Sam was concerned. Less than an hour ago, a noise woke him from his sleep, and armed only with an umbrella, he had checked to see if everything was okay. Wolf had uncovered a woman who was close to death, the police had responded to the 911 call, and the FBI turned up. Despite the fact that there might be somone lurking around outside, the FBI agent had hotfooted it to the hospital to try to talk to the injured woman, and the chief had followed him. No one had checked to see if anyone was still around and might be dangerous.
In the hospital, the FBI agent had upset the medical staff when he tried to speak to the woman. She had screamed as though her life was still at risk. The senior nurse rushed into the room and asked him to leave until the patient recovered.
The chief watched with bemusement, but said nothing.
The FBI agent sat stiffly, twiddling his thumbs. He was in a huge hurry and wanted to hear what if anything, the woman knew. Her screaming bothered him and he had no time for delays.
All these questions would have to wait. His main concern right now was the protection of his family. Anyone lurking around outside must be aware that there was a dog on the premises. Wolf had made enough noise to wake the whole neighbourhood. Still, he double checked that the doors were locked and the windows secure before he climbed the stairs to bed.
When Sam entered the bedroom, his wife was sound asleep. He doubted that he would find it so easy to drop off after all the commotion, but he was tired.
After a restless night, Sam was up early, but not as early as his wife. She was already fixing breakfast when he entered the kitchen.
His wife was a marvelous cook and today was making lemon pancakes. This was Sam's favorite food.
He was thankful she was okay and still functional.
He looked at the pancakes and then at his wife. She had a pleasant smile on her face and he was pleased that she was feeling good. He would do his best to show his appreciation for the breakfast but not overdo it. The fact that he didn't like lemon pancakes would have to remain his secret.
took his wife literally hours to prepare. On his birthday she fixed a double portion.
Sam walked over to his wife and gave her a hug.
"Does there need to be a reason?" Sam replied with a smile.
"I'm okay, if that's what you're thinking. I'm not worrying about last night."
"You'll leave that to me, right?"
"Heck no, you just let it go. Let the police deal with it."
"He was kinda cute ..."
His wife raised her eyebrows and laughed.
"Well, I'll be ... there I was thinking that you'd be upset with all that blood and hysteria and all ... but all you recall from last night is the guy from the FBI!"
"Just trying to take your mind away from messing in things that don't concern you. I know you ..."
Sam shrugged. His wife knew him only too well. He was already figuring out what he was going to do next.
The doctor worked quickly on the woman. He gave her morphine for pain, covered her with heated blankets and felt her abdomen.
Miraculously, she quit screaming and relaxed. She said, "HE tried to kill me." Who was "He" they wondered?
A pair of eyes was seen briefly looking through th e window and the woman screeched when she saw therm.
They drew the shade and carried on. They let Wolf go outside so he could sniff around.
As soon as his wife left the house for work, Sam called the hospital and asked to speak to the doctor who attended the injured woman. The nurse who answered the call, asked, "Are you related to the patient?"
Sam explained that he had found the woman lying in the snow outside his home, and he wanted to check her recovery.
"I'm sorry, sir, but if you are not a relative, I cannot help you," the nurse said.
"Could I please just speak to the doctor?" Sam asked again.
"No, sir, only relatives can enquire about patients."
Sam thanked the nurse and hung up. He wondered if he should just leave it. He had a busy day ahead, so for now, he would have to wait and maybe talk to the chief later.
In the meantime, Wolf had found a culprit. An old man who appeared to be homeless, was wandering about with a gigantic knife in hand .CREEPY!
Sam was pissed. He understood that hospital personnel were following procedures, but he was not about to be brushed off by procedures. He would find another way to talk with the doctor. The first thing he would do is contact the Chief for information. As far as he was concerned, the Chief was in charge and not the FBI, especially with his suspicion that the FBI was responsible for the injuries to the woman. The FBI had no jurisdiction without a warrant. They had come onto his property without a warrant. He had called the police, not the FBI. He called the police station and asked to speak with the Chief.
"Chief Murphy is not in at the moment, can I take a message"?
"Have you identified the woman who was injured" asked Sam.
"I understand that. Can you give me the name of the attending physician, for Madam "X"?
"That I can do. His name is Dr. Sommers.".
That evening after a delicious pot roast prepared by his wife, Sam settled down in front of the television to watch the NFL match between the Jacksonville Jaguars and the Baltimore Ravens. No sooner had he sat down than the doorbell rang. Sam heard his wife open the door and invite someone in. When he looked up, Chief Murphy was starring down at him. Sam's wife left the room to leave the two men to talk.
Chief Murphy did not look happy. He said, "Deputy Snyder tells me you phoned the hospital, and when you got no joy out of them, you wheedled the doctor's name out of my deputy. Hell Sam, it's bad enough with the FBI on my back without you interfering."
"Hold on a minute, Chief," Sam retaliated, "you left last night without checking to see who was lurking around. Today a guy with a knife was hanging around, but no sign of you or Deputy Snyder. Well fine, I'll protect myself if the police aren't interested."
The only defense Sam could think of was a bigger knife.
Sam had second thoughts. He had Wolf for protection. Having a knife might provide additional protection if attacked, however it would only be used in self-defense. Killing was abhorrent to Sam. Subduing a suspected assailant made more sense. He recalled the number of times when innocent people were reportedly harmed, even killed, by knee-jerk responses. No, he would not use any weapon in an aggressive manner unless he knew that the person intended to inflict harm. He relied on Wolf's instincts.
In the meanwhile, Sam had more pressing matters. By challenging the Chief, he had hoped to get more cooperation. Yes, that was the better tactic. It was the job of the police, not his, he thought.
"Chief Murphy. It is my understanding that the police are engaged to defend and protect. Am I wrong?
"She is stable", replied Murphy.
The Chief decided to leave the matter there. He had warned Sam to back off and stay out of police business, and Sam had inferred that he was going to persist. Arguing further served no purpose. "Whatever you do, Sam, keep it to yourself. Oh, and stay away from the FBI. Those guys can get you into a whole load of trouble."
Sam nodded but decided not to say anything more.
"I'll see myself out," said the chief.
After he left, Sam could not concentrate on the football match. His mind was busy working on what to do next.
Sam was perplexed. The warning from the Chief in reference to the FBI raised the question again. Why were they involved? Did the Chief have some beef with the FBI causing him concern? Sam felt no concern about the FBI involving himself, however the reaction of the woman when she saw the Agent was a concern. Were they responsible for beating her and inflicting the wounds? Who was she? He was determined to find out.
the window where she was being kept,to his horror he saw piles of blood oozing off her bed and piling up on the floor..
The next day was a Saturday. Sam's wife set our early to visit the mall to shop for groceries and a few other items. Sam decided to take Wolf with him to have a look around the yard to see if there were any clues out there. A heavy blanket of snow surrounded the house. Wolf's paw marks were everywhere; seems the dog had already had a good sniff around.
Wolf ran ahead to the pile of wood Sam had stacked for the long winter. Then he barked and wagged his tail.
"What have you found?" Sam called out to the dog.
Wolf's response was quick . He lowered his head and began to dig fiercely.
Sam wished his woodpile weren't so high. It was hard for Wolf to get to the bottom of it.
Suddenly, Wolf stopped digging. He pulled on a red scar that he held tight in his teeth. It looked like a woman's scarf. Sam quickly began digging at that spot. "Was there a body under the snow?" he wondered. Then he spied a purse and pulled that out. He was curious to learn what was in the purse but first he needed to see if there a body concealed beneath the snow. After clearing away the snow, he was satisfied that there was nothing more hidden. He opened the purse and saw a Passport. He quickly opened the Passport and saw the photo of the woman he had rescued. The name on the Passport was that of Olga Molotov. A Russian name. "Wow", exclaimed Sam out loud. Wolf perked up his ears standing alert as if waiting for some command. Sam patted Wolf on the head and said,, "Good Boy. You did good." Wolf wagged his tail showing his appreciation and began sniffing again. While Sam waited to see if Wolf found anything else, his thoughts returned to the Passport and the woman. "Was she the reason the FBI was involved?"
Sam decided not to mention the passport or the scarf to his wife. He had agreed with the chief to keep things to himself if he found anything. He realised this was evidence, and he would have to alert the police but not until Monday morning.
When he returned to the house, Wolf gave up digging and ran from the yard for another pat on the back. Sam complied. "Good dog," he said. Then he walked inside and hid the scarf and passport in his briefcase. His wife would be home soon, so he decided to stay home until she arrived. He would need an excuse to give him a few hours away from home to make some more enquiries. He came up with an idea; he only hoped his wife would buy it.


The Daily Assignment and Goal Chart can be a valuable and useful form in your homeschool program. This card allows students to set and track goals. This form is not required and does not need to be returned to Bridgeway Academy. Students should enter their name in large letters at the top of the card. The card is two-sided which allows it to be used for two weeks.
Students should be trained to set reasonable goals and accomplish them regularly. The Daily Assignment and Goal Chart helps students maintain an orderly and consistent chart of their goals and their daily progress and achievement. This procedure teaches students to strive to accomplish their goals each day. As time passes, students learn that they can accomplish large amounts of work by being consistent and doing small amounts of work each day. Note: If instructor guides are available for the courses your student is taking, the pacing in the instructor guides should be reviewed and used in the setting of goals.
The student determines the page numbers to be completed in each subject and fills in the appropriate box on the chart.
As students complete their goals in each subject; instruct them to draw a diagonal line through each completed goal.
The student enters the page numbers of the work they plan to do the next day in that subject. The student must be required to enter specific page numbers in each subject using a pen.
The chart should be checked each day to make sure that the student has actually completed the previous day's goals and has set reasonable new goals in each subject. This checking should be done each day before or after study time.
It is recommended that you do not allow students to scratch out or cover up goals. Any goal changes should be made by the parent.


