text:
Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement
David C. Grossman, Susan J. Curry, Douglas K. Owens, Michael J. Barry, Aaron Caughey, Karina W. Davidson, Chyke A. Doubeni, John W. Epling, Alex R. Kemper, Alex H. Krist, Martha Kubik, Seth Landefeld, Carol M. Mangione, Michael Pignone, Michael Silverstein, Melissa A. Simon, Chien Wen Tseng
IMPORTANCE: Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015. OBJECTIVE: To update the 2012US Preventive Services Task Force (USPSTF) recommendation on the prevention of falls in community-dwelling older adults. EVIDENCE REVIEW: The USPSTF reviewed the evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. FINDINGS: The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls and that multifactorial interventions have a small benefit. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults. The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate. CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 yearsor older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.
JAMA - Journal of the American Medical Association
https://doi.org/10.1001/jama.2018.3097
Grossman, D. C., Curry, S. J., Owens, D. K., Barry, M. J., Caughey, A., Davidson, K. W., ... Tseng, C. W. (2018). Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement. JAMA - Journal of the American Medical Association, 319(16), 1696-1704. https://doi.org/10.1001/jama.2018.3097
Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement. / Grossman, David C.; Curry, Susan J.; Owens, Douglas K.; Barry, Michael J.; Caughey, Aaron; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W.; Kemper, Alex R.; Krist, Alex H.; Kubik, Martha; Landefeld, Seth; Mangione, Carol M.; Pignone, Michael; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien Wen.
In: JAMA - Journal of the American Medical Association, Vol. 319, No. 16, 24.04.2018, p. 1696-1704.
Grossman, DC, Curry, SJ, Owens, DK, Barry, MJ, Caughey, A, Davidson, KW, Doubeni, CA, Epling, JW, Kemper, AR, Krist, AH, Kubik, M, Landefeld, S, Mangione, CM, Pignone, M, Silverstein, M, Simon, MA & Tseng, CW 2018, 'Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement', JAMA - Journal of the American Medical Association, vol. 319, no. 16, pp. 1696-1704. https://doi.org/10.1001/jama.2018.3097
Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey A, Davidson KW et al. Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement. JAMA - Journal of the American Medical Association. 2018 Apr 24;319(16):1696-1704. https://doi.org/10.1001/jama.2018.3097
Grossman, David C. ; Curry, Susan J. ; Owens, Douglas K. ; Barry, Michael J. ; Caughey, Aaron ; Davidson, Karina W. ; Doubeni, Chyke A. ; Epling, John W. ; Kemper, Alex R. ; Krist, Alex H. ; Kubik, Martha ; Landefeld, Seth ; Mangione, Carol M. ; Pignone, Michael ; Silverstein, Michael ; Simon, Melissa A. ; Tseng, Chien Wen. / Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement. In: JAMA - Journal of the American Medical Association. 2018 ; Vol. 319, No. 16. pp. 1696-1704.
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title = "Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement",
abstract = "IMPORTANCE: Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7{\%} of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5{\%} of which needed medical treatment or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015. OBJECTIVE: To update the 2012US Preventive Services Task Force (USPSTF) recommendation on the prevention of falls in community-dwelling older adults. EVIDENCE REVIEW: The USPSTF reviewed the evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. FINDINGS: The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls and that multifactorial interventions have a small benefit. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults. The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate. CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 yearsor older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.",
author = "Grossman, {David C.} and Curry, {Susan J.} and Owens, {Douglas K.} and Barry, {Michael J.} and Aaron Caughey and Davidson, {Karina W.} and Doubeni, {Chyke A.} and Epling, {John W.} and Kemper, {Alex R.} and Krist, {Alex H.} and Martha Kubik and Seth Landefeld and Mangione, {Carol M.} and Michael Pignone and Michael Silverstein and Simon, {Melissa A.} and Tseng, {Chien Wen}",
doi = "10.1001/jama.2018.3097",
journal = "JAMA - Journal of the American Medical Association",
T1 - Interventions to prevent falls in community-dwelling older adults us Preventive Services Task Force recommendation statement
AU - Grossman, David C.
AU - Curry, Susan J.
AU - Owens, Douglas K.
AU - Barry, Michael J.
AU - Caughey, Aaron
AU - Davidson, Karina W.
AU - Doubeni, Chyke A.
AU - Epling, John W.
AU - Kemper, Alex R.
AU - Krist, Alex H.
AU - Kubik, Martha
AU - Landefeld, Seth
AU - Mangione, Carol M.
AU - Pignone, Michael
AU - Silverstein, Michael
AU - Simon, Melissa A.
AU - Tseng, Chien Wen
N2 - IMPORTANCE: Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015. OBJECTIVE: To update the 2012US Preventive Services Task Force (USPSTF) recommendation on the prevention of falls in community-dwelling older adults. EVIDENCE REVIEW: The USPSTF reviewed the evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. FINDINGS: The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls and that multifactorial interventions have a small benefit. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults. The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate. CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 yearsor older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.
AB - IMPORTANCE: Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015. OBJECTIVE: To update the 2012US Preventive Services Task Force (USPSTF) recommendation on the prevention of falls in community-dwelling older adults. EVIDENCE REVIEW: The USPSTF reviewed the evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. FINDINGS: The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls and that multifactorial interventions have a small benefit. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults. The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate. CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 yearsor older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.
U2 - 10.1001/jama.2018.3097
DO - 10.1001/jama.2018.3097
JO - JAMA - Journal of the American Medical Association
JF - JAMA - Journal of the American Medical Association
10.1001/jama.2018.3097


