-1739. Thompson, S. K., Gartner, R. (2014). The spatial distribution and social context of homicide in Torontos neighborhoods.Journal of research in crime and delinquency,51(1), 88-118. Wang, P., Pan, J., Luo, Z. (2015). The impact of income inequality on individual happiness: Evidence from China.Social Indicators Research,121(2), 413-435.