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[UVPAFUG] Press Release for meeting on 14 Feb 2009
The next regular, second-Saturday-of-the-month meeting of the Utah Valley PAF (Personal Ancestral File) Users Group will be on Saturday, 14 Feb 2009 (Valentine's Day!), from 9 am until noon IN THE EDGEWOOD/RIVERSIDE LDS CHAPEL, 3511 North 180 East, Provo, Utah. Note the Group has moved from their old location to this new LDS chapel which is behind the Jamestown shopping plaza on the east side of University Avenue in the Provo "River Bottoms". You get to it by going on 3700 North east from University Avenue and then south on 180 East. There is a map showing the new and old locations on our website given below. The main presentation, AVOIDING PITFALLS IN YOUR FAMILY HISTORY RESEARCH, will be given by Jake Gehring of the LDS Church's Family History Department. Every genealogical researcher must take care not to fall victim to some classic poor behaviors in the field. These include not performing a thorough survey of available research, lack of research documentation, and failing to take advantage of educational opportunities to further their own skills. This presentation will help you learn practical and sensible ways to approach these problems to improve your research and make genealogy more rewarding. Jake Gehring is former editor of Genealogical Computing and lecturer and author of several dozen articles in genealogical journals on topics ranging from GIS to lineage-linked databases to query management. He has been heavily involved in genealogical publishing and digital publishing technologies for over ten years. His career highlights to date include work as product manager for search features and functionality at Ancestry.com, the largest genealogical web site on the Internet; director for RootsWeb.com, the largest free community of genealogists on the web; and publisher for HeritageQuest, a division of ProQuest Information and Learning, the largest and most successful provider of genealogical data to public and academic libraries in the United States. Jake is currently employed with the LDS Church as manager of its Data Operations Group. He is responsible for key processes that publish genealogical records on the Internet. Jake is active in the professional genealogical community and currently serves as President of the Association of Professional Genealogists. Jake graduated from Brigham Young University with a degree in Genealogy/Family History and lives in Woods Cross, Utah with his wife and family.
Following the main presentation there will be several classes taught concerning technology and family history. As usual, there will be something for everyone at all levels of expertise. The classes currently scheduled for this meeting are the following: (1) FAP 2 PAF, by Ralph Hansen (Only Ralph knows what that title means.); (2) Documenting Sources in PAF5 and new FamilySearch, by Duane Dudley; (3) Q&A: Avoiding Pitfalls in Your Research, by Jake Gehring; (4) Video of last month's main presentation: FamilySearch Wiki: Now and in the Future, by Michael Ritchey; (5) Legacy 7, by Joel Graham; (6) RootsMagic 3/4, by Bruce Buzbee; and (7) Ancestral Quest 12.1, by Gaylon Findlay.
Donald R. Snow, recently returned from the England London Mission, London Family History Centre
Retired Professor of Mathematics, Brigham Young University, Provo, Utah snowd@math.byu.edu
Posted by snowd at 2/03/2009 04:39:00 PM No comments:
[UVPAFUG] Press Release for meeting on 14 Feb 2009...

redpajama_set_name: RedPajamaCommonCrawl


Engagement shoots are not only a time to get some beautiful photos for your Save the Date cards or Engagement announcement but can be a great time to build a relationship with your photographer. Your once-in-a-lifetime event is going to be something you want your photographer to get excited about and want to stay longer than they are scheduled to. It may not be just about the whole wedding entirely, like the reception details or venue location, but because the photographer loves you and would want to go above and beyond what is the norm for any other couple they have worked with.
On the flip side, engagement sessions are a good time to point out anything you did not like: specific poses, or how your arm was in a certain shot, etc. Present your observation not in a condemning way, but in a way that lets your photographer know that these are things to look out for or not do on the day of the wedding. Like I said, your once-in-a-lifetime event cannot be redone, so engagement sessions are sometimes practice as each couple is different.


Thank you - been hoping that someone would release a good mp4 version of this.
And einduwara (above comment) is a trolling idiot.
einduwara is probably a bot, is a scam.
Similar advertisements were added to a lot of new torrents last night.
Downloading Seeding Star Wars The Last Jedi (2017) [BluRay] [720p] [YTS.AM] from to 0 peers.


The cable television industry is in the midst of a radical transformation as it faces new competition from direct-broadcast satellites and new opportunities in Internet access and digital television.
All of this and more will be on the agenda as the California Cable Television Assn. hosts the annual Western Cable Show at the Anaheim Convention Center on Wednesday through Friday. Industry executives--including Tele-Communications Inc.'s John Malone and Time Warner's Ted Turner--and regulators from the Federal Communications Commission will share their views with an expected 23,000 attendees. For information, go to http://www.cct-assn.org/html/westshow.htm or call (510) 428-2225.
* If you're in the market for a car, visit the California Air Resources Board's Web site (http://www.arb.ca.gov/msprog/ccbg/ccbg.htm) and check out which models have been certified as low-emission vehicles for the 1995-97 model years. Read up on just how clean these cars are and see an Emission Control Information Label before heading to the showroom.
* The 1996 Orange County Annual Survey is now online at http://www.communications.uci.edu/~inform/ocas/ocas.html. The survey, now in its 15th year, monitors social, economic and political trends. This year's edition has a special focus on the county's recovery from bankruptcy and attitudes toward volunteerism and charitable giving.
* Houghton Mifflin Interactive, publisher of the Caldecott Award-winning children's Christmas story "The Polar Express," is sponsoring a charity campaign to donate books to children's hospitals. Point your Web browser to http://www.polarexpress.com and post a holiday message. Houghton Mifflin will donate one book for every 25 messages received.
* FedEx ("The World on Time") has a Web site (http://www.fedex.com) so you can track the packages you've sent. Now you can visit SledEx ("Christmas on Time") to track the progress of holiday gifts en route to your home. Point your browser to http://www.sledex.com and admire this holiday-inspired spoof.
* The Los Angeles County Museum of Art is the largest museum west of the Mississippi and now it has a Web site to match. At http://www.lacma.org, you'll find schedules of upcoming exhibits, films and other events, interviews with artists, archived information from past exhibits and links to other art museums on the Internet. Coming soon: access to the museum's research library catalogs.
* Have you saved copies of your important computer files? You can back up 500 pages worth of data for free on the Internet with NetBack (http://www.netback.com). Saved files can be recalled and modified 24 hours a day. There is a charge for storing more than 500 kilobytes.
* The Red Cross comes to the aid of people in crisis situations around the world. To learn more about the group's activities and find out how you can help, visit http://www.redcross.org. The home page for the Los Angeles chapter (http://www.earthlink.net/~redcrossla) includes suggestions for care packages to send to service men and women stationed in Bosnia and a list of facilities where you can donate blood.


text:
Mit Tetragramm kann gemeint sein:

 ein vierteiliges N-Gramm
 die griechische Bezeichnung des vierbuchstabigen hebräischen Gottesnamens JHWH
 ein mitunter komplexes Schriftzeichen, das in ein einheitliches, annähernd quadratisches, virtuelles Frame eingeschrieben ist und für vertikalen wie horizontalen Textsatz verwendet werden kann, d. h. traditionell Sinogramme, aber auch die damit kompatiblen Jamo-Blöcke, Kana-Syllabogramme, vollbreiten lateinischen Zeichen etc.

Siehe auch:
 Tetragrammkreuz

redpajama_set_name: RedPajamaWikipedia


text:
Mohammad Aleq (, also Romanized as Moḩammad Āleq; also known as Garkaz Maḩalleh) is a village in Gorganbuy Rural District, in the Central District of Aqqala County, Golestan Province, Iran. At the 2006 census, its population was 388, in 74 families.

References

Populated places in Aqqala County


Shaker Bottles-Global Market Status & Trend Report 2013-2023 Top 20 Countries Data offers a comprehensive analysis on Shaker Bottles industry, standing on the readers' perspective, delivering detailed market data in Global major 20 countries and penetrating insights. No matter the client is industry insider, potential entrant or investor, the report will provides useful data and information.
Next articleGlobal Pyrargyrite Market 2018-2023 Analysis and Growth by Top Manufacturers Gallerie, Rockstone and more.


The foster family is central to the work we do in child welfare. Without the dedication and the commitment of these foster families, we would not be able to provide the protection some children in our district desperately need.
To a large extent, people do not realize this, but should know that children who have to be placed outside their natural surroundings are usually the result of some type of problem in the home. If and when it becomes necessary, a child is placed in a foster home until the situation at home becomes stable again.
During this period of time, the child needs to feel safe, loved, and secure. These are the important attributes the foster family can—and do—supply while, at the same time, combine this giving of affection with keeping their own family life balanced.
Children's Aid Societies in Ontario provide substitute care for more than 20,500 children annually. Canadian Foster Family Week provides a focus for our community to recognize the contributions and commitment of these foster families, and an opportunity for us to alert the public to the need for more foster parents to care for children in need.
This week is a tribute to these very dedicated families as they are a very vital part of our community.


We got together with some of our favorite Nashville vendors for a beautifully styled, moody and romantic "wedding."
With some of the most beautiful, deep tones and stunning flowers and a handsome bride and groom, we were ecstatic to serve up some delicious drinks.
Want some delicious drinks served at your dream wedding? Head here to book a call with us! Contact us.