Neil Joined Ahrens Investment Partners in January 2005. He is a graduate of the University of Louisiana, with a BS degree in business. He is a Chartered Financial Consultant and his working life has been in financial services including 25 years with Northwestern Mutual Life and management positions with New York Life and Met Life. He works with people in the Oil and Gas Business and related fields especially with retirees.
412 Settlers Trace Lafayette, Tel: (337) 981-1376 Fax: (337) 981-6684 Email: [email protected]Advisory services offered through Ahrens Investment Partners, LLC, An SEC Registered Investment Adviser.
Client accounts are established at Fidelity Brokerage Services, LLC, Member NYSE / SIPC. Ahrens Investment Partners does not take possession of any client funds or securities. Fidelity sends monthly statements and trade confirmations directly to the client, and on-line access to account information is available.
References herein to Ahrens Investment Partners , LLC as a "registered investment adviser" or any reference to being "registered" does not imply a certain level of skill or training.


Weighed in this morning at 202 lbs, no change from yesterday.
Yesterday, I took a ride with my friends to a fish shack in Carlsbad, CA. I had a shrimp salad, a cup of clam chowder, and a Pepsi. That's all I ate for the day. No exercise.
Today, I'm going to stick to the beef jerky diet.
I've told some friends that I've lost some weight already with this diet regimen of mine. They all sound supportive, albeit amused by the "beef jerky diet". I tell them it's the "manly way to diet".
I can already tell that some of my t-shirts feel more loose now. I have some t-shirts that were smaller than the normal "extra large" sizes, and thereby fitted tightly around my gut, emphasizing its girth. Now, they fit more loosely. I'm wearing t-shirts I haven't worn in a long time.


