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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act (1995)
Chapter: Advocating for Quality of Care and Quality of Life for Residents of Long-Term Care Facilities
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Suggested Citation:"Advocating for Quality of Care and Quality of Life for Residents of Long-Term Care Facilities." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
Advocating for Quality of Care and Quality of Life for Residents of Long-Term Care Facilities
Long-term care (LTC) ombudsmen1 advocate to protect the health, safety, welfare, and rights of the institutionalized elderly in nursing facilities and board and care (B&C) homes. Given the dramatic changes that are occurring in the entire LTC sector, the need for such advocates is compelling. A multiplicity of factors—sociodemographic, economic, political, and clinical—are converging in ways that call for significant attention to the quality of care and quality of life needs of all persons who require LTC services. This report from the Institute of Medicine (IOM) addresses important aspects of these issues—specifically the LTC ombudsmen's ability to deal with problems concerning care provided to and quality of life achieved by elderly residents of LTC facilities.
Improving the quality of life for residents of LTC facilities requires a basic understanding of the overall LTC system in the United States. This system is dynamic. Policymakers and providers are developing new approaches to delivering LTC services in residential settings. For example, increasingly, a broad range of housing alternatives provide some level of supportive services to older residents. As managed care organizations attempt to reduce hospital utilization and move patients into either the ambulatory or LTC arena, many LTC institutions will provide more acute or intensive health care services.
The term "ombudsman" carries no meaning with respect to the gender of the occupant of the position. Indeed, in the United States, the vast majority of long-term care ombudsmen are women.
Moreover, it is likely that LTC will continue to evolve as demographic and other changes interact with the health care and LTC reform processes.
The following overview briefly reviews the issues of aging, disability, and financing for LTC services. This chapter answers the following questions: What exactly are LTC services? Who uses LTC services? Who pays for them? Finally, issues relating to the quality of LTC services are discussed.
WHAT IS LONG TERM CARE?
"LTC services" is a broad term used to describe a constellation of services used by people with disabilities. Such services may include health care, housing, transportation, and other social and supportive services. In a 1991 report, the IOM defined disability as "the expression of a physical or mental limitation in a social context—the gap between a person's capabilities and the demands of the environment"; thus, disabilities may include physical, mental, and cognitive impairments (IOM, 1991a).2 Disability is often measured in terms of "activities of daily living" (ADLs); these include tasks such as eating, getting in or out of a bed or chair, toileting, bathing, and dressing (Katz et al., 1963). A broader view includes "instrumental" ADLs (IADLs); these are activities required for independence, such as preparing meals, grocery shopping, arranging for transportation, managing personal finances, taking medications, telephoning, and housekeeping. Thus, LTC can involve an immense array of services to assist individuals of all ages, and with a wide range of impairments, in achieving a meaningful life according to their own expectations and yardsticks. This is indeed a considerable challenge.
The fact that the current health care system emphasizes acute medical care complicates this picture. Practitioners and systems of care experience great difficulty adapting to the long-term trajectory of chronic health and disability problems (Corbin and Strauss, 1988). The trajectory itself can be quite unpredictable (Verbrugge and Balaban, 1989). Reimbursement mechanisms such as Medicare, aimed specifically at the elderly and disabled, provide financing for medically oriented care related to acute health problems. To date, federal policy response to growing LTC needs has been limited, and private LTC insurance has not provided coverage for the great majority of Americans (Ball and Bethell, 1989; Estes et al., 1993). Thus, most people in this country are not able to avail themselves fully of the complex set of services typically considered to be LTC. This problem might not attract significant attention from the public or from policymakers were it not for the
The Disability in America report focuses chiefly on the prevention of disability (and the consequent gain in quality of life) among the nonelderly.
fact that the population of individuals who need LTC services is large and growing. The associated costs of these services are great, and they are increasing as well. Thus, both U.S. policymakers and families are having to consider issues of LTC policy, as well as questions related to the utilization of chronic care services and expenditures for these services (Estes et al., 1993).
WHO USES LONG TERM CARE?
Typically, LTC is associated with the elderly, although many older persons never require such care. The percentage of people over 65 years of age is growing rapidly in the United States. In 1990, they represented 13 percent of the total population, but by 2020 they will account for 18 percent. The proportion of those over the age of 85 (the "oldest old") is growing most rapidly of all. The number of people over age 85 is expected to grow from 3 million in 1990 to 8.1 million in 2030 and to continue to rise to over 15 million by 2050 (U.S. Senate, Special Committee on Aging, 1991).
In 1991, although only 2.7 percent (766,000) of elders between the ages of 65 and 84 lived in nursing facilities, nearly 18 percent (552,000) of elders 85 and older lived in nursing facilities. Less than 1 percent (216,020) of the elderly (65 and older) resided in B&C homes (Sirrocco, 1994). In the same year, it was estimated that 17 percent (5.3 million) of elders 65 and older living in their communities needed some assistance with an IADL or an ADL. Just over one million persons in this group needed assistance with three or more ADLs (AARP, 1994b).
Elderly residents of LTC facilities (nursing facilities, B&C homes, and other group residential homes) are the designated constituency of the ombudsman. An effective ombudsman strategy must be tailored to the characteristics of the group on whose behalf the ombudsman advocates.
Nursing Facility Residents
Nursing facility residents typically are female, white, and very old (in their eighties). These residents tend to suffer from multiple chronic diseases and functional impairments (AHCA, 1994). More than half enter the nursing facility from an acute-care hospital (Lewis et al., 1985). Under such circumstances, illness, time pressures, and constraints on available nursing facility beds means that they or their agents may not have the opportunity to select a nursing facility carefully. Too often, nursing facility residents have not chosen to enter a particular nursing facility or any facility at all (Coulton et al., 1989; Reinardy, 1992; Thuras and Kane, in press).
In addition to their need for LTC services, some characteristics of nursing facility residents render them vulnerable to abuse, exploitation, or neglect (Kane and Caplan, 1990). Substantial proportions of nursing facility residents suffer some degree of cognitive impairment from conditions such as Alzheimer's disease or other dementias. Many nursing facility residents suffer sensory impairments, which interfere with their vision, hearing, speech, and ability to communicate. Some are bed- or chair-bound because of severe or deteriorating diseases that affect mobility. Many nursing facility residents have interested and involved friends and family members. However, elderly people who never married, who have no children, or who have no surviving children are overrepresented in nursing facilities.
Nursing facility residents are often poor, and this makes them especially vulnerable. The approximately 50 percent of residents who receive some payment from Medicaid have exhausted their assets, and, although the amount varies from state to state, they are generally allowed to keep only about $40 a month for personal needs (such as clothing, cigarettes, and phone calls). Others have lost effective control of their financial affairs. Typically, nursing facilities identify a representative payee other than the resident to pay bills. Because of this some residents are also at risk of financial exploitation.
Despite the common profile described above, nursing facility residents also differ markedly from each other in many ways. They differ in their interests, preferences, talents, education, life experiences, cultural backgrounds, and languages. Other differences among residents include: the reason for admission to the nursing facility, the anticipated length of stay, and expected prognosis. Although the average length of stay in a nursing facility is about a year, half of all people admitted to a nursing facility stay three months or less, and of these, half again die in the facility or after a short hospitalization. In contrast, some people stay for a long time. Kemper and Murtaugh (1991) found that people surviving to age 65 had a 42 percent probability of an admission to a nursing facility, an 11 percent probability of staying in a nursing facility for more than a year, and a 5 percent probability of staying in a nursing facility for five years or more.
Within the short-stay group of nursing facility residents, some people receive short-term rehabilitation for conditions such as hip fracture and stroke, and some people receive terminal care or hospice services. These residents are less likely than those who stay for longer periods to suffer cognitive impairments, and their stay is more likely to be funded by Medicare. Within the long-stay group, some people are cognitively intact but functionally very impaired (perhaps because of conditions such as multiple sclerosis, pulmonary disease, or advanced arthritis), and some people are cognitively impaired but may well be ambulatory and capable and desirous of considerable activity. Some nursing facilities also house residents who are comatose, in vegetative states, as well as people on life support systems such as ventilators. Each of
these populations—rehabilitation clients, hospice clients, people in comas, long-stay residents with only physical illnesses, and long-stay residents with cognitive impairments—and their concerned agents and relatives are likely to need advocates, but the characteristic problems presented may differ dramatically, as may the strategies of the advocates.
Although the average age of a nursing facility resident is in the mid-eighties, younger people also live in nursing facilities. Many are chronically mentally ill or developmentally disabled. Some of these younger, long-stay residents suffer from spinal cord injuries or deteriorating neurological diseases. In many areas of the country, persons with acquired immunodeficiency syndrome (AIDS) may live in nursing facilities when their disease reaches the advanced stage. Characteristic needs for advocacy may apply to some of these vulnerable populations. In addition, people under 60 (especially those who are disabled but not sick) are known to have particular problems achieving a satisfactory lifestyle in nursing facilities.
Residents of Board and Care Homes and Other Residential Settings
Between 600,000 and one million elderly and disabled persons are estimated to reside in B&C homes, also known as domiciliary care homes, personal care homes, residential care facilities, homes for the aging, rest homes, adult congregate living facilities, assisted living facilities, and adult foster care homes. These facilities provide residents with food, shelter, and 24-hour supervision or protective oversight. Usually they provide some form of supportive service or assistance as well. Such facilities vary significantly in size (from 2 beds to more than 1,000), monthly charge (from $383 to more than $4,000), and range and intensity of services provided (from no services to daily nursing care). Some facilities are targeted or marketed to younger persons with chronic mental illness or developmental disabilities, others are targeted to the elderly, and yet others serve a mixed-age population. The quality of care and life provided by these facilities to residents also varies (Dittmar and Smith, 1983; Reisacher, 1985; Mor et al., 1986; Eckert et al., 1987; U.S. House of Representatives, 1989; Hawes et al., 1993).
Further, the payment systems and regulatory structures that apply to these facilities also vary enormously. Within a single state, multiple classes of facilities can exist, each with its own target population and its own set of rates and regulations concerning staffing, admissions, and standards of care. In at least 10 states, multiple agencies are responsible for licensing various types of B&C homes that serve a primarily elderly or mixed-age population of residents; in many states, entirely separate classes of homes are licensed by
departments of mental health or developmental disabilities (Hawes et al., 1993).
In 1990 more than 32,000 licensed B&C homes across the country provided services to "a primarily elderly/mixed population of residents," which includes older persons, persons with chronic mental illness, and persons with mental retardation or developmental disabilities (Hawes et al., 1993). This estimate excludes homes that are licensed by departments of mental health for special populations (e.g., homes serving only persons with chronic mental illness or group homes for persons with developmental disabilities), as well as homes specifically licensed for other special populations, such as children and persons receiving substance abuse treatment. Adding these other categories of homes probably brings the total number of B&C homes in the nation to more than 36,000 facilities (DHHS, 1982; Clark et al., 1994). In addition, an unknown number of unlicensed B&C homes are in operation. Such homes include both illegally unlicensed homes that avoid licensure altogether and legally unlicensed homes that fall outside the licensing requirements of particular states. Estimates place the number of unlicensed B&C homes as high as 28,000 (U.S. House of Representatives, 1989).