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News> Hong Kong> Content
Saturday, October 20, 2018, 13:56
HK-Zhuhai-Macao Bridge to open to traffic on Oct 24
By He Shusi
Saturday, October 20, 2018, 13:56 By He Shusi
Journalists take photos on the Hong Kong section of the Hong Kong-Zhuhai-Macao Bridge during a press preview of the bridge on Oct 19, 2018. (PARKER ZHENG / CHINA DAILY)
HONG KONG – Hong Kong-Zhuhai-Macao Bridge will officially open to cross-boundary traffic at 9 am next Wednesday, a day after the bridge's opening ceremony at the HZMB Zhuhai Port at 9 am on Tuesday, Secretary for Transport and Housing Frank Chan Fan announced on Friday.
READ MORE: HK-Zhuhai-Macao Bridge wins green light for operation
Nine years in the making since December 2009, the 55-kilometer bridge is the first sea span across the Pearl River Estuary. Once operational, it will shorten the driving time between Hong Kong International Airport and Zhuhai from about four hours to 45 minutes, Chan told Hong Kong journalists during a tour of the bridge's Hong Kong Port - which was open to the media for the first time.
It will serve as the focal point between Guangdong, Hong Kong and Macao, thereby further consolidating Hong Kong's position as a regional aviation and logistics hub
Frank Chan, HK Secretary for Transport and Housing
"The bridge is not just a mega transport infrastructure jointly built by Guangdong, Hong Kong and Macao," Chan said. "It will serve as the focal point between Guangdong, Hong Kong and Macao, thereby further consolidating Hong Kong's position as a regional aviation and logistics hub."
In light of the development of the Guangdong-Hong Kong-Macao Greater Bay Area, the bridge will be instrumental in enhancing the flow of people, goods and capital, as well as technological collaboration within the region, Chan added.
But Chan said that like many other infrastructure projects, the utilization rate of the bridge would increase gradually over time.
Since the Tuen Mun-Chek Lap Kok Link, an important road link connecting the artificial island of Hong Kong Port to the city's urban roads, is not fully complete, all vehicles to the bridge need to share roads going to the HKIA, which is located next to the Hong Kong Port, Chan said.
The Tuen Mun-Chek Lap Kok Link is expected to be completed as soon as 2020, Chan said. As a result, the government will gradually release the quota for Hong Kong private cars to use the HZMB. This is in order to maintain the smooth operation of traffic around the airport and the Hong Kong Port at Lantau Island.
According to Su Yi, head of the Working Group on Cross-boundary Policy Research for bridge operator HZMB Authority, it is estimated that about 10,000 to 20,000 cars and 50,000 people will use the bridge every day in the first year of its operation.
ALSO READ: HZMB: Making every detail matter
By 2030, 12 years after the bridge opens, the number will rise to around 29,100 cars and 126,000 passengers a day, according to latest estimates from the special administrative region government.
Chan said the SAR government has invited the Airport Authority to submit a proposal on how to make the best use of the Hong Kong Boundary Crossing Facilities Island on Lantau Island. This is with a view to building an aerotropolis and creating synergies with the development of HKIA.
The latest Policy Address released on Oct 10 proposed "Lantau Tomorrow Vision ", to enhance the functions of Lantau as a "double gateway" connecting the city to the world and other cities in the Bay Area.
Welcoming the bridge's becoming operational, Teddy Chung Wai-tong, chairman of Hong Kong cross-boundary coach operator One Bus Hong Kong Macau, said the announcement was too close to the commissioning date. This left them little time to schedule their services for passengers.
Since the bridge opens on a weekday at short notice, Chung predicts the bridge's passenger volume will not be satisfactory. He said his company will only operate three shifts of buses on the first day; tickets will be on sale on Monday.
heshusi@chinadailyhk.com


Win a copy of Immortal: Love Stories with Bite edited by P. C. Cast (BenBella, Aug. 2008)(PDF excerpt)(exclusive to Borders) from Teen Libris!
Peek: "Enter to win one of three copies of the vampire short story anthology Immortal: Love Stories That Bite, signed by editor P.C. Cast.
"You'll also get five 'vampire bite' tattoos from Boutique du Vampyre in New Orleans, to get into the vampire spirit!"
Deadline: July 31. See guidelines and more!
Note: This vampire-themed YA anthology will include short stories by P. C. Cast, L. J. Smith, Cynthia Leitich Smith, Kristin Cast, Rachel Caine (author interview), Tanith Lee, Nancy Holder, Richelle Mead, and Claudia Gray.
P. C. Cast is the New York Times bestselling author of the House of Night series (Marked, Betrayed, Chosen, Untamed) with her daughter Kristin Cast. She lives in Oklahoma.


More info:Price per person sharing a double room. Price includes: - B&B accommodation for 6 nights - Dinner day 1 - 9 activities In option: private transportation with chauffeur/guide All our travel programs can be adjusted on request.
On this tailor made Loire Valley holiday we can fit in as many chateaus, sights and sipping of fine wines as you like, however this sample itinerary below has been a great favourite with guests to date.
A region full of cultural heritage, fine architecture and stunning landscapes, we have chosen a 16th century water mill for you to stay in, part of a former monastery and enveloped by the Loire Valley's natural riches. Located within walking distance of Bléré, go on walks to explore vineyard covered hills, visit chateaux such as magnificent Chenonceau, take a river barge trip on the Loire and visit the troglodytic site at "La Magnanerie de Bourré with its famous silk worm cave.
At the mill, stay in one of four large and elegant guest bedrooms, all ensuite. Breakfast is included, including fresh local fruits, fine French bread of course, and plenty of homemade jams. We also include a French dinner in the traditional "table d'hôtes" style, dining together with your hosts and other guests at the mill. A highlight for many of our guests, this make a great start to a lovely week in the Loire.
The Val de Loire has been included on the UNESCO list of World Heritage sites since 30 November 2000.
The listing specifically covers the Val de Loire and the area situated in general between the two hillsides that border the river between Sully-sur-Loire (Loiret) and Chalonnes-sur-Loire (Maine-et-Loire), a distance of 280 km and an area of almost 800 sq. km.
In these program, discover the charming scenery of the Loire Valley: authentic villages, vineyards on hillsides as far as the eye can see, immersed in the unique light of the Loire, make you savor all the pleasures that the green and lush "Garden of France" offers you.
Our agency tries to promote mainly eco-friendly activities with no harm to environment. The trip focus on enjoying nature and the beauty of the Loire Valley. All the trips are self-guided. This aims to have a more personal and rich experience. We make efforts in giving as much information as possible to the travelers about the region they are visiting. This to ensure that even without a guide, the travelers are aware about the sensitivity of the region they visit. As an example, we plan a visit a to an organic wine producer in Vouvray.
Because this area is only accessible by car, when selecting a car for the road trip, we search for low consumption car. Nevertheless, once within the region, we provide the traveler with details for hike, walks and where to rent a bike.
Our aim is to offer customers a chance to discover the Loire Valley, a secret France by offering a original itineraries off the beaten path. Customers will stay at in a small guesthouse in Bourré, the accommodation is a small B&B away from the city centers and from the crowds. They are in the most authentic places. As always, our B&B have been selected to ensure that you will be able to exchange with you host and meet locals.
You will have the chance to meet people that offer warm hospitality, ensure comfort and cleanliness and who are willing to share their environment. We select local suppliers that have the same vision as us to reduce the environmental impact of tourism and preserve local surroundings.
We have selected local guides and craftsmen to ensure that our activity benefits the local economy. Our guides are able to offer an insight into the local culture and are able to guide visitors to less known sites and unknown treasures.
Our vast experience and extensive knowledge enable us to propose packages that will give a true insight into the country they visit. Packages are selected in close relationship with customers and suppliers. We guarantee to replace or refund unavailable products, giving reassurance to the customer.


text:
Island Health
Anacortes, Washington
Orthopaedic Surgery Physician
Emergency Medicine Physician
Wilkes-Barre, Pennsylvania
Total Joints Orthopedic Surgeon Physician
Location: Anacortes, Washington
Island Family Physicians is seeking a full-time Family Medicine physician to join a well-established private practice in Anacortes, Washington. You will be part of a private practice that is affiliated with Family Care Network and attached to Island Health - a four-star, Medicare-rated hospital with over 190 physicians and providers serving the greater Skagit County area. Island Family Physicians offers comprehensive care services which include Obstetrics and prenatal care, preventative and wellness care, Sports Medicine, minor procedures and Geriatrics. The team comprises four physicians and two nurse practitioners, and the position offers excellent growth opportunities, including the option to work on a board or as a project champion. This is a great opportunity to join a passionate and patient-centered group working to improve the health and wellness for the entire community of Anacortes, while also enjoying a healthy work-life balancing in this beautiful region of the Pacific Northwest. #LI-NB1
Opportunity to work on a board or work as a project champion
Mix of inpatient/outpatient care
Inpatient call coverage required
Strong, collegial team
New graduates are welcome to apply
Compensation is between $200,000 and $225,000 per year
Medical benefits plans available
Employee Assistance Plans available
Dental, orthodontia and vision coverage provided
Flexible Spending Account program
Life/AD&D plans
Retirement benefits include 401k with company match or Profit Sharing Plan
Where You'll Work
Island Health, a Level III trauma center and Level II stroke center, is a 43-bed facility in Anacortes, Washington with 170 board-certified physicians and providers. With a four-star Medicare rating, Island Health was named a Top 100 Rural & Community Hospital by The Chartis Center for Rural Health. It also received service excellence awards in Orthopedic Surgery, Joint Replacement, Spinal Fusion Surgery, Obstetrics and Emergency Care.
Where You'll Live
Anacortes is a historic city on north Puget Sound easily accessible by driving across the Deception Pass Bridge or taking the ferry to and from Seattle. Due to fortunate coastal weather patterns, Anacortes receives only 21 inches of rain annually and is known for hiking, boating and the pods of orcas living just offshore. With a tight-knit community and majestic views of the islands and snow-capped mountains, Anacortes is a beautiful place to call home.
Who You'll Work For
Island Health is the center of health and wellness in Washington's Skagit County, providing comprehensive health services at its award-winning hospital in Anacortes and its eight primary and specialty care clinics. Recognized as one of the most innovative small health systems in the country, Island Health has a four-star rating by Medicare. Island Health is committed to its mission to deliver quality, compassionate and personalized healthcare to the communities it serves.
Equal Opportunity Employer including disability/veteran
Job ID Number: 18658
About Island Health
Tell us your why, we'll find your where. Provider Solutions & Development is a community of experts founded within Providence, a purpose-driven, 51-hospital health system, out of a clear need to change recruitment. We're not focused on quotas, and we don't work on commission. We support and serve physicians and advanced practice clinicians with heart, from residency to retirement, so you can do the same for your patients. With exclusive access to hundreds of positions across the nation, we offer holistic, personal career coaching that puts your needs first. We don't just fill positions, we fulfill individuals by taking the time to help you find where you're meant to be at every step of your journey. Start the conversation today by connecting with us on https://info.psdconnect.org/HCC.
Connections working at Island Health
https://careers.acsm.org/jobs/17979384/family-medicine-physician