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text:
July 2017, Volume 27, Issue 3
Shangri-La and the integration of mental health care in Australia
Published 26 July 2017. https://doi.org/10.17061/phrp2731723
Citation: Rosenberg S. Shangri-La and the integration of mental health care in Australia. Public Health Res Pract. 2017;27(3):e2731723.
Sebastian Rosenberg | Brain and Mind Centre, University of Sydney, NSW, Australia
Sebastian Rosenberg | sebastian.rosenberg@sydney.edu.au
SR has previously provided paid consultancy services to the NDIS and is currently working with one PHN.
SR is the sole author.
We wanted the best, but it turned out like always. (Viktor Chernomyrdin)1
According to literary legend, Shangri-La is an idyllic and harmonious place. Mental health is aspiring to its own Shangri-La in the shape of better integrated care. But do current reforms make integrated practice more or less likely? And what can be done to increase the chances of success?
The aim of this article is to review the current state of mental health reforms in Australia now under way across Primary Health Networks, the National Disability Insurance Scheme, psychosocial support services and elsewhere. What are these changes and what are the implications for the future of integrated mental health care? Is Shangri-La just over the horizon, or have we embarked instead on a fool's errand?
What do we mean by integrated mental health care?
Current reforms
Three steps forward
The evidence for integrated care in mental health is strong, and current mental health reforms purport to foster integrated care; however, a range of problems are emerging
Priority must be given to secondary mental health services, both clinical and nonclinical, as glue to bind primary and acute systems, and create a more durable continuum of care
The move to decentralise responsibility for mental health service planning, funding and delivery should in no way diminish the need for strong accountability and benchmarking
The trajectory of 25 years of Australian mental health reform appears in doubt. The 1992 National Mental Health Strategy2 set the nation on a path towards closure of the asylums and the development of a network of community mental health services designed to help people with a mental illness live well in the community. This was to be backed up by a new and robust approach to accountability that would enable the Australian community to determine whether what was being done was actually helping. Although it is possible to critique this strategy, its intent was clear, and its role as a rallying flagship undeniable. We had a map to paradise.
The central theme of the current round of mental health reforms seems far harder to identify. Multiple reforms are occurring simultaneously, with different origins and purposes. Spending on mental health has stalled.3 Access rates remain a massive problem, particularly among certain demographic groups4, and the number and rate of suicides in Australia are climbing.5
This article reviews emerging policy issues that are likely to have significant impact on mental health practice. It first considers evidence concerning the applicability of integrated care to mental health: what are the key components of such an approach, and the suggested characteristics and benefits? The article then surveys the contemporary policy landscape to assess whether the most recent raft of mental health reforms makes it more or less likely that the goal of more integrated care will be achieved. Analysis includes a review of key policy changes and funding decisions that have affected programs, services and providers. Concepts such as integration, person-centred care and stepped care are explored in this context.
The immediacy of these important shifts requires consideration of material from a wide range of sources. Changes are occurring before or without formal research. This article therefore draws on a wide range of contemporary sources to demonstrate emerging views and concerns, in addition to traditional, more formal sources. The article concludes by suggesting three practical steps that could clarify the direction of mental health reform and provide new impetus towards better integrated care.
The working premise behind integration is that, to provide more effective and efficient mental health care, it is important to improve integration between the primary, secondary and tertiary sectors, and across mental, physical and social services. Key factors that can drive integration of mental health care (Box 1) include the need for 'horizontal' integration within primary care, to bring physical and mental health services together, as well as 'vertical' integration in the health system to enable effective partnership between primary, secondary and tertiary mental health services.6 There is clearly also a need to establish integration with sectors outside health, particularly housing, employment, education and community services.7 Effective integration of mental health care depends on the extent to which some key factors are addressed. Done well, these factors are enablers of integration. Done poorly, they become barriers.
Box 1. Key factors in integration of mental health care7
Taking local context into account
Engaging key stakeholders in informal or formal partnerships
Articulating governance procedures and identifying leaders
Financing reforms sustainably
Establishing appropriate infrastructure and resources (including considering colocation of services)
Accounting for organisational culture
Encouraging respectful communication
Providing interprofessional education
Reducing stigmatisation and discrimination
Collecting adequate data that assess quality of care
To drive a more integrated approach, the Australian Government has placed pivotal importance on the role to be played by the 31 Primary Health Networks (PHNs). Australian Government spending on mental health was $3 billion in 2014–158, with about 35% of this going to services provided under Medicare. A further 30% went to a variety of mental health–related programs provided by the Australian Government (such as mental health nurses and suicide prevention). Some of this parcel of funding has now been distributed to the PHNs to 'commission' related services. In announcing the reforms, [then] Minister for Health Sussan Ley said:
… in response to the National Mental Health Commission's Review of Mental Health Programmes and Services we committed to changing the 'one size fits all' approach to mental health services. We want to be absolutely sure people would receive the right support at the right time, and not fall through the cracks.9
This is ambitious, particularly when the gist of repeated major inquiries characterises the mental health 'system' as mostly cracks.10,11 Strong evidence indicates that many face a large gap in life expectancy, as well as the impact of metabolic syndrome and the general health problems associated with poor lifestyle12, the bread and butter of good primary care.
The advent of the National Disability Insurance Scheme (NDIS) is another key change with important ramifications for mental health. The Australian Government has allocated other existing mental health expenditure to the NDIS from programs previously managed by the Department of Health, as well as from other agencies (such as Partners in Recovery, Personal Helpers and Mentors, and Day to Day Living in the Community). State and territory governments are also transferring funding previously allocated to psychosocial support services to the NDIS. Although largely anecdotal, experience so far from NDIS trial sites is of profound disruption and uncertainty for these organisations and their clients.13