Not all B&C homes are small and homelike. A recent study of 10 states found that, while 67 percent of licensed homes are small (2–10 beds), fully two-thirds of all beds are found in medium to large-sized homes (>10 beds). Indeed, one-third of all beds are found in homes with more than 50 beds. Much the same holds true for unlicensed homes, if one includes in this group other retirement communities and congregate settings (including apartments) that provide the same type of services as licensed B&C homes.3 In these unlicensed facilities, more than half the residents live in facilities with more than 50 beds (Hawes et al., 1994).
Compared with nursing facility residents, B&C residents are more likely to be younger and more functionally independent. However, studies have found significant levels of disability among residents, and both anecdotal reports and more recent studies suggest a population that is aging and that experiences significant levels of chronic disease, functional impairment, cognitive impairment, and chronic mental illness (Hawes et al., 1994).
Preliminary results from a 1993 study by the Research Triangle Institute and the Assistant Secretary for Planning and Evaluation (RTI/ASPE) indicate that, in the 10 study states, 30 percent of B&C residents were over 84 and another 30 percent were between the ages of 75 and 84 (Hawes et al., 1994). Only 20 percent of the residents in the RTI/ASPE study were under 65 years of age (Hawes et al., 1994). These results suggest that residents entering
Many retirement communities and other congregate living facilities are accredited through private accrediting agencies but not licensed per se by the state.
B&C homes are older and that much of the B&C population is aging in place. For example, many residents placed in B&C homes as a result of the deinstitutionalization movement of the late 1960s and 1970s are now passing into old age and are increasingly in need of traditional elderly supportive services in addition to mental health services (Seltzer and Kraus, 1987).
Similarly, the level of chronic disease and dependency in ADLs is lower among B&C residents than among nursing facility residents, but the types and levels of impairment are noteworthy. One-third of residents reported some form of degenerative joint disease, one-quarter reported circulatory and heart disorders, one-quarter reported hypertension, and one-seventh reported respiratory disorders (Dittmar and Smith, 1983). Estimates of impairments in mobility sufficient to limit physical activity outside the facility range from 31 to 44 percent. Approximately half of all elderly B&C residents needed help with at least one ADL (Dittmar and Smith, 1983; Mor et al., 1986).
Recent data imply that the level of impairment for residents in B&C homes may have increased over the past decade. Studies in the early 1980s found less than 10 percent of residents were incontinent of bladder, whereas a 1993 study found over 20 percent were incontinent of bladder (Hawes et al., 1994). Dittmar and Smith (1983) found only 3 percent of residents using wheelchairs and only 2 percent bed- or chair-bound in 1983, but again, 10 years later Hawes and colleagues (1994) found that 15 percent of residents were using wheelchairs and 7 percent were bed- or chair-bound.
These studies also suggest a level of cognitive impairment that, while lower than that found in nursing facilities, is still significant. Estimates of mild "confusion" to mild cognitive impairment ranged from 30 to 39 percent (Dittmar and Smith, 1983; Reisacher, 1985; Mor et al., 1986). Nelson (1987) found that 20 percent of the residents in B&C homes were severely impaired, 73 percent experienced some level of mental impairment, and 28 percent were identified by the physicians as having dementia. Hawes and colleagues (1994) found just over one-third of the residents presented with moderate to severe cognitive impairment.
Residents of B&C homes also exhibit a high level of chronic mental illness. Even among homes serving a primarily elderly population, studies consistently find that between 10 and 15 percent of residents in these homes are mentally retarded or experience developmental disabilities and approximately 33 percent are diagnosed as having a chronic mental illness (Dittmar and Smith, 1983; Mor et al., 1986; Hawes et al., 1994).
LONG-TERM CARE EXPENDITURES AND SOURCES OF FUNDS: WHO PAYS?
Any discussion of expenditures for LTC services (specifically, the issue of who pays) must begin with the fact that the majority of this care is provided by informal providers—family, friends, church members, voluntary groups, and others. It is difficult to assess the magnitude or the "costs" of this informal care, precisely because it is typically not provided on a fee basis and is uncounted. However, most experts agree it is substantial. Some authorities estimate that 70 percent of disabled elders rely exclusively on help from spouses, children, or other informal sources (Liu et al., 1985). The burden and indirect cost of this informal care falls heavily on women: 75 percent of informal caregivers are women, and many of them are elderly themselves (Pepper Commission, 1990; England et al., 1991). Caregivers, employers, and society all experience costs associated with informal caregiving, from foregone income to lost productivity to tax revenues not collected.
Nursing facility care consumes the bulk of current spending and projected spending on LTC, despite the preference of most elderly to remain in their own homes. Of the roughly $60 billion spent on nursing facility care in 1991, Medicaid paid more than $28 billion, nursing facility residents and their families paid nearly $26 billion, Medicare paid nearly $3 billion, and other private sources (including private insurance) and government programs paid more than $2 billion. In contrast, only about $10 billion was spent on home care in 1991. Medicare paid $4.4 billion; Medicaid paid $1.4 billion; state and local governments contributed $1.3 billion; and funds from private health insurance and other private sources, including money paid directly by LTC consumers and their families, totaled $2.6 billion. Other federal programs, such as those funded through the Older Americans Act (OAA) and the Social Services Block Grant program, contributed about $1.2 billion (FY 1993) and $588 million (FY 1991), respectively, for services to older people (AARP, 1994b).
The exact costs associated with B&C are almost impossible to estimate, although it can be assumed to be less than either nursing facility or home- and community-based care since there are fewer residents living in these types of facilities. Often the cost of care in these facilities is paid directly by consumers and their families as part of their rent, rather than by third-party payers such as Medicare. A study by the U.S. House of Representatives, Select Committee on Aging (1989) estimated that about half of elderly B&C residents pay for their care solely with private resources. It is known that a number of B&C residents receive Supplemental Security Income (SSI), a federal/state income supplement for poor elderly and disabled individuals. Some states provide SSI supplements for services in B&C homes (Hawes et al., 1993). Accordingly, some B&C homes are quite expensive and cater to
a fairly affluent clientele; others adjust their rates to the relatively low SSI reimbursement levels.
Implications for ombudsman work are many. Because in almost all states the Medicaid reimbursement rate is lower than the private-pay rate, ombudsmen have become involved in Medicaid discrimination issues, where nursing facility residents or their families believe that a resident receiving Medicaid has been transferred inappropriately in the facility, discharged to a hospital and not taken back, or generally treated worse than private-pay residents. Ombudsmen have also advocated for systemic reform on the amount of money residents are allowed to retain for personal needs. Finally, because of concerns among many sectors of society, including policymakers, providers, and some of the general public, to contain costs, particularly through Medicaid reimbursement rates, ombudsmen operate in an atmosphere of resource scarcity. This scarcity tempers individual advocacy for the kind of service and lifestyle that might be most desirable for the consumer, and at the same time it underscores the need for systemic advocacy. Society faces the triple challenges of assuring that LTC services are delivered as efficiently as possible, designing new services that will meet the preferences of elders and their families, and assuring the quality of these services.
QUALITY OF CARE AND QUALITY OF LIFE
"Quality of care" and the broader concept "quality of life" are sometimes contrasted in health care discussions. Some argue that, if people are forced to relocate their residence in order to receive health-related services in a cost-effective manner, then the providers of those services are bound to hold themselves accountable for quality of life as well as quality of care. In fact, the Nursing Home Reform Law of 1987 requires nursing facilities to do just that.
In comparison to hospitals, nursing facilities and, particularly, B&C homes are low-technology environments. Nevertheless, these settings (including subacute care units in nursing facilities) provide medical and nursing care that must still meet a standard of technical adequacy. If various medical and nursing protocols (e.g., for administration of medications, management of catheters, monitoring of specific diagnostic conditions, skin care of bed-bound people) are ignored, outcomes for residents will suffer.
As early as the 1970s, federal demonstration projects in nursing facility quality assurance (Kane et al., 1979) established protocols for adequate care
of common problems and conditions seen in nursing facilities. Since that time, the typical nursing facility resident has become more frail, and many nursing facilities are undertaking more difficult procedures and caring for sicker people. The resident is indeed also a "patient" if he or she has just been discharged from a hospital after a stroke or a heart attack and still needs skilled treatment and monitoring. Prospective hospital payment, instituted in the mid-1980s, has led to quicker and sicker hospital discharges and more physically vulnerable residents. Ombudsman advocacy programs may have to become increasingly sophisticated about medical and nursing procedures. Ombudsmen may need access to experts in health care, including geriatricians, to assess complaints and determine investigatory courses to take and remedies to suggest individually and systemically.
Structural, process, or outcome criteria can be used as measures of quality of care (Donabedian, 1966). Structural criteria are those that pertain to an entire organization. For example, structural criteria such as the training and supervision of staff, the record system, the procedures for infection control, and the quality of the physical plant and equipment may all reasonably be thought to affect the processes of care and, hence, subsequent health and functional outcomes. While the current emphasis is in resident outcomes and evaluation of the actual care provided, historically, nursing facility regulations relied heavily on such criteria; B&C regulations have remained at a far less developed state. Process criteria pertain to the appropriate and correct performance of specific procedures. One can ask about a wide range of procedures: Were they necessary? Were they performed correctly? One can ask certain questions about specific procedures as well. For example, regarding antibiotic medications, one can ask: Do all those receiving antibiotics need them? Do some people who do not receive antibiotics need them? Were the antibiotics given correctly (the right drug, the right dose, the right conditions, the right monitoring for side-effects)? Outcome measures are typically considered to be the end results of health care in terms of biologic, psychologic, and functioning variables. They may include various health indicators such as death rates, rates of illness, rates of specific complications of illness, functional abilities, and pain or discomfort.
The often ambiguous role of the physician, who may be a consultant or outside practitioner and whose performance cannot readily be controlled by the facility, complicates the maintenance of quality of care in residential settings. Other professional personnel (e.g., psychologists, physical therapists, and speech therapists) may also be outside contractors, especially in small facilities. Patterns for delivering primary health care in B&C homes and other residential facilities are even less well supervised, and critics fear that inadequate attention is paid to residents' existing health problems and new ones that may arise (U.S. House of Representatives, 1989). For example, the presence of or
need for physicians and other health professionals who understand geriatrics in nursing facilities and B&C homes may be a factor in appraising the patterns of complaints and issues of quality of care in LTC facilities.
Quality of life is an expansive topic that encompasses broad notions of human existence. Highly personal views about one's environment and living situation, as well as profound philosophical, religious, and spiritual beliefs and attitudes about life and death inform each person's position on the subject (Lohr, 1992). Anthropological and ethnographic studies in nursing facilities point to problems in achieving a reasonable quality of life (Shield, 1988; Lidz et al., 1992; Gubrium, 1993). After all, a nursing facility is more than a setting in which residents receive care, it is their home, although for some it is only a temporary home. Unfortunately, however, the physical structure of most nursing facilities allows for little privacy, especially as most residents must share rooms. Partly because of routines and conventions—many of which are providers' responses to regulations—and partly because of room sharing, residents maintain little personal control over many aspects of their daily lives. Disputes arise over matters such as roommate and table-mate selection. Residents who are cognitively intact complain about enforced proximity to residents who are cognitively impaired. Residents who are cognitively impaired may be restricted in their activities, both for their own safety and so that they do not intrude on the space and possessions of others. Many residents may lack meaningful activities. Kane and Caplan (1990) pointed out the myriad difficulties of developing normal lifestyles in traditional nursing facilities given heterogeneous populations, rules and regulations that govern conduct of residents, and lack of physical space and privacy.