An Albion audience was treated to a wide variety of choral music when the Nebraska Wesleyan Universtiy Choir performed in concert last Friday evening, Jan. 18, at St. Michael's Church in Albion under the direction of William Wyman.
This was the choir's fifth performance in Albion under sponsorship of the Albion Area Arts Council. About 75 people attended the concert, which was followed by a reception for the choir and audience in the church basement. Albion was the 10th stop on the choir's regional tour, which included performances in Missouri, Kentucky, Tennessee, Kansas and Nebraska.


text:
layout: page
title: Wild Protector Financial Dinner
date: 2016-05-24
author: Wayne Buckley
tags: weekly links, java
status: published
summary: Ut eu elit convallis, posuere nisl vestibulum, posuere odio. Donec.
banner: images/banner/office-01.jpg
booking:
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  endDate: 07/31/2016
  ctyhocn: ZCLHXHX
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published: true
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Aliquam lobortis massa eu mauris blandit, et aliquet nibh cursus. Pellentesque gravida mollis dictum. Donec lorem justo, aliquet non volutpat nec, sollicitudin id ante. In et risus tincidunt, ornare diam sit amet, malesuada diam. Suspendisse potenti. Sed faucibus consectetur est a porta. Interdum et malesuada fames ac ante ipsum primis in faucibus. Curabitur non nibh vestibulum, rutrum metus non, rutrum lectus. Aliquam et tincidunt quam. Aenean lacinia at eros id viverra.

* Etiam in risus venenatis dui porttitor tincidunt et vitae massa
* Integer in nunc et sapien maximus faucibus.

Vivamus rhoncus ornare mauris pellentesque luctus. Nunc posuere, turpis sed sagittis dictum, lacus ligula fringilla elit, non ultrices lectus magna sit amet lacus. Nam sit amet fermentum nunc. Duis lectus est, tincidunt eget velit et, hendrerit ultrices turpis. Nam rutrum est in ipsum faucibus, blandit tincidunt tortor pellentesque. Vestibulum tempus id odio vitae pellentesque. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Praesent porta enim massa, a ornare ipsum lobortis a. Mauris scelerisque, nibh a interdum euismod, nisl lacus convallis tellus, vitae fermentum dui tellus in risus. Maecenas sit amet dictum arcu, sit amet interdum leo. Sed in lectus feugiat, pretium diam eget, dignissim sem. Aenean eu tincidunt nibh, ut mattis dolor. Proin auctor sollicitudin massa sit amet mattis.

redpajama_set_name: RedPajamaGithub


text:
2017 Puerto Lopez CAMTRI Triathlon American Championships
Results: 2017 Puerto Lopez CAMTRI Triathlon American Championships | Elite Men
Puerto Lopez, Ecuador • 22 Oct, 2017
Elite Men Elite Women U23 Men U23 Women
1 Manoel Messias 1996 BRA 42 01:42:15 00:15:21 00:00:43 00:54:03 00:00:22 00:31:48
2 Taylor Forbes 1993 CAN 8 01:42:46 00:15:36 00:00:44 00:53:53 00:00:24 00:32:12
3 Juan Jose Andrade Figueroa 1993 ECU 9 01:43:00 00:15:31 00:00:40 00:54:00 00:00:24 00:32:28
4 Luciano Taccone 1989 ARG 1 01:43:18 00:15:43 00:00:40 00:53:46 00:00:23 00:32:48
5 Carlos Javier Quinchara Forero 1988 COL 3 01:43:34 00:15:24 00:00:43 00:54:03 00:00:28 00:32:58
6 Brian Moya 1993 COL 4 01:43:40 00:15:25 00:00:41 00:54:05 00:00:22 00:33:09
7 John Rasmussen 1991 CAN 7 01:43:51 00:15:45 00:00:42 00:53:43 00:00:24 00:33:19
8 Dario Chitti 1993 ITA 21 01:44:04 00:15:41 00:00:41 00:53:49 00:00:22 00:33:33
9 Martin Ulloa 1994 CHI 48 01:44:10 00:15:35 00:00:45 00:53:51 00:00:25 00:33:35
10 Matheus Diniz 1990 BRA 17 01:44:24 00:15:44 00:00:42 00:53:47 00:00:25 00:33:48
11 Jason Wilson 1990 BAR 23 01:44:29 00:15:19 00:00:42 00:54:13 00:00:27 00:33:50
12 Collin Chartier 1993 USA 12 01:44:41 00:15:36 00:00:46 00:53:47 00:00:24 00:34:09
13 Felipe Barraza 1991 CHI 11 01:44:57 00:15:22 00:00:43 00:54:07 00:00:24 00:34:23
14 Danilo Pimentel 1986 BRA 2 01:45:03 00:15:31 00:00:44 00:53:54 00:00:21 00:34:34
15 Ramón Armando Matute 1994 ECU 43 01:45:06 00:15:16 00:00:42 00:54:11 00:00:23 00:34:37
16 Javier Martin 1998 CHI 50 01:45:40 00:15:34 00:00:45 00:53:52 00:00:25 00:35:06
17 Peter Vega 1996 PAN 58 01:45:52 00:15:30 00:00:44 00:53:55 00:00:27 00:35:17
18 Gaspar Riveros 1990 CHI 15 01:46:02 00:15:30 00:00:44 00:53:54 00:00:27 00:35:28
19 Flavio Morandini 1994 ARG 44 01:46:19 00:15:29 00:00:47 00:53:54 00:00:28 00:35:43
20 Juan Sebastian Rubio 1992 COL 10 01:46:25 00:15:44 00:00:45 00:55:53 00:00:22 00:33:43
21 Kauê Willy 1996 BRA 41 01:46:34 00:15:35 00:00:44 00:53:51 00:00:28 00:35:57
22 Gonzalo Raul Tellechea 1985 ARG 5 01:46:38 00:16:42 00:00:40 00:55:00 00:00:29 00:33:48
23 Fabian Villanueva Moehl 1993 MEX 16 01:46:59 00:15:44 00:00:43 00:55:55 00:00:22 00:34:16
24 Diego Moya 1998 CHI 60 01:47:35 00:15:17 00:00:46 00:54:09 00:00:25 00:36:59
25 Matthew Wright 1992 BAR 6 01:47:44 00:15:23 00:00:42 00:56:15 00:00:22 00:35:04
26 Andres Cabascango 1989 ECU 19 01:47:57 00:16:28 00:00:44 00:55:11 00:00:25 00:35:11
27 Jacob Slife 1996 USA 65 01:48:04 00:16:27 00:00:43 00:55:18 00:00:25 00:35:14
28 Eduardo Londoño Naranjo 1997 COL 46 01:48:21 00:15:48 00:00:41 00:55:59 00:00:22 00:35:33
29 Vicente Trewhela 1995 CHI 47 01:48:43 00:15:30 00:00:47 00:53:55 00:00:23 00:38:10
30 Matías Quintana 1988 ARG 35 01:48:55 00:16:28 00:00:47 00:55:12 00:00:25 00:36:06
31 Luis Diego Piedra Rojas 1997 CRC 64 01:49:11 00:16:28 00:00:47 00:55:08 00:00:23 00:36:27
32 Patrick Smith 1964 CAN 68 01:49:17 00:15:52 00:00:43 00:55:52 00:00:22 00:36:30
33 Edouard Garneau 1996 CAN 49 01:49:37 00:16:27 00:00:44 00:55:16 00:00:23 00:36:48
34 Yamil Amuch 1992 ARG 33 01:50:18 00:16:42 00:00:45 00:54:58 00:00:28 00:37:27
35 Thomas Windisch 1995 CAN 66 01:50:24 00:16:39 00:00:45 00:55:02 00:00:26 00:37:34
36 Alejandro Cañas 1993 ESP 34 01:50:30 00:15:40 00:00:45 00:56:05 00:00:26 00:37:36
37 Yhousman Perdomo 1996 VEN 53 01:50:32 00:15:29 00:00:42 00:56:16 00:00:24 00:37:44
38 Wesley Matos 1988 BRA 26 01:50:36 00:15:39 00:00:45 00:56:06 00:00:26 00:37:42
39 Renze Postma 1996 ARU 56 01:50:51 00:15:29 00:00:48 00:56:18 00:00:24 00:37:54
40 Facundo Medard 1995 ARG 52 01:50:53 00:16:42 00:00:43 00:58:13 00:00:21 00:34:55
41 Federico Venegas 1990 CRC 31 01:51:09 00:16:27 00:00:43 00:55:09 00:00:28 00:38:24
42 Gerardo Vergara 1989 GUA 22 01:51:14 00:16:23 00:00:47 00:55:12 00:00:25 00:38:28
43 Michael Arishita 1994 USA 45 01:52:04 00:15:45 00:00:42 00:56:02 00:00:26 00:39:11
44 Santiago Beltran 1990 ARG 20 01:52:26 00:16:49 00:00:43 00:58:07 00:00:29 00:36:20
45 Bruno Vieira 1997 BRA 61 01:52:42 00:16:26 00:00:43 00:55:23 00:00:22 00:39:50
46 Gabriel Bravo 1997 ECU 59 01:53:10 00:15:52 00:00:42 00:59:17 00:00:26 00:36:56
47 Juan Diego Cuesta Santana 1996 ECU 69 01:53:37 00:16:36 00:00:47 00:58:15 00:00:22 00:37:39
48 Jose Gomez De La Torre Prato 1990 PER 27 01:53:47 00:16:27 00:00:47 00:55:15 00:00:25 00:40:55
49 Eduardo Lass 1992 BRA 14 01:54:09 00:15:45 00:00:46 00:59:06 00:00:27 00:38:07
50 Andrew Roos 1985 USA 28 01:54:14 00:15:46 00:00:46 00:55:59 00:00:27 00:41:18
51 Gustavo Adolfo Pontaza Pivaral 1990 GUA 25 01:58:40 00:16:46 00:00:42 00:58:08 00:00:23 00:42:43
LAP Miguel Angel Rodriguez 1997 ECU 55 LAP 00:16:43 00:00:47 00:00:00 00:00:00 00:00:00
LAP Jose Antonio Saenz Merida 1991 GUA 29 LAP 00:16:47 00:00:46 00:00:00 00:00:00 00:00:00
LAP Leandro Gallina 1996 ARG 62 LAP 00:15:44 00:00:45 00:00:00 00:00:00 00:00:00
LAP Federico Scarabino 1996 URU 57 LAP 00:16:29 00:00:45 00:00:00 00:00:00 00:00:00
LAP Matias Nicolas Müller 1993 ARG 24 LAP 00:17:47 00:00:42 00:00:00 00:00:00 00:00:00
LAP Hector Francisco Hichaj Aguilar 1993 GUA 30 LAP 00:19:22 00:00:40 00:00:00 00:00:00 00:00:00
LAP Freddy Andres Rosado Solis 1989 ECU 32 LAP 00:16:45 00:00:46 00:00:00 00:00:00 00:00:00
LAP Felipe Santiago Ladino Herrera 1991 COL 36 LAP 00:16:42 00:00:46 00:00:00 00:00:00 00:00:00
LAP Jean Carlo Monge Cascante 1998 CRC 63 LAP 00:15:45 00:00:45 00:00:00 00:00:00 00:00:00
LAP Maximiliano Alberto Barranque Clavijo 1995 URU 67 LAP 00:16:47 00:00:44 00:00:00 00:00:00 00:00:00
DNF Martin Bedirian 1989 ARG 18 DNF 00:15:28 00:00:45 00:00:00 00:00:00 00:00:00
DNF Jaime González Buganza 1994 MEX 54 DNF 00:15:34 00:00:44 00:00:00 00:00:00 00:00:00
Program notes:
Technical Delegate: Esteban Benitez/MEX. Race Referee: Jimmy Arauz/ECU. Competition Jury: Esteban Benitez/MEX, Barry Siff/USA, Julio Ramirez/ECU. Distances: Swim 1500m (1 lap), Bike 38km (8 laps), Run 10km (4 laps). Water temperature 22ºC. Air Temperature 23ºC. Wetsuits not allowed.