The NDIS is not permitted to fund anything that might otherwise be funded in the health sector (state or national). PHNs cannot 'commission' nonclinical services. This will emasculate Australia's already peripheral community mental health sector.14 There is concern that large numbers of people currently receiving community mental health services will miss out and the vital psychosocial support workforce will vanish.15 Modelling conducted using the National Mental Health Service Planning Framework indicates that 290 000 Australians will experience a severe mental illness that needs community support16, but the NDIS anticipates providing packages of care for only 57 000 people with a mental illness.17
There is fundamental tension between the usual determination of 'permanence' with respect to disability and the concept of recovery.18 Both the episodic nature of much of mental illness and the philosophy that underpins recovery mean that the usual criteria that drive compensation payments are difficult to apply. Our current capacity to predict the course of mental illness over the long term is limited. The task of integrating mental health care is made more challenging by the highly individualised and fluctuating nature of the course of illness.
This raises the apparent clash between the current rhetoric of individualised, person-centred care (dominant in the NDIS) and traditional approaches to population health planning (as more evident in state health planning). The review by the National Mental Health Commission19 also promoted regional and local autonomy in responding to mental illness. Planning for the successful integration of mental health care would benefit from a clearer understanding of whether this integration is to occur at the level of the jurisdiction, the region or the individual.
The current reforms also promise new integration through the implementation of 'stepped care' – an accurate and appropriate titration of the mental health response based on regular and rigorous monitoring of the patient's health status.20 In relation to mental health reform in Australia, it seems that a much looser definition is being applied – along the lines of 'the right service at the right time'.9
On this basis, 31 PHNs have each developed their own conceptualisation of 'stepped care'. Across these versions, there are different ideas about how many steps there are or should be. Do the steps start with mental health promotion, proceed to acute admission and then move back down some scale of acuity to home? Or are we focusing only on stepped primary mental health care? And do the steps only relate to health services, or are there important steps also in relation to housing, education and employment services? The extent to which state and territory governments buy into the model of 'stepped care' is dubious. 'Horizontal' links between state-funded mental health services and other critical state-funded services, such as those provided by community services and housing departments, are typically tenuous.
The NDIS is not mentioned as part of stepped care. Its inclusion would permit further consideration of how best to marry the population-type planning being undertaken by the PHNs and Local Health Districts (LHDs) with the individualised planning approach inherent in the NDIS.
Large numbers of people are missing out on services of unknown quality while the key to hospital avoidance – the community mental health sector – is being asset-stripped before an NDIS takeover. It is increasingly difficult to find a mental health service between the general practitioner/psychologist and the front door of the emergency department of the local public hospital. The bar for admission to acute inpatient care is becoming insurmountable to all but the sickest.
This has created a phenomenon described as the 'missing middle' – a large cohort of people with mental health conditions too complex for primary care but not severe enough to qualify for hospital admission or an NDIS package of care. The alarming paucity of secondary mental health care available in Australia leaves this large population particularly vulnerable. It is clearly a complicated environment for mental health reform, seemingly driven more by concern for who pays than what works.
With large and poorly connected reforms such as the PHNs and the NDIS in full swing, what should be done to start to better join things up? There are three key tasks.
1. Clarify the theory of change
Implementation has been a traditional weakness in mental health reform.21 PHNs, LHDs, NDIS providers and other community sector organisations will not come together by magic to deliver integrated care, particularly when there are real reasons justifying their ongoing separation. The importance of understanding regional context in effective change processes is well understood and needs support.22
Developing a sustained method of change has been recognised overseas as a critical element of successful reform.23 This is much less so in Australia. The NSW Agency for Clinical Innovation has set out a process for developing and implementing effective new models of care.24 To be clear, this reform task is not about mental health. This is about the application of specific technologies and processes designed to make change happen.
2. Funding for reform
Change costs money. Genuine processes of codesign are deep and offer rich insight, but take considerable time and resources to engineer. International studies have found that project success rates are much higher when there is specific funding to support change in areas such as planning, training, communications, sustainability and monitoring.25
PHNs are struggling to maintain existing services with the limited funds they have been allocated. There is little, if any, new funding for change.
Funding rules also need to match intentions around flexibility. In the same way the NDIS cannot fund health services, current rules make it difficult, if not impossible, for PHNs to fund nonclinical services for mental health clients.26 It is well understood that these kinds of psychosocial support services are critical to keeping people living well in the community.27 Leaving aside the small number of NDIS package recipients, if PHNs are not funding these services, who is?
3. Strong accountability
Accountability has been at the heart of mental health reform from the very first national mental health plan. Yet despite repeated commitments, accountability remains very weak and inappropriately focused on inputs (dollars spent) and outputs (numbers of occasions of service, beds, etc.).28 There is no validated collection of the experience of care for consumers and carers. We do not have a good understanding about the housing or employment status of people with a mental illness, nor their quality of life. There is a risk that the reporting process will revert to template-driven nonsense. Although ostensibly independent, the PHNs are already subject to ongoing missives from the Department of Health about services, data, reporting and so on.29
There is, of course, a tension between the regional independence that underpins the reforms and the need to nationally promulgate good practice. Accountability can assist here and should be a priority. Measuring the quality of care provided by individuals and organisations, and reporting the results, is linked both conceptually and empirically to reductions in variations in care and increases in the delivery of effective care.30 In short, accountability can drive quality improvement. Some state-based PHNs have come together to look at opportunities for shared learning and benchmarking. This type of activity must become the norm.
Integrated mental health practice is difficult. Many PHNs and LHDs are operating to meet their related but separate goals, and the NDIS is working independently. Disparate approaches risk perpetuation of systemic cracks. The rationale for more integrated mental health care does not seem as obvious as proponents of the reforms may have hoped.
It is critical in addressing this issue that priority be given to secondary mental health services, both clinical and nonclinical, as glue to bind primary and acute systems, and create a more durable continuum of care.