In 1987, partly as a result of an earlier IOM study (1986), Congress enacted a comprehensive nursing facility reform law that emphasized the need to ensure that residents achieve a good quality of life. Mandates in the law included new general conditions or standards for nursing facilities to meet regarding residents' rights and quality of life. The same reform required that those who inspect nursing facilities observe and speak to samples of residents themselves to determine whether these conditions are met, rather than relying solely on medical records and staff reports.
Despite the substantial progress of the 1987 reform, quality of life is an elusive concept to define and to measure in the nursing facility or LTC context. It encompasses such constructs as dignity, satisfaction, social involvement, autonomy, and happiness. For those who cannot participate in an interview because of cognitive or sensory impairments, the difficulties of measuring quality of life are immense. Even cognitively intact residents may
not report dissatisfaction for fear of reprisals or because they are unclear about the standard of care they should expect. Also, how does one balance quality of life as illustrated by the constructs listed above with narrower concepts about adequate quality of care and the safety of residents? Although facilities must respect residents' choices, in some facilities concerns for safety and physical well-being continue to overrule residents' preferences for particular lifestyles. Nursing facilities' concerns about legal and regulatory liability often militate toward safety first (Kapp, 1987).
Residential settings other than nursing facilities may permit more personal autonomy for residents (Mollica et al., 1992; Kane and Wilson, 1993), in part because fewer standards prevail about staffing, physical care, and safety. Some commentators are concerned, however, that such environments insufficiently protect many vulnerable adults. The hope is that new models of residential LTC will be developed that allow persons with severe disabilities to receive care while leading a normal lifestyle and achieving privacy and control over their immediate environment. Although good models of such care exist, perennial scandals suggest that many B&C homes offer very little service, in environments that fall far short of minimal adequacy.
Quality of life, like quality of care, can be measured by structure, process, and outcomes. Indeed, Wilson (1993), writing about assisted living, argues that some structural standards for the environment are essential to autonomy and a normal lifestyle. She advocates private occupancy rooms with full baths, kitchenettes, locking doors, and individual temperature controls. Procedures for handling such issues as individualized care planning, resident governance, complaints and grievances, lost property, room transfers, and informed consent may well facilitate quality of life; LTC ombudsmen in some jurisdictions have been active in efforts to establish such procedures. Also, staff behavior that is respectful of the dignity and choice of residents is a key factor in achieving a high standard of quality of life. However, quality of life is best measured by the subjective well-being and satisfaction of each individual resident.
ASSURING, ASSESSING, AND IMPROVING QUALITY
Assuring quality in LTC residential facilities should proceed in three steps: (1) define quality in operational terms and establish standards for performance, (2) assess care to determine whether standards are met, and (3) correct problems that have been identified. The following discussion focuses on the quality assurance systems in nursing facilities; similar systems for B&C facilities have not been developed to the same degree and vary a great deal among states (Hawes et al., 1993; Phillips et al., 1994).
Quality has been a preoccupation in nursing facilities for decades (IOM, 1986). The ombudsman program actually arose in response to the widespread
perception of problems in nursing facility quality. Over the years, however, quality assurance activities have multiplied and strengthened; therefore the ombudsman program must now be viewed in relationship to other activities in place in nursing facilities.
Out of concern for quality of care and quality of life in nursing facilities, several policies have been put in place. For example, all nursing facilities are licensed by the states in which they are located. Nursing facilities receiving payment from Medicaid and Medicare (virtually all nursing facilities in the country) are certified by the government; the rules for certification are established federally, but a state agency, usually a unit within the department of health, actually conducts the inspections, known as "surveys." Local health and safety inspectors typically examine nursing facilities to make sure that they are following building codes, food safety codes, fire codes, and other ordinances. Although sometimes difficult to obtain, licensing inspections and certification surveys are available to the public.
Historically, the effectiveness of remedies to correct problems in nursing facilities has been limited. States may employ many strategies to correct problems in nursing facilities, ranging from educational and consultative approaches to punitive or coercive approaches. "Carrots" for improving good performance include consultation, educational programs, and (slightly more coercive) peer pressure from role models or feedback on a facility's performance compared with peers. "Sticks" to improve performance include civil fines, withdrawal of license or certification, holds on new admissions, receivership actions, and criminal procedures.
The history of quality assurance in nursing facilities, which is beyond the scope of this report, is reviewed in a 1986 IOM study that made far-reaching recommendations for federal policy in this area. As a result of the 1986 IOM study and the subsequent 1987 legislation, the following changes were made:
New quality standards were developed in four areas: quality of care, resident assessment, residents' rights, and quality of life.
A standardized resident assessment instrument, known as the minimum data set, was established, and all nursing facilities are expected to use it to assess each resident at intervals and as a basis for care planning.
Surveys became oriented to resident outcomes and surveyors began to obtain more information directly, by observing and interviewing residents.
A concerted effort was made to reduce use of chemical and physical restraints (e.g., unnecessary sedatives, trunk restraints such as vests, geri-chairs that prevent rising, and limb restraints).
Training standards and requirements for competency evaluation were developed for nursing assistants.
Preadmission screening was mandated for individuals whose primary diagnosis is mental retardation or mental health problems.
Intermediate sanctions, such as fines, were recommended, and a new series of rules on enforcement procedures developed (although the final rules have not yet been published).
In 1987, these changes began to be phased in—a slow and lengthy process that is far from complete. Although the Health Care Financing Administration of the Department of Health and Human Services (DHHS) at the federal level and various state certification agencies bore the responsibility of implementing these changes, LTC ombudsman programs have been active in advocating for changes, monitoring the conduct of regulatory reform, providing training and consultation to state surveyors and the staff at individual facilities on quality of life and rights issues, training at the individual facility level, and informing residents and families about the reform. Thus, ombudsman activities for the past decade have been concerned with and shaped by the anticipation, inception, and implementation of new laws and regulatory reforms.
THE INSTITUTE OF MEDICINE STUDY
The LTC ombudsman program is relied on to address and solve many of the ills that presently afflict the LTC sector in this nation. Indeed, the program currently serves as a model for "health care ombudsman" programs that may be deemed desirable (or necessary) as broader health care reform moves forward in the United States. However, the effectiveness of this program is not well understood and neither is its potential for providing a meaningful impact beyond the relatively narrow settings it currently serves.
Understandably, policymakers—at the urging of ombudsmen themselves—concluded that a more in-depth examination of the program was warranted, in order to examine its present strengths and weaknesses and its potential future contributions. To obtain this examination, the Congress of the United States directed, in the 1992 reauthorization of the OAA, that the Commissioner on Aging of the Administration on Aging (AoA) conduct a study of the state LTC ombudsman programs.
This report is the culmination of that work, which commenced in October 1993. The IOM appointed a 16-member expert committee chaired by Carroll L.Estes, Ph.D., of the University of California, San Francisco. (For a complete list of committee members and their affiliations see the committee roster on page iii. For biographical sketches of the committee members, see Appendix D.) The committee comprised individuals recognized for their expertise in LTC, medicine, medical sociology, health care policy and research, clinical research, health law, health care administration, state government policy and program administration, consumer advocacy, public health, voluntarism, and the LTC ombudsman program.
The committee was charged to assess the effectiveness of the LTC ombudsman programs in the areas set forth in Section 211 of the 1992 OAA amendments. Also, the committee was charged to identify and, when appropriate, make recommendations on public policy strategies by which the program can better achieve its objectives. The committee's deliberations address the following:
the availability of, access to, unmet need for, and effectiveness of the ombudsman program for residents of LTC facilities (including B&C facilities and other similar adult care facilities);
the adequacy of federal and other resources available to operate the programs throughout the United States;
the extent of compliance and an analysis of factors that enhance or impede compliance with the program's mandates and standards;
the presence of any actual and potential conflicts of interest in the administration and operation of the programs; and
the need for and feasibility of providing ombudsman services to older individuals who do not reside in LTC facilities but are users of health and LTC services, such as home health care. This analysis is to draw from existing state ombudsman programs that serve elderly individuals who reside in settings other than LTC facilities.
To inform itself on issues pertaining to this charge, the committee engaged in several factfinding activities. Information was gathered from site visits; commissioned papers; structured, systematic contacts with directors of state units on aging, state and local LTC ombudsmen, LTC physicians, and grassroots advocacy groups; a one-day invitational symposium; a public hearing; two "open-mike" sessions at national professional conferences; discussions with four national associations of LTC facility providers; and a technical panel that was convened twice and called upon as needed throughout the course of the study. (For more detail on the committee's activities, see Appendix C.)
ORGANIZATION OF THIS REPORT
This report addresses the issues raised by the congressional mandate and its charge. The committee offers findings and recommendations where it concluded that current strengths of the state LTC ombudsman program could be built upon or present deficiencies warranted explicit correction. Before moving into questions related to policy, the report describes in Chapter 2 the current status of the ombudsman program. Chapter 3 then discusses the question of whether the program complies with current mandated activities and
responsibilities. Chapter 4 assesses the conflicts of interest found in the administration and operation of the program. Chapter 5 explores in more depth the committee's views on the program's effectiveness and offers some ideas about how program effectiveness might be enhanced. Chapter 6 examines the adequacy of the program's resources. Chapter 7 inquires into the need and feasibility of an expansion of the present program into other populations and other settings. Finally, Chapter 8 presents the committee's view of the future of LTC and what part the LTC ombudsman program will play in it.
Appendix A provides descriptive information on OAA programs and the network of agencies providing them. Appendix B is the statutory base for the LTC ombudsman program (Title VII, Chapter 2, of the OAA). Appendix C gives details on study activities. Appendix D provides biographical information on committee members.
Next: Overview of the Older Americans Act Long-Term Care Ombudsman Program »
Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act Get This Book
Front Matter i–xii
Contents xiii–xiv
Summary 1–24
Advocating for Quality of Care and Quality of Life for Residents of Long-Term Care Facilities 25–40
Overview of the Older Americans Act Long-Term Care Ombudsman Program 41–78
State Compliance in Carrying Out the Long-Term Care Ombudsman Programs 79–100
Conflicts of Interest 101–128
Effectiveness of the State Long-Term Care Ombudsman Programs 129–184
Adequacy of Resources 185–204
Expansion of the Long-Term Care Ombudsman Program 205–230
Closing Comments 231–236
Appendix A: Older Americans Act: A Staff Summary (A Publication of the Select Committee on Aging) 251–260
Appendix B: Title VII--Allotments for Vulnerable Elder Rights Protection Activities: Chapter 2 261–268
Appendix C: Study Activities 269–280
Appendix D: Biographies of Committee Members 281–288
Glossary and Acronyms 289–291