text:
Jean Carlos Crispín Castillo, né le , est un coureur cycliste dominicain.

Biographie

En début d'année 2019, Jean Carlos Crispín s'impose au sprint sur la deuxième étape de la Vuelta a la Independencia Nacional.

Palmarès
 2019
  de la Vuelta a la Independencia Nacional

Notes et références

Liens externes

Coureur cycliste dominicain
Naissance en juin 1992
Naissance en République dominicaine


text:
Гло́мма (або Ґломма, ) — найбільша та найдовша річка Норвегії. Довжина становить 598 км, а басейн покриває 13 % площі країни у її південній частині. Середня витрата води — 698 м³/с, загальна площа басейну 42 441 км² (з них 422 км² на території Швеції).

Назва
У норвезькій мові назва Glomma використовується у фюльке Естфол та Акерсгус, а у Гедмарку та Сер-Тренделагу назва вимовляється і пишеться як Glåma. Стара назва річки — Glaumr, походить від давньоскандинавського raumr, що позначає «гучний шум» чи «грім».

На честь річки названо кілька топонімів, зокрема Гломдаль та Гломос.

Опис
Гломма витікає з озера Еурсунн біля міста Рерус у фюльке Сер-Тренделаг і впадає в Ослофіорд біля Фредрікстада. Долина Гломми в Гедмарку, приблизно від Алвдала до Сулера, має назву Естердален і є однією з найбільших долин у Норвегії. Біля селища Вормсунн у муніципалітеті Нес у фюльке Акерсгус у Гломму впадає річка Ворма, що витікає з найбільшого в Норвегії озера — М'єса. У фюльке Естфолл Гломма ділиться на дві протоки. Головна з них (східна) проходить через Сарпсборг (де розташований найпотужніший водоспад Північної Європи Сарпсфоссен) і Фредрікстад. Західна протока від озера Існесфіорден до озера Вістерфлу має назву Огордсельва. За озером Вістерфлу річка знову ділиться на дві протоки — східна знову впадає в головну протоку Гломми, а західна — у море неподалік від Фредрікстада.

Каскад ГЕС
На Гломмі розташований ряд великих гідроелектростанцій: ГЕС Bingsfoss, ГЕС Солбергфосс, ГЕС Kykkelsrud, ГЕС Вамма, ГЕС Сарп, ГЕС Hafslund, ГЕС Borregaard

Галерея

Примітки

Посилання

Література
 Scandinavia; An Introductory Geography, de Brian Fullerton y Alan Williams, Praeger Publishers, 1972.