Change costs money and is a complex, time-consuming process. It must be emphasised that the move to decentralise responsibility for mental health service planning, funding and delivery should in no way diminish the need for strong accountability and benchmarking.
Consumers, carers, service providers and the general community want to know how their mental health system is performing in comparison with others, and that an effective system of quality improvement is in operation. Current mental health reforms are ambitious. Key ingredients in successful change cannot be missed, or we risk things turning out as always.
© 2017 Rosenberg. This article is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.
1.	The Economist. London: The Economist Newspaper Limited; 2017. Viktor Chernomyrdin; 2010 Nov 4 [cited 2017 Jul 28]; [about 4 screens]. Available from: www.economist.com/node/17414237
2.	Australian Government Department of Health. Canberra: Commonwealth of Australia. National mental health strategy; 2014 Apr 17 [cited 2017 Jul 28]; [about 2 screens]. Available from: www.health.gov.au/internet/main/publishing.nsf/content/mental-strat
3.	Rosenberg S, Salvador-Carulla L. Accountability for mental health: the Australian experience. J Ment Health Policy Econ. 2017;20(1):37–54. PubMed
4.	Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results. Canberra: Commonwealth of Australia; 2007. Available from: www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/6AE6DA447F985FC2CA2574EA00122BD6/$File/43260_2007.pdf
5.	Australian Bureau of Statistics. Causes of death, Australia, 2013. Canberra: Commonwealth of Australia; 2015. Available from: www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2013~Main%20Features~Leading%20Causes%20of%20Death~10001
6.	Bywood PT, Brown L, Raven M. Improving the integration of mental health services in primary health care at the macro level. PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research and Information Service; 2015 [cited 2017 Jul 18]. Available from: www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/publications/pdfs/phcris_pub_8443.pdf
7.	Oliver-Baxter J, Bywood P, Brown L. Integrated care: what policies support and influence integration in health care across New Zealand, England, Canada and the United States? PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research and Information Service; 2013. Available from: www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/publications/pdfs/phcris_pub_8414.pdf PubMed
8.	Mental Health Services in Australia. Canberra: Australian Institute of Health and Welfare; 2016. Australian Government expenditure on mental health‑related services; 2016 [cited 2017 Jul 7]; [about 4 screens]. Available from: mhsa.aihw.gov.au/resources/expenditure/aus-govt-mh-services
9.	The Hon. Sussan Ley MP: Member for Farrer. Albury, NSW: The Hon Sussan Ley MP; 2017. Boost to mental health services underway; 2016 Oct 10 [cited 2017 Jul 7]; [about 2 screens]. Available from: sussanley.com/boost-to-mental-health-services-underway
10.	The Senate Select Committee on Mental Health. A national approach to mental health – from crisis to community. Canberra: Commonwealth of Australia; 2006 [cited 2017 Jul 7]. Available from: www.aph.gov.au/binaries/senate/committee/mentalhealth_ctte/report/report.pdf
11.	Mendoza J, Bresnan A, Rosenberg S, Elson A, Gilbert Y, Long P, et al. Obsessive hope disorder: reflections on 30 years of mental health reform in Australia and visions for the future. Summary report. Caloundra, QLD: ConNetica; 2013 [cited 2017 Jul 7]. Available from: cairns.health.qld.libguides.com/ld.php?content_id=8809934
12.	Rosenbaum S, Samaras K, Teasdale S. Physical health ignored in people with mental illness. The Conversation. 2017 Jan 19. Available from: theconversation.com/physical-health-ignored-in-people-with-mental-illness-69040
13.	Naufal R. Shitstorm: a short history of NDIS implementation. Disability Services Consulting. 2016 Aug 16 [cited 2017 Jul 18]. Available from: www.disabilityservicesconsulting.com.au/resources/shitstorm
14.	Crowther L. Roadmap for reform in community mental health. Croakey. 2017 Feb 20 [cited 2017 Jul 18]. Available from: croakey.org/roadmap-for-reform-in-community-mental-health
15.	Williams T, Smith G. Can the National Disability Insurance Scheme work for mental health? Aust N Z J Psychiatry. 2014;48(5):391–4. CrossRef | PubMed
16.	McGrath D. Mental Health Australia Submission to the Joint Standing Committee on the National Disability Insurance Scheme into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition: attachment 1. Canberra: Mental Health Australia; 2017 [cited 2017 Jul 7]. Available from: www.aph.gov.au/Parliamentary_Business/Committees/Joint/National_Disability_Insurance_Scheme/MentalHealth/Submissions
17.	NDIS. Canberra: National Disability Insurance Scheme Launch Transition Agency; 2013. Nearly 700 people with psychosocial disability are part of the NDIS: media release; 2014 Oct 10 [cited 2017 Jul 7]; [about 3 screens]. Available from: www.ndis.gov.au/document/nearly-700-people-psychosocial-dis.html
18.	Nicholas A, Reifels L. Mental health and the NDIS: a literature review. Melbourne: Mind Australia; 2014 [cited 2017 Jul 7]. Available from: www.ndis.gov.au/html/sites/default/files/files/Mental-health-and-the-NDIS-Literature-Review.pdf
19.	National Mental Health Commission. Contributing lives, thriving communities: report of the national review of mental health programmes and services. Volume 1. Canberra: NMHC; 2014 [cited 2017 Jul 7]. Available from: www.mentalhealthcommission.gov.au/media/119905/Vol%201%20-%20Main%20Paper%20-%20Final.pdf
20.	Bower P, Gilbody S. Stepped care in psychological therapies: access, effectiveness and efficiency. Narrative literature review. Br J Psychiatry. 2005;186:11–7. CrossRef | PubMed
21.	Hickie IB. Time to implement national mental health reform. Med J Aust. 2015;202(10):515–7. CrossRef | PubMed
22.	Bate P. Context is everything. London: The Health Foundation; 2014 [cited 2017 Jul 7]. Available from: www.health.org.uk/sites/health/files/PerspectivesOnContextBateContextIsEverything.pdf
23.	Weiss CH. Nothing as practical as good theory: exploring theory-based evaluation for comprehensive community initiatives for children and families. In: Connell JP, Kubisch AC, Schorr LB, Weiss CH, editors. New approaches to evaluating community initiatives. Washington, DC: Aspen Institute;1995. p. 65–92.
24.	Agency for Clinical Innovation. Understanding the process to develop a model of care: an ACI framework. Sydney: Agency for Clinical Innovation; 2013 [cited 2017 Jul 7]. Available from: www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/181935/HS13-034_Framework-DevelopMoC_D7.pdf
25.	IBM. Making change work. Somers, NY: IBM Corporation; 2008 [cited 2017 Jul 7]. Available from: www-07.ibm.com/au/pdf/making_change_work.pdf
26.	Australian Government Department of Health. Annexure A1 – primary mental health care. Canberra: Commonwealth of Australia; [cited 2017 Jul 7]. Available from: www.health.gov.au/internet/main/publishing.nsf/Content/F4F85B97E22A94CACA257F86007C7D1F/$File/Annexure%20A1%20-%20Primary%20Mental%20Health%20Care.pdf
27.	Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. Br J Psychiatry. 2004;185:283–90. CrossRef | PubMed
28.	Rosenberg S, Hickie IB, McGorry PD, Salvador-Carulla L, Burns J, Christensen H, et al. Using accountability for mental health to drive reform. Med J Aust. 2015;203(8):328–30. CrossRef | PubMed
29.	Australian Government Department of Health, Primary Health Networks. Primary Health Networks primary mental health care funding: mental health activity work plan. Canberra: Commonwealth of Australia [cited 2017 Jul 7]. Available from: www.health.gov.au/internet/main/publishing.nsf/content/2126B045A8DA90FDCA257F6500018260/$File/Mental%20Health%20Activity%20Work%20Plan%202016-17%20template.docx
30.	Institute of Medicine. Improving the quality of health care for mental and substance-abuse conditions. Washington, DC: National Academies Press (US); 2006. CrossRef | PubMed