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Lajos Kocsis [lajoš kočiš] (18. června 1947 Segedín – 9. října 2000 Budapešť) byl maďarský fotbalista, záložník.

Fotbalová kariéra
V maďarské lize hrál za Salgótarjáni BTC a Honvéd Budapešť. V maďarské lize nastoupil ve 309 ligových utkáních a dal 111 gólů. V Poháru vítězů pohárů nastoupil ve 4 utkáních a dal 2 góly a v Poháru UEFA nastoupil ve 18 utkáních a dal 2 góly. Za maďarskou reprezentaci nastoupil v letech 1969–1975 ve 33 utkáních a dal 7 gólů. Byl členem maďarské reprezentace na Mistrovství Evropy ve fotbale 1972, kde Maďarsko skončilo na 4. místě, nastoupil v semifinálovém utkání. S olympijskou reprezentací Maďarska získal zlaté medaile na LOH 1968 v Mexiku, kde nastoupil v 5 utkáních, a stříbrné medaile na LOH 1972 v Mnichově, nastoupil v 7 utkáních a dal 1 gól.

Ligová bilance

Externí odkazy

 National Football Teams
 Worldfootball.net

Maďarští olympijští vítězové ve fotbale
Fotbalisté Honvédu Budapest
Narození 18. června
Narození v roce 1947
Narození v Segedíně
Úmrtí 9. října
Úmrtí v roce 2000
Úmrtí v Budapešti
Muži
Hráči Mistrovství Evropy ve fotbale 1972

redpajama_set_name: RedPajamaWikipedia


It's been quite some time since our last update, we've apparently been enjoying summer quite a bit more than expected….
It was a mild and overcast day, very unlike any other July in Rhode Island. We had started our stretching routine and gotten the bibs that would mark us official participants in the Providence Craft Brew Races. I was a bit apprehensive of the task ahead knowing full well that my training schedule had been delayed a few weeks by a sprained ankle. There was a mixture of emotions from the RIBS team who boasted 22 bodies when all was said and done. We weren't sure what the outcome of the day would be but we did know that after a short run we'd be swigging samples of the finest craft beers around.
The call came and we gathered at the starting line…and waited….and waited. Anticipation led to boredom and eventually a deep thirst for some cool suds. Every so often we caught a glimpse of Matt, the race organizer, glued to his phone and getting gray hairs by the second. We all paused to pay respect to our country and those who fight for it during the National Anthem.
Finally, the time came and we were off. Kate disappeared in a cloud of smoke before anyone knew where she was. The rest of us stayed in a group for most of the first mile but eventually separated. After a while I was all alone, I guess you really do have to train to run a 5K. As I was plodding steadily along, I saw members from all the teams, wearing their requisite jerseys. The two largest teams, The Running Fools and Bucket brewery had a steady stream of runners throughout the whole race. I saw many other smaller teams such as RIGPO, Craft Brew Supplies sometimes passing me, other times in lock step.
Passed the first water station we made our way down to the Point Street Bridge and on passed the Wild Colonial. I would have stopped in for a beer if it hadn't been 11 in the morning, oh and I was being timed after all. We crossed back over the river and went back through downtown to Empire street. Finally as we rounded the Trinity corner we caught sight of our goal, the finish line. I decided it was better to run across the finish line rather than walk. Just one last short push and the torture would be over.
I crossed the line grabbed my medal and looked for my team. They were nowhere to be found, but I knew where they were, they were already sampling. The festival was already getting crowded but there was still plenty of choices and short lines. It was similar to the winter festival but since we had no table, all could drink and enjoy. We spent the rest of the time sampling great brews and talking amongst ourselves about the race, running, beers and anything else we could think of.
All in all, the Craft Brew Races were a wonderful event and we look forward to next years race. I personally will train up a bit more but just so I can have an earlier crack at the beer.