Річки Норвегії


text:
Disability is not the defining feature
Nipun Malhotra
Characters with disabilities in Hindi cinema have come a long way from objects to be pitied or laughed at
I loved the trailer of the movie Zero. It's a Shah Rukh Khan movie that also features Anushka Sharma and Katrina Kaif. Mr. Khan plays a dwarf. Ms. Sharma plays a woman with cerebral palsy using a wheelchair. But it doesn't seem to be a movie about disability in the traditional Indian sense. More on that later.
Disability that's in your face
The first known movie to feature disability in a meaningful way in Hindi cinema was Jeevan Naiya (1936). In this movie, the lead character abandons his wife on learning that she belongs to a family of dancers. Later, he is blinded in an accident and is nursed by a woman who he eventually falls in love with. Of course that woman is his wife. Karma comes a full circle.
And that's what continued in subsequent films: either karma and its lessons or pity. In Sholay (1975), Thakur, the police officer (Sanjeev Kumar) has his arms amputated by the infamous Gabbar (Amjad Khan). Thakur hires two mercenaries to avenge Gabbar and his gang. This leads to a final duel between Gabbar and Thakur. And what does Thakur do? He crushes Gabbar's arms with spikes. Thakur probably thought that living with a disability is worse than dying.
Khamoshi (1996) was about deaf parents, their daughter and their inability to allow her to move on. Taare Zameen Par (2007) and Black (2005) focused on the schooling challenges of the dyslexic, and the deaf and blind, respectively. Two other big-ticket movies with disabled characters in the recent past have been Margarita With a Straw (2015), which explored the sexuality of a woman with cerebral palsy, and Guzaarish (2010), which was the story of a paralysed magician-turned-radio jockey and his legal battle to end his life. What's common in all these movies is that disability is in your face. It's the overarching theme of the movie. I loved the storytelling in these films. However, disability is what defined them. And let's admit it: disability is not the sexiest theme to bring in people to the theatres.
Of course there is another category too, where disabled characters provide comic respite at the cost of their disability. However, I shall refrain from commenting on it to not give these highly offensive movies any undue attention.
So why am I so excited about Zero? Going by the trailer, Mr. Khan, who plays a dwarf, is shown the photo of a girl played by Ms. Sharma. He's immediately smitten and decides to attend an event where she's speaking. Only on seeing her in person does he realise that she has cerebral palsy and, as a result, is on a wheelchair. He's sad but nevertheless continues to pursue her and eventually succeeds.
He confesses to having a safe, stable life if he marries her. The trailer up to this point looks like the quintessential Bollywood movie. Dwarf meets wheelchair, they fall in love and live happily ever after. Except we live in the 21st century. This isn't the Raju (Raj Kapoor) from Mera Naam Joker being a circus clown collecting a bunch of heartbreaks in the process. Mr. Khan doesn't want to just live life. He wants to live it king size. He wants adventure. Maybe he even wants to be a moron. Not satisfied with cerebral palsy-stricken Ms. Sharma, he pursues Ms. Kaif who seems to be playing a silver screen actor with millions of fans. They meet and they kiss (perhaps the Indian Censor Board didn't let them take things further). And when things go wrong, she calls him "Zero" and he presumably runs back to Ms. Sharma — but she is no helpless, egoless wheelchair-user waiting to have him back in her life. She seems angry and wants her revenge. "The relationship is now on an equal footing," she says, glaring into the camera.
The characters are no 'divine' individuals seeking sympathy. The government might have called the disabled "divyang" (divine individuals), but Mr. Khan might truly be playing a divyang moron in the movie. The characters here are human beings with hopes and aspirations, shades of black and white, and happen to have disabilities. It doesn't seem to be a movie on disability. It seems to be a love triangle with characters with disabilities.
Responding to criticism
And that is why I was so saddened to read criticism about this movie from some pockets of the disabled community. The movie was questioned for not having actors with disabilities play these roles. I do believe that the first challenge is to get people to the theatres to watch movies related to disability. Having stars of course helps. Secondly, and more importantly, these stars inadvertently become brand ambassadors of the cause. These are important issues considering that I come across middle-aged government engineers, police officers and bureaucrats who claim to have never come across a person with a disability even today. If big stars will get them to the theatres, so be it.
Besides, I do find the idea that only actors with disabilities can portray characters with disabilities bizarre. We didn't complain that Dangal didn't have wrestlers playing wrestlers, or that Sanju didn't have Sanjay Dutt playing Sanjay Dutt, or that an alien didn't star in PK. What we need is for actors to be properly sensitised to the role they're signing up for. Daniel Day-Lewis got into the skin of his character, Christy Brown, who had cerebral palsy in My Left Foot. He did this not just by interacting with people with the disability but by actually refusing to leave his wheelchair through the shoot of the film. He had to be carried around by crew members and insisted on being spoon-fed. The movie was critically acclaimed and he won an Oscar for it.
Persons with disabilities in India are breaking barriers. The next generation wants no sympathy. Varun Khullar was paralysed waist down after an accident in Manali in 2014. The accident forced him to start using a wheelchair but didn't stop him from accomplishing his dreams. He studied music and started deejaying at parties. He is the resident DJ at a club in New Delhi. Divyanshu Ganatra was just 19 when glaucoma claimed his eyesight. He runs an adventure sport company. Nidhi Goyal was diagnosed with a degenerative eye disorder at the age of 15. She converted her subsequent dating misadventures into an internationally acclaimed stand-up comedy sketch.
I am glad that Hindi cinema is learning from society and going beyond looking at characters with disabilities as either objects to be pitied or laughed at.
Nipun Malhotra is a wheelchair user. He's founder, Wheels For Life (www.wheelsforlife.in) and CEO, Nipman Foundation. Twitter: @nipunmalhotra. Email: nipun@nipunmalhotra.com
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text:
Kno2's Therasa Bell Named to NASL Board of Directors
Healthcare leader will advocate for post-acute and long-term care constituents to close interoperability gaps with mainstream healthcare
Therasa Bell
I am honored to have been selected, and look forward to to the opportunity to work hard on behalf of NASL and our partners and customers.
BOISE, Idaho (PRWEB) November 03, 2021
Kno2®, the company leading the future of healthcare communication, today announced that Therasa Bell, president and chief technology officer, has been elected by the membership body as a Director to the Board of the National Association for the Support of Long-Term Care (NASL). NASL represents the federal legislative and regulatory interests of ancillary service providers, focusing on the intersection of clinical, diagnostic testing and health information technology (Health IT) issues.
NASL's non-paid Directors support the work of NASL with mission-based leadership and strategic governance. NASL's Board of Directors work with the executive vice president on policy, strategy, industry relationships, and advocacy for the post-acute sectors.
"Kno2 has been an instrumental and integral member of NASL, and our IT Committee in particular, for the last several years. Now, we are delighted to welcome Kno2 President & CTO Therasa Bell to the NASL Board," commented NASL EVP Cynthia Morton. "We are confident that her passion for making digital health a reality for all providers and her expertise with driving connectedness will bolster NASL's efforts to advocate for those who are caring for America's most vulnerable citizens and to advance interoperability that includes the long term and post-acute care sector."
Therasa Bell has 20+ years of experience in driving connectivity, technology, and interoperability solutions to improve care coordination and communication. By working with and deploying IT solutions across healthcare including payers, health systems, large ambulatory clinics, post-acute providers and diagnostic service providers, Bell has extensive experience in understanding the innerworkings of the healthcare ecosystem, in particular, a narrow focus to how information is created, shared and reused throughout. As President and CTO, she is responsible for Kno2's innovation, vision and engineering, and holds six patents for patient information exchange under the company.
"Kno2 is passionate about driving connectivity to all of healthcare. From the inception of the company, we have worked tirelessly on behalf of providers that surround the health system but have not benefited from federal incentives for transitioning to interoperable exchange of PHI, many of whom are also members of NASL," said Therasa Bell. "As a respected and influential voice in the post-acute and senior community, NASL continually has the opportunity to shed light and lobby for important items that have meaningful impact on this community of providers we serve. Bell continues, "I am honored to have been selected, and look forward to the opportunity to work hard on behalf of NASL and our partners and customers."
Bell's two-year term begins immediately.
About NASL
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Primary Health Care Research & Development
Shifting care from community ho...
Core reader
Shifting care from community hospitals to intensive community support: a mixed method study
Local setting
Length of Stay (LOS)
Qualitative findings
Patient interviews
Main conclusions
Strengths and limitations
Implications for future evaluations
Primary Health Care Research & Development, Volume 19, Issue 1
Kate S. Williams (a1), Stoyan Kurtev (a2), Kay Phelps (a3), Emma Regen (a3), Simon Conroy (a4) and Andrew Wilson (a5)
1 Senior Research Fellow in Nursing, Department of Health Sciences, University of Leicester, Leicester, UK
2 Information Analyst, Department of Health Sciences, University of Leicester, Leicester, UK
3 Research Fellow, Department of Health Sciences, University of Leicester, Leicester, UK
4 Professor of Geriatric Medicine, Department of Health Sciences, University of Leicester, Leicester, UK
5 Professor of Primary Care Research, Department of Health Sciences, University of Leicester, Leicester, UK
DOI: https://doi.org/10.1017/S1463423617000603
Published online by Cambridge University Press: 13 September 2017
Table 1 Sources of admission for community hospital (CH) and intensive community support (ICS) patients
Figure 1 Time trends for admissions to community hospital (CH) and intensive community support (ICS). *End of ICS introduction period
Figure 2 Average length of stay (LOS) for community hospital (CH) and intensive community support (ICS), excluding patents transferred from CH to ICS. *End of ICS introduction period
Table 2 Discharge destination for community hospital (CH) and intensive community support (ICS) patients
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To examine how the introduction of intensive community support (ICS) affected admissions to community hospital (CH) and to explore the views of patients, carers and health professionals on this transition.
ICS was introduced to provide an alternative to CH provision for patients (mostly very elderly) requiring general rehabilitation.
Routine data from both services were analysed to identify the number of admissions and length of stay between September 2012 and September 2014. In total, 10 patients took part in qualitative interviews. Qualitative interviews and focus groups were undertaken with 19 staff members, including managers and clinicians.
There were 5653 admissions to CH and 1710 to ICS between September 2012 and September 2014. In the five months before the introduction of ICS, admission rates to CH were on average 217/month; in the final five months of the study, when both services were fully operational, average numbers of patients admitted were: CH 162 (a 25% reduction), ICS 97, total 259 (a 19% increase). Patients and carers rated both ICS and CH favourably compared with acute hospital care. Those who had experienced both services felt each to be appropriate at the time; they appreciated the 24 h availability of staff in CH when they were more dependent, and the convenience of being at home after they had improved. In general, staff welcomed the introduction of ICS and appreciated the advantages of home-based rehabilitation. Managers had a clearer vision of ICS than staff on the ground, some of whom felt underprepared to work in the community. There was a consensus that ICS was managing less complex and dependent patients than had been envisaged.
ICS can provide a feasible adjunct to CH that is acceptable to patients. More work is needed to promote the vision of ICS amongst staff in both community and acute sectors.
There is growing evidence that alternatives to acute hospital admission, especially for older people, can deliver comparable or better clinical outcomes, with higher satisfaction and potentially lower costs (Conley et al., 2016). In the United Kingdom, the National Audit Office concluded that: 'Many emergency admissions to hospital are avoidable and many patients stay in hospital longer than is necessary' (National Audit Office, 2013). In response, intermediate care services have been established to avoid admission or enable early discharge. Local commissioners have had discretion over which specific services to support and develop, for example whether to invest in community hospitals (CH) or home-based intermediate care, such as intensive community support (ICS). However there is limited evidence to guide commissioners on which form of intermediate care is most effective, and so decisions appear often to be made on the basis of local history, tradition and availability of estates, including CHs. The 2014 national audit of intermediate care reported mean budgets for home-based and bed-based intermediate care were £0.8M and £1.2M, respectively, per 10 000 weighted population, with little change from the previous year. Average costs per episode of care were £1045 for home-based services and £5549 for bed-based services (NHS Benchmarking Network, 2014).