redpajama_set_name: RedPajamaCommonCrawl


At Balcan Plastics First Film Extruding, we believe that an excellent product must be backed by exceptional customer service. As so accurately reflected in our slogan "Quality Plastic Film and Bags Made Easy ", one of our main goals is gaining our customers' trust and loyalty.This goal is achieved thanks to our highly qualified staff in the production process as well as in customer service and technical support. Our customer service team is dedicated to satisfying our customers' needs and is always here to assist you with the utmost in professional yet personal service.


text:
Q: Kubernetes cert-manager issue I've deployed cert-manager on cluster. It was working. Recently i noticed that when i try open service which configured through ingress complaining about expired certificate.
I checked in kubernetes certificate shown as its up to date. But when i open service via browser it says that cert expired.
I recreated issuer and certificate again and noticed that cert-manager didnt created "certificaterequest". and "order". So the question is how can i force cert-manager to create cert-request and order.

A: The first thing I'd would check is what is the actual expire date of the certificate that your browser is receiving while requesting the web page. You can check this by clicking the padlock near the address in your browser.  If this looks correct, check your personal computer time and date whether it's showing the current one (not the future one).
If this is not the case then you can force issuing the certificate with the following methods:

*

*Set the renewBefore field on the certificate resource to 1440h (two months before expire date. It should be enough to trigger the certificate reissuing.

*Delete the secret first and then the certificate. This will cause the cert-manager to issue a new certificate.

Also check out this cert-manager issue on github.

redpajama_set_name: RedPajamaStackExchange


This strengthened my resolve not to get plants at garden centers this spring. You will locate much more magnificent magnolias and rhododendrons at Borde Hill , with the former in flower and the latter starting to bloom (and so early this year, that the garden has opened a week ahead of schedule to enable guests to actually appreciate the visual delights on offer you). To preserve the serenity and non-pollution of this lovely garden we discourage the use of golf carts on the boardwalk unless definitely required, and only following seeking and receiving permission to do so. Some skilled garden designers are also landscape architects , a more formal level of training that normally calls for an advanced degree and usually a state license. Spring Grove Cemetery and Arboretum in Cincinnati is a nice location to walk, with ponds, fountains, a nice assortment of trees & shrubs (and the monuments are exciting).
In Hampshire, there's the Sir Harold Hillier Gardens , with its comprehensive magnolia collection close to the major property at the heart of the garden. Highlighted are garden pioneers such as Mary Foster (of Foster Botanical Garden fame), who solicited the aid of botanist Harold Lyon to restore the Foster Botanical Garden, as well as other individuals who developed their own botanical gardens, numerous for private use. I really dislike employing chemicals on our lawn and garden due to the fact of the harm it may do to the birds and butterflies (and me!) that reside right here. Lasagna gardening is basically the very same idea as the Back to Eden garden, just with different material. I encourage any person who is feeling any level of pressure in their life to just devote some time each day in a garden.
When planted next to other brightly colored flowers (e.g. red, yellow, orange), white flowers decrease the intensity of these bright colors, hence giving the garden a far more balanced, harmonious look. The true king of this garden are the big selection of species from the showy protea family members, featuring 60 diverse varieties. Beautiful Sketch of the Summer time Garden 🙂 Hmm you sound like somebody who has done your study nicely each about the munstead wood and squidoo. Fort Worth Iris Society and The Garden Club Council of Greater Fort Worth is proud to present this dazzling display of flower arrangements and horticultural delights. As much as I get pleasure from ornamentals, my accurate love is native plants and I stuff them into every single empty spot in the garden. The Na 'Aina Kai Botanical Garden is a accurate magical paradise exactly where you can knowledge the multiple moods and diversity of its beauty.
Besides the big Japanese garden with teahouse, there are fine bonsai on show in their own garden connected to the visitor center. The family members will collect on the patio to take in the splendor of the contorted filbert—believed to be the biggest in the state of Washington. These are also yet another fantastic choice if you have concerns with bending more than or have physical limitations, but nevertheless want to garden. All of the plants at the Garden of Eden come from South Pacific, South American and Central American rain forests.
You are transported to gorgeous areas beyond our shores: classic Italy, stately England, lush tropical Bali and our own Evergreen State of Washington. This garden is a marriage of cultures, starting with the ethos of the American barbeque infused with a new level of opulence. Butter-hued actions lead to a modest plaza of the very same color-all designed from stone. Major Terrace – the oldest portion of the garden dating from 1853, was planted by Dr. Hildebrand and where the Hillebrands constructed their home. The McBryde Garden contains investigation and conservation collections whilst the Allerton Garden is a landscaped estate garden. This garden represents a gorgeous snapshot of what nature does ideal-providing lovely landscapes for us to get pleasure from.