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Norwegian journalist denied entry in Russia
Tags: Norway, russia
Barents Observer Editor Thomas Nilsen was on business trip with a delegation from the Danish Parliament´s Committee of Foreign Affairs, on 8 March 2017, when he learned that he can't enter Russia, despite having a valid visa. When Nilsen arrived in Borisoglebsk, the cross-border point between Russia and Norway, he was told by FSB border guards that he is not allowed to enter due to security reasons. Barents Observer quoted Nilsen describing the incident:
"I was told it was necessary to deny me access to Russia for the purpose of state security. The officers could not elaborate further and it was obvious the decision was taken somewhere else."
Nilsen has been for a long time a supporter for increasing cross-border cooperation in the region. The Barents Observer is an independent newspaper that is focusing on the European and Russian Arctic news.
Russian Embassy in Norway commented on the situation on their official website. In the statement they explained that as a counter measure for sanction lists against Russia, the list of Norwegians that cannot enter Russia was developed. The list was sent to the Ministry of Foreign Affairs of Norway in November 2016 and the journalist's name was on that list. The Norwegian Union of Journalists, backed by the European Federation of Journalists (EFJ), condemned these actions:
"The Norwegian Union of Journalists has sent a protest to the Russian ambassador in Oslo, emphasizing the importance of free access for all individual journalists. The European principle of freedom of speech and media freedom is under serious threat if we let governments decide who will be allowed to report from their country, based on how positive or negative the individual journalist has reported – which we suspect is what has happened in this case."
Photo Credit: Atle Staalesen/Barents Obsever
DEG Meeting

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: IntelliJ keyboard shortcut to turn text into a XML 'tag pair' I inadvertently used a shortcut key.It can automatically change the string into a label pair, As in the picture.
process:

*

*Enter the text.

*Enter shortcut key.

*Generate .
But I can not reproduce. Does anyone know what this shortcut key is? Thanks!

A: This is default IntelliJ behaviour in a XML file (and a HTML file and maybe some other file types too):

*

*Enter some text

*Hit TAB

*IntelliJ turns the text immediately prior to the cursor into an 'tag pair'

For example:

*

*Enter foo

*Hit TAB

*IntelliJ turns foo into <foo></foo>
If you find that auto completion feature useful you might also be interested in the html/xml live templates. See Preferences > Editor > Live Templates. Here's a screenshot:

redpajama_set_name: RedPajamaStackExchange


RootlessJB is enabled by SH and can be used to liberate devices running Apple's A11, A10, and A9 processors. With that being said, all iPhones beginning with iPhone 6S and ending with iPhone X and iPads are compatible with this tool as long as they are running chips older than the A12X Bionic. Before you get too excited about this, only developers should use this.
Jake James does not offer root access with his tool which means that you will not be as free to use it as jailbreaking usually is. In addition to this Cydia or Cydia Substrate, package managers are not supported. You need to use SSH if you want to install any tweaks.
The developer mentioned in a tweet that the 3.1 updated version can tweak unsandboxed apps which means that it can't be used to tweak sandboxed apps.
If you are a developer and own a compatible device, we provide you with a step by step guide on how to use RootlessJB to liberate your device running iOS 12-12.1.2.
Go to jailbreaks.fun by firing up the Safari Browser on your iPad or iPhone.
Use the search bar to search for RootlessJB and the tool will show up in the results.
To download it on your device hit the Get button and wait.
Go to your Settings app on your device in order to trust the certificate by going to General > Profiles and Device Management. Give permission.
Now you can launch RootlessJB by turning on Airplane Mode. Before tapping the Jailbreak button, you should make sure that the Tweaks toggle is enabled.
After the process is complete, your iOS device will respring. This way you are announced that your device has been liberated successfully. In case it restarts you need to try it again because it means it did not work.


Items where Author is "Khaki-khatibi, F."
Khaki-khatibi, F. and Yaghoubi, A.R. and Vatankhah, A.M. (2013) Study on the relation between the levels of trace elements and minerals with cardiac ventricular rupture in rats. Feyz Journal of Kashan University of Medical Sciences, 16.
This list was generated on Thu Apr 25 21:01:06 2019 EDT.


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Patterson Inn
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The Patterson Historic Inn
A stately and distinguished National Landmark, the Patterson Inn is situated on a quarter acre of exquisitely landscaped grounds in the heart of one of Denver's original high-end neighborhoods. Historically intriguing yet complete with all the comforts of modern amenities, it offers a luxurious reprieve from the stresses of everyday life.
The Patterson Inn features nine luxurious suites, each designed around its own unique theme. Furnishings in each room reflect the personality of that room, as well as the history and elegance of the building, and each includes its own private bath. From the decadence of the Antoinette, to the old world feel of the Prague, each distinctive room promises its own special experience. Explore the rooms using the links on the left to discover more!
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10 Trendy Ways To Improve On SPORTS BETTING
admin November 29, 2022 no Comments
All people are banned from advertising or selling any football betting exercise in which FA laws prohibit them from engaging.
This, nevertheless, only applies to individuals of their private capacities.
For instance, if a club is sponsored by a betting firm and said firm locations its logo on the club's equipment, the staff's players are not in violation of the betting rules.
The Football Association, the governing physique for affiliation football in England, has imposed soccer betting bans on all individuals involved within the sport—players, managers, match officials, and membership staff.
The scope of these bans varies based on degree of the English soccer pyramid.
The sportsbook would additionally get four seats on the team aircraft for an away football recreation and 4 premium season tickets to soccer, basketball and hockey video games.
เว็บบาคาร่าออนไลน์UFA656 Find the best participant prop bets for each game and keep up with player stats and covers stay in the course of the games.
It's broadly accepted that the first online betting site was the iconic Intertops website, which took its first sports bet in 1996.
It ushered within the period of on-line betting, a trend that may change the industry eternally.
Kansas Sports Activities Betting
West Virginia additionally sprang into action following the Supreme Court ruling.
BetLucky was available for a quick time as a cell option, however it shut down the following 12 months due to a know-how dispute.
DraftKings and FanDuel went live in WV soon thereafter and have since been joined by other operators.
Anyone betting on Detroit wants the Lions to lose by 1-4 points or win the sport.
The favourite is the team that is extra more likely to win the game and can get a minus sign next to its odds.
When oddsmakers release a betting line on a recreation, the first thing they do is resolve which team ought to be the favorite and which ought to be the underdog.
While signing up to play in authorized states isn't difficult, what to do from there can lead to plenty of questions.
The excellent news is that the educational curve for betting on sports is beatable.
We have a number of dedicated useful resource pages that provide detailed info on all of the basics.
Bet Wherever In Nevada, Colorado & Iowa
Sports betting was banned in the majority of the world within the first few many years of the twentieth century.
Most football (soccer, gridiron soccer, rugby, etc.) matches, as nicely as basketball video games, use a system known as a point unfold.
Bookmakers decide the variety of factors that will function a variety for a specific contest.
A bet on the favoured group requires that the bettor yield the purpose spread.
For example, an underdog staff could also be wager as +4, that means it has 4 points added to its last rating for functions of determining the profitable bettor.
In 2004 and 2006, Koellerer was banned for six months due to his dangerous behavior.
In addition, in August 2010, he facilitated betting by placing odds for matches and had links for putting bets.
Such actions instead represent violations of the ICC's code of conduct.
The 'edit bet' feature can be utilized by gamblers to 'unsettle straight accumulators' earlier than matches have started or whilst they're in-play.
The function may also be used for to swap single bets for new bets, and the gambler is given a new bet selection valued at the bookie's cash out worth to reflect live market/game odds for the original bet.
Today, no less than 12 states, including New York, have fast-tracked the licensing course of.
Find A Quick Way To GAMBLING SITE


This talk will focus on Data discovery tools such as Tableau and Qlikview in the context of Government data. Invariably, the Government data is complex and most of the efforts are focused on getting and using this data. This session will focus on the challenges encountered while analyzing Government data and how to address these challenges based on my experiences working with various Government departments. OpenStreetMaps have been used all along to encourage freely reusable geo-spatial data.
Venkateswaran Mahadeva ('Venkat')leads the Analytics practice at Wipro BPS. His job involves using rich visualization tools to analyze large amounts of structured and unstructured data for Healthcare, Energy and Transportation verticals.He has worked with the Government sector in India as part of his earlier stint with a start-up. This talk would primarily focus on using data discovery tools such as Tableau and Qlikview in the context of Government data.
Venkat holds a B. Tech degree from Indian Institute of Technology, Chennai and an MBA from Indian Institute of Management, Lucknow.
Neither the slides nor the video give enough information about the talk. Could you update the slides and submit a 2 minute video on what you intend to cover with this talk?
Hi Abhishek- Have sent the slides to Zainab. I couldn't upload them due to some login issues. Will send the video soon. Thanks.
Have uploaded the latest slides. This version supercedes the version sent to Zainab. Thanks.
Hi Abhishek - Have updated the slides and posted the latest version. A 2 min video on the talk has also been submitted.