A narrative review of CH found very little evaluative work on effectiveness and efficiency (Heaney et al., 2006). Studies have shown that they tend to be used as an additional service rather than an alternative to acute hospital (Cook and Porter, 1998) and this is supported by a recent national benchmarking report which found no association between CH provision and acute bed use (NHS Benchmarking Network, 2013). However length of stay (LOS) in acute hospital was marginally less where CH provision was greater, suggesting CH is used as a step-down facility. The overall finding was wide variation both in volume and type of CH. The only trial of rehabilitation in CH found greater independence was achieved in this setting compared with rehabilitation in acute hospitals, with similar cost effectiveness (Young et al., 2007; O'Reilly et al., 2008).
There is stronger evidence that home-based care can be effective. A Cochrane review concluded that admission avoidance hospital at home (HAH) produced similar clinical outcomes to acute hospital care and higher levels of patient satisfaction, at broadly similar cost (Shepperd et al., 2008; 2009a). A review comparing early discharge HAH with continued admission found similar costs and outcomes, but that people admitted to HAH were more satisfied and, amongst older people and stroke patients, less likely to be discharged to residential care (Shepperd et al., 2009b).
In summary, evidence supports the development of services to provide alternatives to acute hospital admissions, but it is less clear what form or forms these should take, and specifically there have been no studies examining the relationship between CH and home-based intermediate care.
Local health provision includes a large acute hospital with emergency department facilities in the city, with a network of CHs provided by the Community Trust in eight locations across the county. The changes evaluated in this paper comprised the introduction of ICS, reduction in CH capacity and a shift to Advanced Nurse Practitioner led care, supported by 'interface geriatricians', in both settings. ICS was designed as an alternative to CH for those with more intensive needs than could be provided by existing community services. It was anticipated that most rehabilitation patients previously managed in CH would be managed in ICS, with the exception of those needing 24 h care. It provides a package of care delivered by generic workers, therapists, dieticians, long-term condition specialists and social care, with a projected average LOS of 20 days. Both services were designed to serve a predominantly older population.
The purpose of the current study was to examine the impact of introducing the ICS service. Specifically, to assess how the introduction of ICS affected admissions to CH, to examine how the two services interacted and to explore the views of patients, carers, health professionals and other stakeholders on both services.
Routine data provided by the Community Trust were analysed for CH from April 2012 and for ICS from its introduction in September 2012 to September 2014. These data included information on age and sex of patients and source of admission, LOS and discharge destination.
Data from CH included information on the date of admission, type (emergency, planned or other), source (eg, home, hospital), age, diagnosis, LOS and discharge destination. Data from ICS were collected from SystmOne, an electronic record used in primary care. This included referral date, source of admission, referral source and in urgency, reason for referral (in free text) and LOS. Data on age and gender were requested but was not obtained. Clinical data, for example diagnoses and severity, were not collected in a retrievable form for ICS patients.
Number of admissions and average LOS for both services were calculated monthly during the study period. Referral source and discharge destinations were compared for the total study period.
The qualitative component of the study (conducted in 2014) comprised semi-structured interviews with patients who had received care in CH or ICS and interviews and focus groups with stakeholders of the service, including service providers and managers. Topic guides (available from the authors) were developed for both. The focus groups covered three geographical locations and the numbers of interviewees was balanced across CH and ICS. Participants were identified purposively, in order to ensure the inclusion of different professional groups and grades of staff. Patients were recruited by clinical staff at the time of admission and written consent was obtained before the interview.
Interviews were analysed by K.P. and E.R. using the framework approach (Gale et al., 2013). Emerging themes from both the staff and patient interviews were used to generate a coding framework which was subsequently used to code the interview transcripts thus enabling further development and modification of the key themes. Patterns, associations, concepts and explanations in the data were identified via a process of mapping and interpretation. Analysis was facilitated by the use of NVivo 10 (Castleberry, 2014). Themes generated during analysis were regularly discussed and validated by several members of the research team.
Ethics permission was obtained on 02 December 2013 from NRES Committee North West – Haydock (reference 13/NW/0760).
In total, there were 5653 patients admitted to CH and 1710 to CH. As shown in Table 1, the main source of admission to CH was the acute hospital (88%), with a relatively small number of patients admitted from their home, including some who transferred from ICS. In contrast, most (64%) admissions to ICS were from home, with most of the remainder admitted from CH.
ED=emergency department.
Figure 1 shows time trends for the total number of patients admitted to both services, admissions to each service and the number of transfers from ICS to CH. In the five months before ICS was started, the average number of patients admitted per month to CH was 217. In the final five months when both services were fully operational, average numbers of patients admitted were: CH 162 (a 25% reduction), ICS 97, total 259 (a 19% increase).
Average LOSs were calculated for patients who were admitted to and discharged from ICS or CH, as shown in Figure 2. Mean LOS was 20.0 days for ICS and 25.8 days for CH, and both decreased during the study period.
Table 2 shows discharge destinations for CH and ICS. A higher proportion of patients from ICS were discharged home (79 versus 61%) and a lower proportion was admitted to an acute hospital (15 versus 30%). Deaths during admission were less in ICS (2% or less compared with 5% in CH).
We had planned to interview a purposive sample of patients, but as fewer patients than expected were recruited, all who consented and were able to be contacted were interviewed (n=10).
Four interviews were with patients who had received care in CH and six were with patients who had received ICS, three of whom had also received care in CH immediately before receiving ICS. All interviews took place three to six months following discharge from CH or ICS.
Of the four patients who received care in a CH, three were female (aged 82, 90 and 91 years) and one was male (aged 78 years). LOS ranged from two to five weeks. All four returned home following their admission. Of the six patients who received ICS, five were female [aged 34, 74 (×3) and 80 years] and one was male (aged 75 years). LOS of participants ranged from two to five weeks. Familiarisation with the transcripts identified the following themes: choice and information, positive and negative views of each service and preferred place of care.
CH: patients' views and experiences
Choice and information
All participants were transferred to CH from acute care for rehabilitation. Most reported they were happy with the decision to transfer to CH but some were not asked where they wanted to go and had little choice about location, which was determined by bed availability.
'They didn't ask me, they just said that they were going to send me to a rehabilitation hospital and it was CH1'.
(P05)
'No. I mean I just kept saying CH2's where I would like to go. I would have gone to CH4 or CH1. I would not have gone to CH5 or CH6 because that defeated the objective of trying to get you nearer to your home and family. I mean what's the point? I can't see a point of that one at all'.
Most patients were complimentary about the care they received in CH, in particular the caring attitude and competence of the nurses. The environment and more personalised care in CH were compared favourably with care in acute hospital settings.
'but I think with it (acute hospital) being a bigger institution, bigger set up there, I think I didn't feel quite as individual, I found I had more individuality at CH4. I liked the scale of the place. It was much more friendly and intimate'.
Staff were felt not always to be responsive to patients' requests for assistance, particularly with regard to toileting and at night.
'The worst bits were the night shifts.. you'd ask a nurse, they'd always say "oh see you in a minute" and never did, made me angry at first, I got used to it in the end'.
Preferred place of care
Patients strongly identified CH as their preferred place of care. Those patients who received CH care followed by ICS felt that they had needed CH care and could not have gone straight home with ICS from acute hospital. The safe environment, with staff always present to deal with any problems, was identified as a key benefit. This was contrasted with the potential for isolation at home where care was delivered in intermittent visits.
'I think it [CH] probably did [help], because you haven't got to worry about anything. I mean, if I'd have been at home, I would have been on my own quite a bit of the time, however much help I'd got. I'd have been there and I think I would have been a bit worried. I felt safe in hospital'.
'It would have been a lot easier to be in CH1 than be at home, because if I needed medical attention I'd got it immediately there'.
ICS: patients' views and experiences
The degree of choice and information provided about ICS appeared to be mixed. One patient was simply told that she was being referred to ICS, primarily for physiotherapy, without much information or choice:
'They just referred me and that was it. Yeah, I didn't know. They just said the physio would be coming out to me'.
More positively, another patient, who received ICS following a stay in CH, felt that she was given appropriate information about ICS:
'Well yes, I mean cos I said to [name], OK, what's ICS? I mean obviously, and I said it, cos she said "Oh you'll have a community nurse". I said "What, a district nurse?" "No" she said "They're different, they're in the ICS team"'.
Most patients commented on the professionalism and caring attitude of the nurses who visited them at home while they received the service. As a result of the standard and quality of nursing care, patients felt safe and secure receiving their care in a community setting. There was appreciation of regular contacts and flexibility in response to need. The speed with which equipment, aids and adaptations were put in place at home was highlighted as a positive aspect of the service.
'Well it was as if to say "we're here, should you need us, let us know", so it was almost like you have this service and we're happy to come and do whatever it is that we can to help you out'
'They put fantastic things in. Yeah. I mean they did all the, that was put through to them and they did exactly what the OT had told them to do…'
Some patients had expected more contact from their GPs, but appreciated that when ICS had identified the need for GP involvement this was arranged promptly.
'They got one of the doctors to come who I'd never seen before but she came and decided that she wasn't terribly happy with the look of it, the next day I was whizzed off to Acute Hospital 1 for a scan'.
Some patients reported delays in the ICS service starting, ranging from one to several days. Problems with the physiotherapy component of ICS were also highlighted by some patients. The service was not as 'intensive' as expected with visits not occurring as frequently as anticipated or delivered by physiotherapy assistants rather than fully qualified staff. Delays in responding to requests for support were also reported.
'I think they (ICS) didn't come out for the first day or two, which surprised me. I had a feeling that – I thought there'd be somebody there the next day'.
'Well it (physiotherapy) wasn't intensive by my standards, like it was -, they were very nice, very charming, very everything, but I don't think we had more than once, or one and a half times'.
Patients who had received care in CH before receiving ICS had valued the CH phase of their rehabilitation and felt that they could not have gone straight home with ICS from acute hospital.
Patients who were 'stepped up' to ICS spoke firmly in favour of this as their preferred place of care. The convenience of receiving care at home, being able to remain amongst family and friends and avoiding admission to hospital were identified as the main benefits of ICS.
'In fact [name of nurse] did say to me "you could come into hospital" but of course that would be even more intrusive than if I had the ladies coming in'.
In total, 19 members of staff were interviewed alone or in small focus groups. Three senior staff (clinical and managerial) were interviewed singly, including the most relevant top-level managers responsible for the two services. In addition nurses and therapists from ICS and CH took part in a series of three focus groups, each with five or six participants. Unfortunately, despite several approaches, it was not possible to secure interviews with commissioners of the service or with any GPs as originally intended. Familiarisation with the transcripts identified the following themes: benefits/advantages and challenges/disadvantages of each service.
Benefits and advantages of CH care
The perceived benefits of CH care included patient safety and confidence due to 24 h support. Therapy input, equipment and outcomes were felt to be superior due to the time therapists could spend with patients in a safe environment with a level of equipment that could not be provided at home.
'In hospital you've got more staff available, so if you've got somebody that needs two or three staff to keep them safe while you're practising mobility or transfers it's easier to do than in the community because you've got things like parallel bars'.