text:
package test.dependent;

import static org.testng.Assert.assertTrue;

import org.testng.annotations.Test;

public class DifferentClassDependsOnGroupsTest1 {
  @Test(groups = { "mainGroup" })
  public void test0() {
    assertTrue(1 == 0); // Force a failure
  }

  @Test(dependsOnGroups= {"mainGroup"})
  public void test2() {
  }
}

redpajama_set_name: RedPajamaGithub


Kindly note that Asiasoft Passport will be undergoing maintenance on 14th July from 0800hrs (+8 GMT) to 1000hrs (+8 GMT).
All functions of Asiasoft Passport will be unavailable during the stated time period.
In addition, the game's Cash Shop will also be down for maintenance 0800hrs to 1000hrs.


text:
namespace GafferModule
{

void bindStringPlug();

} // namespace GafferModule

#endif // GAFFERMODULE_STRINGPLUGBINDING_H


text:
An Unique Civil Defense Ministry Of Sister Mary Magdalen Rozmajzl during the Cold War
Compiled by Sr. Anita Rolenc, Notre Dame Sisters archivist
The decades of the 1960s was noted for the conflicts in the world. Besides the War in Vietnam in which American military forces were involved, there was the 6-Day War of Israel versus Syria, Egypt and Jordon. The Cold War between the Union of Soviet Socialist Republics (USSR) and the United States presented a direct and dangerous confrontation. Consequently, President John F. Kennedy, shortly after taking office, advised Americans to build shelters to protect their families against atomic fallout in the event of a nuclear exchange with the Soviet Union.
A response to the Cuban Missile Crisis
In October 1962, what came to be known as the Cuban Missile Crisis, resulted in a 13-day conflict between the United States and the Soviet Union. The Soviet Union had placed nuclear missiles, capable of destroying major cities in the United States, in Cuba.
The U.S. Civil Defense Program would provide protection for every American. While Americans accepted the president's order, the Notre Dame Sisters began the process of establishing a shelter in their building.
Fallout shelters
Mother M. Loyola Samek, the president of the community, applied for two Fallout Shelter Licenses or Privileges for Notre Dame Convent and Notre Dame Academy. Both were accepted by the Director of Civil Defense William P. Durkee on December 21, 1965.
Mother Loyola was appointed manager of the shelter at the convent, and Sr. Magdalen Rozmajzl as deputy of operations. The Notre Dame Convent shelter, located on the basement floor and in the basement area under the kitchen, would have in stock food for 100 spaces, 12 water drums, 2 drums for Sewage Disposal, 2 Sanitation kits, 2 Medical Kits A (for 50-65 persons) and one RADEF (acronym for Radiology Defense kit). This shelter was 81 cubic feet in area.
The Academy Shelter had a capacity for 620 in the 881 cubic feet area of the lower level of the academy. Sr. Eleanor Kramolisch, teacher at the Academy, was the shelter manager, and Sr. Magdalen, the RADEF monitor. This Shelter had food for 621 spaces, 112 water drums, 13 Sanitation kits, no sewage disposable drums, 2 Medical Kits for 300-325 persons, and 1 RADEF kit.
Hawaiian Punch and hotdogs
The food stored in the shelters consisted of Campbell's Soup, Hawaiian Punch, Tang drink mix, candy bars, Kellogg's Corn Flakes, crackers, cookies, peanut butter, canned vegetables, beans, and preserved meats, such as Spam and hot dogs.
As RADEF monitor, Sr. Magdalen was well qualified. Among her many college courses were listed general and advanced physics, nuclear physics, inorganic and organic chemistry, nuclear chemistry and instrumentation. Through the extension division of the University of Nebraska, Sister completed courses in Radiological Monitoring for Instructors, Civil Defense Shelter Management, and Emergency Operations Simulation Training. After completing the Radiological Monitoring Instrument Operator's Course, Sister applied for the privilege to teach the Civil Defense Adult Education Course, Radiological Monitoring. In June 1967, Sister was approved by the Nebraska Civil Defense Agency as Radiation Protection Officer with the right to use the CD V-778 Radiation Training Source Set.
Sister Mary Magdalen Rozmajzl
Sister Magdalen, who had completed her 50th year as a teacher and 25th at Notre Dame Academy, added Civil Defense instruction to her activities in July of 1967. She enrolled two classes of Notre Dame Sisters who were teachers in lowa, Kansas, South Dakota and Nebraska. Using her own science lab at the Academy as a training center, she taught thirty-five Sisters who completed their RAMONT (Radiological Monitor Training Course) training by August 2, 1967 when they were presented with certifications as RADEF Monitors by Wm. Dean Noyes, Omaha/Douglas County Civil Defense Coordinator.
It should be noted that Notre Dame Academy was one of three Catholic organizations where lab space and science personnel provided the training. The other two were Sr. Anna Marie of Mercy High and Sr. Mary Mechtilde of the College of St. Mary.
Sr. Magdalen offered classes for parents and friends of Notre Dame Academy. The first, held in January 1968, included seventeen individuals from the Florence area. Another class of fourteen was taught in April of that year. These individuals in the event of a nuclear disaster would be able to predict and evaluate the early effects of nuclear detonations, and would, after the immediate dangers of radiation had subsided, initiate and direct extensive decontamination operations so as to return the community to normalcy. Fortunately for all concerned, there was no nuclear disaster that called for the services of the RAMONT personnel.
Information obtained from the personal file of Sr. Magdalen Rozmajzl.