Photos and memorabilia from the Grateful Dead's May 8, 1977, concert in Barton Hall.
Of more than 2,300 concerts over the Grateful Dead's 30-year touring career, there is one performance more famous than others, widely considered their best: May 8, 1977, in Cornell's Barton Hall.
Cornell, Ithaca and Tompkins County will celebrate the concert's 40th anniversary Monday, May 8, with events including a 6 p.m. Cornell Chimes concert in McGraw Tower.
Conners and Cornell University Press will be part of a 40th anniversary celebration at the State Theatre at 7:30 p.m. The event – with a 1977 ticket price of $6.50 – will feature an acoustic set by local band Terrapin Station and a listening party for the remastered concert recording's official release by Rhino Entertainment (as "Cornell 5/8/77").
The half-hour chimes concert will feature five Grateful Dead songs and three other selections from the 1960s. The setlist and other updates will be posted Monday to the event's Facebook page.
The original event poster by Jay Mabrey '77.
Liz Field, a communication specialist with Cornell Information Technologies, contacted head chimesmaster Serim An '17 in December with the idea to play a Grateful Dead song on the anniversary.
To An's knowledge, the Dead had never been in the Chimes repertoire, and "almost all of the students this year didn't know any Grateful Dead songs. Some of the older chimesmasters who'd been playing for over 20 years, they were great fans of the Grateful Dead" and volunteered to help, she said.
An, along with Jennifer Lory-Moran '96, MAT '97; Gretchen Ryan '97, Scott Silverstein '08 and Julia King, Ph.D. '17, arranged the songs. They will be performed solo and in duos by An, Lory-Moran, Ryan, Joshua Chan '18, John Lee '18 and Billie Sun '19. McGraw Tower will be closed during the concert and listeners are welcome to gather on the Arts Quad, Ho Plaza and Libe Slope.
Conners will sign copies of his book at The Cornell Store at 4:30 p.m. and at the State Theatre.
Cornell University Press Director Dean J. Smith, an avowed Deadhead and veteran of 60 shows from 1982 to 1995, proposed a book about the famed concert at his interview for the job in December 2014.
Phil Pascuzzo and Scott Levine of Cornell University Press designed the cover of the book.
Conners signed on as author in 2015, and conducted 30 interviews for the book, which Rhino has now included in "May 1977: Get Shown the Light," a deluxe box set of four Terrapin Station Tour shows including Barton Hall. The limited-edition 11-CD set sold out all 15,000 copies in pre-orders by early February. (The hardcover book, released April 11, had a first pressing of 22,000. The book and the definitive Cornell recording are available separately).
The book's cover features silver embossing, with a special Grateful Dead skull version of the Cornell Press colophon on the dust jacket. The text includes a chapter on the song "Dark Star" and Conners' listener's guide to the Dead.


Sources: Yahoo! Finance, Barron's, djindexes.com, London Bullion Market Association.S&P 500, Dow Jones Global ex-US, Gold, Bloomberg Commodity Index returns exclude reinvested dividends (gold does not pay a dividend) and the three-, five-, and 10-year returns are annualized; the DJ Equity All REIT Total Return Index does include reinvested dividends and the three-, five-, and 10-year returns are annualized; and the 10-year Treasury Note is simply the yield at the close of the day on each of the historical time periods.
Here's the good news: Corporate earnings have been strong. As of July 20, 17 percent of the companies in the Standard & Poor's 500 Index had reported second quarter results. More than 85 percent of those companies reported positive earnings surprises, according to FactSet, which means they earned more than expected. "It appears the lower tax rate is more than offsetting the impact of rising costs, resulting in a record-level net profit margin for the index for the second quarter," explained FactSet.
The U.S. bond market has been less sanguine than the U.S. stock market. Debate has focused on the flattening yield curve. The yield curve reflects the difference in yield on U.S. Treasuries from short- to long-term. Normally, investors expect to earn higher yields when they lend their money for longer periods of time (e.g. invest in longer-term bonds). At the end of last week, two-year U.S. Treasuries yielded 2.6 percent and 30-year Treasuries yielded 3.0 percent. Some say when short-term rates rise above long-term rates, inverting the yield curve, recession is ahead.
Consider the entrepreneurial example set by a New York City (NYC) deli owner who was trying to figure out how to stay in business on the Lower East Side of Manhattan. The answer was selling air, reports The Indicator From Planet Money: "So when you buy a plot of land in New York, it comes with what are called 'air rights.' That essentially says how much you are allowed to build on that plot of land. Let's say you buy a plot of land and it comes with 10 stories worth of air rights, you could build a 10-story building on it." The deli owned five stories worth of air rights, or 27,960.66 square feet of air. How much was all that air worth? Reportedly, a developer in New York paid about $17 million for it.
Guess who negotiates air deals in NYC……That's right: Air brokers.
P.S. Please feel free to forward this commentary to family, friends, or colleagues. If you would like us to add them to the list, please reply to this email with their email address, and we will ask for their permission to be added.
Investors are becoming more discriminating. Trade tensions escalated as the U.S. administration expanded tariffs on Chinese goods last week. You wouldn't have known by watching the performance of benchmark indices, though. Just four of the 25 national stock market indices tracked by Barron's – Australia, Italy, Spain, and Mexico – moved lower. However, if you look a little deeper into the performance of various market sectors, you discover an important fact: The market tide wasn't lifting all stocks. It has been said a rising tide lifts all boats. When translated into stock-market speak, the saying becomes, 'A rising market tide lifts all stocks.' In other words, when the market moves higher, stocks tend to move higher, too. That wasn't the case last week. Barron's reported investors have become more selective: "We went from a market where everything moved largely together to one where sector fundamentals began to matter more than where the S&P 500 was going…At the sector level, it's apparent that no one has been ignoring tariffs. While the S&P 500 has gained 1.7 percent over the past month of trading, industrials and materials have dropped 2.5 percent, while financials have slumped 2.9 percent, hit by a double whammy of trade fears and a flattening yield curve. Utilities and consumer staples have outperformed, gaining 8.1 percent and 3.5 percent, respectively." Utilities and Consumer Staples are considered to be non-cyclical or defensive sectors of the market because they are not highly correlated with the business cycle.
Defensive companies tend to perform consistently whether a country's economy is expanding or in recession. For example, a household's need for power, soap, and food doesn't disappear during a recession. As a result, the revenues, earnings, and cash flows of defensive companies remain relatively stable in various economic conditions. In addition, the share prices of these companies tend to be less susceptible to changing economic conditions. Defensive stocks tend to outperform the broader market during periods of recession and underperform it during periods of expansion.
There's a carbon dioxide (CO2) shortage. really, it's true. Many people agree the world has too much CO2. It's the reason representatives from countries around the world signed the Paris Climate Agreement. They committed to "adopt green energy sources, cut down on climate change emissions, and limit the rise of global temperatures," reported National Public Radio. The effort has been less successful than many had hoped, according to the International Energy Association (IEA). After several years without increases, energy-related emission rose by 1.4 percent in 2017. That's the rough equivalent of putting 170 million more cars on the road, reported Scientific American. Emissions rose primarily in Asia, although the European Union (EU) saw increases, too. The biggest decline was in the United States. There's a certain irony there, since President Trump announced he would withdraw from the agreement in June 2017, reported The Washington Post. Despite realizing a 1.5 percent increase in  emissions, the EU is experiencing a shortage of food-grade CO2. The Economist reported: "Food-grade CO2 is a vital ingredient: it puts the fizz in carbonated drinks and beer, knocks out animals before slaughter and, as one of the gases inside packaging, delays meat and salad from going off. A shortage of the stuff has therefore created havoc in food makers' supply chains." The EU's food-grade CO2 is a harvested by-product of processes for making ammonia and other chemicals, reported The Economist. Three of Britain's five ammonia plants have been closed because farmers are using less fertilizer, and CO2 does not deliver enough revenue to keep the plants running. Let's hope the shortage of CO2 doesn't affect the supply of beverages available to World Cup fans.
"What's got global market watchers worried is that China's stocks are sliding in tandem with its currency, the renminbi or yuan…That suggests China is using the exchange rate as a weapon. 'The most effective way for China to retaliate [against] rising U.S. tariffs is to weaken the yuan,' according to the July Bank Credit Analyst. That could roil financial markets, however. The dual declines in China's equity market and currency are raising concerns of a repeat of 2015. Treasury strategists at NatWest Markets recall that the drop in the yuan that summer sparked severe equity market losses, including a 10.5 percent correction in the S&P 500." That may explain, in part, why U.S. Treasury bills were so popular last week, although it probably didn't hurt the yield on short-term Treasuries was roughly equivalent to the dividends paid by the Standard & Poor's 500 Index. The coming weeks may deliver more excitement than Fourth of July fireworks.
Investment advice offered through Research Financial Strategies, a registered investment advisor. * This newsletter and commentary expressed should not be construed as investment advice.


Search our finding aid collection on Memory BC.
The Central United Church Archives in Toronto give researchers easy access to information on all the United Church Archives across Canada.
This web site does for the whole of Canada what the B.C. Archival Union List does for British Columbia.