(FG1F5)
Patient management led by advanced nurse practitioners (ANPs) was welcomed by CH staff and was felt to have improved the quality of care, enabling care of more complex patients and reduced LOS. ANP's had access to advice from geriatricians when required, which gave them confidence to keep patients in CH when they may previously have been admitted to an acute hospital.
'Fantastic, they've (ANPs) reduced incidents, compliance for anti-microbial prescribing is enhanced – all sorts of things and our standards of nursing care on the wards has improved because the ANPs are canulating, drips are going up where they wouldn't – before they would have been transferred back to the Acute. So the ANPs are very, very good, equivalent to registrars'.
(I3)
Challenges and disadvantages for CH care
The challenges and disadvantages in CH brought about by the changes to the system of care included staff unhappiness at the closure of CH wards, leaving a feeling of vulnerability. Though staff valued the ANP's, some reported feeling 'out of their depth' and inadequately trained to deal with the higher level of nursing care required by more complex patients being cared for on the wards. It was felt that ANP's were performing the role or ward managers rather than clinical leads, and that the support from geriatricians was not adequate.
'But I think overall because of the higher dependency in the more ill patients that we've got, … I would definitely prefer to see three trained staff on in the morning, if not evening as well'.
'If somebody's been acutely unwell or whatever, it's been a 999 ambulance or it's been phoning the geriatrician directly and saying "I've got this patient with these signs and symptoms, what would you like me to do?". I've never been able to arrange a visit'.
Benefits and advantages of ICS
The perceived benefits of the ICS service were that patients could go home from both acute and CH sooner than was previously the case. It was felt that most patients prefer to be at home and their relatives find it easier to visit patients at home than in hospital. There was a view that recovery and rehabilitation was better and faster in a patients usual environment, and that patient outcomes were improved by the ICS service. It was felt that the increased community therapy input had led to a higher level of support for patients at home, improved care in the community overall and increased the capacity of the community services.
'We get people that would otherwise have been in institutional/hospital settings into their own homes sooner, hopefully healthier, and that they do more for themselves in their own homes and therefore recover quicker…'
'We get patients out of hospital sooner and provide the therapy and the nursing that they would get in hospital but at home. So it releases the beds earlier'.
ANP management and the ICS service being embedded into existing service teams was felt to have improved continuity of care for patients who could be followed through their journey of care by the same staff. ICS was felt to have reduced admissions and readmissions to hospital, and facilitated early hospital discharge thus reducing LOS in hospital for individuals. ICS and ANP management was thought to have reduced pressure on GP's and changed CH staff attitudes about who could be cared for in their own homes. The creation of the ICS service and the moving of staff from closing CH wards to community teams meant that there were no enforced staff redundancies when services were reorganised. Finally care at home was thought to be cheaper than CH care, thus the ICS service was perceived to be saving money for the Community Trust.
'So the structure of the service, as it was originally conceived, was such that it should have been able to receive slightly sicker patients than your average intermediate care service. So we had, you know, not just intermediate care nurses; we had ANPs, who are – a different breed. And we had the agreement and support from geriatricians to provide that high level of supervision'.
'When I've discharged patients from the (CH) ward it's meant that I've been able to follow people up at home. And I have done it and it's nice, because you've seen them in the ward and you say "I'll see you when you're at home" and then you go out and see them at home'
'When we re-provided the (ICS) service we were able to identify some efficiencies that came from that. That wasn't the driver for doing this, but there was a reduction in – because you don't have the infrastructure of the hospital overheads and so on'.
Challenges and disadvantages of ICS
Some staff believed that the ICS service was not providing an equivalent level of support for patients to that provided in CH. There was a view that lower levels of therapy input, lack of equipment, and poor rehabilitative environment at home were not adequate to enable patients to achieve their full potential and maximise their outcomes. It was also felt that there was inadequate access to specialist services such as speech and language therapists and dieticians in the community.
'Because we are more a sort of general service – we haven't got the specialist skills necessarily to do whatever they want like in hospital'.
'Yeah – I can't see many benefits to the patients other than they're at home. Because as we've said the care and attention that they get is obviously limited when they're at home'.
CH staff, including ANP's, felt reluctant to send patients home with ICS when they perceived them to require a high level of assistance, perhaps unconvinced that patients would be safe without someone on hand 24 h a day. They also felt that the additional administration in trying to get a patient home with ICS and the additional care they would need was prohibitively time consuming for complex patients.
'So whereas we would be treating people in the gym more, now patients aren't brought down to our gym as much as they're treated on the ward, because of all the telephone calls, all the paperwork that needs to go alongside in facilitating that discharge'.
The outcome of this was that the patients being cared for by the ICS service were less complex and less dependent than was originally envisaged.
'if we had proper ICS patients then I think we would struggle to really rehab them at a good enough level'
'So it may be that our intention of taking a population out of community hospitals and putting them into ICS has been achieved, but not with the cohort that we originally intended'.
There was thought to be a very wide interpretation of the eligibility criteria for the ICS service leading to confusion about who was appropriate for the service, and CH staff felt that this was inconsistently applied.
'I think we get anyone – we're always saying "they've got to be safe overnight" but that could be for anybody – it could be Social Services, the care call or nursing'.
'I think the criteria for referring patients [to ICS] seems to change sort of every other week'.
The fact that ICS was provided by the same staff that provided other community services meant that some staff were reallocated during high level of need or staff sickness. The number of services provided in the community and locality dependent referral systems was perceived to make access to community services confusing and inconsistent.
'I think the difficulty is that we have the ICS, ICT, Heart, Community Therapy, Community Nursing – what used to be Rapid Response or whatever – so the GPs or some hospitals will just refer into (intermediate care)'
The ANP's, though highly valued in CH, were perceived as not providing sufficient support for ICS patients, perhaps because of lack of experience in working in the community. ICS staff spoke of their frustration at not being able to access ANP support and having to revert to GP support.
'You know they need certain help, you can then contact (ANP) who then says too busy, phone the GP. After you're told that so many times, you think oh forget them. I'm going to the GP, my time is just as precious as yours'.
'Some of the ANPs we've recruited don't have a natural affinity for working in the Community and have struggled with having to visit people in their home. And I think some of them if you spoke to them would be honest and say "I don't like the ICS element of my job because I liked being on the ward"'.
(I3T)
The way the CH wards were closed and the ICS service introduced led to some staff resentment and dissatisfaction. Some CH staff who were moved to community teams did not feel consulted, and did not feel that they had a choice in their new roles. They felt there had been inadequate training and support in recognition that community work was very different to work on in-patient wards.
'It's very different going to see somebody in a hospital ward to going to seeing somebody out in their own home when there's only you there…It's about pulling on different resources as well, knowing what resources that you can pull on in the community'.
'They needed more staff then in the (community) and if you were willing to do that then you could do that. You had your interviews, most people got what they wanted. It's a case of if you want a job then that's where you are going. When all the wards closed down there was, from the hierarchy, there was absolutely no support whatsoever. Staff morale was dire'.
The study has shown that an intensive, home-based service is consistent with a reduction of CH provision, in this case by 25%. There is a risk that a service designed to be a substitute may increase demand and so provide additional rather than alternative provision. The finding that total admissions to both services increased after ICS was introduced raises this possibility, although there are several other potential explanations, including increases in the number of older people and the introduction of ANPs to CH, which may have led to patients being admitted who would previously received care in an acute hospital. It should also be noted that nationally, intermediate care has about half the capacity needed to maximise its impact (NHS Benchmarking Network, 2014).
When introduced, it was expected that ICS would provide equivalent care for rehabiliation patients previously admitted to CH (except for a minority needing 24 hour care). However the quantitative data show that CH and ICS provide care for patients with different needs or at different stages on the care pathway; the majority of admissions (88%) to CH were discharges from acute hospitals, whereas over 80% of patients admitted to ICS were from home. Nearly 80% of ICS patients were discharged home, compared with 54% of CH patients, LOS were generally shorter and death rates lower.
Results from the qualitative interviews show that both patients and staff consider CH and ICS to be complementary, the latter providing a lower intensity service. Both groups reported a trade off between the safety of an environment that provides 24 hour care and the convenience and comfort of being at home. The preference for rehabiliation in a community rather than acute setting is in line with other studies (Green et al., 2008; Small et al., 2009).
Staff interviews revealed some differences between managers who expressed a clear vision of the potential for home-based care, and operational staff who had more reservations about both the principle of managing patients with higher needs at home, and the practicalities of delivery, for example provision of home-based equipment. Although ANP led care was welcomed by both groups (as well as patients), this approach seemed to work better in CH than ICS. This is perhaps unsurprising given that most staff were used to working in a hospital environment, but demonstrates the need for the vision to be communicated as well as the need for training and clear operational procedures, such as criteria for admission to ICS. Others have noted the 'emotional labour' that staff have to undertake during service transitions (Fillmore and Le May, 2015).
As well as promoting the vision of intensive care in the community, several steps need to be taken if, as planned, ICS is to be expanded to take a higher proportion of rehabilitation patients currently managed in CH. These include raising awareness of the service as a potential discharge destination within the acute sector, ongoing support and training for staff whose background is in a CH or acute setting, and ensuring the service is adequately resourced, both to provide high levels of staffing when needed, and to reduce delays in putting services and equipment in place.
The main strength of the study is the insights it provides into the shift from CH to home-based care, incorporating quantitative data and the views of patients and professionals.
Quantitative elements of the evaluation were limited by the lack of routine data for patients receiving ICS, including demographic information (age, sex, ethnicity), clinical data such as diagnosis, and information about readmissions. This lack prevented examination of case mix and any meaningful economic evaluation, which would be essential to enable commissioners to make informed decisions about development of these services (Clegg et al., 2016).
Another limitation was failure to recruit a larger sampling frame of patients to be interviewed and the possibility of selection bias in those who were recruited by clinical staff, which could provide an over-favourable impression of both services. Clinical staff either did not see recruitment to research as a legitimate role for them, or did not appreciate the purpose of the study or its importance to the Trust. Finally, the failure to recruit commissioners to the qualitative study means that we lack an important perspective.
Although clinical systems for GPs and community staff are useful for coordinating the care of individual patients across intermediate and primary care, there is a need for a core data set to be collected by services for routine monitoring and evaluation. Ideally this would be linked to primary care databases to enable, for example, frailty profiles to be examined (Clegg et al., 2016). Future evaluations also need to maximise engagement by clinical staff, and would benefit from a more collaborative approach than we were able to achieve, using models such as 'researcher in residence' (Marshall et al., 2014).
The authors thank the Community Trust and its staff and patients for their cooperation. The study was supported by a steering group comprising commissioners, providers and PPI representatives.
The study was funded by the Community Trust.
Simon Conroy was clinical director of the Community Trust during the study. No other authors have any conflicts.
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