text:
Local Visionary Treaty 1 chiefs experienced strategists
Visionary Treaty 1 chiefs experienced strategists
By: Glenn Hudson Posted: 4:00 AM CDT Monday, Jul. 5, 2021
There were some big names who gathered at Lower Fort Garry to negotiate Treaty 1 — chiefs Yellow Quill and Henry Prince, among other leaders and visionaries — whose goal was to use their experience and negotiating savvy to create an agreement that would foster an enduring relationship of mutual obligation between First Nations and the new colonial government.
This foundational agreement, made after much cultural conflict and linguistic confusion, quickly turned into a trail of broken promises and a long-standing dispute that continues to this day.
Those who put pen to paper on Aug. 3, 1871, for the Anishinaabe and Muskegon (Swampy Cree) represented the original five First Nations of Treaty 1 (which became seven, but that's another story).
Together, they governed territory that included a vast swath of what is now southern Manitoba — stretching to Steinbach and east to the Ontario border; to Gimli in the north; to near Brandon in the west; south to the U.S. border, including the important trade and travel routes of Winnipeg and Portage la Prairie.
Oozawekwun (Yellow Quill) was an experienced and savvy negotiator who led the Portage Nation (now Long Plain, Sandy Bay and Swan Lake), while Miskookenew (Prince) from St. Peter's (Peguis) was a hereditary chief representing one the most powerful First Nations in the territory then and now.
Other First Nations leadership included Kakekapenais (William Pennyfather) from Fort Alexander (Sagkeeng); Nashakepenais from Fort Garry (Brokenhead); Nanawananaw, Kewaytayash, and Wakowush from the three communities of Pembina (Roseau River). Each First Nation's representatives were carefully chosen by their respective communities to represent their long-term interests.
Meantime, inside the walls of Lower Fort Garry, the British Crown awaited to fulfil the demands and desired land grab of colonial Canada's new prime minister, John A. Macdonald. Lt.-Gov. Adams G. Archibald, Indian commissioner Wemyss Simpson, Maj. A.G. Irvine, and eight witnesses were sent to get the job done.
First Nations representatives came to the negotiations following the traditional and customary concept of "seven generations" — what we do today affects seven generations forward and seven generations back — ensuring they were mindful of securing benefits for many years to come.
It was this long-term view that drove the Treaty 1 chiefs to insist on long-term recognition of their right-to-livelihood, self-government, and title to their land. By contrast, colonial leaders were pursuing a short-term agenda intended to deliver quick political and economic gains back to Ottawa.
As colonial representatives soon learned, First Nations came to the table with a long history of negotiating tactics and strategy. If they thought the First Nations leaders across from them could be easily influenced into an agreement favourable to the Crown, they quickly learned otherwise.
Prince was a son of Chief Peguis. He watched and learned from his father, who was known as the saviour of Lord Selkirk and the Scots, displaced due to the Highland Clearances in Scotland. Simply put, the Selkirk settlers would not have survived without Peguis's assistance, especially as he further led negotiations of the Selkirk Treaty of 1817.
Following in the footsteps of his father, Prince, a skilled and intuitive leader, advocated first for the Treaty 1 negotiations, then for the implementation of treaties with the Crown. How right he was, for soon after the signing, there were issues with interpretation and implementation. The Crown offered much, but follow-through was lacking.
It should be no surprise then Sgt. Tommy Prince, Canada's most decorated war veteran, was a great-great-grandson of Peguis and part of a family instrumental in creating colonial Canada.
As we continue to share the stories that led to the making of Treaty 1 on Aug. 3, 1871, we will next focus on how these chiefs altered the course of Canada's plan to "unite the country coast-to-coast with minimal negotiations."
Case in point: we are still at the negotiating table today.
Chief Glenn Hudson of Peguis First Nation is a member of the Treaty 1 governing council, composed of Brokenhead Ojibway Nation, Long Plain First Nation, Peguis First Nation, Roseau River Anishinabe Nation, Sagkeeng Anicinabe Nation, Sandy Bay Ojibwe First Nation, and Swan Lake First Nation.
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