Choose some fun names for your wedding signature cocktails!
How to create some fun names for your wedding signature cocktails? We have some ideas to inspire you – so read on and find out more.
Bloody Mary. A staple cocktail that's more than well-known to everyone, Bloody Marry can be very well turned into "Bloody Marry…Me", for example. This is a fun twist your guests will absolutely love – and even if your cocktail is pretty basic, the name will still add a unique twist to it.
Cider. If you love cider and if you want to serve it at your wedding (as such or in delicious cocktails), think of a cute name such as "Always Be My Cider". Romantic and funny, this name is bound to attract all guests towards your signature drink.
Wine. Are you a wine lover? If you plan on serving it at your wedding reception or cocktail hour, "re-brand" it under the "I Am Grapeful to Be With You" name. It's adorable, it has a cute twist to it and it is bound to make people fall in love with your idea.
Searching for wedding rental items to make your big day even more unique? Contact Grand Central Party and come see what we offer! We guarantee you will not be disappointed by our wide array of wedding furniture, glassware, tableware and even tents. Come visit us and you will find everything you need to make sure your wedding is flawless from all points of view!


Place green beans and shallots in a bowl. Drizzle with olive oil, and sprinkle with salt and pepper. Toss with your hands until everything is evenly coated. Add pancetta and toss again. Spread the mixture in an even layer on a sheet pan. Roast for 20-25 minutes or until tender, tossing occasionally.
While the green beans are roasting, toast the nuts in a saute pan over medium heat for 3-5 minutes or until golden.
Divide the green beans evenly among 6 plates. Top evenly with blue cheese and toasted nuts.


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east antrim
east antrim Constituency Details
CONTROLLING PARTYDemocratic Unionist
ELECTORATE0 voters
AREA0 sq. miles
East Antrim is a UK parliament constituency that is represented in the House of Commons by Sammy Wilson of the Democratic Unionist party.
The East Antrim constituency has a total population of 0, of which 0 are eligible (18+) to vote (%).
East Antrim ranks 649th in a list of the largest constituencies in the UK (geographical size), and th in a list of the largest constituencies by population size.
Sammy Wilson
Wikipedia page: http://en.wikipedia.org/wiki/Sammy_Wilson
Address Sammy Wilson MP, House of Commons, London, SW1A 0AA
Political Party Democratic Unionist
Email Address sammywilsonmpjb@yahoo.co.uk
Constituency East Antrim
Election turnout for the East Antrim constituency in 2015 was 53.30%, lower than the average UK turnout at 66.1%.
Alex Wilson Conservative and Unionist Party Male - - -
Margaret Anne McKillop SDLP (Social Democratic & Labour Party) Female - - -
Noel Jordan UK Independence Party Male - - -
Oliver McMullan Sinn F�in Male 22 March 1952 (69) - -
Roy Beggs Ulster Unionist Party Male - - -
Ruth Wilson Traditional Unionist Voice - TUV Female - - -
Sammy Wilson Democratic Unionist Male 04 April 1953 (68) - http://www.sammywilson.org/
Stewart Dickson Alliance Male 08 December 1950 (71) - http://stewartdicksonmla.com/
Election turnout for the East Antrim constituency in 2010 was %, lower than the average UK turnout at 65.1%.
This graph shows the results from 0 people in the East Antrim constituency who have taken our quiz, displaying which party best matches their opinions of the series of questions we ask.


Despite the high winds, I like it up here perched on a ledge at 4300 feet above the desert below. I decide to stay here an extra day, take the tour of the Mitchell Caverns caves, and explore the area a little. No bicycling today.
There are only six campsites here, and mine is the only one that was occupied last night. Despite the heavy winds yesterday evening, it's a pleasant sunny morning here now.
I spend some time trying to identify roads and features in the distance where I might have been.
This could easily turn into a day-long hike way up into the Providence Mountains, but I'm feeling far too lazy today for anything like that.
There are lots of these around here; fortunately I haven't been bitten by one yet.
Earlier this morning, I had considered packing up and moving on, but the allure of the cave tour, another campfire and water at my disposal, easily convinced me to stay another day.
Several cars come and go during the day, especially around the hours of the Mitchell Caverns cave tour, but it looks like the other five campsites here will be vacant tonight again.
I thought the lid felt a little heavy when I opened the can. The sometimes-strong wind here is obviously a known force to contend with.
One of these trails is quite short and has a brochure available to help to identify the plants growing here.
I like how the needles make the cactus look luminous.
After a relaxing campfire and supper, I crawl back into the tent to get some sleep. It's a chilly night again, but without the icy feel of the nights that I spent higher up in the mountains.


In this Marketing Strategy Lab Rant, Jeff Coga rants about how Kobe Bryant's basketball contract kills the Los Angeles Lakers' opportunity to win the 2014-2015 Championship. How can a "leader" claim he'll do whatever it takes, yet he's not willing to let the other people on his team eat? Jeff then covers a business lesson on what Kobe should learn from and how more people should listen to Simon Sinek's philosophy on "Leaders Eat Last".
We would greatly appreciate your reviews on iTunes. Just go to http://www.MarketingStrategyLab.com/reviews and help us hit our goal of 500 reviews in the first 60 days.
0:09 – Question of today: Kobe Bryant, why did you say – "I can sit here and tell you with 100 percent honesty that I'm happy with the effort the organization put forward this summer"?
0:36 – Is Kobe Bryant's contract at $48,500,000 contract ridiculous when he only played 6 games in 2013-2014 season? Would you pay that much money for a player with a torn Achilles and a knee injury on the same leg?
1:15 – Kobe Bryant makes over $31,000,000 from endorsements yet he will not take a pay cut and he's willing to do "whatever it takes" to win?
1:53 – What was Kobe's self-interest? Wanting to be the highest paid NBA player or to win his 6th NBA championship?
2:30 – How come the 2013 – 2014 NBA champs star, Tim Duncan is ONLY getting paid $10,000,000 per year VS Kobe's $23,500,000?
Kobe Bryant's deal good for Lakers?
Regardless of what came to mind, let me explain why I decided to do a Kobe Bryant rant.
First off, I'm a die hard Los Angeles Lakers Fan. I bleed the purple and gold!!! Don't believe me?
After I posted the image above on my Facebook (click here to add me on Facebook)… The power of social media kicked in. My friend, Lucky, saw my Facebook status feed and found me on TV. Not only did he find me on TV but he was quick enough to snap a picture and tagged me in the photo. I'm the guy on the left and right next to me is my good friend Wayne looking back at something on the floor. I'm not exactly sure what he's looking at when Kobe made a basket to tie the game 86 to 86 with 31.5 seconds left. It was a pretty intense game!
Next picture is from another game I went to. My better half actually saw me on TV and tweeted about it. I guess she likes spying on me while making fun of me at the same time. lol This game was courtesy of my good friend, Robert, the bald-headed cool guy sitting next to me . He got me these tickets as an early Christmas gift. Yeah I know, my friends are super cool.
What Can You Learn From Kobe Bryant's $48,500,000 Contract?
If you don't know the back story, I'll give you a quick recap.
Kobe Bryant who lead the Los Angeles Lakers to 5 NBA championships signed a two-year contract in 2013 worth $48,500,000. When he signed this, Kobe was 35 years old being in the league for over 17 years and he just had an injury that 99.9% of all basketball athletes never make a comeback from. He tore his Achilles.
When he signed this contract, the sports world went crazy. Some were against it and some were glad (click here to read full article).
If you don't have time to read it… let me give you the short version.
The Happy Camp: "It's a great way for the Lakers organization to show loyalty and to take care of its star".
Now, lets fast-forward time to today. The Lakers couldn't get any "super stars" like Carmelo Anthony or Lebron James to come play because they didn't have enough cap space.
Kobe also went on to say he was willing to do "whatever it takes" to win another championship before he retires, YET he didn't take a pay cut. To me that doesn't jive.
How can a leader sign such a huge contract knowing it can handicap the team's ability to sign another good player? Fast-forward time to today and we know the cap space wasn't enough. Lakers can't get any super stars.
Just recently I re-listened to a podcast that reminded me why Kobe was so wrong. The podcast is called School of Greatness – hosted by Lewis Howes and he had a guest speaker named Simon Sinek.
Simon has worked with top level CEOs, military leaders, and everyone in between to understand what separates organizations that thrive with those that only survive. You might know him from his wildly successful TED talk, "Start with Why," which is one of the most watched TED talks of all time. If you haven't watched the video… I HIGHLY recommend it.
Kobe's self-interest of making the MAX money has hurt the Lakers and crippled their ability to win a championship in the next two years (unless some miracle happens).
If all of us looked out for the interest of others and serving others first, imagine what the world would be like!
P.S. I would greatly appreciate your review on iTunes. We have a pretty obnoxious goal of getting 500 reviews in the first 60 days. So please click here and leave us a review and comment.
P.S.S. If this is the first time listening to our podcast or reading this blog, please make sure to check out the introductory episode of Marketing Strategy Lab, where we break down what this podcast is all about.
Interesting angle for a conversation about business and marketing! I have to say, you guys are doing a good job of bringing a unique perspective to the table.
There's no doubt Kobe is more worried about Kobe than he is the team. But I don't really blame him for that. He's already got the championships, MVP's, etc. No matter what, he's going down as one of the best players to ever live. He HAS to say he's all for the team and championships. If he said anything else he'd be vilified. I say good for Kobe for taking as much money as he can. If I was an upset Lakers fan I would be more angry at the upper management of the organization than I would be at Kobe. They are the ones responsible for putting the best team together…not Kobe.
I have enjoyed reading this. It's very interesting and fun analysis! Now I see things from a new perspective. Great work!
The world of professional sports and professional athletes is one of smoke and mirrors. Organizations and players pay lip service to fans emotions but the reality is a world away. That's why when you actually get a player who puts his team first, a true leader, it is surprising.
As I read many articles on your site I am really impressed with the way you equate business strategy with sports. This really helps to put things in perspective. One thing I have despised most about the business dealings I have been exposed to is the selfish nature of them. I understand that at times we all have to stick up for ourselves and make sure that dealings are conducted in a fair manner but it perplexes me that this should automatically be at the detriment of others!
Wow Kobe's income is absolutely ridiculous! I can't believe he makes that much and only played 6 games?!?! I totally agree that it is not fair at all to the rest of the team because they will likely lose due to his selfishness! How can the team even allow this to happen? He is injured! Why doesn't the NBA make a bigger deal about this?


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New York State Route 352 (NY 352) is a state highway in the Southern Tier of New York in the United States. It generally parallels the Southern Tier Expressway (Interstate 86 or I-86 and NY 17) from the village of Riverside (exit 45) east through the city of Corning to the city of Elmira (exit 56). The portion of NY 352 west of the hamlet of Big Flats was once part of NY 17; the rest was originally New York State Route 17E. Construction of and improvements to the Southern Tier Expressway have resulted in extensions of NY 352, primarily along the former NY 17 right-of-way.

Route description

NY 352 begins at an intersection with NY 415 (High Street) in village of Riverside. NY 352 proceeds southward along Buffalo Street, a two-lane commercial street for two blocks to an intersection with Denison Parkway. At the Denison Parkway intersection, NY 352 turns east along Denison, while to the west is an interchange with the I-86 and NY 17 (the Southern Tier Expressway). NY 352 now proceeds eastward on Denison Parkway, a four-lane boulevard alongside the Chemung River. After bending southeast and crossing into the Chemung, the route leaves the village of Riverside for the city of Corning.

Through Corning, NY 352 retains the Denison Parkway name, paralleling a former railroad right-of-way into the southern side of the city. The boulevard passes residences for several blocks, until intersecting with South Bridge Street, where it becomes a commercial road through Corning. Remaining four lanes, NY 352 continues east along Denison, passing the site of the former Corning station of the Erie Railroad, which closed in November 1952.  Several blocks to the east, NY 352 intersects with the southern terminus of NY 414 (Cedar Street). NY 352 continues eastward through Corning, crossing businesses until Steuben Street, where residences begin appearing in either direction. A short distance to the east of that, NY 225 begins at an intersection with Conhocton Street, running southeast along Park Avenue.

After NY 225, NY 352 continues east along Denison Parkway, remaining a four-lane boulevard through Corning. Passing south of a park, the route crosses the Chemung River once again, leaving the city of Corning for the hamlet of Gibson in the town of Corning. After crossing the river, NY 352 crosses over the Southern Tier Expressway and enters an interchange with County Route 45 (CR 45; Main Street). NY 352 then turns southward as East Corning Road, a four-lane boulevard that parallels the Southern Tier Expressway, interchanging via a bridge a short distance after. After the interchange, NY 352 passes the Corning Country Club,. then makes a gradual bend to the east, paralleling the Southern Tier and the alignment of the former Erie Railroad, now Norfolk Southern Railway's Southern Tier Line.

NY 352 proceeds eastward on East Corning Road, becoming a divided four-lane arterial, passing south of a quarry. Near Kings Court, NY 352 and the Southern Tier Expressway bend northeast, passing north of the ramp for exit 46. A short distance to the east, NY 352 turns southeast off East Corning Road and crosses over the Southern Tier once again, intersecting with the ramps for exit 46. The route then bends eastward, now a two-lane residential street through the town of Corning. The route soon crosses out of Corning near a power plant and crosses the county line (also the Preemption Line) into Chemung County and enters the town of Big Flats. NY 352 starts proceeding northeast through Big Flats, intersecting with the northern terminus of CR 10 (South Corning Road).

NY 352 continues northeast through Big Flats for several blocks, intersecting with CR 64 (Main Street). Passing south of the village of Big Flats, the route bends further to the southeast, passing Community Park until an intersection with CR 82 (Winters Road). Crossing through the town of Big Flats, NY 352 begins a long distance parallel with the Chemung River, turning southward for a distance before proceeding southeast again. A short distance from the southeastern curve, the route intersects with CR 55 (Harris Hill Road). Nearby this intersection is the National Soaring Museum. After an intersection with Curren Road, NY 352 runs north of a large residential community.

After the residential section, NY 352 starts running alongside the Chemung River, bending southeast past some riverside homes before intersecting with the eastern terminus of NY 225 (Hendy Creek Road). After NY 225, NY 352 crosses the municipal line between the town of Big Flats and the city of Elmira. Now known as West Water Street, NY 352 becomes a four lane residential street through West Elmira. At the intersection with York and Coleman Avenues, the route forks into a divided roadway, with NY 352 east running along West Water Street and NY 352 west running along West Church Street. NY 352 east and West Water Street run through a residential section of West Elmira, bending east and passing homes for several blocks.

NY 352 east begins to bend northeast through Elmira, leaving the West Elmira section, remaining a two-lane residential street. The route returns to the Chemung River once again, passing north of Clinton Island. The route winds eastward, becoming a commercial street through the city, intersecting with South Main Street and Railroad Avenue. At Railroad Avenue, the Southern Tier Line crosses over the alignment from a bridge over the Chemung. Now known as East Water Street, NY 352 soon intersects with NY 14 (Clemens Center Parkway). NY 352 continues eastward for several blocks alongside the Chemung River, passing several baseball fields and industrial buildings, soon entering a diamond interchange (exit 56) with the Southern Tier Expressway (now just NY 17). This interchange serves as the eastern terminus of NY 352, where the right-of-way continues east of CR 1 (Jerusalem Hill Road).

History
In the 1930 renumbering of state highways in New York, a spur of NY 17 between the hamlet of Big Flats and NY 13 in the town of Elmira was designated as NY 17E. At the time, NY 17 was routed on Main Street and Big Flats Road in the vicinity of Big Flats. NY 17E was extended eastward into Elmira in the early 1940s after NY 13 was truncated to a new southern terminus in downtown Elmira. At the time, both NY 13 and NY 17E ended at the junction of Church Street and Madison Avenue, the latter then part of NY 17. NY 17E was extended slightly by 1953 to continue east along Church Street to Sullivan Street and southward on Sullivan Street to Water Street (NY 17).

A bypass for NY 17 in the Elmira area was built in the 1950s. The first section from Horseheads south to the eastern fringe of downtown Elmira was completed in the mid-1950s, resulting in a short eastern extension of NY 17E to the east side of Newtown Creek (exit 56). The second half of the bypass, from East Corning eastward to Horseheads, was open by 1958, and NY 17's original alignment from East Corning (exit 48) to Big Flats became a western extension of NY 17E. In October 1966, under pressure from locals to eliminate confusion between NY 17 east and NY 17E, the latter was renumbered to NY 352.

In the mid-1980s, the NY 17 bypass was extended west to NY 414 (exit 46) in Corning. NY 17 initially exited the expressway south of Gibson at exit 47 to rejoin its original surface alignment into Corning. Although the former routing of NY 17 between exits 47 and 48 lacked a designation, NY 352 was not immediately extended westward from exit 45. The Corning Bypass on NY 17 was completed in the mid-1990s, at which time NY 352 was extended west on the old surface NY 17 across the Gibson Bridge, through downtown Corning and across the Patterson Bridge to exit 45.

Downtown Elmira
NY 352 was reconfigured in Elmira by 1969 to split into two one-way streets in West Elmira. Westbound NY 352 followed Church Street through Elmira while eastbound NY 352 followed Water Street. Eastbound NY 352 left Water Street at Sullivan Street and followed Sullivan Street for three blocks north to Church Street. Here, NY 352 came back together and continued east along Church Street to NY 17 as a two-way street. By 1978, the portion of Sullivan Street between Water Street and John Street was removed. As a result, NY 352 now left Water Street at Madison Avenue and followed Madison north to Church Street. NY 352 eastbound was changed again by 1995 to follow Water Street east to NY 17.

In 2005, the portions of Church and Water Streets east of Hoffman Street were reconfigured to carry two-way traffic. However, NY 352 remains split along the two streets for historical reasons.

Major intersections

See also

New York State Route 417, the next piece of old NY 17 to the west
New York State Route 17C, the next numbered piece of old NY 17 to the east

References

External links

352
Interstate 86 (Pennsylvania–New York)
Transportation in Chemung County, New York
Transportation in Steuben County, New York


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Posts by Misty
January 12, 2017 by Misty
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October 3, 2015 by Misty
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